Peds

Question 1

Treatment Options for Triventricular Hydrocephalus

Answer 1

VP Shunt
ETV
ETV with Choroid Plexus Cauterization

Question 2

ETV Procedure Steps

Answer 2

Stereotactic Navigation
Peelaway sheath
Insert Scope into lateral Ventricle
Identify ventricular anatomy and pass into 3V (often need to find the choroid plexus and follow anteriorly to foramen of monroe)
Floor of 3V… Mammillary bodies, pituitary recess, and TUBER CINEREUM (floor of 3V)
Make hole with blunt end of stealth probe, and then dilate with 5mm fogarty balloon catheter

Optional -> leave a ventricular catheter behind connected to a reservoir.

Follow up 1mo, 3mo, 6mo (MRI), then annually or q2y

Question 3

ETV Pearls

Answer 3

Preop images with high res T2 (FIESTA or CISS) is essential to determine if anatomy is well suited for ETV

Prepontine membranes have been reported as a predictor of postop ETV failure. Typically more than 2mm of space is needed between the basilar artery and clivus to safely perform ETV

More than 90% of choroid needs to be coagulated to improve results of ETV.

Question 4

Normal Volume of CSF in adult ventricles, and subarachnoid Space

Answer 4

100 to 150 mL

Question 5

Rate of CSF Production

Answer 5

0.3 to 0.4 mL CSF per minute…

400 to 500 mL per day

Question 6

Shunt failure rate at 2 years

Answer 6

60% still working

40% had some issue/revision

Question 7

Shunt infection rate at 1 year

Answer 7

4 to 10%

Reduced with antibiotic impregnated catheters

Question 8

Common Causes of Hydrocephalus

Peds

Answer 8

22% Prematurity and IVH
16% Myelomengocele
11% P Fossa brain tumor
8% Aqueductal Stenosis
8% Congenital Communicating
8% Other brain tumors
5% Head Injury

Less Common
intracranial cysts, nonpremature ICH, encephalocele, craniosynostosis

Question 9

ETV Success

Answer 9

ETV Higher Success Rates…

• older children (>1 year)
• adults
• previously unshunted patients
• specific etiologies such as aqueductal stenosis, tectal glioma, P F Tumors

ETV Success Score helps estimate success rates

For neonates and young infants, ETV success rates are low (20-45%)

Question 10

Arachnoid Cyst Facts

Answer 10

1) Most likely Asymptomatic and Don’t Grow
80% Stable over time
20% Change (10% GROW, 10% SHRINK)

2) Children with arachnoid cysts have an increased risk of ICH/SDH
- lifetime risk of 4-9%

3) Fenestration may relieve HA

Question 11

Surgery for Arachnoid Cysts

Answer 11

Controversial
Most are followed.
Case by case basis… surgery if there is growth, symptoms of elevated ICP, hemorrhage, etc

Shunt and Fenestration
Debate as to which is best

Question 12

Main Determinant of Surgery for Pediatric Gliomas

Answer 12

LOCATION

Question 13

Glioma Categories

Answer 13

LOW GRADE
Pilocytic astrocytoma
pleomorphic xanthoastrocytoma
gangioglioma
dysembryoplastic neuroepithelial tumor
WHO II Astrocytoma
WHO II Oligodendroglioma

HIGH GRADE
Anaplastic Astrocytoma
Glioblastoma

BRAINSTEM GLIOMAS
diffuse intrinsic pontine glioma
exophytic meduallary glioma
midbrain tectal glioma

Question 14

Imaging Findings

Oligodendroglioma and WHO II astrocytoma

Answer 14

hypointense T1
hyperintense T2
do not enhance

Question 15

Imaging Findings

PXA
Gangioglioma
Pilocytic Astrocytoma

Answer 15

Cystic and solid components
May have mural nodule (possibly with enhancement)

PXA and GG often in TEMPORAL LOBE

Pilocytic Astrocytoma in CEREBELLUM 60% of the time

DNETs often in frontal or temporal lobe with hypo intense T1 and multilobulated hyper intense appearance on T2, no enhancement

Question 16

Pediatric Glioma Pearls

Answer 16

All tumors that can be safely resected (with acceptable risk) should undergo GTR

Chemo for LGG can delay need for XRT, and in combo with XRT for HGG can improve survival

OS and PFS are most significantly associated with extent of surgical resection AS WELL AS histological grade

Question 17

Pediatric Low Grade Glioma Survival

Answer 17

10 year PFS

85% with GTR