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J. Gordon McComb

✓ Recent information regarding the nature of bulk cerebrospinal fluid formation and absorption is reviewed, integrated with previous knowledge, and applied to the clinical setting.

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Laurence Davidson and J. Gordon McComb

✓The Pott puffy tumor is a subperiosteal abscess associated with underlying osteomyelitis, most often of the frontal bone in conjunction with frontal sinusitis. Intracranial sequelae can include epidural abscess, subdural empyema, intra-parenchymal abscess, meningitis, and dural venous thrombophlebitis, all with resultant neurological deterioration.

Although once common, this entity has become rare since the introduction of antibiotic agents. The authors present an unusual case of a 14-year-old girl suffering from the Pott puffy tumor whose condition was further complicated by a draining epidural–cutaneous fistula and an epidural abscess.

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David I. Sandberg, J. Gordon McComb and Mark D. Krieger

Object

The authors analyzed the chemical composition of intracranial arachnoid cyst fluid to gain greater understanding of potential causes of cyst growth.

Methods

The authors studied 54 pediatric patients who underwent craniotomies for arachnoid cyst fenestration. Cyst fluid was analyzed and results were compared with expected values (EVs) for cerebrospinal fluid (CSF).

The arachnoid cyst fluid values were as follows: protein (median 37 mg/dl, mean 178.2 mg/dl, and EV 25.6 mg/dl), osmolality (median 284 mOsm/kg, mean 285.5 mOsm/kg, and EV 287.2 mOsm/kg), potassium (median 2.6 mEq/L, mean 2.68 mEq/L, and EV 2.88 mEq/L), sodium (median 140 mEq/L, mean 142.2 mEq/L, and EV 143.3 mEq/L), and chloride (median 122 mEq/L, mean 120.77 mEq/L, and EV 120.3 mEq/L). Median glucose was 51 mg/dl (range 26–98 mg/dl). The median white blood cell count in cyst fluid was 1/mm3, and the median red blood cell (RBC) count was 1.5/mm3. All Gram stains and cultures were negative.

No statistically significant correlations were found between arachnoid cyst fluid protein level and elevated RBC count, patient age, or the subsequent need for a shunt. Elevated RBC count in cyst fluid was also not associated with the subsequent need for a shunt.

Conclusions

Fluid from arachnoid cysts has a chemical composition similar to that of CSF, but some of them have significantly elevated protein levels. The authors hypothesize that elevated protein content may contribute to arachnoid cyst expansion in some patients.

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Editorial

Venous infarction

W. Jerry Oakes

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Laurence Davidson, Mark D. Krieger and J. Gordon McComb

Object

The purpose of this study was to evaluate the posterior interhemispheric retrocallosal approach (PIRA) for its safety and efficacy in the resection of pineal region and posterior fossa lesions in children.

Methods

Twenty-nine PIRAs were performed in 26 children between March 1997 and March 2009, and these cases were retrospectively reviewed. There were 15 girls and 11 boys in the series. The median age at the time of surgery was 7 years (range 7 months–17 years). Twenty-seven cases were treated for tumor, 1 for loculated hydrocephalus, and 1 for an aneurysm.

Results

Of the 27 cases treated for tumor, there were 20 (74%) gross-total resections, 5 (19%) subtotal resections, and 2 (7%) biopsies. One bridging vein was sacrificed in 6 cases and 2 bridging veins were divided in 1 case, whereas in 3 cases there was sacrifice of a single deep cerebral vein. No patient developed radiographic evidence of venous infarction. Approach-related complications were low, and included 2 cases of transient homonymous hemianopia. There were no surgery-related deaths.

Conclusions

This approach allows for ample access to pineal region and posterior fossa lesions, with low postoperative morbidity.

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Howard M. Eisenberg, J. Gordon McComb and Antonio V. Lorenzo

✓ With the use of a ventricular perfusion technique, a cerebrospinal fluid formation rate of 1.4 ml/min was determined in a 5-month-old child with a choroid plexus papilloma and hydrocephalus. This rate was slightly greater than four times the rate observed in normal children. The clinical course, as well as a measured absorption rate, indicated that the patient's capacity for absorption was normal.

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Mark D. Krieger, Stefan Blüml and J. Gordon McComb

Object

Diffuse pontine gliomas in children carry a dismal prognosis, with a mean survival of less than 1 year despite therapy. The diagnosis is based on the characteristic changes demonstrated on traditional magnetic resonance (MR) imaging. A few typically MR imaging–appearing pontine masses, however, do not behave in the expected fashion, which calls the original diagnosis into question.

Methods

The authors conducted a retrospective review of data obtained in 42 children (age 6 months–13 years) in whom diffuse pontine glioma had been diagnosed at their institution. Five of these patients (12%) survived longer than expected (> 8 months). There were no differences in these patients in terms of demographics, presentation, traditional imaging findings, or treatment compared with the group as a whole. Magnetic resonance spectroscopy, however, demonstrated two distinct patterns not seen in typical diffuse pontine gliomas. In two patients elevated lipid and lactate levels were shown, with decreased levels of choline, myoinositol, and n-acetyl-aspartate (NAA). In the other patients strikingly elevated choline/creatinine ratios and myoinositol levels were observed in comparison with typical pontine tumors.

Conclusions

These MR spectroscopy patterns demonstrated in this retrospective study seem to convey prognostic information and may lead to an expansion of this diagnostic tool.

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Michael L. Chen, J. Gordon McComb and Mark D. Krieger

Object

Atypical teratoid/rhabdoid tumors (ATRTs) represent a relatively newly categorized neoplastic entity. They commonly present in childhood, and have a rapidly progressive clinical course with a survival time of less than 1 year. Treatment regimens have been nonuniform. In this retrospective review of patients with ATRTs who were treated at the authors' institution according to a uniform protocol, the goal was to assess the efficacy of the treatment and its outcome.

Methods

Over a 7-year period, ATRT was diagnosed in 11 patients (six boys and five girls). The median age of the patients was 61 months, and their ages ranged from 3 months to 17 years. Signs and symptoms began, on average, a little more than 1 month before diagnosis and included the following: headache (36%), nausea and vomiting (46%), lethargy (18%), seizures (27%), cranial nerve findings (46%), ataxia (18%), long tract findings (18%), and hydrocephalus (46%). Tumor location was cortical in four patients, in the pineal region in four, in the posterior fossa in two, and spinal in one. In one patient disseminated disease was revealed on the initial imaging study; seven patients had disseminated tumor subsequently. Treatment consisted of chemotherapy in 11 patients, chemotherapy and local radiation in five, and chemotherapy and craniospinal radiation in three. Six patients are alive, three have died, and two were lost to follow-up review. The mean time to death was 24 months, and ranged from 2 to 67 months. Among the surviving patients the mean duration of follow up is 18.5 months and ranges from 2 to 37 months. The median time to progression was 3.5 months.

Conclusions

Atypical teratoid/rhabdoid tumors are malignant lesions with rapid progression. Further study is necessary to determine the efficacy of therapy.

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Howard Tung, Corey Raffel and J. Gordon McComb

✓ To determine the significance of cerebrospinal fluid (CSF) eosinophilia, the charts of 106 patients treated with shunt-related procedures during the calendar year 1985 were reviewed. Sixty-nine patients presented for a shunt revision; their charts were retrospectively reviewed from the time of shunt insertion until January, 1988. The remaining 37 patients had a ventriculoperitoneal shunt inserted during the study period and were subsequently followed to January, 1988. A total of 558 shunt-related procedures were performed on these patients during the study period, with a mean follow-up period of 6.9 years. The infection rate was 3.8%.

Eosinophilia was diagnosed when eosinophils accounted for 8% or more of the total CSF white blood cell count. Ventricular CSF eosinophilia occurred in 36 patients sometime during their clinical course. These 36 patients required a mean of 8.5 shunt revisions, while the remaining patients required a mean of 2.5 revisions (p < 0.001). Shunt infections were also more frequent in patients with eosinophilia (p < 0.01). In no case was peripheral eosinophilia or a parasitic infection present.

This study demonstrates that CSF eosinophilia is common in children with shunts. Children with this laboratory finding will experience more shunt failures. In addition, the new appearance of eosinophilia in the CSF of a patient with a shunt in place suggests the possibility of a shunt infection.