Pediatrics

The specialty of pediatric neurosurgery requires an intimate knowledge of embryology, genetics, physiology, and nervous system development. Physical examination and surgical techniques vary with patient's age, and additional attention is given to social circumstances because the patients are without autonomy. Congenital disorders that are present at birth, ie, myelomeningocele and hydrocephalus, may present with distinct diagnostic challenges as the body matures. Operations such as spinal fusion, when it is done in toddlerhood vs teenage years, require different preparations and postoperative follow-ups. It is for these reasons, among others, that an additional year of fellowship training is required upon completion of neurosurgical residency to practice pediatric neurosurgery in the United States. The topics covered in this section are not meant to be comprehensive. The treatment of hydrocephalus, either with cerebrospinal fluid (CSF) shunts or other diversion methods, are practiced by adult and pediatric neurosurgeons alike. These operations typically made up 20% to 40% of case volumes in a pediatric neurosurgical service. Operations for craniosynostosis, encephalocele, and myelomeningocele are done almost exclusively in children. They are good examples of how neurosurgical treatments have evolved over time with technological advancements and a deeper understanding of disease pathophysiology. In the subsection on skull fracture, a by and large nonoperative entity, readers’ attention is directed to issues that are nonetheless neurosurgical: concussion management, discernment of child abuse, and the need for longer term follow-up compared to that offered to an adult patient population. For a comprehensive coverage of these topics and others, the medical students may refer Principles and Practice of Pediatric Neurosurgery or other textbooks. CHAPTER 1: COMMUNICATING AND NONCOMMUNICATING HYDROCEPHALUS Case Presentation A 16-yr-old female with no previous past medical history presents with 2 wk of progressive headaches, nausea, and vomiting. Her exam is significant for moderate papilledema. Imaging demonstrated ventriculomegaly of the lateral and third ventricles with transependymal flow and convexity sulcal effacement. Sagittal imaging demonstrated a web in the cerebral aqueduct (Figure 1).FIGURE 1.: Axial and sagittal T2-weighted MRI demonstrating obstructive hydrocephalus from a web in the cerebral aqueduct and the associated typical MRI findings.Questions What are the most common presenting symptoms of hydrocephalus in infants and children? Infant: Headache; Children: Restricted Upgaze Infant: Increasing head circumference; Children: Restricted Upgaze Infant: Bulging fontanelle; Children: Irritability Infant: Increasing head circumference; Children: Irritability Infant: Bulging fontanelle; Children: Nausea/Vomiting What is the leading cause of hydrocephalus in infants in the United States? Spina bifida Aqueductal stenosis Hemorrhage Infection Trauma What is the most common complication of ventriculoperitoneal (VP) shunting? Infection Seizure Symptomatic hemorrhage Shunt failure Short-term memory loss What is the most common complication of endoscopic third ventriculostomy (ETV)? Basilar artery injury Short-term memory loss Failure of ETV Endocrine abnormality Infection Which patient below carries the highest likelihood for third ventriculostomy success? 1-mo-old posthemorrhagic 1-yr-old postinfectious 1-yr-old myelomeningocele 10-yr-old post-traumatic 10-yr-old tectal glioma Introduction Hydrocephalus is derived from the Greek words “hudro” meaning water and “kephale” meaning head. In the most basic understanding, hydrocephalus is an increase in CSF within the central nervous system (CNS) resulting in increased intracranial pressure (ICP) from (1) an obstruction of CSF flow or (2) either increased production or impaired absorption. While a number of different classification systems are used, communicating versus noncommunicating are the terms most commonly discussed in clinical practice. “Noncommunicating” hydrocephalus implies that CSF flow out of the ventricular system to the subarachnoid space is impaired or obstructed. The term communicating denotes impaired absorption at a point after CSF reaches the subarachnoid space. Additional terms include hydrocephalus ex vacuo describing enlargement of CSF fluid spaces due to brain atrophy without an increase in ICP, and normal pressure hydrocephalus, a condition with enlarged CSF spaces but normal ICP on testing. Epidemiology and Causes Pediatric hydrocephalus is the most common treated neurosurgical problem in infants and children; however, recent studies demonstrate an overall declining incidence. The current estimated incidence ranges from 1 in every 500 to 1000 children. The decreasing incidence is likely related to a number of factors including: improved prenatal care and education, a decline in the incidence of spina bifida and preterm infants, and improved perinatal and prematurity care. Common causes of infantile and pediatric hydrocephalus include congenital and genetic hydrocephalus, myelomeningocele associated hydrocephalus, posthemorrhagic hydrocephalus, postinfection hydrocephalus, noncommunicating hydrocephalus secondary to mass lesions, and post-traumatic hydrocephalus. Currently, intraventricular hemorrhage (IVH) is the leading cause of infantile hydrocephalus. Clinical Presentation The majority of children with hydrocephalus present at birth or shortly thereafter, but in pediatrics symptoms vary by age due the presence of open cranial sutures. The Monro-Kellie doctrine describes the relationship between ICP and the volume of intracranial components. After the cranial sutures and fontanelle are closed, patients’ symptoms are more closely related to elevated ICP. However, at birth when the cranial sutures are still open, infants more commonly present with increasing head circumference. Table 1 summarizes the most common presenting symptoms of hydrocephalus for infants and children. TABLE 1. - Clinical Presentation of Hydrocephalus Infants Children Increasing head circumference: 81% Irritability: 27% Bulging fontanelle: 71% Delayed milestones: 20% Delayed milestones: 21% Nausea/vomiting: 19% Loss of upward gaze: 16% Headache: 18% Lethargy: 13% Lethargy: 18% Focal neurological deficits: 12% New seizures/change in Pediatric hydrocephalus treatment vary on the cause and of For infants, require surgical the patient a more and include fontanelle ventricular ventricular and ventricular to shunts shunts may the need for in and not require for CSF require for CSF but are to have a and and to may a in the treatment of hydrocephalus on the clinical and with the surgical to hydrocephalus include CSF and ETV without and with A is a CSF diversion with a ventricular a and a In and the that time have in the of Currently, is to of 1 system over and systems have demonstrated in in for include the of demonstrated a The of but other common include and to include ETV and ETV with ETV is in of hydrocephalus. is with the of an The lateral is and the is the third the of an is made the in the of the third an for CSF flow 2 and A for the of of ETV on the age, and the presence of a previous and The of to ETV to the of the ETV in the need for a The at this however, to be in the need for additional in with to patient of endoscopic of the lateral the relationship of the to the The third is the of of the of the third (1) the to the body the TABLE - ETV of of ETV at Shunt previous brain to 1 Aqueductal stenosis treatment and and are in Table The for is failure or with failure for noncommunicating hydrocephalus. treatment and and are in Table The for is failure or with failure for noncommunicating hydrocephalus. ETV a more and a of CSF pediatric neurosurgeons are to that the need for of a TABLE - of CSF and ETV Shunt ETV Infection Infection 20% preterm with age of Basilar injury loss Symptomatic Case patient with noncommunicating hydrocephalus with the of CSF flow at the of the cerebral treatment of hydrocephalus with an the postoperative imaging Axial and sagittal T2-weighted MRI demonstrating and improved CSF sulcal is flow the in the the ventricles not in a in of to the of cranial infants most commonly present with increasing head circumference. Children typically to or hydrocephalus associated with prematurity is the most common for in Shunt may up to to 40% within the year after Infection in of Hemorrhage in but is Seizure and memory loss in The failure of ETV is to a for the is likely to of with ETV are but Basilar artery injury in refer to the ETV Hydrocephalus is of the most common disorders that adult and pediatric neurosurgeons of hydrocephalus be treated without a in an common and complication of endoscopic third of cerebrospinal fluid in pediatric hydrocephalus. of an system for the treatment of hydrocephalus. from endoscopic third ventriculostomy compared with in hydrocephalus the ETV endoscopic third ventriculostomy and as treatment for a and not a secondary of large pediatric hydrocephalus Principles of Pediatric New CHAPTER Case Presentation A for prenatal neurosurgical after a a (Figure as as a 2 children at term normal without perinatal and is no history of congenital The to a MRI (Figure ventriculomegaly with an of 2 and an open with myelomeningocele at Axial of the head. the of the and the of the due to 2 Sagittal demonstrating the myelomeningocele at and 2 Axial of the brain demonstrating ventriculomegaly with an of Axial the demonstrating the open spinal What is the of open in the at of secondary of the What treatment are to the of the an is the and the likelihood of 20% 40% the patient and is the likelihood of hydrocephalus given an of 20% Epidemiology is the most common open and the most common congenital of the It is associated with a of and and that on the spinal due to 2 and a of hydrocephalus. the of open between 1 and out of every In the United the is It is that with in of child age the of A clinical in with no history of previous by to either of or a significant in vs and overall congenital in children to in the treatment with the of by and with may the by In in the with to the associated with a in the of is a of of the in or the of a the to the and to the after these the to a that the the of The is with the that the the and and the the and the the is as the over the The and from the the from the The typically the Failure of and of the of the to for section for infants with to demonstrate a in neurological between and surgical of myelomeningocele is in the of to the of (Figure While is in surgical the surgical include of the from the the the of the from the of the and the may be a to a is and over the may require to to without for of be in the of the to this in and the of myelomeningocele at birth to surgical head is to the CSF be from the open demonstrating the to the and for myelomeningocele (Figure on the by in that of neurological due to the from of the and injury from fluid neurological in demonstrated the 2 and be with prenatal in the a between and and wk to for myelomeningocele associated with 2 The a of and need for CSF at of age, and at of The after demonstrated a to for of of patients to for a CSF compared to of patients to of patients treated with at compared to 21% of patients treated with for myelomeningocele at of the after open and of the have to an increase in for of However, this is not without a of prematurity and related in the of the In of the with on are and in the and the to to these is not a While a 27% in for hydrocephalus and CSF of patients still The is of as children treated with at without of children in the still required studies of patients with myelomeningocele have demonstrated that below are associated with an 20% of patients with at and the a patient with an may from by this a patient with an is still to with and a patient with an be to of the of the of patients in the for the need for CSF diversion to on the For patients without ventriculomegaly at the time of the of hydrocephalus 20% with compared to with For patients with ventriculomegaly the with versus with patients ventriculomegaly at the time of hydrocephalus of children with vs with and ventricular are to the likely of and A of the care of children with myelomeningocele is in a spina bifida These for neurosurgical issues hydrocephalus, CSF due to 2 and due to a may to central and and These symptoms are with a CSF children of because the is to after and the is as the to and progressive loss of increased and in the as as loss of and and progressive Children with myelomeningocele require in spina bifida by pediatric for pediatric for and other and and social the of is in the of the not the spinal and are be to in the patients require and The likelihood of hydrocephalus is with ventricular at the time of the most common congenital of the due to failure of the and of the and from and and the of myelomeningocele by to The demonstrated that hydrocephalus CSF diversion in patients with and of the not the hydrocephalus in patients with ventriculomegaly at the time of presents significant to the and prenatal is is to and hydrocephalus and and is a spina bifida of the of by Spina bifida A a in A of prenatal versus of for myelomeningocele and the need for cerebrospinal fluid CHAPTER Case Presentation A with of the the but more on brain development. when from the and on the of the from the at an no other skull and the exam A head that is in the and in the with a and is of of the of Sagittal A head for a when from with is of of the of Sagittal A from the to the with an normal be In to craniosynostosis, in a head to Epidemiology is the of or more cranial sutures. It an incidence of 1 in to are with or The are in an however, is and The sutures are typically and is an with and of in the are to to increased of and Common include and Hydrocephalus may be present in Sagittal is the most common The cause is factors include of a hydrocephalus, and and It is to be to by clinical examination in the and it from the most common head or the child to be for that the skull to the it be to the associated with of a the normal cranial sutures. In (Figure is on the the child to or with of the and resulting in a from the are at an Sagittal in (Figure the head is in the and in the with a and or the of the sagittal in (Figure the head is in the and in the may be a of the of the head when from the (Figure causes of the and of the and of the the and are a given the to the in (Figure the is and with a when from The may be The is the that may a after the without is likely not and be (Figure causes but the and are of resulting in a when from the and are are in cranial sutures and skull sagittal done for other Sagittal of the of in this the majority of it be that of sutures sagittal and resulting in In is the for of sutures such as the to cause head These are however, that are the of this to is that the may be open or in of is diagnostic on imaging be the to the is skull however, of the skull at a to or skull carries a of head more a of overall head leading to increased ICP. the of the of the is for treatment is The of treatment are to the and the The is open between and of age the are a in and (Figure no postoperative are the open is typically associated with need for a for 2 to an and more on the neurosurgical have for open of The for a and are the endoscopic the the of the or to (Figure additional is is and the patient is for after an on the neurosurgical The a a and on the in the are skull is It to be every and is by an this is between and of age for to of the of head in the year of The is by 1 of endoscopic of craniosynostosis, in from between the the is and the is the endoscopic the the of the are in with the to a to the The of is on patient age, and of the is is and the patient is for after an on the neurosurgical to a is required to the The is between and of age for The of is the of a between the pediatric and the because and are to of of is as as the such as are and may have a with compared to the open but this is to however, is that of and to a pediatric by 2 of is required to of Case The and head are for imaging is The be that is not is not and that is not to brain or development. The head is likely to as the child and on the is the child be to to the of the as as head the child head for be but to the incidence of it is that a child on in a of of a be but is not sagittal in a skull that is in the and in the the sagittal may or may not be present in in a and and due to a is of the without is likely not and be not require surgical is by with of the and resulting in a may to to of be and from by clinical examination in the is diagnostic on exam skull a be The most common cause for head is in a when from be that is not is not and that is not to brain or development. the without is most with of the and be of and to a pediatric by 2 of is required to Pediatric for care of patients with the of of and for the of patients with causes of of in and from techniques for of the and and postoperative for treatment of The of in the clinical and of sagittal CHAPTER CSF Case Presentation A child to the because of a of of increasing and no in the and are no in the by and posthemorrhagic hydrocephalus that required of a CSF from the no surgical a but is in of and is The is is but with open and imaging ventricular volume increased over normal with of What is the most still in this for of the system brain imaging examination the of CSF What is the most likely obstruction of the ventricular of the treatment is is the most likely The to how this child be in the 2 Epidemiology CSF is an treatment for hydrocephalus of but CSF shunts case and the clinical of the failure in the of and failure are after the is that may be improved over these A recent by the to in the 13% to 16% are from the of the but the patient's as of a of in the of For that to in and The most of is A of have but of medical between and Shunt of with almost to attention within of in a child with a carries the of as or of the Delayed due to from of is not among shunts with in the that Shunt is more covered in a in this and for the of this the of be Clinical The symptoms and of include the symptoms and of hydrocephalus. Infants may present with and or with failure to and They may head of the of the and children nausea, vomiting. common symptoms are and include failure of or other of the and that may be a to and Children with myelomeningocele and shunts are to be as at the of the myelomeningocele symptoms such as and have in the past to at the related to the 2 or to but clinical that such symptoms to of may more to the fluid the or the in a after of CSF absorption may due to or in a leading to or CSF in the system be The is a of but the that the to and the at it are of the presence of a over of time CSF be in on a CSF and more symptoms at the time of at the time of A to and to from is more in the of CSF but is a not to on a Hydrocephalus not children from other causes of and vomiting. as as other and are by symptoms that be from failure by imaging and of time is common in and the of to or of to an or typically in in the of a is as The is at the of the by patients and be it be for in is may be The of the of failure is of brain imaging at the time of symptoms with In the majority of ventricular volume when a of and is a of that in the of the the other imaging may be by the is as imaging is as by in a of the of of the of intracranial but out of for T2-weighted MRI is imaging is not in the most the imaging be and additional is A number of have practice in The on when imaging is not or is is The and are with and with in The at the or the is with a CSF be to the and flow be by the open of the the ventricular of the is obstructed. CSF pressure in the of the be the of the In the presence of pressure is a for ventricular this in the of is with a of A to the diagnostic is the New a to the of a of of a a that the flow of the be to be of Shunt A of with the is at the time of this but it may to for brain imaging in with clinical of the of failure be after a is a diagnostic treatment for with and may be as time to may be and but diagnostic is to Children with symptoms with failure and diagnostic not be symptoms are and and when intracranial is a diagnostic to the care for ICP and with or a be in the of systems with intracranial A is the child to have a or CSF to for and the between of a is among pediatric is no CSF flow in the and the child is of the may not be flow of CSF be by the be to with symptoms and is CSF is a but it is a the patient and the to the after a for at The of the ventricular the of the ventricular within the of of the ventricular the and of the the of the the of and the age of the are that be in the patient is on the may but knowledge to and that increase the of The a the of the obstruction of the but and to the For of the a by the Hydrocephalus Clinical of the and with and and for at the surgical and of of to of that that the surgical is treated with The these obstruction of the ventricular is the most common cause of and because the other of the system be from this the is The ventricular be from the because obstructive and a of the of the and be with a of the system vary with and the is with the of the of the system may be to the have are in the of ventricular are the most common causes of The ventricular is to the within the that flow is but the more the ventricular the more likely that cause of current to a the of the the with but current cause in Hemorrhage the is almost and it with with of a the is The of hemorrhage typically or more to the of the but failure be CSF is the A of is not to in the The a may be the to a or to the from the the obstructed. is a for ventricular the be or have at the ventricular a be from a is at The to be in of from without the of The is with a large brain that be and the is the be A ventricular is the to a either from or from The of a ventricular is it be with of with of the ventricular the additional of and the ventricular are to in the of as over to of be by with or to between are for more of with and is at the of an additional A common is the child with a in that in the of the or over the the over a is an The causes of are of the of the over time and of the in a of of the not either of these and is but a to the is but the of the and the is to of the of the system with is of the is an to in the care of children and techniques this The practice is to a large to the The and of the be by In the child or the patient with a the is a and to with a or The is of the in the or the is not or be made to by it to a problem and be of a CSF is an for the to and to and to and of and are to as The on attention to in CSF is as as in of neurosurgical In of the the current brain imaging with Shunt and for are diagnostic Children not be with diagnostic and of surgical and be surgical in the of systems and be by of imaging of a child with failure be without of the ventricular is more common failure of the of a CSF CSF failure is a The of be in the of and 2 is In such are in the of but is to for a child is and is for a child is still Shunt Failure of pediatric cerebrospinal fluid shunts related to and of cerebrospinal fluid in pediatric hydrocephalus. in the of ventricular and ventricular of of endoscopic ventriculoperitoneal a A to cerebrospinal fluid the Hydrocephalus Clinical A of the for the of hydrocephalus in pediatric of fluid a of of CSF in of Hydrocephalus Clinical with to the of cerebrospinal fluid from the of flow of cerebrospinal fluid in shunts by of cerebrospinal fluid from the of cerebrospinal fluid failure and of among patients with hydrocephalus. CHAPTER Case Presentation A female with history of and a preterm at wk of a age of 1 hydrocephalus that of a ventricular wk after birth to a wk The

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.