10. Treatment - Surgery
• In general, needed for diagnosis
Exceptions: Germ cell, Brainstem
• Ideal is gross total resection
Balance prognosis vs. morbidity
• Debulking, shunts, reservoirs
- For symptom/ICP reduction, therapy
11. Survival
Type of Tumor 5-Year Survival
Pilocytic astrocytoma About 95%
Fibrillary (diffuse) astrocytoma About 85%
Anaplastic astrocytoma About 30%
Glioblastoma About 20%
Oligodendroglioma About 95%
Ependymoma/anaplastic ependymoma About 75%
PNETs (includes medulloblastoma and pineoblastoma) About 60%
12. Brain Tumors in < 3 year olds
• 60-70% supratentorial
• XRT has significant neuro-cognitive effects
• Goal of therapies:
– Delay XRT to at least 3 yrs old with chemotherapy
most relapse prior to XRT
• Current Recommendation
– Short course (16 wks) chemotherapy
– 2nd look surgery
– Focal (conformal) XRT
– Maintenance chemotherapy
17. Shunt Malfunction
• 30% to 40% of shunts fail in the first year
• 15% fail in the second year
• After 2 years failure rate 1% to 7% per year
• Obstruction is responsible for the majority of
failures
– 60% proximal catheter
– 30% at the valve itself
– 10%distal tubing
18. Antibiotic-impregnated VP Shunt
• 0.15% clindamycin and 0.054% rifampicin
• 11 observational studies showed a statistically
significant difference favouring the antibiotic-
impregnated VPS (RR: 0.37, CI: 0.23,
0.60; P <0.0001)
• One RCT did not show a significant difference
between two groups in the risk of shunt
infection (RR: 0.38, CI: 0.11, 1.30; P = 0.12)
19. Silver-impregnated VP Shunt
• Efficacy of silver-impregnated catheters at
preventing VPS infections is not yet proven
• RCT of EVDs in children and adults, silver-
impregnated EVDs have been shown to reduce
infection from 21.4% (30/140) to 12.3%
(17/138) (P = 0.042)
• Two further observational studies comparing
standard to silver-impregnated EVDs have also
shown a reduction in infection rates
20. • Neuroendoscopy in Infants and the
International Infant Hydrocephalus Study
• BASICS trial: British antibiotic and silver-
impregnated catheters for VP shunts
21. Hydrocephalus – Prognostic Factors
• Etiology – Worse with meningoceles
• Motor and sensory deficits
• Level of meningocele
• Seizures
• Degree of ventricular dilatation
• Age at surgery
• Shunt function and complications
22. Hydrocephalus - Outcome
• Developmental disorders
• Reduced motor function
• Lower IQ
• Decreased visual function
• Risk for developing epilepsy
– Children with epileptic seizures have the worst outcomes
and more likely to have lower IQ
• About 60% of children with hydrocephalus are able to
attend school (although many have difficulties)
• About 40% of children will lead relatively normal lives
25. Craniostenosis
• Surgery
– Cosmesis
– Brain Development
• Extent of surgery
– Conservative surgery in small children
– Extensive cranial vault remodeling after 6 months
• Complications
– Blood loss
– Hypothermia
28. Mild Head Injury
• Controversy regarding policy for hospital admission and
evaluation with CT scan
• CT scan is desirable
– For detection of significant intracranial lesion
– Children with brain lesions have greater cognitive
impairment
– Children with normal CT scan can be discharged
• CT scan is not advisable for all children because of a
remote risk of cancer
– Clinical benefits of CT scan should outweigh the small
absolute risks
– Justification of any CT scan is important
A decreasing order of probability of intracranial injury
•Skull fracture
•Focal neurological deficit
•Coagulopathy
•Post-traumatic seizures
•Previous neurosurgery
•Visual symptoms
•Bicycle and pedestrian accident
•Loss of consciousness
•Vomiting
•Severe or persistent headache
•Amnesia
•GCS < 14
•Intoxication
•Scalp hematoma/laceration
29. Diffuse axonal injury (DAI) - mortality
Radiological (MRI)
• Lesions of the hemispheres only: 14%
• Unilateral lesions of the brainstems, deeper
lesions: 24%
• Bilateral lesions of the pons with or without
any of the lesions of lesser grades: 100%
Firsching R, et al .Acta Neurochir. 2001.
Weiss N, et al. Critical Care 2007.
35. Spina bifida occulta
• Sacral or lumbosacral is commonest
• Requires no treatment at birth
• Potential for the spinal cord to become fixed
(tethered) at the site of the lesion during
growth of child
36. Meningocele
• Neurological function outcome is usually more
favorable
• Surgery to close the lesion
• Long-term needs will depend on the extent of
neurological deficits and level of involvement
38. Preoperative care
• Prevent infection
– At the site of the lesion
– Meningitis
– Ventriculitis
– Urinary infections
• Avoid drying and injury
• Dressing
– Clear Film
– Non-abrasive
– Non-adherent
Nurse prone
Meticulous nappy care
39. Surgery for open defects
• Within 24 hours of birth if no other life
threatening malformations
• Dissecting the neural tissue
• Covering the tissue with fibrous dura
• Skin graft may be necessary
• Shunt may be inserted
40. Neurological care
• Correct positioning of the limbs
• Observation of the skin for any signs of pressure
damage
• Regular position changes
• Regular passive exercises
Perform above with other routines such as
feeding and nappy care
41. Bladder care
• Continuous urine leakage or full bladder after voiding
• Regular renal ultrasound scans
• Intermittent catheterization
• Prophylactic antibiotics
Expressing the bladder by applying pressure over the lower
abdomen during nappy changes may increase the risk of
urinary reflux into the ureters
42. Prevention
Before and during pregnancy
• Folic acid (0.4mg daily)
• Increase to 5mg daily for high risk women
• Avoid smoking and alcohol intake
• Avoid aminopterin, methotrexate, trimethoprim,
valproic acid, carbamazepine, and phenobarbitone
If not using contraceptives, take FOLIC ACID
Jain A, Sharma MC, Suri V, Kale SS, Mahapatra AK, Tatke M, et al. Spectrum of pediatric brain tumors in India: A multi-institutional study. Neurol India 2011;59:208-11
Wilne S, Collier J, Kennedy C, Koller K, Grundy R, Walker D. Presentation ofchildhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007 Aug;8(8):685-95.
Wilne S, Collier J, Kennedy C, Koller K, Grundy R, Walker D. Presentation ofchildhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007 Aug;8(8):685-95.
Jain A, Sharma MC, Suri V, Kale SS, Mahapatra AK, Tatke M, et al. Spectrum of pediatric brain tumors in India: A multi-institutional study. Neurol India 2011;59:208-11
Children with hydrocephalus face developmental disorders as they age. Hydrocephalus patients have reduced motor function, a lower-than-average adult IQ, and decreased visual function; they also are at risk for developing epilepsy.11 The extent of the complications observed is dependent upon the type of hydrocephalus, but patients with epileptic seizures (approximately 30%) have the worst clinical outcomes and, compared with patients who did not develop seizures, are more likely to have an IQ lower than 90.15 About 60% of children with hydrocephalus are able to attend school (although many have difficulties), and approximately 40% of children will lead relatively normal lives. - See more at: http://www.uspharmacist.com/content/d/health%20systems/c/39606/#sthash.0trXZ4LU.dpufhttp://www.uspharmacist.com/content/d/health%20systems/c/39606/#sthash.0trXZ4LU.dpuf
a decreasing order of probability of intracranial injury, include depressed or basal skull fracture, focal neurological deficit, coagulopathy, post-traumatic seizures, previous neurosurgery, visual symptoms, bicycle and pedestrian motor vehicle accident, loss of consciousness, vomiting, severe or persistent headache, amnesia, GCS < 14, intoxication, and scalp hematoma/lacerationontroversy regarding the policy for hospital admission and evaluation with CT scan CT scan is desirable for children with MHI as it is useful for detection of a clinically significant intracranial lesion, prognostication, and decision for dischargeChildren with MHI and brain lesions on CT scan have greater impairment on cognitive testinghildren with normal CT scan after MHI can be discharged, and hospitalization is generally unnecessaryCT scan is not advisable for all children because of a remote risk of cancern a recent study on cancer due to CT scan, the authors found that the use of CT scans in children to deliver cumulative doses of about 50 mGy (i.e. 2-3 CT scans) almost tripled the risk of leukemia, and doses of about 60 mGy tripled the risk of malignant brain tumor.
a Subcutaneous lipoma. b Subcutaneous lipoma associated with an angiomaand a dimple. c Tail. d“Queue de faune”. e-h Angiomas
