Biomedical subjects
Publications and source records attributed to E B Hendrick.
The long-term postoperative follow-up of children treated for craniopharyngioma is influenced by the patient's age at time of diagnosis, tumor location, texture, interface and adherence to brain, and achievements of the first operation. These factors will be examined as they apply to 51 children treated at the Hospital for Sick Children, Toronto. A brief comment on the role of irradiation treatment is also provided.
The authors describe the operative repair and results in 16 cases of craniofacial dysmorphism. The craniofacial dysmorphic states are presumably caused by premature closure of basal skull sutures in combination with the coronal sutures. Hydrocephalus is commonly associated with these conditions and contributes to the bizarre appearance as well as the abnormal mentation that some of these patients display. Early neurosurgical intervention using the procedure of lateral supraorbital ridge advancement yields excellent results in the majority of these infants.
14 children with central nervous system gangliogliomas are reviewed. The tumors were most frequently located in the cerebral hemisphere and often were cystic and calcified. Total removal was performed in only 1 patient. A well-defined plane of cleavage could not obtained in the majority of tumors at surgery. All patients are alive on follow-up and only 1 is neurologically disabled. Radiation therapy was given to 4 patients postoperatively. The clinical course of patients given postoperative radiation therapy was not different from that of those who were not irradiated. The histological aspects of the tumors are described.
Mesenchymal tumors arising from the dura in three newborn babies are described, with discussion of their clinical and pathological significance.
The authors review 48 cases of craniopharyngioma in children treated during 25 years, 1950 to 1975. Complete excision of the tumor, attempted in 23 patients, was possible in 17. The authors advocate aggressive treatment aimed at complete excision of the tumor, using radiotherapy only when adherence of the tumor to the internal carotid artery precludes total excision, and symptoms recur.
31 children with spina bifida occulta who have presented with back pain, scoliosis, a progressive neurological deficit involving lower limbs or a neurogenic bladder have been found to have a tethered spinal cord. Release of the tethered spinal cord has always relieved pain, frequently occrected a progressive scoliosis, and arrested or improved neurogenic foot deformities as well as neurogenic bladder.
The authors describe a T-tube Silastic shunting device which has been used for lumboperitoneal shunting in 62 patients with communicating hydrocephalus during the past 3 years. In 38 patients it was inserted as a primary shunting procedure; 24 patients had the shunt inserted following problems secondary to arachnoiditis created by a polyethylene-type lumboperitoneal shunt. The shunt described here has not led to arachnoiditis when inserted as a primary shunting procedure. In 61% of patients no operative revisions of their shunt has been required to date, and 81% continue to do well on their T-tube type shunt.
The authors have routinely inserted a ventriculoperitoneal shunt in all patients with a posterior fossa tumor and hydrocephalus some 7-10 days prior to craniotomy. Forty-one patients with medulloblastoma were treated in this fashion and of these, four metastasized through the shunt and died of systemic metastases without evidence of recurrent tumor in their central nervous system. A millipore filter which can be incorporated in the shunt has been used by the authors during the past 18 months in an effort to prevent metastatic spread through the shunt.
In summary, the care of the patient with head trauma is not dissimilar to any other acutely ill individuals. Careful, systematic observation and recording of changing factors and physical signs is necessary. Proper application and appropriate treatment in response to dynamic changes will provide a satisfactory result as in any other form of illness or trauma. The patient with multiple injuries may call for compromise in treatment, however with the exception of gross hemorrhage, the head injury should take precedence in the early period following injury for there are other factors that may prove fatal. Do not accept unnecessary delay in the treatment of other injuries on the grounds that the patient has had a head injury. The orthopedic surgeon can treat the fractured femur, the plastic surgeon-the face, and the general surgeon-the abdomen, without jeopardizing brain recovery. The treatment of the patient with head trauma, as treatment of any other individual in present day medical practice, has become more of a team effort, not only involving the neurosurgeon, but the pediatrician, the specialist in pulmonary physiology, and other expert groups.
As a result of the authors' experience they advocate posterior fossa decompression in patients with myelomeningocele at the first sign of compression of bratn stem or the cervical cord or both. If decompression is not undertaken at once the impaired gag and cough reflexes place the child at risk. He may develop pneumonia. If decompression is delayed too long full neurological recovery will not occur. The removal of bone and the opening of dura must be carried down to the bottom of the tonsillar tip, sometimes as low as C7. The most dramatic improvement occurs in infants whose symptoms are life threatening. Less dramatic but just as real is the improvement in older children. Although investigations such as myelography and ventriculography will show the malformation, they are not essential. The associated visible malformations and the clinical condition are the most reliable means of making the diagnosis. Delaying the decompression risks the life of the infant and threatens the quality of life for the older child.
The authors have reviewed the charts of 107 patients undergoing 119 surgical procedures in the prone position for posterior fossa or upper cervical lesions. The intraoperative complications encountered include cardiac arrhythmia, respiratory complications, cardiac arrest, hypothermia, air embolus and technical difficulties. In all but three children the problems were minor and easily remedied. The use of controlled ventilation appears to reduce blood loss, permits excellent relaxation of the exposed tissues and had some anesthetic advantages.
The authors studied the effects on cerebrospinal fluid (CSF) absorption of chronic administration and acute withdrawal of steroids in dogs. CSF absorption was measured by determining the amount of isotope (indium 111DTPA) recovered over a 4-hour period after injection into the cisterna magna. Resistance to CSF absorption was estimated by determining rates of low of Ringer's lactate infusion into the cisterna magna over a range of pressure gradients between CSF and sagittal sinus. Steroid withdrawal was associated with a marked reduction in CSF absorption and an increase in resistance to CSF flow. Dogs on steroids also showed reduced CSF absorption although the reduction was not statistically significant when compared with controls. The results are discussed in terms of possible mechanisms of action of steroids on CSF absorption, the etiology of the benign intracranial hypertension syndrome and the use of steroids and in the control of intracranial hypertension.
Two cases of unilateral proptosis associated with intracranial schwannomas in children are described. In both cases, tumour occupied both the orbit and middle cranial fossa, where in one case the intracranial component was extradural and in the other intracerebral. Possible sites of tumour origin are discussed.
The stroke syndrome in adults encompasses a limited number of lesions occurring over an extended age-span. In children the syndrome includes a wide variety of lesions seen in only one and one-half decades. This general review examines common aspects of the syndrome as it is seen in children. Attention is paid to cerebrovascular occlusive disease, arteriovenous malformations, intracranial aneurysms, spontaneous intracerebral hematomas and cerebrovascular complications of cardiac surgery. Conclusions are based on the authors' experience in treating patients in the Hospital for Sick Children, Toronto
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