1. Common Neurosurgical
Problems in Children
Dhaval Shukla
Additional Professor of Neurosurgery
NIMHANS, Bangalore

2. • Hydrocephalus
• Congenital Malformations
• Brain Tumors
• Head injury

3. Brain Tumors
• 20-30% of cancers in children
• 2nd most common neoplasm
• Most occur before age 10 years
• Male/Female = 1.3/1.0

5. Symptoms in Small Children
Macrocephaly 40%
Vomiting 30%
Irritability 25%
Lethargy 21%
Abnormal Gait/ Coordination 18%
Weight Loss 15%
Raised ICP 10%
Seizures 10%
Focal Neurological Deficits 10%
Abnormal Eye Movement 5%
Developmental Delay 5%

7. Histological Types

8. Diagnosis

9. Treatment
Tumor Type Surgery XRT Chemo
Medulloblastoma +++ CrSp +++
Low grade astro +++ focal ----
cerebellar +++ ???? ----
optic glioma NO ???? ????
High grade astro/GBM +++ +++ ?
Brain stem glioma (exophytic) focal ?
Ependymoma +++ focal ----
Germ cell tumor ? bx +++ +++

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

13. Large, Small, and Abnormal Head

14. • Macrocephaly (Head circumference > 97th percentile)
– Hydrocephalus
• Enlargement of the ventricles
– Macrocrania
• Increased skull thickness
– Megalencephaly
• Enlargement of the brain
• Microcephaly (Head circumference < 3rd percentile)
– Craniosynostosis
• Abnormal shape of the skull

15. Hydrocephalus

16. Hydrocephalus – Treatment Options

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

23. Craniostenosis

24. Craniostenosis

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

26. Head Injury

27. Traumatic Brain Injury

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.

30. Diffuse Axonal Injury

31. Minimal Protocol for MRI
• A 3-dimensional T1-weighted, preferable
sagittal, sequence, which allows multiplanar
reconstruction
• Axial T2-weighted sequence
• Axial DWI sequence
• Axial SWI sequence

32. Spina Bifida

33. Epidemiology
• 1/3rd of all congenital malformations
• 75% of fetal deaths
• 40% of deaths during the first year of life
• Cause not known in 75%

34. Cutaneous manifestations

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

37. Myelomeningocele
• Apparent at birth
• Legs, bladder and bowel are usually affected
• Hydrocephalus is usually present

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

43. SCM