Handbook of Pediatric Neurosurgery

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Thieme

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Handbook of Pediatric Neurosurgery
George I. Jallo, MD
Professor of Neurosurgery, Pediatrics and Oncology
Institute for Brain Protection Sciences
Johns Hopkins All Children’s Hospital
St. Petersburg, Florida
Karl F. Kothbauer, MD
Associate Professor of Neurosurgery
University of Basel
Basel, Switzerland
Chief of Neurosurgery
Lucerne Cantonal Hospital
Lucerne, Switzerland
Violette M.R. Recinos, MD
Assistant Professor
Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Division of Pediatric Neurosurgery, Cleveland Clinic
Cleveland, Ohio
275 illustrations
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Library of Congress Cataloging-in-Publication Data
Names: Jallo, George I., editor. | Kothbauer, Karl F., editor. |
Recinos, Violette M. R., editor.
Title: Handbook of pediatric neurosurgery / [edited by]
George I. Jallo, Karl F. Kothbauer, Violette M.R. Recinos.
Description: New York : Thieme, [2018] | Includes
bibliographical references and index.
| Identi ers: LCCN 2018008565 (print) | LCCN 2018009192
(ebook) | ISBN 9781604068801 | ISBN 9781604068795
(softcover) | ISBN 9781604068801 (e-book)
Subjects: | MESH: Nervous System Diseases–surgery | Child |
Infant | Neurosurgical Procedures | Nervous System
Diseases–diagnostic imaging
Classi cation: LCC RD593 (ebook) | LCC RD593 (print) | NLM
WS 340 | DDC 617.4/8–dc23
LC record available at
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ISBN 978-1-60406-879-5
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To my children, Maxwell, Nicholas, and Alexis, who have helped shape my career
and interests in pediatric neurosurgery.
George I. Jallo
To my son, Florian, whose talents and dedication fascinate and continue to inspire me.
Karl F. Kothbauer
For Pablo, Elisa, Sebastian, and Nicolas, who are my daily reminders that life is beautiful.
Violette M.R. Recinos

(Trang không có chữ)

Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Mark S. Greenberg
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
G. Narenthiran
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix
Alan R. Cohen
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxi
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii
About the Editors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxv
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii
Section I General and Critical Care
1

ICP Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
Tiago Morgado, Anthony A. Figaji
1.1

Introduction . . . . . . . . . . . . . . . . . .

2
1.2

Pathophysiology . . . . . . . . . . . . . .

2
1.3

ICP Monitoring . . . . . . . . . . . . . . . .

5
1.4

Treatment of Raised ICP . . . . . . .

7
1.5

Summary . . . . . . . . . . . . . . . . . . . . .

10
1.6

Questions. . . . . . . . . . . . . . . . . . . . .

10
References . . . . . . . . . . . . . . . . . . . .

10
2

Pain Management for Pediatric Neurosurgical Patients . . . . . . . . . . . . . . .

12
Joanne E. Shay
2.1

Introduction . . . . . . . . . . . . . . . . . .

12
2.2

Pediatric Pain Assessment . . . . .

12
2.3

Pediatric Pharmacokinetics . . . .

13
2.4

Impact of Preexisting
Comorbidities on Analgesic
Management . . . . . . . . . . . . . . . . .

13
2.5

Analgesic Considerations for
Specific Neurosurgical
Procedures . . . . . . . . . . . . . . . . . . .

15
2.6

Common Analgesics Used in
Children . . . . . . . . . . . . . . . . . . . . . .

18
2.7

Review Questions (True or False)
23
References . . . . . . . . . . . . . . . . . . . .

23
Section II Neuroradiology
3

Conventional Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26
Thierry A.G.M. Huisman
3.1

Introduction . . . . . . . . . . . . . . . . . .

26 3.2

Skull Radiography . . . . . . . . . . . . .

26
vii

3.3

Sinus Radiography . . . . . . . . . . . . .

26
3.4

Stenvers and Schüller
Radiography. . . . . . . . . . . . . . . . . . .

26
3.5

Shunt Survey . . . . . . . . . . . . . . . . . .

26
3.6

Cervical Spine and
Craniocervical Junction . . . . . . . . .

27
3.7

Thoracic and Lumbosacral
Radiography. . . . . . . . . . . . . . . . . . .

27
3.8

Total Spine Radiography. . . . . . . .

27
4

Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28
Thierry A.G.M. Huisman
4.1

Introduction . . . . . . . . . . . . . . . . . . .

28
4.2

Anatomical Ultrasonography of
the Brain . . . . . . . . . . . . . . . . . . . . . .

28
4.3

Doppler Ultrasonography of the
Brain . . . . . . . . . . . . . . . . . . . . . . . . . .

29
4.4

Ultrasonography of the Spine . . .

30
4.5

Ultrasonography of the
Orbits . . . . . . . . . . . . . . . . . . . . . . . . .

30
4.6

Ultrasonography of the Head
and Neck . . . . . . . . . . . . . . . . . . . . . .

31
Reference . . . . . . . . . . . . . . . . . . . . .

31
5

Computed Tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32
Thierry A.G.M. Huisman
5.1

Introduction . . . . . . . . . . . . . . . . . . .

32
5.2

Hounsfield Units . . . . . . . . . . . . . . .

32
5.3

Intravenous Contrast Media . . . .

32
5.4

CT Angiography, CT Venography,
and CT Perfusion . . . . . . . . . . . . . . .

32
5.5

Limitations of CT Contrast
Agents . . . . . . . . . . . . . . . . . . . . . . . .

33
5.6

Radiation Exposure . . . . . . . . . . . .

33
5.7

Indications . . . . . . . . . . . . . . . . . . . .

33
References . . . . . . . . . . . . . . . . . . . .

34
6

Conventional Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35
Thierry A.G.M. Huisman
6.1

Introduction . . . . . . . . . . . . . . . . . . .

35
6.2

T1- and T2-weighted
Sequences . . . . . . . . . . . . . . . . . . . . .

35
6.3

Contrast-enhanced T1-weighted
MRI . . . . . . . . . . . . . . . . . . . . . . . . . . .

35
6.4

Fat-saturated T1- and
T2-weighted Sequences . . . . . . . .

36
6.5

Fluid-attenuated Inversion
Recovery . . . . . . . . . . . . . . . . . . . . . .

36
6.6

T2*-Gradient Echo and
Susceptibility-weighted
Imaging . . . . . . . . . . . . . . . . . . . . . . .

36
6.7

Inversion Recovery
Sequences . . . . . . . . . . . . . . . . . . . . .

36
6.8

Heavily T2-weighted MRI . . . . . . .

36
6.9

Ultrafast MRI . . . . . . . . . . . . . . . . . .

37
6.10
Contraindications for MRI . . . . . .

37
Contents
viii

7

Advanced MRI Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38
Thierry A.G.M. Huisman
7.1

Introduction . . . . . . . . . . . . . . . . . .

38
7.2

Magnetic Resonance
Angiography and Venography. .

38
7.3

Cerebrospinal Fluid Flow
Imaging . . . . . . . . . . . . . . . . . . . . . .

38
7.4

Di usion-weighted Imaging and
Di usion Tensor Imaging . . . . . .

38
7.5

Perfusion-weighted Imaging . . .

39
7.6

1H-Magnetic Resonance
Spectroscopy . . . . . . . . . . . . . . . . .

40
7.7

Functional MRI . . . . . . . . . . . . . . . .

40
7.8

Digital Subtraction Angiography

40
References . . . . . . . . . . . . . . . . . . . .

41
Section III Neurology
8

The Neurological Examination of the Infant and Child . . . . . . . . . . . . . . . . .

44
Neil R. Friedman
8.1

Introduction . . . . . . . . . . . . . . . . . .

44
8.2

History . . . . . . . . . . . . . . . . . . . . . . .

44
8.3

Examination . . . . . . . . . . . . . . . . . .

48
9

Spinal Cord Tracts and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

58
Micol Babini, Francesco Sala
9.1

Introduction . . . . . . . . . . . . . . . . . .

58
9.2

Ascending Tracts . . . . . . . . . . . . . .

59
9.3

Descending Tracts . . . . . . . . . . . . .

60
9.4

Development . . . . . . . . . . . . . . . . .

61
References . . . . . . . . . . . . . . . . . . . .

62
10

Migration Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

63
Gary Hsich
10.1
Introduction . . . . . . . . . . . . . . . . . .

63
10.2
Malformations . . . . . . . . . . . . . . . .

63
References . . . . . . . . . . . . . . . . . . . .

67
11

Neurofibromatosis Type 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68
Ben Shofty, Liat Ben-Sira, Hagit Toledano-Alhadef, Felix Bokstein, Shlomi Constantini
11.1
Introduction . . . . . . . . . . . . . . . . . .

68
11.2
Genetics and Cellular Biology . .

68
11.3
Diagnosis and Clinical
Presentation . . . . . . . . . . . . . . . . . .

68
11.4
Management . . . . . . . . . . . . . . . . .

69
11.5
Imaging . . . . . . . . . . . . . . . . . . . . . .

69
11.6
Cutaneous Manifestations . . . . .

70
11.7
Optic Pathway Gliomas . . . . . . . .

71
11.8
Other NF1 Brain Tumors . . . . . . .

73
Contents
ix

11.9
NF1 Brain Function . . . . . . . . . . . . .

74
11.10 NF1 Skeletal Manifestations . . . .

74
References . . . . . . . . . . . . . . . . . . .

74
12

Medical Management for Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

77
Sarah A. Kelley, Adam L. Hartman
12.1
Introduction . . . . . . . . . . . . . . . . . . .

77
12.2
Treatment of Status Epilepticus .

77
12.3
Specific Anticonvulsant Uses . . . .

77
12.4
Brief Overview of the Most
Commonly Used Anticonvulsant
Medications . . . . . . . . . . . . . . . . . . .

80
12.5
Medication Side E ects . . . . . . . . .

81
12.6
Drug–Drug Interactions . . . . . . . .

81
12.7
Discontinuation of
Anticonvulsant Therapy . . . . . . .

81
12.8
Treatment in the Setting of
Comorbidities . . . . . . . . . . . . . . . .

82
12.9
Dietary Therapy. . . . . . . . . . . . . . .

82
12.10 Common Clinical Questions. . . .

82
12.11 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . .

82
References . . . . . . . . . . . . . . . . . . .

82
Section IV Tumor
13

Pediatric Scalp and Skull Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

84
Rajiv R. Iyer, Lee S. Hwang, Je rey P. Mullin, Violette M.R. Recinos
13.1
Introduction . . . . . . . . . . . . . . . . . . .

84
13.2
Cephalohematoma . . . . . . . . . . . . .

84
13.3
Epidermoids/Dermoids . . . . . . . . .

85
13.4
Langerhans Cell Histiocytosis . . .

86
13.5
Fibrous Dysplasia . . . . . . . . . . . . . .

86
13.6
Hemangiomas . . . . . . . . . . . . . . . . .

87
13.7
Sinus Pericranii . . . . . . . . . . . . . . . .

87
13.8
Growing Skull Fracture . . . . . . . .

88
13.9
Aneurysmal Bone Cyst . . . . . . . .

88
13.10 Osteoma, Osteoblastoma, and
Osteoid Osteoma . . . . . . . . . . . . .

89
13.11 Sarcoma and Neuroblastoma . .

89
References . . . . . . . . . . . . . . . . . . .

89
14

Supratentorial Tumors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

91
Eveline T. Hidalgo, Nir Shimony, Karl F. Kothbauer
14.1
Introduction . . . . . . . . . . . . . . . . . . .

91
14.2
Clinical Presentation . . . . . . . . . . .

91
14.3
Clinical Evaluation . . . . . . . . . . . . .

91
14.4
Imaging . . . . . . . . . . . . . . . . . . . . . . .

92
14.5
Preoperative Management . . . . .

92
14.6
Perioperative Management . . . .

93
14.7
Postoperative Management . . .

93
14.8
Complications . . . . . . . . . . . . . . . .

94
14.9
Low-Grade Gliomas (Di use,
Juvenile Pilocytic Astrocytoma). .

95
14.10 High-Grade Gliomas . . . . . . . . . . .

96
Contents
x

14.11 Pleomorphic
Xanthoastrocytomas . . . . . . . . . .

97
14.12 Primitive Neuroectodermal
Tumors . . . . . . . . . . . . . . . . . . . . . . .

98
14.13 Atypical Teratoid Rhabdoid
Tumors . . . . . . . . . . . . . . . . . . . . . . .

99
14.14 Desmoplastic Neuroepithelial
Tumors . . . . . . . . . . . . . . . . . . . . . . . 100
14.15 Gangliogliomas . . . . . . . . . . . . . . . 100
14.16 Ependymomas . . . . . . . . . . . . . . . . 101
14.17 Meningiomas . . . . . . . . . . . . . . . . . 102
14.18 Surgical Pearls . . . . . . . . . . . . . . . . 102
14.19 Common Clinical Questions . . . . 103
14.20 Answers to Clinical Questions . . 103
References . . . . . . . . . . . . . . . . . . . . 103
15

Hypothalamic and Optic Pathway Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Rajiv R. Iyer, Nir Shimony, George I. Jallo
15.1
Introduction/Epidemiology . . . . 107
15.2
Clinical Presentation. . . . . . . . . . . 107
15.3
Diagnostic Imaging . . . . . . . . . . . . 107
15.4
Treatment . . . . . . . . . . . . . . . . . . . . 108
15.5
Summary . . . . . . . . . . . . . . . . . . . . . 111
References . . . . . . . . . . . . . . . . . . . . 111
16

Craniopharyngiomas and Other Sellar Tumors . . . . . . . . . . . . . . . . . . . . . . . . . 112
David S. Hersh, Rafael U. Cardenas, Nir Shimony, Mari L. Groves
16.1
Introduction . . . . . . . . . . . . . . . . . . 112
16.2
Craniopharyngiomas . . . . . . . . . . 112
16.3
Rathke’s Cleft Cysts . . . . . . . . . . . 112
16.4
Pituitary Adenomas . . . . . . . . . . . 112
16.5
Embryology and Pathology . . . . 112
16.6
Papillary Craniopharyngiomas . 113
16.7
Clinical Presentation. . . . . . . . . . . 113
16.8
Craniopharyngiomas . . . . . . . . . . 113
16.9
Rathke’s Cleft Cysts . . . . . . . . . . . 114
16.10 Pituitary Adenomas . . . . . . . . . . . 114
16.11 Examination and Diagnostic
Workup . . . . . . . . . . . . . . . . . . . . . . 114
16.12 Neuroimaging . . . . . . . . . . . . . . . . 114
16.13 Ophthalmological Evaluation. . . 115
16.14 Endocrine Workup . . . . . . . . . . . . 115
16.15 Classification Systems . . . . . . . . . 116
16.16 Nonsurgical Management. . . . . . 116
16.17 Surgical Approaches . . . . . . . . . . . 116
16.18 Surgical Technique . . . . . . . . . . . . 117
16.19 Postoperative Care . . . . . . . . . . . . 121
16.20 Adjuvant Treatment . . . . . . . . . . . 121
16.21 Outcomes . . . . . . . . . . . . . . . . . . . . 121
16.22 Clinical Pearls . . . . . . . . . . . . . . . . . 122
16.23 Common Clinical Questions . . . . 123
16.24 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 123
References . . . . . . . . . . . . . . . . . . . . 123
Contents
xi

17

Germ Cell Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Gerald F. Tuite, Stacie Stapleton
17.1
Introduction . . . . . . . . . . . . . . . . . . . 125
17.2
Epidemiology Factors . . . . . . . . . . 125
17.3
Predisposing Factors . . . . . . . . . . . 125
17.4
Pathophysiology . . . . . . . . . . . . . . . 126
17.5
Pathology . . . . . . . . . . . . . . . . . . . . . 126
17.6
Molecular Biology. . . . . . . . . . . . . . 127
17.7
Radiographic Findings of
Intracranial Germ Cell Tumors . . 127
17.8
Presenting Signs and Symptoms 128
17.9
Laboratory Evaluation . . . . . . . . . . 128
17.10 Nonsurgical Management . . . . . . 129
17.11 Surgical Indications . . . . . . . . . . . . 129
17.12 Surgical Technique . . . . . . . . . . . . . 129
17.13 Postoperative Care . . . . . . . . . . . . . 130
17.14 Surgical Complications . . . . . . . . . 130
17.15 Radiation Therapy and
Chemotherapy. . . . . . . . . . . . . . . . . 130
17.16 Prognosis . . . . . . . . . . . . . . . . . . . . . 132
17.17 Surgical Pearls . . . . . . . . . . . . . . . . . 132
17.18 Common Clinical Questions. . . . . 133
17.19 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 133
References . . . . . . . . . . . . . . . . . . . . 133
18

Pineal Region Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Scellig S.D. Stone, Alan R. Cohen
18.1
Introduction . . . . . . . . . . . . . . . . . . . 136
18.2
Anatomy and Physiology . . . . . . . 136
18.3
Classification of Tumors . . . . . . . . 137
18.4
Clinical Presentation . . . . . . . . . . . 137
18.5
Investigations . . . . . . . . . . . . . . . . . 138
18.6
Management . . . . . . . . . . . . . . . . . . 139
18.7
Treatment and Outcomes. . . . . . . 139
18.8
Endoscopic and Microsurgical
Approaches. . . . . . . . . . . . . . . . . . . . 139
18.9
Complications . . . . . . . . . . . . . . . . . 143
18.10 Common Clinical Questions. . . . . 143
18.11 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 143
References . . . . . . . . . . . . . . . . . . . . 144
19

Intraventricular Tumors in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Bryan S. Lee, Vikram B. Chakravarthy, Nir Shimony, Violette M.R. Recinos
19.1
Introduction . . . . . . . . . . . . . . . . . . . 145
19.2
Ependymoma . . . . . . . . . . . . . . . . . . 145
19.3
Choroid Plexus Papilloma and
Carcinoma. . . . . . . . . . . . . . . . . . . . . 146
19.4
Subependymoma . . . . . . . . . . . . . . 147
19.5
Subependymal Giant Cell
Astrocytoma . . . . . . . . . . . . . . . . . . 148
19.6
Central Neurocytoma . . . . . . . . . . 148
Contents
xii

19.7
Clinical Presentation. . . . . . . . . . . 149
19.8
Surgical Approach and
Techniques . . . . . . . . . . . . . . . . . . . 149
19.9
Postoperative Management and
Complications. . . . . . . . . . . . . . . . . 150
19.10 Common Clinical Questions . . . . 152
19.11 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 152
References . . . . . . . . . . . . . . . . . . . . 152
20

Posterior Fossa Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Christian A. Schneider, Nir Shimony, Karl F. Kothbauer
20.1
Introduction . . . . . . . . . . . . . . . . . . 154
20.2
Neurosurgical Management of
Pediatric Posterior Fossa Tumors 154
20.3
Surgical Considerations . . . . . . . . 155
20.4
Specific Pediatric Posterior Fossa
Tumors . . . . . . . . . . . . . . . . . . . . . . . 160
20.5
Common Clinical Questions . . . . 165
20.6
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 166
References . . . . . . . . . . . . . . . . . . . . 166
21

Brainstem Gliomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Mari L. Groves, Rafael U. Cardenas, Nir Shimony, George I. Jallo
21.1
Introduction . . . . . . . . . . . . . . . . . . 169
21.2
Anatomy . . . . . . . . . . . . . . . . . . . . . 170
21.3
Examination . . . . . . . . . . . . . . . . . . 171
21.4
Nonsurgical Management. . . . . . 171
21.5
Surgical Indications. . . . . . . . . . . . 172
21.6
Surgical Technique . . . . . . . . . . . . 173
21.7
Complications. . . . . . . . . . . . . . . . . 173
21.8
Postoperative Care . . . . . . . . . . . . 175
21.9
Outcomes . . . . . . . . . . . . . . . . . . . . 175
21.10 Surgical Pearls . . . . . . . . . . . . . . . . 175
21.11 Common Clinical Questions . . . . 176
21.12 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 176
References . . . . . . . . . . . . . . . . . . . . 176
22

Intramedullary Spinal Cord Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Karl F. Kothbauer
22.1
Introduction . . . . . . . . . . . . . . . . . . 178
22.2
Neurosurgical Management of
Intramedullary Spinal Cord
Tumors . . . . . . . . . . . . . . . . . . . . . . . 178
22.3
Specific Types of Intramedullary
Spinal Cord Tumors. . . . . . . . . . . . 181
22.4
Summary . . . . . . . . . . . . . . . . . . . . . 185
22.5
Common Clinical Questions . . . . 185
22.6
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 186
References . . . . . . . . . . . . . . . . . . . . 186
Contents
xiii

23

Tumors of the Spinal Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Dominic N.P. Thompson, Nir Shimony
23.1
Introduction . . . . . . . . . . . . . . . . . . . 188
23.2
Clinical Presentation . . . . . . . . . . . 188
23.3
Investigations . . . . . . . . . . . . . . . . . 189
23.4
Tumor Types . . . . . . . . . . . . . . . . . . . 189
23.5
Treatment Considerations . . . . . . 192
23.6
Complications and Their
Prevention . . . . . . . . . . . . . . . . . . . . 194
23.7
Surgical Pearls . . . . . . . . . . . . . . . . . 195
23.8
Common Clinical Questions. . . . . 195
23.9
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 195
References . . . . . . . . . . . . . . . . . . . . 195
Section V Cerebrovascular Disorders
24

Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Edward R. Smith
24.1
Introduction and Anatomy. . . . . . 198
24.2
Epidemiology and
Pathophysiology . . . . . . . . . . . . . . . 198
24.3
Presentation and Evaluation . . . . 198
24.4
Treatment and Surgical
Indications . . . . . . . . . . . . . . . . . . . . 200
24.5
Surgical Technique . . . . . . . . . . . . . 201
24.6
Complications . . . . . . . . . . . . . . . . . 202
24.7
Postoperative Care and
Follow-up . . . . . . . . . . . . . . . . . . . . . 202
24.8
Outcomes . . . . . . . . . . . . . . . . . . . . . 202
24.9
Surgical Pearls . . . . . . . . . . . . . . . . . 203
24.10 Common Clinical Questions. . . . . 203
24.11 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 203
References . . . . . . . . . . . . . . . . . . . . 204
25

Arteriovenous Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Edward R. Smith
25.1
Introduction and Anatomy. . . . . . 205
25.2
Epidemiology and
Pathophysiology . . . . . . . . . . . . . . . 205
25.3
Presentation and Evaluation . . . . 205
25.4
Treatment and Surgical
Indications . . . . . . . . . . . . . . . . . . . . 207
25.5
Surgical Technique . . . . . . . . . . . . . 208
25.6
Complications . . . . . . . . . . . . . . . . . 208
25.7
Postoperative Care and
Follow-up . . . . . . . . . . . . . . . . . . . . . 209
25.8
Outcomes . . . . . . . . . . . . . . . . . . . . . 209
25.9
Surgical Pearls . . . . . . . . . . . . . . . . . 209
25.10 Common Clinical Questions. . . . . 209
25.11 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 210
References . . . . . . . . . . . . . . . . . . . . 210
Contents
xiv

26

Pediatric Cavernous Malformations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Rajiv R. Iyer, Mari L. Groves, Nir Shimony, George I. Jallo
26.1
Introduction/Epidemiology . . . . 213
26.2
Pathology . . . . . . . . . . . . . . . . . . . . 213
26.3
Diagnostic Imaging . . . . . . . . . . . . 213
26.4
Clinical Presentation. . . . . . . . . . . 214
26.5
Natural History. . . . . . . . . . . . . . . . 215
26.6
Surgical Indications, Techniques,
and Outcomes . . . . . . . . . . . . . . . . 215
26.7
Radiosurgery . . . . . . . . . . . . . . . . . 217
26.8
Common Clinical Questions . . . . 217
26.9
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 217
References . . . . . . . . . . . . . . . . . . . . 218
Section VI Developmental and Congenital Cranial Disorders
27

Chiari Malformations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Karl F. Kothbauer
27.1
Introduction . . . . . . . . . . . . . . . . . . 222
27.2
Anatomy . . . . . . . . . . . . . . . . . . . . . 222
27.3
Clinical Findings . . . . . . . . . . . . . . . 223
27.4
Diagnostic Evaluation. . . . . . . . . . 223
27.5
Nonsurgical Management. . . . . . 224
27.6
Surgical Indications. . . . . . . . . . . . 224
27.7
Surgical Technique . . . . . . . . . . . . 224
27.8
Complications. . . . . . . . . . . . . . . . . 225
27.9
Postoperative Care . . . . . . . . . . . . 226
27.10 Outcomes . . . . . . . . . . . . . . . . . . . . 226
27.11 Surgical Pearls . . . . . . . . . . . . . . . . 226
27.12 Common Clinical Questions . . . . 227
27.13 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 227
References . . . . . . . . . . . . . . . . . . . . 227
28

Encephaloceles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Elizabeth J. Le, Rafael U. Cardenas, Mari L. Groves
28.1
Introduction . . . . . . . . . . . . . . . . . . 229
28.2
Classification. . . . . . . . . . . . . . . . . . 229
28.3
Pathogenesis . . . . . . . . . . . . . . . . . 229
28.4
Epidemiology . . . . . . . . . . . . . . . . . 230
28.5
Clinical Findings and Diagnosis . 231
28.6
Surgical Management . . . . . . . . . 232
28.7
Posterior Encephaloceles . . . . . . 232
28.8
Anterior Encephaloceles . . . . . . . 235
28.9
Surgical Pearls . . . . . . . . . . . . . . . . 239
28.10 Common Clinical Questions . . . . 240
28.11 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 240
References . . . . . . . . . . . . . . . . . . . . 240
Contents
xv

29

Congenital Arachnoid Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Gianpiero Tamburrini
29.1
Introduction . . . . . . . . . . . . . . . . . . . 242
29.2
Pathogenesis . . . . . . . . . . . . . . . . . . 242
29.3
Epidemiology . . . . . . . . . . . . . . . . . . 242
29.4
Sylvian Fissure Cysts . . . . . . . . . . . 242
29.5
Sellar Region Cysts . . . . . . . . . . . . . 244
29.6
Cerebral Convexity Cysts . . . . . . . 246
29.7
Interhemispheric Fissure Cysts . . 246
29.8
Quadrigeminal Plate Region
Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . 247
29.9
Infratentorial Arachnoid Cysts . . 248
29.10 Common Clinical Questions. . . . . 250
29.11 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 250
References . . . . . . . . . . . . . . . . . . . . 250
30

Neuroenteric Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Peter A. Christiansen, John A. Jane, Jr
30.1
Introduction . . . . . . . . . . . . . . . . . . . 253
30.2
Radiographic Features. . . . . . . . . . 253
30.3
Surgical Management and
Outcome . . . . . . . . . . . . . . . . . . . . . . 254
30.4
Common Clinical Questions. . . . . 254
30.5
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 254
References . . . . . . . . . . . . . . . . . . . . 255
31

Intracranial Lipomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Tina Lovén, Mark A. Mittler
31.1
Introduction . . . . . . . . . . . . . . . . . . . 256
31.2
Anatomy . . . . . . . . . . . . . . . . . . . . . . 256
31.3
Presentation . . . . . . . . . . . . . . . . . . . 257
31.4
Radiographic Imaging and
Di erential Diagnosis . . . . . . . . . . 257
31.5
Surgical Considerations . . . . . . . . 258
31.6
Surgical Pearls . . . . . . . . . . . . . . . . . 259
31.7
Common Clinical Questions. . . . . 259
31.8
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 259
References . . . . . . . . . . . . . . . . . . . . 259
32

The Dandy–Walker Malformation: Disorders of Cerebellar
Development and Their Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Greg Olavarria
32.1
Introduction: Incidence,
Genetics, and Evaluation. . . . . . . . 261
32.2
Di erential Diagnosis . . . . . . . . . . 261
32.3
Management and Outcomes . . . . 263
References . . . . . . . . . . . . . . . . . . . . 263
Contents
xvi

33

Craniosynostosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Christopher D. Kelly, Martin H. Sailer, Raphael Guzman
33.1
Introduction . . . . . . . . . . . . . . . . . . 264
33.2
Classification. . . . . . . . . . . . . . . . . . 264
33.3
Epidemiology . . . . . . . . . . . . . . . . . 264
33.4
Etiology and Genetic Factors . . . 265
33.5
Craniosynostoses and Their
Treatment . . . . . . . . . . . . . . . . . . . . 268
33.6
Surgical Treatment . . . . . . . . . . . . 271
33.7
Conclusion . . . . . . . . . . . . . . . . . . . . 272
33.8
Common Clinical Questions . . . . 273
33.9
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 274
References . . . . . . . . . . . . . . . . . . . . 274
34

Management of Craniofacial Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Miguel A. Medina III, Gerhard S. Mundinger, Amir H. Dorafshar
34.1
Introduction . . . . . . . . . . . . . . . . . . 276
34.2
Embryology/Development . . . . . 276
34.3
Genetics . . . . . . . . . . . . . . . . . . . . . . 277
34.4
Surgical Approaches . . . . . . . . . . . 279
34.5
Summary . . . . . . . . . . . . . . . . . . . . . 285
34.6
Common Clinical Questions . . . . 285
34.7
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 286
Reference . . . . . . . . . . . . . . . . . . . . . 286
35

Germinal Matrix Hemorrhage in Premature Infants . . . . . . . . . . . . . . . . . . . 288
Moise Danielpour, Lindsey Ross
35.1
Introduction . . . . . . . . . . . . . . . . . . 288
35.2
Pathophysiology of Germinal
Matrix . . . . . . . . . . . . . . . . . . . . . . . . 288
35.3
Epidemiology . . . . . . . . . . . . . . . . . 289
35.4
Etiology of Posthemorrhagic
Ventricular Dilation. . . . . . . . . . . . 289
35.5
Clinical Presentation. . . . . . . . . . . 289
35.6
Diagnosis . . . . . . . . . . . . . . . . . . . . . 290
35.7
Pathology Associated
with IVHp. . . . . . . . . . . . . . . . . . . . . 292
35.8
Treatment . . . . . . . . . . . . . . . . . . . . 292
35.9
There is no Data to Prove
Superiority of Either VSG Shunt
or Reservoir Placement . . . . . . . . 293
35.10 Prognosis . . . . . . . . . . . . . . . . . . . . . 294
35.11 Conclusion . . . . . . . . . . . . . . . . . . . . 294
References . . . . . . . . . . . . . . . . . . . . 295
36

Surgical Management of Hydrocephalus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Martina Messing-Jünger
36.1
Introduction . . . . . . . . . . . . . . . . . . 297
36.2
Surgical Indications. . . . . . . . . . . . 297
36.3
Shunt Implantation . . . . . . . . . . . . 298
36.4
Endoscopic Third
Ventriculostomy . . . . . . . . . . . . . . 302
Contents
xvii

36.5
Common Clinical Questions. . . . . 303
36.6
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 304
References . . . . . . . . . . . . . . . . . . . . 304
37

Treatment of Hydrocephalus in the Developing World . . . . . . . . . . . . . . . . 305
Rodrigo Mercado, Jesus A. Villagómez, Luis A. Arredondo
37.1
Introduction . . . . . . . . . . . . . . . . . . . 305
37.2
Acquired . . . . . . . . . . . . . . . . . . . . . . 305
37.3
Treatment . . . . . . . . . . . . . . . . . . . . . 305
37.4
Surgical Indications and
Contraindications . . . . . . . . . . . . . . 306
37.5
Surgical Technique . . . . . . . . . . . . . 307
37.6
Complications . . . . . . . . . . . . . . . . . 309
37.7
Postoperative. . . . . . . . . . . . . . . . . . 310
37.8
Common Clinical Questions. . . . . 310
37.9
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 311
References . . . . . . . . . . . . . . . . . . . . 311
Section VII Developmental and Congential Spinal Disorders
38

Abnormalities of the Craniocervical Junction and Cervical Spine . . . . . 314
Jared S. Fridley, Christina Sayama, Andrew Jea
38.1
Introduction . . . . . . . . . . . . . . . . . . . 314
38.2
Anatomy . . . . . . . . . . . . . . . . . . . . . . 314
38.3
Examination . . . . . . . . . . . . . . . . . . . 314
38.4
Nonsurgical Management . . . . . . 317
38.5
Surgical Indications . . . . . . . . . . . . 317
38.6
Surgical Technique . . . . . . . . . . . . . 317
38.7
Complications . . . . . . . . . . . . . . . . . 318
38.8
Postoperative Care . . . . . . . . . . . . . 318
38.9
Outcomes . . . . . . . . . . . . . . . . . . . . . 318
38.10 Surgical Pearls . . . . . . . . . . . . . . . . . 319
38.11 Common Clinical Questions. . . . . 319
38.12 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 319
References . . . . . . . . . . . . . . . . . . . . 319
39

Spina Bifida: Classification and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Lorelay Gutierrez, Luis A. Arredondo, Rodrigo Mercado
39.1
Introduction . . . . . . . . . . . . . . . . . . . 321
39.2
Spina Bifida Occulta . . . . . . . . . . . . 321
39.3
Spina Bifida Aperta. . . . . . . . . . . . . 321
39.4
Embryology . . . . . . . . . . . . . . . . . . . 322
39.5
Clinical Presentation . . . . . . . . . . . 322
39.6
Prenatal Assessment . . . . . . . . . . . 322
39.7
Postnatal Assessment . . . . . . . . . . 322
39.8
Common Clinical Questions. . . . . 323
39.9
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 323
References . . . . . . . . . . . . . . . . . . . . 323
Contents
xviii

40

Pathophysiology and Management of Tethered Cord
(Including Myelomeningocele). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Eelco W. Hoving
40.1
Definitions . . . . . . . . . . . . . . . . . . . . 325
40.2
Pathophysiology of TCS. . . . . . . . 325
40.3
Pathophysiology of Recurrent
Tethered Cord. . . . . . . . . . . . . . . . . 326
40.4
Assessment of TCS . . . . . . . . . . . . 326
40.5
Imaging of TC . . . . . . . . . . . . . . . . . 327
40.6
Treatment of Tethered Cord. . . . 327
40.7
Intraoperative Neuromonitoring
in TCS . . . . . . . . . . . . . . . . . . . . . . . . 329
40.8
Outcome in TCS . . . . . . . . . . . . . . . 329
40.9
Complications. . . . . . . . . . . . . . . . . 329
40.10 Surgical Pearls . . . . . . . . . . . . . . . . 329
40.11 Common Clinical Questions . . . . 329
40.12 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 330
References . . . . . . . . . . . . . . . . . . . . 330
41

Intraspinal Lipomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Rodrigo Mercado, Luis A. Arredondo, Lorelay Gutierrez, Jesus A. Villagómez
41.1
Introduction . . . . . . . . . . . . . . . . . . 332
41.2
Classification. . . . . . . . . . . . . . . . . . 332
41.3
Clinical Presentation. . . . . . . . . . . 332
41.4
Imaging . . . . . . . . . . . . . . . . . . . . . . 333
41.5
Surgical Treatment . . . . . . . . . . . . 333
42

Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Anthony J. Herzog, Paul D. Sponseller
42.1
Introduction . . . . . . . . . . . . . . . . . . 335
42.2
Nonsurgical Treatment . . . . . . . . 338
42.3
Surgical Treatment . . . . . . . . . . . . 338
42.4
Complications. . . . . . . . . . . . . . . . . 340
42.5
Conclusion . . . . . . . . . . . . . . . . . . . . 340
42.6
Common Clinical Questions . . . . 340
42.7
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 340
References . . . . . . . . . . . . . . . . . . . . 341
43

Achondroplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Debraj Mukherjee, Moise Danielpour
43.1
Introduction . . . . . . . . . . . . . . . . . . 342
43.2
Cervicomedullary Compression
342
43.3
Spinal Stenosis . . . . . . . . . . . . . . . . 343
43.4
Hydrocephalus . . . . . . . . . . . . . . . . 343
References . . . . . . . . . . . . . . . . . . . . 343
Contents
xix

Section VIII Functional Disorders
44

The Evaluation and Classification of Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Sarah A. Kelley, Adam L. Hartman
44.1
Introduction . . . . . . . . . . . . . . . . . . . 346
44.2
Definitions . . . . . . . . . . . . . . . . . . . . 346
44.3
Classification of Epilepsy . . . . . . . 346
44.4
Evaluation of Epilepsy . . . . . . . . . . 348
44.5
Common Clinical Questions. . . . . 349
44.6
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 349
References . . . . . . . . . . . . . . . . . . . . 350
45

Surgical Management of Childhood Epilepsy: Temporal and
Extratemporal Pathologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Aurelia Peraud
45.1
Introduction . . . . . . . . . . . . . . . . . . . 351
45.2
Epilepsy Disorders in Childhood
Epilepsy . . . . . . . . . . . . . . . . . . . . . . . 351
45.3
Presurgical Evaluation . . . . . . . . . . 352
45.4
Neuroimaging . . . . . . . . . . . . . . . . . 352
45.5
EEG Investigations . . . . . . . . . . . . . 352
45.6
Surgical Options . . . . . . . . . . . . . . . 353
45.7
Summary. . . . . . . . . . . . . . . . . . . . . . 355
References . . . . . . . . . . . . . . . . . . . . 355
46

Surgical Management of Childhood Epilepsy: Corpus Callosotomy
and Vagal Nerve Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Oguz Cataltepe
46.1
Introductıon . . . . . . . . . . . . . . . . . . . 358
46.2
Corpus Callosotomy. . . . . . . . . . . . 358
46.3
Vagal Nerve Stımulatıon . . . . . . . . 361
46.4
Conclusion . . . . . . . . . . . . . . . . . . . . 365
46.5
Common Clinical Questions. . . . . 365
46.6
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . . 365
References . . . . . . . . . . . . . . . . . . . . 365
47

Surgical Management of Pediatric Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Michael M. McDowell, Michelle Q. Phan, Richard C.E. Anderson
47.1
Introduction . . . . . . . . . . . . . . . . . . . 368
47.2
Epidemiology and
Pathophysiology . . . . . . . . . . . . . . . 368
47.3
Diagnosis and Examination . . . . . 368
47.4
Nonsurgical Management . . . . . . 370
47.5
Surgical Indications . . . . . . . . . . . . 371
References . . . . . . . . . . . . . . . . . . . . 377
Contents
xx

Section IX Trauma
48

Neonatal Brachial Plexus Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Jonathan Pindrik
48.1
Introduction . . . . . . . . . . . . . . . . . . 382
48.2
Anatomy . . . . . . . . . . . . . . . . . . . . . 382
48.3
Examination . . . . . . . . . . . . . . . . . . 383
48.4
Nonsurgical Management. . . . . . 384
48.5
Surgical Indications. . . . . . . . . . . . 384
48.6
Surgical Technique . . . . . . . . . . . . 384
48.7
Complications. . . . . . . . . . . . . . . . . 387
48.8
Postoperative Care . . . . . . . . . . . . 387
48.9
Outcomes . . . . . . . . . . . . . . . . . . . . 387
48.10 Surgical Pearls . . . . . . . . . . . . . . . . 387
48.11 Common Clinical Questions . . . . 388
48.12 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 388
References . . . . . . . . . . . . . . . . . . . . 389
49

Pediatric Spine Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Douglas Brockmeyer
49.1
Introduction . . . . . . . . . . . . . . . . . . 390
49.2
Epidemiology . . . . . . . . . . . . . . . . . 390
49.3
Pathophysiology . . . . . . . . . . . . . . 390
49.4
Anatomy . . . . . . . . . . . . . . . . . . . . . 390
49.5
Specific Injuries . . . . . . . . . . . . . . . 391
49.6
Examination . . . . . . . . . . . . . . . . . . 393
49.7
Prehospital Management . . . . . . 393
49.8
Nonsurgical Management. . . . . . 394
49.9
Surgical Indications. . . . . . . . . . . . 394
49.10 Surgical Technique . . . . . . . . . . . . 394
49.11 Complications. . . . . . . . . . . . . . . . . 395
49.12 Outcomes . . . . . . . . . . . . . . . . . . . . 395
49.13 Postoperative Care and
Rehabilitation of Spinal
Cord Injury . . . . . . . . . . . . . . . . . . . 395
49.14 Surgical Pearls . . . . . . . . . . . . . . . . 395
49.15 Common Clinical Questions . . . . 395
49.16 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 396
References . . . . . . . . . . . . . . . . . . . . 396
50

Pediatric Peripheral Nervous System Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Kambiz Kamian, Andrew T. Healy
50.1
Introduction . . . . . . . . . . . . . . . . . . 397
50.2
Peripheral Nerve Anatomy . . . . . 397
50.3
Mechanism of Neuronal Injury . 397
50.4
Sunderland’s Classification . . . . . 398
50.5
Examination . . . . . . . . . . . . . . . . . . 398
50.6
Neurophysiology . . . . . . . . . . . . . . 399
50.7
Imaging . . . . . . . . . . . . . . . . . . . . . . 400
50.8
Nonsurgical Management. . . . . . 400
Contents
xxi

50.9
Surgical Repair. . . . . . . . . . . . . . . . . 400
50.10 Pearls . . . . . . . . . . . . . . . . . . . . . . . . . 401
50.11 Postoperative Care/Follow-up . . 401
50.12 Brachial Plexus. . . . . . . . . . . . . . . . . 402
50.13 Extremities . . . . . . . . . . . . . . . . . . . . 404
50.14 Upper Extremity . . . . . . . . . . . . . . . 404
50.15 Lower Extremity . . . . . . . . . . . . . . 405
50.16 Common Clinical Questions. . . . 406
50.17 Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . 406
References . . . . . . . . . . . . . . . . . . . 406
51

Management of Pediatric Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Linda W. Xu, Gerald A. Grant
51.1
Introduction . . . . . . . . . . . . . . . . . . . 409
51.2
Initial Emergency Room
Evaluation . . . . . . . . . . . . . . . . . . . . . 409
51.3
Management of Mild TBI . . . . . . . 410
51.4
Management of Severe TBI and
Polytrauma . . . . . . . . . . . . . . . . . . . . 412
51.5
Surgical Pearls . . . . . . . . . . . . . . . . 418
51.6
Common Clinical Questions. . . . 419
51.7
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . 419
References . . . . . . . . . . . . . . . . . . . 419
52

Abusive Head Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Mark S. Dias
52.1
Definitions and Nomenclature . . 423
52.2
Clinical Presentation . . . . . . . . . . . 424
52.3
Di erential Diagnosis of AHT . . . 425
52.4
Work-up of AHT . . . . . . . . . . . . . . . 426
52.5
Treatment . . . . . . . . . . . . . . . . . . . . 426
52.6
Outcome . . . . . . . . . . . . . . . . . . . . . 427
52.7
Other Considerations. . . . . . . . . . 427
References . . . . . . . . . . . . . . . . . . . 427
Section X Infections
53

Evaluation and Management of Pediatric Intracranial Infections . . . . 430
Jonathan R. Ellenbogen, Richard P.D. Cooke, Conor L. Mallucci
53.1
Introduction . . . . . . . . . . . . . . . . . . . 430
53.2
Bacterial Meningitis . . . . . . . . . . . . 430
53.3
Viral Meningitis . . . . . . . . . . . . . . . . 434
53.4
Encephalitis . . . . . . . . . . . . . . . . . . . 436
53.5
Brain Abscess, Subdural
Empyema, and Extradural
Empyema . . . . . . . . . . . . . . . . . . . . . 440
53.6
Common Clinical Questions. . . . 445
53.7
Answers to Common Clinical
Questions . . . . . . . . . . . . . . . . . . . . 446
References . . . . . . . . . . . . . . . . . . . 446
Contents
xxii

54

Evaluation and Management of Pediatric Spinal Infections . . . . . . . . . . . 448
Lydia J. Liang, Mari L. Groves
54.1
Introduction . . . . . . . . . . . . . . . . . . 448
54.2
Anatomy . . . . . . . . . . . . . . . . . . . . . 450
54.3
Examination . . . . . . . . . . . . . . . . . . 452
54.4
Nonsurgical Management. . . . . . 455
54.5
Surgical Indications. . . . . . . . . . . . 455
54.6
Surgical Technique . . . . . . . . . . . . 456
54.7
Complications. . . . . . . . . . . . . . . . . 457
54.8
Postoperative Care . . . . . . . . . . . . 457
54.9
Outcomes . . . . . . . . . . . . . . . . . . . . 457
54.10 Surgical Pearls . . . . . . . . . . . . . . . . 458
54.11 Common Clinical Questions . . . . 458
54.12 Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 458
References . . . . . . . . . . . . . . . . . . . . 458
55

Surgical Considerations in Tuberculosis, Fungal, and Parasitic
Infections of CNS in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Chandrashekhar Deopujari, Dattatraya Muzumdar, Sonal Jain
55.1
Introduction . . . . . . . . . . . . . . . . . . 460
55.2
Pathogenesis . . . . . . . . . . . . . . . . . 460
55.3
Tuberculous Meningitis . . . . . . . . 460
References . . . . . . . . . . . . . . . . . . . . 478
Section XI Operating Room Basics
56

Neuronavigation in Pediatric Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
Ulrich-Wilhelm N. Thomale
56.1
Introduction . . . . . . . . . . . . . . . . . . 484
56.2
Terminology . . . . . . . . . . . . . . . . . . 484
56.3
Technique . . . . . . . . . . . . . . . . . . . . 484
56.4
Indications . . . . . . . . . . . . . . . . . . . . 487
56.5
Common Clinical Questions . . . . 489
56.6
Answers to Common Clinical
Questions. . . . . . . . . . . . . . . . . . . . . 490
References . . . . . . . . . . . . . . . . . . . . 490
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
Contents
xxiii

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Foreword
George I. Jallo and his distinguished collaborators
have assembled a succinct and practical guide for the
eld of pediatric neurosurgery,and yet have managed
to beautifully cover the depth and breadth of the
discipline.
The organization, evenness of coverage, and the
consistency bespeak a strong editorial hand.
This book is destined to become a classic reference
for those involved in the care of pediatric neurosur-
gery patients at every level. The greatest bene ciaries
of this wonderful text will undoubtedly be the
patients for whom we care.
Mark S. Greenberg, MD, FAANS
Associate Professor of Neurosurgery
University of South Florida
Morsani College of Medicine, Tampa, Florida
Author of “Handbook of Neurosurgery”
xxv

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Foreword
Residents, fellows, and neurosurgeons have for long
needed a crisp, condensed, and authoritative book in
pediatric neurosurgery. Residents starting in pediat-
ric neurosurgery rms have needed a book to rapidly
get an overview of this very broad specialty. The
pediatric neurosurgery fellows have required a book
to help them master the core knowledge required of
them and in revising for board exams. Consultants
have required a quick reference to refresh their
knowledge, where parents of their patients come to
see them having done varying levels of reading off
the web. At last, such a book is now available in the
form of Dr George I. Jallo’s Handbook of Pediatric
Neurosurgery!
The Sine qua non of any handbook is to identify the
“trees” and direct the readers for further study.
Dr Jallo has assembled international experts to con-
tribute to such an excellent multiauthored manual.
Each chapter is a compendium of distilled key con-
cepts, facts, and nuances; the remarkable achieve-
ment of this book is that in each chapter, these have
been incorporated into a cohesive narrative, aided
and abetted by exquisite diagrams and illustrative
images, in an immensely appealing way. The book
can be read from cover to cover or be dipped into and
out of, as desired. At the end of each chapter, the
authors have listed relevant references.
Besides his mastery over operative pediatric neu-
rosurgery and prodigious research, Dr Jallo has been
at the forefront of pediatric neurosurgical education
through training residents and fellows at Johns Hop-
kins, lectures at courses, invited webinars, internet-
based academic conferences, his other previously
published highly regarded books, and through co-
organizing the International Neurosurgery Resident
Course (INRC). This Handbook of Pediatric Neurosur-
gery adds to his already impressive holistic contribu-
tion to world-wide pediatric neurosurgical education.
Iam con dent that like Youman’s and Greenberg’s,
this “Jallo’s” will become a neurosurgery classic in its
own right. The relevance, lucidity, and beauty of this
book, which makes it such a joy to study from, will no
doubt garner converts to pediatric neurosurgery—a
book that pediatric neurosurgery can be very proud
of. More importantly, the Handbook of Pediatric Neu-
rosurgery would constantly help all neurosurgeons
who care for children to provide better care!
G. ‘Naren’ Narenthiran, BSc (MedSci) (Hons), MB,
ChB, MRCSE, FEBNS, FRCS (SN)
Charing Cross Hospital, London, UK
Penn State University, Hershey, Pennsylvania
Neurosurgery Research Listserv, Southampton, UK
xxvii

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Foreword
“The most valuable of all talents is that of never using
two words when one will do.”
Thomas Jefferson
This is a no-nonsense, concise, thoughtfully compiled
handbook that will serve as an invaluable reference
for those interested in pediatric neurosurgery. There
is no uff here,just the facts.And there are lots of facts
indeed,ranging from the fundamentals of intracranial
pressure monitoring to advanced neuroimaging and
state-of-the-art adjuvant therapy for complex brain
tumors.
What makes the work unique is its ease of use as a
pocket reference about pediatric neurosurgery. It
provides the busy reader with on-the- y rapid access
to nuts-and-bolts essentials along with focused
details and handy clinical pearls. We owe a debt of
gratitude to George I. Jallo and the international
group of authors he has assembled for putting togeth-
er this indispensable resource.
Alan R. Cohen, MD, FACS, FAAP, FAANS
Chief of Pediatric Neurosurgery
Professor of Neurosurgery, Oncology and
Pediatrics
Carson-Spiro Professor of Pediatric Neurosurgery
The Johns Hopkins University School of Medicine,
Baltimore, Maryland
xxix

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Preface
Many textbooks have been published focusing on
pediatric neurosurgery, and while these texts are
available in print or online, they remain inaccessible
for the neurosurgery resident or midlevel provider
who is on call to manage these children. We have
developed this rst edition of the handbook to pro-
vide a concise and practical text that covers the
important aspects of caring for these children. It is
comprehensive, readable, and distilled for the perti-
nent pearls that are important in managing the neu-
rosurgical disease processes that may arise in the
hospital, emergency room, or outpatient setting.
This text was not meant to be a comprehensive
reference book on pediatric neurosurgery, as many
such texts already exist. The strength and bene ts of
this handbook lie in its portability and its practical
approach to the most common disease processes.
There is a list of references at the end of each chapter
to provide more comprehensive understanding for all
the topics.
George I. Jallo, MD
Karl F. Kothbauer, MD
Violette M.R. Recinos, MD
xxxi

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Acknowledgments
We are grateful to all our contributors for the quality
of their submission.We also thank the staff at Thieme,
Timothy Hiscock and Prakash Naorem, without
whom this text would not have been possible. We
also cannot forget all the midlevel providers,students,
residents, and fellows who have contributed to the
shaping of this handbook. In particular, we are
grateful to Nir Shimony, Rajiv Iyer, Meleine Sosa-
Martinez, and Brooks Osburn who were the real force
behind the topics and chapters.
George I. Jallo, MD
Karl F. Kothbauer, MD
Violette M.R. Recinos, MD
xxxiii

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About the Editors
George Jallo, MD, Professor of Neurosurgery, Pediatrics and Oncology at
the Johns Hopkins University School of Medicine, joined the faculty in
2003 after training under Dr. Fred Epstein. He was the Chief of Pediatric
Neurosurgery at Johns Hopkins Hospital before relocating to Johns
Hopkins All Children’s Hospital (St. Petersburg, Florida) in September
2015 as Director of the Institute for Brain Protection Sciences (IBPS). He
leads a team of neurosurgeons,neurologists,psychiatrists,psychologists,
developmental pediatricians, sports medicine physicians, and physia-
trists, who all care for pediatric neurological disorders and conditions. As
an internationally respected pediatric neurosurgeon, with expertise in
epilepsy, tumors of the brain and spinal cord, intraoperative neurophys-
iological monitoring for eloquent tumors, and use of minimally invasive
technologies such as endoscopy and keyhole surgery, he felt the need for
a handbook in pediatric neurosurgery for the neurosurgery trainee and
midlevel provider.
Karl F. Kothbauer, MD, Associate Professor of Neurosurgery at the Uni-
versity of Basel, Switzerland, and Chief of Neurosurgery at the Lucerne
Cantonal Hospital, Lucerne, Switzerland, completed fellowship training
in pediatric neurosurgery under Fred J. Epstein in New York. In 2004, he
founded and since then developed the Division of Neurosurgery in
Lucerne. As a neurosurgeon and pediatric neurosurgeon, his broad
experience and expertise centers on brain tumor surgery, endoscopic
neurosurgery, surgery for dysraphic conditions, and, in particular, sur-
gery for intramedullary spinal cord tumors in children and adults.
He is an internationally recognized expert and researcher in the eld
of application of intraoperative neurophysiology in neurosurgery, par-
ticularly the development of neuromonitoring of the motor pathways.
From 2009 to 2011,he served as president of the International Society for
Intraoperative Neurophysiology (ISIN).
Violette M.R. Recinos, MD, Assistant Professor of Neurosurgery at the
Cleveland Clinic Lerner College of Medicine, is an ABNS- and ABPNS-
certi ed pediatric neurosurgeon who is the Section Head of Pediatric
Neurosurgery at the Cleveland Clinic. She graduated with a major in
Neuroscience from the Johns Hopkins University, and stayed on to
complete her medical school, neurosurgical residency, and pediatric
neurosurgery fellowship at the Johns Hopkins School of Medicine. In
residency, she also completed a 2-year NIH fellowship in Neuro-Oncol-
ogy, investigating local delivery of chemotherapeutic agents in the
treatment of brain tumors. She maintains an active research laboratory
focused on the investigation of CNS tumors.
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Contributors
Richard C.E. Anderson, MD, FACS, FAAP
Associate Professor of Neurological Surgery
Division of Pediatric Neurosurgery
Columbia University
Morgan Stanley Children’s Hospital of New York
Presbyterian
New York, New York
Luis A. Arredondo, MD
Head
Pediatric Neurosurgery Department
Hospital Civil Fray Antonio Alcalde
Jalisco, Mexico
Micol Babini, MD
Neurosurgeon
Pediatric Neurosurgery
Institute of Neurosurgery
University Hospital of Verona
Verona, Italy
Liat Ben-Sira, MD
Director
Pediatric Imaging, “Dana” Children’s Hospital
Gilbert Israeli Neuro bromatosis Center (GINFC),
Tel-Aviv Medical Center
Tel-Aviv University
Tel-Aviv, Israel
Felix Bokstein, MD
Co-director, Adult Neuro-oncology Program and
Adult NF1 Clinic
Department of Oncology
Gilbert Israeli Neuro bromatosis Center (GINFC)
Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
Douglas Brockm eyer, MD
Professor of Neurosurgery
Marion L Walker Endowed Chair
Division Chief
Pediatric Neurosurgery
University of Utah
Salt Lake City, Utah
Rafael U. Cardenas, MD, MHS
Fellow
Division of Pediatric Neurosurgery
Department of Neurosurgery
Weill Cornell Medicine
New York, New York
Oguz Cataltepe, MD
Professor of Neurosurgery and Pediatrics
Director, Pediatric Neurosurgery and Epilepsy
Surgery
Department of Neurosurgery UMass-Memorial
Medical Center
University of Massachusetts Medical School
Worcester, Massachusetts
Vikram B. Chakravarthy, MD
Resident Physician
Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine
Cleveland Clinic
Cleveland, Ohio
Peter A. Christiansen, MD
Resident Physician
Department of Neurosurgery
University of Virginia Health System
Charlottesville, Virginia
Alan R. Cohen, MD, FACS, FAAP
Professor of Neurosurgery, Oncology and Pediatrics
Chief, Division of Pediatric Neurosurgery
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Shlom i Constantini, MD, MSc
Professor and Chair
Department of Pediatric Neurosurgery, “Dana”
Children’s Hospital;
Gilbert Israeli Neuro bromatosis Center (GINFC),
Tel-Aviv Medical Center,
Tel-Aviv University
Tel-Aviv, Israel
Richard P.D. Cooke, MD
Consultant Microbiologist
Department of Microbiology
Alder Hey Children’s Hospital
Liverpool, UK
xxxvii

Moise Danielpour, MD, FACS
Vera and Paul Guerin Family Chair in Pediatric
Neurosurgery
Associate Professor, Neurosurgery
Director, Pediatric Neurosurgery and Center for
Pediatric Neurosciences
Cedars Sinai Medical Center
Advanced Health Sciences Pavilion
Los Angeles, California
Chandrashekhar Deopujari, MCh, MSc
Professor and Head
Department of Neurosurgery
Bombay Hospital Institute of Medical Sciences
Mumbai, India
Mark S. Dias, MD, FAANS, FAAP
Professor of Neurosurgery and Pediatrics
Vice Chair for Neurosurgical Education
Director of Pediatric Neurosurgery
Penn State Health, Penn State College of Medicine
Hershey, Pennsylvania
Am ir H. Dorafshar, MBChB, FACS, FAAP
Associate Professor
Department of Plastic Surgery
Johns Hopkins Medical Institute
Baltimore, Maryland
Jonathan R. Ellenbogen, BMedSc (Hons),
MBChB (Hons), FRCS (Neurosurgery)
Paediatric Neurosurgery Fellow
Department of Neurosurgery
Alder Hey Children’s Hospital
Liverpool, UK
Anthony A. Figaji, MD, PhD
Professor and Head of Pediatric Neurosurgery
Pediatric Neurosurgery
Institute for Child Health, Red Cross Children’s
Hospital
Cape Town, South Africa
Jared S. Fridley, MD
Neurosurgery Resident
Department of Neurosurgery
Baylor College of Medicine
Houston, Texas
Neil R. Friedm an, MB, ChB
Director
Center for Pediatric Neurosciences
Cleveland Clinic’s Neurological Institute
Cleveland Clinic
Cleveland, Ohio
Gerald A. Grant, MD, FACS
Arline and Pete Harman Endowed Faculty Scholar
Stanford Child Health Research Institute
Division Chief, Pediatric Neurosurgery
Vice Chair for Pediatric Neurosurgery and Associate
Program Director of Neurosurgery
Associate Professor, Department of Neurosurgery
Stanford University/Lucile Packard Children’s
Hospital
Stanford, California
Mari L. Groves, MD
Assistant Professor of Neurosurgery
Department of Neurosurgery
Johns Hopkins Hospital
Baltimore, Maryland
Lorelay Gutierrez, MD
Consultant
Pediatric Neurosurgery Department
Hospital Civil Fray Antonio Alcalde
Jalisco, Mexico
Raphael Guzm an, MD
Professor of Neurosurgery and Neurosciences
Vice Chair Department of Neurosurgery
Chief Pediatric Neurosurgery
Department of Neurosurgery
University Hospital Basel
University Children’s Hospital Basel (UKBB)
Basel, Switzerland
Adam L. Hartm an, MD, FAAP, FANA
Associate Professor of Neurology & Pediatrics
Department of Neurology
Johns Hopkins Hospital
Baltimore, Maryland
Andrew T. Healy, MD
Neurosurgeon
Carolina Neurosurgery and Spine Associate
Concord, North Carolina
Contributors
xxxviii

David S. Hersh, MD
Resident
Department of Neurosurgery
University of Maryland
Baltimore, Maryland
Anthony J. Herzog, MD
Orthopedic Resident
Department of Orthopedic Surgery
Johns Hopkins University
Baltimore, Maryland
Eveline T. Hidalgo, MD
Clinical Instructor
Division of Pediatric Neurosurgery
Department of Neurosurgery
NYU Langone Health
New York, New York
Eelco W. Hoving, MD, PhD
Professor
Department of Neurosurgery
University Hospital Utrecht
Utrecht, The Netherlands
Gary Hsich, MD
Staff Pediatric Neurologist
Center for Pediatric Neurosciences
Cleveland Clinic
Cleveland, Ohio
Thierry A.G.M. Huism an, MD, EQNR, EDiPNR
Professor of Radiology, Pediatrics, Neurology, and
Neurosurgery
Chairman, Department of Imaging and Imaging
Science, JHBMC
Director, Division Pediatric Radiology and Pediatric
Neuroradiology, JHH
Johns Hopkins Medicine
Baltimore, Maryland
Lee S. Hwang, MD
Resident Physician
Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine
Cleveland Clinic
Cleveland, Ohio
Rajiv R. Iyer, MD
Resident
Department of Neurosurgery
Johns Hopkins Hospital
Baltimore, Maryland
Sonal Jain, MCH
Superspecialty Medical Of cer
Department of Neurosurgery
King Edward Memorial Hospital and Seth G.S.
Medical College
Mumbai, India
George I. Jallo, MD
Professor of Neurosurgery, Pediatrics and Oncology
Institute for Brain Protection Sciences
Johns Hopkins All Children’s Hospital
St. Petersburg, Florida
John A. Jane, Jr., MD
Professor of Neurosurgery and Pediatrics
Neurosurgery Residency Program Director
Department of Neurosurgery
University of Virginia Health System
Charlottesville, Virginia
Andrew Jea, MD, MHA
Professor and Chief
Department of Pediatric Neurosurgery
Riley Hospital for Children
Department of Neurological Surgery
Indiana University School of Medicine
Indianapolis, Indiana
Kam biz Kam ian, MD, FRCS(C), FAANS
Amber Rollins Endowed Chair in Pediatrics
Neurosurgery Chair
Department of Pediatrics Neurosurgery
Boonshoft School of Medicine
Wright State University
Dayton Children's Hospital
Dayton, Ohio
Sarah A. Kelley, MD
Assistant Professor, Neurology and Pediatrics
Director, Pediatric Epilepsy Monitoring Unit
Johns Hopkins Hospital
Baltimore, Maryland
Contributors
xxxix

Christopher D. Kelly, MD
Attending Neurosurgeon
Kantonsspital Aarau
Aarau, Switzerland
Karl F. Kothbauer, MD
Associate Professor of Neurosurgery
University of Basel
Basel, Switzerland
Chief of Neurosurgery
Lucerne Cantonal Hospital
Lucerne, Switzerland
Elizabeth J. Le, MD
Resident
Department of Neurosurgery
University of Maryland
Baltimore, Maryland
Bryan S. Lee, MD
Resident Physician
Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine
Cleveland Clinic
Cleveland, Ohio
Lydia J. Liang, BS
Student
Johns Hopkins University School of Medicine
Baltimore, Maryland
Tina Lovén, DO
Pediatric Neurosurgeon
Division of Neurosurgery
Mercy Hospital
Spring eld, Minnesota
Conor L. Mallucci, MD
Consultant Paediatric Neurosurgeon
Department of Neurosurgery
Alder Hey Children’s Hospital
Liverpool, UK
Michael M. McDowell, MD
Resident
Department of Neurological Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Miguel A. Medina III, MD
Assistant Professor
Director of Microsurgery
Miami Cancer Institute
Plastic and Reconstructive Surgery
Miami, Florida
Rodrigo Mercado, MD
Head
Functional Neurosurgery Clinic
Hospital Civil de Guadalajara
Functional Neurosurgery
Unit of Movement Disorders and Neurodegenerative
Diseases
Hospital San Javier
Jalisco, Mexico
Martina Messing-Jünger, MD
Associate Professor of Neurosurgery
Heinrich-Heine-University, Düsseldorf, Germany
Head of Department
Pediatric Neurosurgery
Asklepios Klinik-Sankt Augustin, Germany
Mark A. Mittler, MD
Co-Chief, Division of Pediatric Neurosurgery
Steven and Alexandra Cohen Children’s Medical
Center of New York
Director of Quality Assurance, Department of
Neurosurgery
Northwell Health
Clinical Associate Professor of Neurosurgery and
Pediatrics
Hofstra-Northwell School of Medicine
New York, New York
Tiago Morgado, MD
Resident in Neurosurgery
Division of Neurosurgery
Groote Schuur Hospital
Cape Town, South Africa
Debraj Mukherjee, MD, MPH
Chief Neurosurgery Resident
Robert Wood Johnson Foundation Scholar
Congress of Neurological Surgeons Leadership Fellow
Council of State Neurosurgical Societies Washington
Fellow
American Association of Neurological Surgeons
Young Neurosurgeons Committee Representative
Department of Neurosurgery
Cedars-Sinai Medical Center
Los Angeles, California
Contributors
xl

Jeffrey P. Mullin, MD, MBA
Assistant Professor
Department of Neurosurgery
University of Buffalo
Buffalo, New York
Gerhard S. Mundinger, MD
Assistant Professor Craniofacial, Plastic, and
Reconstructive Surgery
Louisiana State University Health Sciences Center;
Department of Cell Biology and Anatomy
Louisiana State University Health Sciences Center;
Director of Plastic Surgery
Children’s Hospital of New Orleans
New Orleans, Louisiana
Dattatraya Muzum dar, MCh, FRCSI, FACS (USA)
Professor
Department of Neurosurgery
King Edward Memorial Hospital and Seth G.S.
Medical College
Mumbai, India
Greg Olavarria, MD
Faculty, University of Central Florida College of
Medicine
Co-Director, Craniofacial Program; Co-Director,
Epilepsy Surgery Program; Trauma Quality Liaison
Department of Neurosurgery
Arnold Palmer Hospital for Children
Orlando, Florida
Aurelia Peraud, MD
Professor of Pediatric Neurosurgery
Department of Neurosurgery
University Hospital Ulm
Ulm, Germany
Michelle Q. Phan, MD
Resident
Department of Neurosurgery
Cincinnati Children’s Hospital
Cincinnati, Ohio
Jonathan Pindrik, MD
Assistant Professor
Division of Pediatric Neurosurgery
Department of Neurological Surgery
Nationwide Children’s Hospital and The Ohio State
University College of Medicine
Columbus, Ohio
Violette M.R. Recinos, MD
Assistant Professor
Department of Neurosurgery
Cleveland Clinic Lerner College of Medicine of Case
Western Reserve University
Division of Pediatric Neurosurgery
Cleveland Clinic
Cleveland, Ohio
Lindsey Ross, MD
Resident Physician
Department of Neurosurgery
Cedars-Sinai Medical Center
West Hollywood, California
Martin H. Sailer, MD, PhD
Attending Neurosurgeon
Department of Neurosurgery
University Hospital Basel
Basel, Switzerland
Francesco Sala, MD
Professor of Neurosurgery
Department of Neurosciences, Biomedicine and
Movement Sciences
University Hospital Verona
Verona, Italy
Christina Sayam a, MD, MPH
Pediatric Neurosurgery Fellow
Department of Neurosurgery
Texas Children’s Hospital
Houston, Texas
Christian A. Schneider, MD
Pediatric Neurosurgeon
Department of Neurosurgery
Universitäts-Kinderspital beider Basel
Basel, Switzerland
Joanne E. Shay, MD, MBA
Assistant Professor
Director of Pediatric Remote Anesthesia Services
Pediatric Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
Contributors
xli

Nir Shim ony, MD
Pediatric Neurosurgery Fellow
Department of Neurosurgery
Johns Hopkins University
Institute for Brain Protection Sciences
Johns Hopkins All Children’s Hospital
St. Petersburg, Florida
Ben Shofty, MD, PhD
Resident Physician
Department of Neurosurgery
Gilbert Israeli Neuro bromatosis Center (GINFC)
Tel-Aviv Medical Center
Tel-Aviv University
Tel-Aviv, Israel
Edward R. Sm ith, MD
R. Michael Scott Chair in Neurosurgery
Associate Professor, Harvard Medical School
Department of Neurosurgery
Boston Children’s Hospital
Boston, Massachusetts
Paul D. Sponseller, MD, MBA
Professor and Chief of Pediatric Orthopaedics Surgery
Johns Hopkins Children’s Center
Baltimore, Maryland
Stacie Stapleton, MD
Director of Pediatric Neuro-Oncology Program
Assistant Professor of Pediatrics
Johns Hopkins Medicine
Cancer and Blood Disorders Institute
Johns Hopkins All Children’s Hospital
St. Petersburg, Florida
Scellig S.D. Stone, MD, PhD, FRCSC
Assistant Professor
Department of Neurosurgery
Boston Children’s Hospital
Harvard Medical School
Boston, Massachusetts
Gianpiero Tam burrini, MD
Professor
Department of Pediatric Neurosurgery
Institute of Neurosurgery
Catholic University Medical School
Rome, Italy
Ulrich-Wilhelm N. Thom ale, MD
Head
Department of Pediatric Neurosurgery
Charité Universitätsmedizin Berlin
Berlin, Germany
Dom inic N.P. Thom pson, MBBS BSc FRCS (SN)
Paediatric Neurosurgeon
Department of Paediatric Neurosurgery
Great Ormond Street Hospital for Children NHS
Foundation Trust
London, UK
Hagit Toledano-Alhadef, MD
Clinical Director
The Gilbert Israeli Neuro bromatosis Center (GINFC)
“Dana” Children’s Hospital, Tel-Aviv Medical Center
Tel-Aviv University
Tel-Aviv, Israel
Gerald F. Tuite, MD
Pediatric Neurosurgeon
Institute for Brain Protection Sciences
Johns Hopkins All Children’s Hospital
St. Petersburg, Florida
Jesus A. Villagóm ez, MD
Consultant
Centro de Neuro-Radiocirugia San Javier
Gamma Knife
Hospital San Javier
Jalisco, Mexico
Linda W. Xu, MD
Neurosurgery Resident
Department of Neurosurgery
Stanford University Hospital and Clinics
Stanford, California
Contributors
xlii

I
Section I
General and Critical Care
1 ICP Management

2
2 Pain Management for
Pediatric Neurosurgical
Patients

12

1 ICP Management
Tiago Morgado, Anthony A. Figaji
1.1 Introduction
Management of raised intracranial pressure (ICP)
occupies a central role in neurocritical care, but
exact recommendations on how to monitor
ICP and how to best respond to elevations in ICP
remain somewhat contentious. Moreover, although
ICP monitoring and management is usually consid-
ered in the context of traumatic brain injury (TBI),
several other acute comatose conditions are also
subject to the problems of raised ICP and brain
ischemia and may benefit from ICP management.1
This chapter will discuss the management of raised
ICP in the setting of TBI in children, but these prin-
ciples may well apply to other conditions.
Numerous strategies exist for reducing ICP. The
control of ICP without a good understanding of
cerebral hemodynamics and homeostasis, how-
ever, may well cause more harm than good. It is
essential that ICP-directed therapies are tailored to
individual cases, and that a thought process
appraising the potential adverse e ects of each
treatment modality is applied. Ideally, ICP moni-
toring should be employed as part of a multimodal
neuromonitoring setup, as correlation of ICP and
the therapies directed at it with other neurophy-
siological parameters provides a more complete
assessment of the dynamic cerebral pathological
state. This ultimately leads to more well-informed,
controlled, and safer therapeutic interventions.
Although “normal” ICP is di cult to define, it is
generally accepted that in nonpathological states
ICP in children is usually less than 10 to 15 mm Hg.
The association of raised ICP with poor neurologi-
cal outcome is widely reported. It is also known
that there is an association between increas-
ed ICP and pediatric TBI outcomes, as well as
between protocol-driven ICP-lowering strategies
and improved outcomes. However, recent data
have highlighted the potential for getting this
wrong. ICP monitoring allows for objective assess-
ment of ICP, but does not necessarily reveal the
cause of increased ICP and how the brain responds
to various treatments. Studies directly assessing
the e ect of ICP monitoring on outcome have pro-
duced conflicting results. Although some authors
go as far as suggesting that ICP monitoring itself is
associated with worsening of survival,2 recent
research has found an association between ICP
monitoring and reduced mortality in both the
adult and pediatric age groups.3 A randomized
controlled trial performed at hospitals in Bolivia
and Ecuador that had previously not used ICP
monitoring failed to show the expected benefit of
ICP monitoring on outcome.4,5 However, the study
has several limitations, and whether these findings
can be extrapolated to more organized centers
is controversial. Still, it raises the question of
whether blindly controlling ICP at a threshold of
20 mm Hg in all patients makes physiological
sense. A study looking at the e ect of adherence to
specific ICP and cerebral perfusion pressure (CPP)
targets found that despite acceptable ICP control,
many patients still su ered episodes of compro-
mised brain oxygenation.6
There are several potential adverse e ects of
ICP-lowering treatments. For example, injudicious
hyperventilation may result in cerebral vasocon-
striction and ischemia, overzealous use of diuretics
may result in adverse hemodynamic changes and
electrolyte abnormalities, and decompressive cra-
niectomy (DC) may directly harm the brain. It is
important therefore that ICP management is an
individualized process, tailored to each patient,
preferably with more information than just the ICP
number. Where possible, the etiology of ICP
increases should be determined and there should
be a feedback loop to determine the e ects of the
ICP treatment.
1.2 Pathophysiology
1.2.1 Anatomy and Physiology of
ICP and Cerebral Perfusion
Changes in ICP
The cranium is a rigid structure with little (in
infants) or no ability to increase in volume. Its con-
tents, made up of brain, blood, and cerebrospinal
fluid (CSF), are incompressible. As the Monro–
Kellie doctrine states, an increase in the volume of
one intracranial component (brain, blood, or CSF)
results in an equal compensatory decrease of
another, the total intracranial volume being fixed.
CSF egress from the cranial compartment to the
spinal cisterns is usually one the first compensa-
tory mechanisms to occur in this scenario,
followed by decreased intracranial venous blood
volume. As these “bu ering” processes become
2

exhausted, ICP begins to rise at an exponential
rate. As cerebral compliance (defined as the change
in intracranial volume divided by the change in
ICP) decreases, even a minimal increase in intracra-
nial volume may result in a rapid rise in ICP
(Fig. 1.1). Infants are more protected from this
phenomenon as a result of open fontanels and
sutures, but even their reserves of compliance may
become quickly exhausted and ICP can rise to very
high levels. As this pathological state progresses,
cerebral blood flow (CBF) decreases if CPP is signifi-
cantly compromised. When CBF falls below critical
thresholds (approximately 18–20 mL/100 g/min in
stroke studies), potentially irreversible hypoxic-
ischemic damage to neurons and glia may occur.
ICP and Cerebral Perfusion
CPP is the di erence between mean arterial pres-
sure (MAP) and ICP: CPP =MAP – ICP. Calculation
of this is a ected by where the MAP is zeroed: at
the level of the heart or the head. Treatment
threshold values for the above parameters remain
controversial in adults and even more so in chil-
dren, who have changing normative blood pres-
sure (BP) and ICP values across the age range.
There are no widely accepted data on normal ICP
values in infants and children. Although 20 mm Hg
is recommended as the ICP cuto above which in-
tervention is required, it is likely that this value is
well above the normal ICP in small children and
infants, and that secondary brain injury may occur
below this value. At the same time, the cause of
the ICP increase should also be considered. For
example, hyperemia is likely more common in
children and presumably has di erent consequen-
ces at a given ICP number. The target for CPP is
even less clear, as it depends not only on ICP but
also on the changing normative values for BP
across a wide physiological age range. All of these
increase the heterogeneity of TBI and so interac-
tion between ICP and other neurophysiological
parameters is complex.7
Failure of Cerebral Autoregulation
In adult physiology, autoregulation fails below a
CPP of 40 to 50 mm Hg or above a CPP of 150 mm
Hg; therefore, CBF decreases, potentially resulting
in tissue ischemia and neuronal injury (Fig. 1.2).
Furthermore, increased metabolic demand and the
disruption of homeostatic mechanisms (such as
pressure autoregulation and flow-metabolism
coupling) may result in tissue ischemia despite a
CPP range that would be adequate in the uninjured
brain.8 Pediatric guidelines published in 2012 sug-
gested an age-related CPP threshold of 40 to
50 mm Hg below which neurological outcome is
significantly worsened; however, the evidence on
which this is based is weak.9
Herniation
Brain shift occurs when there is compartmentali-
zation of pressure within the cranium. The classic
herniation syndromes are subfalcine, transtento-
rial, and “coning” (across the foramen magnum)
(Fig. 1.3). Brainstem distortion results in cranial
nerve palsies (most commonly oculomotor and
abducens nerve palsies), hemiparesis, Cushing’s
Fig. 1.1 Monro–Kellie doctrine and
cerebral compliance curve.
ICP Management
3

response, and respiratory arrest. The occurrence of
these syndrom es depends on the rapidity of the
rise in ICP, the cause and location of the increased
volume, the tentorial configuration, and the size
and shape of the posterior fossa.
1.2.2 Causes of Raised ICP in TBI
Table 1.1 lists several mechanisms that may con-
tribute to a raised ICP in TBI.10
Mass Lesions
● In trauma, intracranial mass lesions such as sub-
dural, epidural, and intracerebral hematomas
and contusions may contribute to both focal and
global increases in ICP.
Cerebral Edema
● Both di use and/or perilesional edem a often
contributes to raised ICP. This usually involves a
Fig. 1.2 Reduced brain tissue oxygen tension (Pto2) as a result of increase in ICP.
Decussation of
pyramidal tract
Pyramidal
tract
Tentorium
1
2
3
4
cerebelli
Compression
Contralateral
cerebral peduncle
Falx cerebri
Medulla
oblongata
Pons
Mesiobasal
temporal lobe
Epidural
hematoma
Fig. 1.3 Cerebral herniation
syndromes in TBI. 1, subfalcine
herniation; 2, central herniation; 3,
uncal transtentorial herniation; 4,
tonsillar herniation. (Reproduced from
Schuenke, Schulte, and Schumacher,
Atlas of Anatomy, 2nd edition, ©2016,
Thieme Publishers, New York.
Illustration by Karl Wesker.)
Table 1.1 Causes of raised ICP in TBI
Expansive

Hematoma (EDH/SDH/ICH)
Parenchymal

Cerebral edema
Contusion
Vascular

Arterial vasodilation
Venous congestion
Loss of cerebral autoregulation
Hydrocephalus
Seizure
Abbreviations: EDH, extradural hemorrhage; ICH, intra-
cerebral hemorrhage; SDH, subdural hemorrhage.
General and Critical Care
4

combination of both vasogenic and cytotoxic
edema as a result of blood–brain barrier
dysfunction and cellular energy failure.
● Sodium and water imbalance due to central
nervous system and hypothalamic–pituitary axis
dysfunction may aggravate this, as may
overzealous fluid resuscitation.
Vascular
Loss of Autoregulation, Abnormal
Vascular Reactivity, and Hyperemia
● Disrupted vascular reactivity of the injured brain
plays a significant role in pathologically raised
ICP. Several intrinsic systems regulate perfusion
to neuronal tissue and ensure cerebral tissue
homeostasis.
● Pressure autoregulation, metabolism-perfusion
coupling, and vascular carbon dioxide tension
(Pco2) reactivity are important mechanisms in
this regulation.
● Pressure autoregulation, which maintains a
constant CBF within a CPP range of
approximately 50 to 150 mm Hg (but which may
be di erent in children), may be disrupted to
varying degrees, causing BP and CBF (and
volume) to assume a passive relationship
because of a lack of vasoreactivity. The brain is
therefore at greater risk of increased ICP
when BP is raised and of ischemia when BP
is lowered.
● Similarly, flow-metabolism uncoupling may
result in hyperemia and increased ICP.
Changes in Pco2
● Carbon dioxide is known to have a potent
vasoactive e ect.
● Head-injured patients with a depressed level of
consciousness, diminished respiratory drive and
lower cranial nerve dysfunction are prone to
hypoventilation and CO2 retention, potentially
resulting in cerebral arterial vasodilation
and increased intracranial blood content
and ICP.
● Conversely, intentional or accidental iatrogenic
hyperventilation is common—especially because
the respiratory tidal volume is so small—and
may cause profound decreases in CBF. The
pediatric brain is very sensitive to changes in
arterial Pco2, which has significant consequences
for ICP and CBF.
Intracranial Venous Congestion
● Several factors may contribute to increased
venous pressure, which in turn results in
decreased venous return from the head and
neck, and increased ICP.
● High airway pressures result from several causes,
including ventilator settings and patient agitation,
and should be avoided whenever possible.
● Other causes for decreased venous return from
the head, such as constrictive endotracheal tube
fixation tape, cervical collars, and poor patient
positioning, are common avoidable causes for
potentially harmful increases in ICP.
Hydrocephalus
● Hydrocephalus is not uncommon in TBI,
although less so in children than in adults.
● Communicating hydrocephalus may be due to
traumatic subarachnoid hemorrhage;
noncommunicating hydrocephalus may be due
to hematomas or infarcts with mass e ect,
especially in the posterior fossa.
Seizure
● Epileptic activity (both convulsive and
nonconvulsive) may increase both ICP and cerebral
metabolic demand in patients with TBI. Sometimes
the only evidence of subclinical seizures may be
rapid and repeated changes in ICP and BP. Where
possible, continuous electroencephalogram (EEG)
monitoring should be used.
1.3 ICP Monitoring
1.3.1 Indications
Despite only level III evidence supporting the use
of ICP monitoring in infants and children with
severe TBI, a significant body of evidence suggests
that monitoring ICP may be of benefit in this pa-
tient group.9 There is little evidence to support
routine ICP monitoring in moderate TBI, although
this may be indicated in specific cases. ICP moni-
toring in other conditions remains to be defined,
but it is likely that an ICP-targeted approach may
also benefit these patients.1
1.3.2 Methods
Table 1.2 summarizes the various methods of
ICP measurement. Both external ventricular drain
(EVD) and dedicated ICP monitoring devices are
ICP Management
5

used to measure ICP. EVD provides the most accu-
rate measurement of ICP and can be used as a ther-
apy for raised ICP, allowing for drainage of CSF.
However, there is a higher risk of malposition,
infection, and hematoma on insertion. Further-
more, EVD is limited by not being able to measure
ICP and drain CSF simultaneously; therefore, epi-
sodes of increased ICP may be missed.11 When
manually evaluating the level at which an EVD
drains as an indication of ICP, it should be remem-
bered that this pressure measurement is in centi-
meters of water (cm H2O), and not millimeters of
mercury (mm Hg). Conversion of ICP to mm Hg is
achieved by multiplying the value by a factor of
0.74 (e.g., 20 cm H2O ×0.74 =15 mm Hg).
Several di erent ICP monitors are available for
invasive monitoring. These devices may function
on a fiberoptic, strain gauge, or pneumatic mecha-
nism. The usual accepted pressure range for these
monitors is 0 to 100 mm Hg, with an error of no
more than 2 mm Hg between 0 and 20 mm Hg
(as advised by the Association for the Advance-
ment of Medical Instrumentation). Placement of
the pressure monitor probe varies. Intraparenchy-
mal monitors, although perhaps more invasive
than extra-axially sited devices, provide the most
accurate, reliable pressure measurements in this
group, and are the most commonly used type of
monitor in the setting of TBI.9,11 When placed by
experienced personnel, the risk of infection or
hemorrhage is very low. EVD and ICP monitors are
sometimes used in conjunction.11 The most widely
used probes include Camino fiberoptic ICP moni-
toring device (Integra Neuroscience, Plainsboro,
NJ) and the Codman Microsensor ICP transducer
(Johnson & Johnson, New Brunswick, NJ). Recently,
a combined ICP and brain tissue oxygen probe
was introduced (Raumedic AG, Helmbrechts, Ger-
many); however, this still requires wider valida-
tion. Noninvasive methods of ICP measurement
have attracted interest since the 1960s. Various
strategies of indirectly assessing ICP have been
developed, including measuring changes in blood
flow velocity with transcranial Doppler, measure-
ment of optic nerve sheath diameter, and even
measuring cochlear fluid pressure via tympanic
membrane displacement, all of which have dem-
onstrated potential in determining ICP, usually as a
spot measurement. However, none of these modal-
ities have reached a standard of accuracy and
reliability for continuous measurement of ICP to
replace invasive monitoring. Although head com-
puted tomography (CT) scanning plays a role in
estimating ICP in pediatric TBI, it remains an unre-
liable method of detecting raised ICP because of its
poor sensitivity.12
Recording and graphical display of ICP (and
other neurophysiological parameters) augments
the clinical value of ICP monitoring. Systems such
as Intensive Care Monitoring Plus (ICM +, Cam-
bridge University, UK13) allow for real-time display
of ICP (and calculated variables such as CPP) trends
at the bedside. This system not only assists with
patient treatment and decision-making in the ICU,
but also records a multitude of parameters, form-
ing a database that may later be analyzed and used
for research purposes. Continuous recording iden-
tifies more episodes of adverse changes in the
monitored variables and allows for appreciation of
the dynamic interplay, for example, the relation-
ship between BP and ICP.
1.3.3 Raised ICP—When to Treat?
Numerous studies have shown sustained elevation
in ICP to be associated with death or poor outcome
in severe pediatric TBI. There are, however, little
data on normal values for pediatric ICP. Although
level II evidence exists that treatment should be ini-
tiated at an ICP threshold of 20 mm Hg in adult
patients with severe TBI, no such studies exist for
the pediatric population. This cuto is extrapolated
to children, but it is highly likely that this value
might not be appropriate for smaller children and
infants, whose lower MAP and CPP (and less robust
autoregulatory capacity) probably necessitate a
lower ICP target. The duration of ICP elevation is
also significant and should be included in the deci-
sion of whether or not ICP should be treated.
A number of ICP waveforms may be observed
with continuous visual charting of ICP. Pulse waves
reflect small changes in ICP related to arterial
pulsation within the intracranial compartment.
Breathing waves represent a second-class wave
Table 1.2 Methods of measuring ICP
External ventricular drain
ICP monitoring devices

Intraparenchymal
Subdural/subarachnoid
Epidural
Noninvasive methods

Transcranial Doppler
ultrasound
Optic nerve sheath
diameter measurement
Cochlear fluid pressure
measurement
Abbreviation: ICP, intracranial pressure.
General and Critical Care
6