Category Archives: Pediatrics

Nursing Care of the Pediatric Neurosurgery Patient

Nursing Care of the Pediatric Neurosurgery Patient

Nursing Care of the Pediatric Neurosurgery Patient

List Price:$149.00


This updated third edition is a detailed reference for nurses and other health care providers who care for children with neurosurgical conditions. The explanations of pathophysiology, anatomy, neurodiagnostic imaging, and treatment options for each neurosurgical diagnosis will help to clarify the rationale behind the nursing care. Descriptions of presenting symptoms, history and findings on neurological examination will help nurses understand the neurological disorder and identify problems. New chapters have been added on skull and scalp anomalies, pediatric concussion, abuse head trauma and on neuroimaging. Each chapter includes case studies, impact on families, patient and family education, and practice pearls. Staff and student nurses working in clinics, critical care units, pediatric units, operating rooms, post-anesthesia care units, emergency departments, and radiology departments will benefit from the information presented. Although this book is written for nurses, child life therapists, physical and occupational therapists, medical students and neurosurgery residents will also find it helpful. Parents of children with neurosurgical disorders will also find it a useful resource in understanding their child’s condition.

Product Details

  • Published on: 2017-04-28
  • Original language: English
  • Number of items: 1
  • Dimensions: 10.25″ h x 7.25″ w x 1.50″ l,
  • Binding: Hardcover
  • 613 pages

Editorial Reviews


From the reviews:

“…The attributes of this text result in a much wider appeal than to just pediatric neurosurgical nurses. This book will prove useful to anyone remotely interested in pediatric neurosurgery. I have no hesitation in recommending a copy be in every neurosurgical residency library. Hospitals will find this a useful textbook reference to place on the pediatrics floors for nurses and pediatric house staff to be able to quickly and concisely review any of the various neurosurgical subjects along with appropriate surgical interventions. Libraries will find this book is a must addition if they have patrons interested in neurosurgery. My only caveat is that I suspect this book will have a high disappearance (ie, “borrowing”) rate due to its value as a great educational tool.” (J.T. Goodrich, JAMA, November 2007)

“This book provides a one-of-a-kind clinical resource for nursing staff who work with this challenging population of patients. In addition to the easy-to-read text, this book includes 119 figures and 61 tables of valuable information to enhance nursing practice. … is written for nurses who are for pediatric neurosurgery patients but is also a tremendous reference for students and others in the healthcare profession. … This book will be a tremendous resource for me, and for the patients and staff with whom I work.” (Julie A Warren, Doody’s Review Service, August, 2007)

“The architecture of the book, subdivided in 12 multi-authored chapters, is quite solid, each contribution offering the basic knowledge necessary to understand the pathophysiology of a given disease, the essential of the surgical management, and the nurses’ considerations. Each chapter is nicely illustrated and enriched by numerous tables aimed at illustrating specific points, as well as providing further sources of information when needed … . Although this book is written by nurses, also medical students and neurosurgeons in training will find its reading quite useful.” (Concezio Di Rocco, Child’s Nervous System, Vol. 23, 2007)

From the Back Cover
This updated third edition is a detailed reference for nurses and other health care providers who care for children with neurosurgical conditions. The explanations of pathophysiology, anatomy, neurodiagnostic imaging, and treatment options for each neurosurgical diagnosis will help to clarify the rationale behind the nursing care. Descriptions of presenting symptoms, history and findings on neurological examination will help nurses understand the neurological disorder and identify problems. New chapters have been added on skull and scalp anomalies, pediatric concussion, abuse head trauma and on neuroimaging. Each chapter includes case studies, impact on families, patient and family education, and practice pearls. Staff and student nurses working in clinics, critical care units, pediatric units, operating rooms, post-anesthesia care units, emergency departments, and radiology departments will benefit from the information presented. Although this book is written for nurses, child life therapists, physical and occupational therapists, medical students and neurosurgery residents will also find it helpful. Parents of children with neurosurgical disorders will also find it a useful resource in understanding their child’s condition.

About the Author

Cathy C. Cartwright, MSN, RN-BC, PCNS, FAAN is a Pediatric Clinical Nurse Specialist and Director of Advanced Professional Practice at Children’s Mercy Hospital, Kansas City, Missouri. Prior to this position, she worked at the Children’s Hospital, University Hospitals and Clinics, Columbia, Missouri in a variety of positions, including Pediatric Clinical Nurse Specialist in Neurosurgery, Manager of Pediatric Services, Pediatric Outreach Coordinator, and Manager of the Pediatric Intensive Care Unit. She has received many awards, including the 2015 Magnet Nurse of the Year for Exemplary Professional Practice, an Excellence in Advanced Practice Award from the American Association of Neuroscience Nurses, March of Dimes Future of Nursing Award (Pediatric) and a Circle of Excellence Award (Management). She was President of the American Association of Neuroscience Nurses in 2009-10, having previously served on its Board of Directors. She has an extensive publication record and has given numerous national and international presentations.
Donna C. Wallace is currently a Pediatric Nurse Practitioner in the Neurosurgery Division of Banner Children Specialists, at Cardon Children’s Medical Center in Mesa, Arizona. Prior to that, she was a Nurse Practitioner for 16 years at the Barrow Neurological Institute in Phoenix, Arizona. Ms. Wallace has been a manager, and has also held several teaching positions. She has received several awards including the Mary Decker Mentorship Award, and the Excellence in Advanced Practice Award, from the American Association of Neuroscience Nursing (AANN). Additionally, she has served on the AANN Board of Directors.  Her passion for writing has resulted in numerous articles and lectures.

Journal of Neurosurgery: Pediatrics March 2017

  • FREE

    Factors influencing outcomes of the treatment of positional plagiocephaly in infants: a 7-year experience

    Sandi Lam, MD, MBA1, I-Wen Pan, PhD1, Ben A. Strickland, MD1, Caroline Hadley, MD1, Bradley Daniels, BS1, Jim Brookshier, CPO, LPO2, and Thomas G. Luerssen, MD1 1Department of Neurosurgery/Division of Pediatric Neurosurgery, Texas Children’s Hospital/Baylor College of Medicine; and 2Hanger Clinic, Houston, Texas

    Pages 273-281

    Abstract | Full Text | PDF (3028 KB) | Add to Favorites

  • The health belief model and factors associated with adherence to treatment recommendations for positional plagiocephaly

    Sandi Lam, MD, MBA1, Thomas G. Luerssen, MD1, Caroline Hadley, MD1, Bradley Daniels, BS1, Ben A. Strickland, MD1, Jim Brookshier, CPO, LPO2, and I-Wen Pan, PhD1 1Department of Neurosurgery/Division of Pediatric Neurosurgery, Texas Children’s Hospital/Baylor College of Medicine; and 2Hanger Orthotics, Houston, Texas

    Pages 282-288

    Abstract | Full Text | PDF (1390 KB) | Add to Favorites

  • Preoperative transdural collateral vessels in moyamoya as radiographic biomarkers of disease

    Armide Storey, BS1, R. Michael Scott, MD1, Richard Robertson, MD2, and Edward Smith, MD1Departments of 1Neurosurgery and 2Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts

    Pages 289-295

    Abstract | Full Text | PDF (5810 KB) | Add to Favorites

  • Possible toxicity following embolization of congenital giant vertex hemangioma: case report

    Ingrid Kieran, MD1, Zaitun Zakaria, MD2, Chandrasekaran Kaliaperumal, FRCSEd2, Declan O’Rourke, MRCP3, Alan O’Hare, FRCR4, Eoghan Laffan, FFR5, John Caird, FRCSI(SN)2, Mary D. King, FRCPI, FRCPCH3, and Dylan J. Murray, FRCS, FDS, FFD1Departments of 1Plastic and Craniofacial Surgery, 2Neurosurgery, 3Pediatric Neurology, and 5Radiology, Temple Street Children’s University Hospital; and 4Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland

    Pages 296-299

    Abstract | Full Text | PDF (3000 KB) | Add to Favorites

  • Correlations of atrial diameter and frontooccipital horn ratio with ventricle size in fetal ventriculomegaly

    Jared M. Pisapia, MD1,2, Martin Rozycki, MS2, Hamed Akbari, MD, PhD2, Spyridon Bakas, PhD2, Jayesh P. Thawani, MD1, Julie S. Moldenhauer, MD3, Phillip B. Storm, MD1,4, Deborah M. Zarnow, MD5, Christos Davatzikos, PhD2, and Gregory G. Heuer, MD, PhD1,4 1Department of Neurosurgery; 2Center for Biomedical Image Computing and Analytics, University of Pennsylvania; 3Center for Fetal Diagnosis and Treatment, Special Delivery Unit; and Divisions of 4Neurosurgery and 5Neuroradiology, Children’s Hospital of Philadelphia, Pennsylvania

    Pages 300-306

    Abstract | Full Text | PDF (5343 KB) | Add to Favorites

  • Hydrocephalus in a patient with an unruptured pial arteriovenous fistula: hydrodynamic considerations, endovascular treatment, and clinical course

    Jesús A. Morales-Gómez, MD1, Vicente V. Garza-Oyervides, MD1, José A. Arenas-Ruiz, MD1, Mariana Mercado-Flores, MD2, C. Guillermo Elizondo-Riojas, MD, PhD2, Frederick A. Boop, MD3, and Ángel Martínez-Ponce de León, MD1 1Servicio de Neurocirugía and 2Centro Universitario de Imagen Diagnóstica, Hospital Universitario “Dr. José Eleuterio González,” Monterrey, Nuevo León, México; and 3Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee

    Pages 307-311

    Abstract | Full Text | PDF (2829 KB) | Add to Favorites

  • Endonasal management of pediatric congenital transsphenoidal encephaloceles: nuances of a modified reconstruction technique. Technical note and report of 3 cases VIDEO

    Mehdi Zeinalizadeh, MD1,2, Seyed Mousa Sadrehosseini, MD3, Zohreh Habibi, MD4, Farideh Nejat, MD4, Harley Brito da Silva, MD5, and Harminder Singh, MD6 1Brain and Spinal Cord Injuries Repair and Research Center, 2Department of Neurological Surgery, and 3Department of Otolaryngology-Head & Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences; and 4Department of Neurological Surgery, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran; 5Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, Washington; and 6Department of Neurological Surgery, Stanford University School of Medicine, Stanford, California

    Pages 312-318

    Abstract | Full Text | PDF (6177 KB) | Add to Favorites

  • Report of effective trametinib therapy in 2 children with progressive hypothalamic optic pathway pilocytic astrocytoma: documentation of volumetric response

    Catherine Miller, MD1, Daniel Guillaume, MD1, Kathryn Dusenbery, MD2, H. Brent Clark, MD, PhD3, and Christopher Moertel, MD4Departments of 1Neurosurgery, 2Radiation Oncology, 3Pathology, and 4Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota

    Pages 319-324

    Abstract | Full Text | PDF (3138 KB) | Add to Favorites

  • FREE

    Initial experience with endoscopic ultrasonic aspirator in purely neuroendoscopic removal of intraventricular tumors VIDEO

    Giuseppe Cinalli, MD, Alessia Imperato, MD, Giuseppe Mirone, MD, Giuliana Di Martino, MD, Giancarlo Nicosia, MD, Claudio Ruggiero, MD, Ferdinando Aliberti, MD, and Pietro Spennato, MDDepartment of Pediatric Neurosurgery, Santobono-Pausilipon Children’s Hospital, Naples, Italy

    Pages 325-332

    Abstract | Full Text | PDF (8382 KB) | Add to Favorites

  • Long-term follow-up of superior gluteal artery perforator flap closure of large myelomeningoceles

    Brett A. Whittemore, MD1, Dale M. Swift, MD2, Bradley E. Weprin, MD2, and Frederick J. Duffy Jr., MD3Departments of 1Neurosurgery and 2Pediatric Neurosurgery, University of Texas Southwestern Medical Center, Dallas; and 3Department of Plastic Surgery, Medical City Hospital, Dallas, Texas

    Pages 333-338

    Abstract | Full Text | PDF (5729 KB) | Add to Favorites

  • Solitary fibrous tumors of the spine: a pediatric case report with a comprehensive review of the literature

    Gregory W. Albert, MD1,2, and Murat Gokden, MD3 1Division of Neurosurgery, Arkansas Children’s Hospital; and Departments of 2Neurosurgery and 3Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas

    Pages 339-348

    Abstract | Full Text | PDF (3947 KB) | Add to Favorites

  • Clinical and surgical management of a congenital Type II split cord malformation presenting with progressive cranial neuropathies: case report VIDEO

    Patrick R. Maloney, MD1, Meghan E. Murphy, MD1, Molly J. Sullan, MS2, Kathryn M. Van Abel, MD2, Shelagh A. Cofer, MD2, John C. Cheville, MD3, and Nicholas M. Wetjen, MD1Departments of 1Neurosurgery, 2Otolaryngology, and 3Pathology, Mayo Clinic School of Medicine, Rochester, Minnesota

    Pages 349-353

    Abstract | Full Text | PDF (6478 KB) | Add to Favorites

  • Interdural cavernous sinus dermoid cyst in a child: case report

    Flavio Giordano, MD1, Giacomo Peri, MD1, Giacomo M. Bacci, MD, PhD2, Massimo Basile, MD3, Azzurra Guerra, MD4, Patrizia Bergonzini, MD4, Anna Maria Buccoliero, MD5, Barbara Spacca, MD1, Lorenzo Iughetti, MD, PhD4, PierArturo Donati, MD1, and Lorenzo Genitori, MD1 1Department of Neurosurgery, 2Neuro-ophthalmology Unit, 3Radiology Unit, and 5Pathology Unit, Anna Meyer Hospital, Firenze; and 4Department of Pediatrics, Ospedale Policlinico, University of Modena, Italy

    Pages 354-360

    Abstract | Full Text | PDF (3846 KB) | Add to Favorites

  • Perioperative outcomes for pediatric neurosurgical procedures: analysis of the National Surgical Quality Improvement Program–Pediatrics

    Benjamin J. Kuo, BS1,2,3, Joao Ricardo N. Vissoci, PhD1,2, Joseph R. Egger, PhD2, Emily R. Smith, PhD1,2, Gerald A. Grant, MD6, Michael M. Haglund, MD, PhD1,2,4, and Henry E. Rice, MD2,5 1Division of Global Neurosurgery and Neuroscience and 2Global Health Institute, Duke University, Durham, North Carolina; 3Duke-NUS Medical School, Singapore; Departments of 4Neurosurgery and 5Surgery, Duke University Medical Center, Durham, North Carolina; and 6Department of Neurosurgery, Stanford University, Stanford, California

    Pages 361-371

    Abstract | Full Text | PDF (1738 KB) | Add to Favorites

  • Letter to the Editor: Postoperative hyponatremia

    María José Mayorga-Buiza, MD, PhD, Mónica Rivero-Garvía, MD, PhD, Javier Márquez-Rivas, MD, PhD, Carlos Velásquez-Rodríguez, MD, and Emilio Gómez-González, PhDHospital Universitario Virgen del Rocío, Seville, Spain; Marqués de Valdecilla Hospital, Santander, Spain; and Seville University, Engineering School, Seville, Spain

    Pages 372-374

    Citation | Full Text | PDF (4495 KB) | Add to Favorites

  • Letter to the Editor: Early seizure prophylaxis in pediatric severe traumatic brain injury: still a long way to go

    Eduardo Mekitarian Filho, MD, MSc, PhDUniversity of São Paulo, São Paulo, Brazil

    Pages 374-375

    Monica S. Vavilala, MD, Qian Qiu, MBA, Paige J. Ostahowski, BA, Nithya Kannan, MD, Douglas F. Zatzick, MD, Richard G. Ellenbogen, MD, Linda Ng Boyle, PhD, Pamela H. Mitchell, PhD, Mark S. Wainwright, MD, PhD, Richard B. Mink, MD, MACM, Jonathan I. Groner, MD, Michael J. Bell, MD, and Christopher C. Giza, MD

    Citation | Full Text | PDF (4495 KB) | Add to Favorites

  • Letter to the Editor: Cranial vault remodeling

    Miguel Gelabert-González, PhD, Eduardo Arán-Echabe, MD, and José María Santín-Amo, MDUniversity of Santiago de Compostela, Spain

    Pages 375-376

    Joseph Lopez, MD, MBA, Alan Utria, MD, Regina S. Cho, BS, Gerhard S. Mundinger, MD, Craig Vander Kolk, MD, George I. Jallo, MD, Edward S. Ahn, MD, and Amir Dorafshar, MBChB

    Citation | Full Text | PDF (4495 KB) | Add to Favorites

Update: Infantile acute subdural hematoma


Acute subdural hematoma in infants is distinct from that occurring in older children or adults because of differences in mechanism, injury thresholds, and the frequency with which the question of nonaccidental injury is encountered.

When trauma occur the motor vehicle accidents are the most frequent.

In the series of Loh et al. the most common cause of injury was shaken baby syndrome 1).

The accuracy of the history obtained from the caregivers of infants may be low in severe infantile head trauma. Therefore, medical professionals should treat the mechanism of injury obtained from caregivers as secondary information and investigate for possible abusive head trauma (AHT) in cases with inconsistencies between the history that was taken and the severity of the injury observed 2).

Chronic subdural effusions in infancy may arise from trauma, from various types of meningitis, from severe dehydration, or “idiopathically” 3).


Diagnosis can be made by computed tomography or magnetic resonance imaging 4).

Large subdural hematoma of the right convexity up to 3 cm thick, which causes severe cerebral compression, with cingulate herniation and transtentorial herniation.

The hematoma shows liquid-liquid levels, with a higher density lower in relation to sedimented hematoma.

Signs of diffuse brain edema.


Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality 5).

Case series


Medical records and films of 21 cases of infantile acute subdural hematoma were reviewed retrospectively. Diagnosis was made by computed tomography or magnetic resonance imaging. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome.

Twenty-one infants (9 girls and 12 boys) were identified with acute subdural hematoma, with ages ranging from 6 days to 12 months. The most common cause of injury was shaken baby syndrome. The most common clinical presentations were seizure, retinal hemorrhage, and consciousness disturbance. Eight patients with large subdural hematomas underwent craniotomy and evacuation of the blood clot. None of these patients developed chronic subdural hematoma. Thirteen patients with smaller subdural hematomas were treated conservatively. Among these patients, 11 developed chronic subdural hematomas 15 to 80 days (mean = 28 days) after the acute subdural hematomas. All patients with chronic subdural hematomas underwent burr hole and external drainage of the subdural hematoma. At follow-up, 13 (62%) had good recovery, 4 (19%) had moderate disability, 3 (14%) had severe disability, and 1 (5%) died. Based on GCS on admission, one (5%) had mild (GCS 13-15), 12 (57%) had moderate (GCS 9-12), and 8 (38%) had severe (GCS 8 or under) head injury. Good recovery was found in 100% (1/1), 75% (8/12), and 50% (4/8) of the patients with mild, moderate, and severe head injury, respectively. Sixty-three percent (5/8) of those patients undergoing operation for acute subdural hematomas and 62% (8/13) of those patients treated conservatively had good outcomes.

Infantile acute subdural hematoma if treated conservatively or neglected, is an important cause of infantile chronic subdural hematoma. Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality 6).


Hwang et al., reviewed a total of 16 infant head injury patients under 12 months of age who were treated in from 1989 to 1997. Birth head injury was excluded. The most common age group was 3-5 months. Early seizures were noted in 7 cases, and motor weakness in 6. Three patients with acute intracranial hematoma and another 3 with depressed skull fracture were operated on soon after admission. Chronic subdural hematomas (SDHs) developed in 3 infants. Initial CT scans showed a small amount of SDH that needed no emergency operation. Resolution of the acute SDH and development of subdural hygroma appeared on follow-up CT scans within 2 weeks of injury. Two of these infants developed early seizures. Chronic SDH was diagnosed on the 68th and 111th days after the injuries were sustained, respectively. The third patient was the subject of close follow-up with special attention to the evolution of chronic SDH in view of our experience in the previous 2 cases, and was found to have developed chronic SDH on the 90th day after injury. All chronic SDH patients were successively treated by subduro-peritoneal shunting. In conclusion, the evolution of chronic SDH from acute SDH is relatively common following infantile head injury. Infants with head injuries, especially if they are associated with acute SDH and early development of subdural hygroma, should be carefully followed up with special attention to the possible development of chronic SDH 7).


A retrospective analysis of the infantile acute subdural hematoma was made by Ikeda et al., with special reference to its pathogenesis.

In 11 of 15 cases, the hematomas were bilateral or a contralateral subdural fluid collection was present. In 7 of 11 patients who underwent operation the collection was bloody fluid and/or clotted blood. In 3 patients, a subdural membrane, as seen in adult chronic subdural hematoma, was found. In only 1 patient with unilateral hematoma was clotted blood present without subdural membrane. The thickest collection of clotted blood was in the parasagittal region. It is postulated that in most cases hemorrhage occurs after minor head injury, from the bridging veins near the superior sagittal sinus, into a pre-existing subdural fluid collection such as chronic subdural hematoma or subdural effusion with cranio-cerebral disproportion, and that infants without intracranial disproportion are unlikely to have acute subdural hematoma caused by minor head injury 8).


Aoki et al. report six Japanese cases of child abuse with subdural hematoma and discuss differences from those in the United States. The majority of abused children with subdural hematomas in Japan have suffered direct violence to the face and head, resulting in external signs of trauma. Failure to detect these external traces of trauma, however, might result in an incorrect diagnosis of infantile acute subdural hematoma attributed to accidental trivial head injury. Child abuse with subdural hematoma in the United States is frequently caused by whiplash shaking injury in which external signs of trauma may not be evident. In the United States, retinal hemorrhage and subdural hematoma together suggest child abuse; some cases of infantile acute subdural hematoma might be mistakenly diagnosed as child abuse. Thus, the constellation of retinal bleeding and subdural hematoma combined with the absence of visible signs of trauma is differently interpreted in the United States and Japan 9).


Twenty-six cases of infantile acute subdural hematoma treated between 1972 and 1983 were reviewed. The series was limited to infants with acute subdural hematoma apparently due to minor head trauma without loss of consciousness, and not associated with cerebral contusion. Twenty-three of the patients were boys, and three were girls, showing a clear male predominance. The patients ranged in age between 3 and 13 months, with an average age of 8.1 months, the majority of patients being between 7 and 10 months old. Most of the patients were brought to the hospital because of generalized tonic convulsion which developed soon after minor head trauma, and all patients had retinal and preretinal hemorrhage. The cases were graded into mild, intermediate, and fulminant types, mainly on the basis of the level of consciousness and motor weakness. Treatment for fulminant cases was emergency craniotomy, and that for mild cases was subdural tapping alone. For intermediate cases, craniotomy or subdural tapping was selected according to the contents of the hematoma. The follow-up results included death in two cases, mild physical retardation in one case, and epilepsy in one case. The remaining 23 patients showed normal development. The relationship between computerized tomography (CT) findings and clinical grading was analyzed. Because some mild and intermediate cases could be missed on CT, the importance of noting the characteristic clinical course and of funduscopic examination is stressed 10).

Case reports


An unusual case of ruptured infantile cerebral aneurysm. An eight-month-old infant was delivered to the hospital in poor condition, after convulsions, with no history of trauma. His emergent CT study revealed acute subdural hematoma. The clinical and radiological picture evoked suspicion that the hematoma was of aneurysmal origin. The infant was operated with special preparations and precautions appropriate for aneurysmal surgery, and has shown a good recovery. It is important to consider the possibility of vascular accident in infants with subdural hematoma of nontraumatic origin. A good outcome may be achieved when appropriate preparations are made prior to surgery 11).


Huang et al. the case of an infant with a traumatic acute subdural hematoma that resolved within 65 hours. A 23-month-old boy fell from a height of approximately 10 m. Brain computed tomography disclosed a left subdural hematoma with midline shift. The associated clots resolved spontaneously within 65 hours of the injury. Although they may mimic more clinically significant subdural hematomas, such collections of clots are likely to be located at least partly within the subarachnoid space. Their recognition may influence decisions regarding both surgical evacuation and the likelihood of non-accidental injury. Clinical and radiographic features distinguishing these “disappearing subdural hematomas” from more typical subdural hematomas are discussed 12)

Own case report

A 1 year old , according to anamnesis provided by the parents, they consulted in the last month for cough clinic with low expectoration, nasal congestion, Tº up to 38ºC of 24 hrs evolution. According to an emergency report: the previous week the patient presents right facial edema, of 2 days duration.

Scratch injuries in legs.

In the next days vomiting with progressive decay.

In the following hours after admission coma, respiratory arrest with bradycardia

Large subdural hematoma of the right convexity up to 3 cm thick, which causes severe cerebral compression, with cingulate herniation and transtentorial herniation.

The hematoma shows liquid-liquid levels, with a higher density lower in relation to sedimented hematoma.

Signs of diffuse brain edema.

In the surgical intervention xanthochromia appears at the beginning, later dark red liquid without clots. Later a subdural membrane is seen on the arachnoid surface, very characteristic of chronic subdural hematoma.

1) , 4) , 5) , 6)

Loh JK, Lin CL, Kwan AL, Howng SL. Acute subdural hematoma in infancy. Surg Neurol. 2002 Sep-Oct;58(3-4):218-24. PubMed PMID: 12480224.


Amagasa S, Matsui H, Tsuji S, Moriya T, Kinoshita K. Accuracy of the history of injury obtained from the caregiver in infantile head trauma. Am J Emerg Med. 2016 Sep;34(9):1863-7. doi: 10.1016/j.ajem.2016.06.085. PubMed PMID: 27422215.


Amacher AL, Li KT. Indirect trauma as a cause of acute infantile subdural hematomas. Can Med Assoc J. 1973 Jun 23;108(12):1530. PubMed PMID: 4714878; PubMed Central PMCID: PMC1941542.


Hwang SK, Kim SL. Infantile head injury, with special reference to the development of chronic subdural hematoma. Childs Nerv Syst. 2000 Sep;16(9):590-4. PubMed PMID: 11048634.


Ikeda A, Sato O, Tsugane R, Shibuya N, Yamamoto I, Shimoda M. Infantile acute subdural hematoma. Childs Nerv Syst. 1987;3(1):19-22. PubMed PMID: 3594464.


Aoki N, Masuzawa H. Subdural hematomas in abused children: report of six cases from Japan. Neurosurgery. 1986 Apr;18(4):475-7. PubMed PMID: 3703222.


Aoki N, Masuzawa H. Infantile acute subdural hematoma. Clinical analysis of 26 cases. J Neurosurg. 1984 Aug;61(2):273-80. PubMed PMID: 6737052.


Adeleye AO, Shoshan Y, Cohen JE, Spektor S. Ruptured middle cerebral artery aneurysm in an infant presenting as acute subdural hematoma: a case report. Pediatr Neurosurg. 2008;44(5):397-401. doi: 10.1159/000149908. PubMed PMID: 18703887.


Huang SH, Lee HM, Lin CK, Kwan AL, Howng SL, Loh JK. Rapid resolution of infantile acute subdural hematoma: a case report. Kaohsiung J Med Sci. 2005 Jun;21(6):291-4. PubMed PMID: 16035574.

XXXIII Reunión de la SENEP 2017

Se celebrará en Madrid los próximos días 9, 10 y 11 de Febrero de 2017.

Este año, el tema escogido para la Reunión es “Encuentro con los expertos” (“Meet the experts”).

8:15 h – 8:30 h Apertura de Secretaría y recogida de documentación.
8:30 h – 9:10 h TALLER: Brainlab (Grupo 1)
9:15 h – 9:55 h TALLER: Osteoplac (Grupo 1)
10:00 h – 10:40 h TALLER: Brainlab (Grupo 2)
10:45 h – 11:25 h TALLER: Osteoplac (Grupo 2)
8:30 h – 9:10 h TALLER: BBraun (Grupo 2)
9:15 h – 9:55 h TALLER: Acuña y Fombona (Grupo 2)
10:00 h – 10:40 h TALLER: BBraun (Grupo 1)
10:45 h – 11:25 h TALLER: Acuña y Fombona (Grupo 1)
11:30 h – 11:50 h Pausa-Café.
11:50 h – 12:10 h Inauguración de la XXXIII Reunión de la SENEP.
12:15 h – 13:45 h “COLUMNA”
Modera: Dr. Antonio Huete Allut y Dr. Mario García Conde.
12:15 h – 12:45 h.
Malformaciones de charnela occipital. Dr. Dominique Thompson.
Paediatric Neurosurgeon, Great Ormond Street Hospital for Children NHS Trust,
Camden, Londres.
12:45 h – 13:15 h.
Syringomyelia in children. Dr. Michel Zerah. Hôpital Necker-Enfants Malades, París.
13:15 h – 13:45 h.
Embriology of the Neural tube defects with costo-vertebral abnormalities
and other congenital abnormalities. Dr Soner Duru. Profesor Doctor.
Universidad de Duzce, Turquía.
13:45 h – 15:30 h Almuerzo de trabajo.
8:30 h – 11:00 h “ONCOLOGÍA”
Modera: Dr. José Hinojosa Mena-Bernal y Dra. Sonia Tejada Solís.
8:30 h – 9:00 h.
Gliomas de la vía óptica: ¿Cuándo intervenir quirúrgicamente?
Dra. Martina Messing-Junger. Neurocirujana. St. Augustine. Asklepios, Bonn.
9:00 h – 9:30 h.
Intraoperative MRI in LGG. Dr. Connor Mallucci.
Alder Hey Children’s Hospital. Liverpool.
9:30 h – 10:00 h.
Tumores de los hemisferios cerebrales. Dr. Artur Da Cunha.
Presidente de la Sociedad Brasileña de Neurocirugía Pediátrica.
10:00 h – 10:30 h.
Antenatal tumors. Dr. Michel Zerah. Hôpital Necker-Enfants Malades, París.
 10:30 h – 11:00 h.
Abordajes a tumores del III Ventrículo. Dr. Fernando Carceller Benito.
Hospital Universitario La Paz, Madrid.
11:00 h – 11:15 h Pausa – Café.
11:15 h – 11:55 h Taller Baxter.
Taller Hemostasia y Sellado
12:00 h – 14:00 h “ONCOLOGÍA”
Modera: Dr. Javier Orduna Martínez y Dr. Enrique Ferrer Rodríguez.
12:00 h – 12:30 h.
El manejo inicial de los Craneofaringiomas a la edad pediátrica: controversias.
Prof. Maurice Choux. Consultor en el Departamento de Neurocirugía
Pediátrica – Hôpital des Enfants, La Timone.

12:30 h – 13:00 h.
Manejo de los tumores de la región pineal. Dr. Amets Sagarribay.
Centro Hospitalar de Lisboa Central.
13:00 h – 13:30 h.
Astrocitomas y ependimomas de fosa posterior.
Dr. Antonio Guillén Quesada.
Hospital San Juan de Dios, Barcelona.
13:30 h – 14:00 h.
Meduloblastoma: actualización diagnóstica y terapéutica. Dra. Belén Rivero Martín.
Hospital Universitario Infantil Niño Jesús, Madrid.
14:00 h – 15:30 h  Almuerzo de trabajo.
9:00 h – 9:40 h TALLER: Epilepsia. Livanova.
10:00 h – 11:40 h “EPILEPSIA”
Modera: Dr. Francisco Villarejo Ortega y Dr. Antonio López López-Guerrero.
10:00 h – 10:20 h.
Demanda estructural de la nueva cirugía de la Epilepsia.
Dr. Enrique Ferrer Rodríguez. Jefe de Servicio de Neurocirugía
Hospital San Juan de Dios, Barcelona.
10:25 h – 10:45 h.
Tratamiento quirúrgico de las displasias corticales en área elocuente:
indicación, técnica y resultados. Dr. Marcelo Budke. Hospital Universitario
Infantil Niño Jesús, Madrid.
10:50 h – 11:10 h.
Estimulación del nervio vago: técnica e indicaciones.
Dra. Cristina Torres Díaz. Hospital de la Princesa, Madrid.
11:20 h – 11:40 h.
Monitorización invasiva en epilepsia infantil.
Dra. Rebeca Conde Sardon. Hospital La Fe, Valencia.
11:45 h – 12:15 h Pausa – Café.
12:15 h – 13:55 h “HIDROCEFALIA”
Modera: Dra. Eva Cardona Gallego y Dra. Beatriz Pascual Martín.
12:15 h – 12:35 h.
Utilidad y controversias en el tratamiento endoscópico de la hidrocefalia
en lactantes. Dr. Mario García Conde. Hospital Universitario de Canarias, Tenerife.
12:40 h – 13:10 h.
Actualizaciones y controversias en la hidrocefalia pediátrica.
Dra. Mª Antonia Poca Pastor. Hospital Universitario Vall D’Hebron, Barcelona.
13:15 h – 13:35 h.
Hidrocefalia posthemorrágica: clasificación pronóstica.
Dr. Bienvenido Ros López. Hospital Regional Universitario, Málaga.
13:35 h – 13:55 h.
Complicaciones y sobredrenaje en las derivaciones de LCR.
Dr. Pablo Miranda Lloret. Hospital La Fe, Valencia.
Círculo de Bellas Artes-Sala Valle Inclán

Book: Pediatric Vascular Neurosurgery: Disorders and their Management

Pediatric Vascular Neurosurgery: Disorders and their Management

Pediatric Vascular Neurosurgery: Disorders and their Management

List Price: $179.00


This book answers frequently asked questions about common pediatric neurosurgical conditions related to vascular malformations of the brain and spinal cord, in an attempt to fill in the gap and answer numerous questions that arises after a diagnosis is made.

Pediatric patients with neurosurgical conditions are almost always referred from either primary care physicians, neurologists internists or a specialist in family medicine. Recently, neurosurgeons treating adult population also refer a pediatric patient to their colleague specialized in this field.
There are over 1500 academic and private hospitals in the US who have dedicated tertiary Neurosurgery services and cater thousands of small children every year, in addition to numerous centers that have level 1 and 2 trauma care. However, there are few tertiary level Pediatric centers which can provide quality care for neurosurgical conditions.
This book is specially written and illustrated for residents, fellows and consultants/attendings in all pediatric related specialties, including but not limited to Neurosurgery, Neurology, Pediatrics, Radiology, Anesthesia.

Product Details

  • Published on: 2017-01-03
  • Original language: English
  • Number of items: 1
  • Dimensions: 9.30″ h x .0″ w x 6.10″ l, .0 pounds
  • Binding: Hardcover
  • 327 pages

Editorial Reviews

From the Back Cover
This book focuses on core concepts of vascular neurosurgery in pediatric population,. It is designed to fill the knowledge gaps and to answer the frequently sought questions on various management strategies for commonly encountered pediatric neurosurgical conditions. The chapters, authored by experts in their respective field, provide a standard of care based on current diagnostic and management guidelines for pediatric neurosurgical diseases.

Pediatric Vascular Neurosurgery – Disorders and their Management is specially written and illustrated for residents, fellows and consultants in all pediatric related specialties, including but not limited to Neurosurgery, Neurology, Pediatrics, Neuroradiology and Neuroanesthesia.

About the Author
Dr Abhishek Agrawal, M.D.: House Staff, Department of Neurosurgery/ Radiology, Brigham and Women’s’ Hospital, Harvard Medical School, Boston.

Dr Gavin Britz, MBCCh, MPH, MBA, FAANS: Chairman, Department of Neurosurgery, Methodist Neurological Institute, Houston, Texas

Update: Caudal duplication syndrome

Spinal and spinal cord duplicity (diastematomyelia) malformations span a wide spectrum of anomalies, ranging from a simple fibrous band splitting the cord into halves to complete duplication of the spine and spinal cord. The more serious forms are rare and only a limited number of cases are on record.

They are usually associated with other systemic malformations, including duplication of vascular structures, of the distal gastrointestinal and urogenital tracts, and possibly limb malformations. The term caudal duplication syndrome has been applied to those instances.

This entity was first described by Dominguez et al.from the Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas. They reported 6 new cases as well as reviewed 8 already reported cases of multiple anomalies and duplication of the distal organs derived from the hindgut, neural tube and adjacent mesoderm 1).

Caudal duplication was considered a rare type of conjoined twins previously 2) in which structures derived from the embryonic cloaca and notochord are duplicated to various extent.

The term encompasses a spectrum and often is quoted as one type of incomplete separation of monovular twins. Bajpai et al., present more evidence giving credence to caudal twining as the mechanism behind the syndrome. 3).


Caudal duplication syndrome is a rare condition with only about 40 cases reported in the literature 4).

Female patients predominate in a ratio of about 2:1, and no familial or racial predilection has been shown 5).


Exact etiology of caudal duplication syndrome is unknown. Various theories have been suggested. Incomplete separation of monozygotic twin has been postulated as the etiologic factor 6) 7).

Pang et al. advanced a unified theory for the spinal cord duplication disorders, suggesting that all result from abnormal adherence between ectoderm and endoderm 8).

In the view of Dominguez et al. these anomalies originate from damage to the mass formed by caudal cells and posterior gut at approximately 25 days of pregnancy 9).


Pathogenesis is unclear. Polytopic primary developmental field defect or a disruption sequence or somatic or germ line mutations in certain developmental genes could be involved 10).

Partial or complete duplication of the organizing centre within a single embryonic disc may increase the risk of mesodermal insufficiency and thus account for the failure of complete development of the cloacal membrane and consequent exostrophy or other aberrations 11).

Clinical features

It is a range of disease comprising gastrointestinal, genitourinary, vertebral, spinal, and limb abnormalities. Common gastrointestinal anomalies include duplication of the colon and rectum, which may be associated with a variety of other anomalies such as imperforate anus, rectal fistula, ventral hernia, omphalocele, duplication of terminal ileum, double appendices, Meckel’s diverticulum, intestinal malrotation, and situs inversus.

Urogenital anomalies comprise duplication of the external and internal genitalia, ureters, and bladder and anomalies of the kidney.

Spinal anomalies include hemivertebra, sacral agenesis, myelomeningocele, diplomyelia, duplication of lumbar spine, butterfly vertebra, and spina bifida 12).

Most patients have associate moderate to severe neurodeficit; although some can be neurologically normal 13).


Treatment consists of staged correction of duplication anomalies. Either stripping of mucosa or resection of duplicated colon and rectum is undertaken. Division of septum in the UB is done to make it a single chamber. Corrective surgery in the form of fusion is done for the external and internal genitalia. Any spinal anomaly is also corrected suitably. Many authors have reported near-normal cosmetic and functional result for these complicated anomalies.

Shah and Joshi 14) suggested removal of one of the hemi-phalluses for cosmetic reasons in males. No corrective surgery was, however, done in the adult female patient reported by them. Liu et al. reported the case of caudal duplication syndrome in which they did multiple stage correction. The bladder septum was removed, the two hemi-phalluses were fused to form one phallus, and the duplicated colon was excised. The patient also had hydronephrotic left kidney and left megaureter, which were removed. Ultimate outcome is good 15).

These patients are difficult to manage posing numerous surgical as well as medical management challenges. Child’s organ systems are usually working normally. Certain questions arise, should one intervene? When should one intervene? And what should be the best intervention, fusion or excision of accessory organ? Organ duplication syndromes are difficult scenarios to manage. Treatment should always be individualized according to the extent of duplication and functionality of the organ systems involved. The malformations that are potentially life-threatening should be addressed first 16).

Case series

In six children with multiple anomalies and duplications of distal organs derived from the hindgut, neural tube, and adjacent mesoderm, spinal anomalies (myelomeningocele in two patients, sacral duplication in three, diplomyelia in two, and hemivertebrae in one) were present in all the patients. Duplications or anomalies of the external genitalia and/or the lower urinary and reproductive structures were also seen in all our patients. Ventral herniation (in one patient), intestinal obstructions (in one patient), and bowel duplications (in two patients) were the most common gastrointestinal abnormalities.

Dominguez et al., believe that the above constellation of abnormalities resulted from an insult to the caudal cell mass and hindgut at approximately the 23rd through the 25th day of gestation. They propose the term caudal duplication syndrome to describe the association between gastrointestinal, genitourinary, and distal neural tube malformations17).

Case reports


A full-term male presented with combination of anomalies including anorectal malformation, duplication of the colon and lower urinary tract, split of the lower spine, and lipomyelomeningocele with Tethered cord.

Samuk et al., report this exceptional case of caudal duplication syndrome with special emphasis on surgical strategy and approach combining all disciplines involved. The purpose of this report is to present the pathology, assessment, and management strategy of this complex case 18).

A 28-year-old female, gravida 2 para 2, with congenital caudal malformation who has undergone partial reconstructive surgeries in infancy to connect her 2 colons. She presented with recurrent left lower abdominal pain associated with nausea, vomiting, and subsequent feculent anal discharge. Imaging reveals duplication of the urinary bladder, urethra, and colon with with cloacal malformations and fistulae from the left-sided cloaca, uterus didelphys with separate cervices and vaginal canals, right-sided aortic arch and descending thoracic aorta, and dysraphic midline sacrococcygeal defect. Hydronephrosis of the left kidney with left hydroureter and inflammation of one of the colons were suspected to be the cause of the patient’s acute complaints. She improved symptomatically over the course of her hospitalization stay with conservative treatments 19).


A 3-month-old male infant had presented with the classical form of the disease i.e., duplication of the gastrointestinal, genitourinary system and vertebral column with anterior abdominal wall hernia and a large lipomeningocele 20).


Sur et al., report the case of a baby presenting on the first day of life with complete duplication of caudal structures below the dorsolumbar level 21).

A 3-day-old male neonate presented with features of anorectal malformation and duplication of the external genitalia. He was subsequently diagnosed with complete duplication of the colon, rectum, bladder, and urethra associated with spinal lipoma 22).


A 13-year-old boy was born with duplicated colon-rectum and anus, diphallus, hydronephrosis of left kidney with megaureter, double bladders and urethras, and vertebral abnormalities. Multiple-stage correction was performed to remove the duplicated colon and the mucosa of the duplicated rectum. A new colon was reconstructed. The left kidney and megaureter were excised. The septum in the bladders was removed to convert the double bladders into a single bladder. The double phalluses were fused into a single penis. After these staged procedures, the boy is now living a normal life 23).

A female infant, born by cesarean delivery (dilation dystocia), was referred at age of 24 hours with a history of “imperforate anus”. Physical examination revealed duplicity of the vulvar introit (urine output by the right orifice and feces by the left). She was submitted to the following imaging exams: (1) echodopplercardiogram – interatrial and interventricular communications; (2) ultrasonography – pelvic left kidney; (3) barium enema – one of the perineal orifices had a communication with the rectum; the other communicated with the vaginal dome and the bladder (urogenital sinus); (4) voiding cystourethrogram (VCU) – two urethral orifices communicating with the bladder, bladder diverticulum on the right side and vesico-ureteral reflux (grade II) on the left side.

Investigation of the spine was done with conventional radiographs (XR), computed tomography (CT) and magnetic resonance imaging (MRI), which disclosed complex malformations of the thoracic and lumbosacral spine, with “S” shaped dextroscoliolis. Aortic duplication was also noted. The vertebral bodies of T1, T2, T4 and T10 were widened and split by an anterior median incisure. A T7 hemivertebra was also present. From T11 level there was complete duplication of the vertebral bodies extending down to the S2 level. The remaining sacral and coccigeal vertebrae were absent. Duplicated vertebrae were joined posteriorly by deformed laminae and encompassed an extremely enlarged spinal canal. The spinal cord was duplicated from level T1 downwards. From L1 level, a large lipoma occupied the spinal canal and communicated with the subcutaneous tissues inferiorly 24).


In a 2-year-old female child, a case of abnormal mass in the perineum with undeveloped feet, duplication of colon, external genitalia, and lumbosacral vertebra was reported by D’Costa et al. 25).


Shah and Joshi reported the case of an asymptomatic adult female with duplication of colon, rectum, anus, urinary bladder (UB), urethra, uterus, cervix, vagina, and external genitalia 26).


Bajpai et al., report successful surgical management of a full-term infant with a constellation of anomalies of caudal duplication syndrome 27).

Radiographic, CT, and MR images of a 15-year-old girl who had lower back pain showed asymmetric lumbar spine duplication with spinal cord tethering secondary to a filum lipoma in the sacrum. Despite gross spinal abnormalities, the patient was neurologically intact and has been followed up with conservative treatment 28).


An autopsy case of a full-term infant with incomplete caudal duplication syndrome associated with multiple anomalies.

These anomalies included a duplicated penis; double urinary bladder with an attenuated tunica muscularis; duplication of lower bowel with two ilia, appendices and colons; colonic hypogangliosis and left imperforated anus associated with rectourethral fistula. Other anomalies consisted of sacral meningomyelocele, sacral duplication with hypoplastic left sacrum and pelvic bones, muscle atrophy and hypoplasia of the left lower extremity, abnormal lobation of liver with stomach entrapment, omphalocele, and right atrial isomerism syndrome. The complex pattern of anomalies suggests the possibility that partial caudal duplication might be part of the spectrum of conjoined twinning 29).

1) , 9) , 17) Dominguez R, Rott J, Castillo M, Pittaluga RR, Corriere JN Jr. Caudal duplication syndrome. Am J Dis Child. 1993 Oct;147(10):1048-52. Review. PubMed PMID: 8213674.
2) Kapoor R, Saha MM. Complete duplication of the bladder, urethra and external genitalia in a neonate: a case report. J Urol 1987; 137:1243-4.
3) , 27) Bajpai M, Das K, Gupta AK. Caudal duplication syndrome: more evidence for theory of caudal twinning. J Pediatr Surg. 2004 Feb;39(2):223-5. PubMed PMID: 14966746.
4) , 7) , 24) Taneja AK, Zaffani G, Amato-Filho AC, Queiroz Lde S, Zanardi Vde A, Menezes-Netto JR. Caudal duplication syndrome. Arq Neuropsiquiatr. 2009 Sep;67(3A):695-6. PubMed PMID: 19722052.
5) , 12) , 14) , 26) Shah KR, Joshi A. Complete genitourinary and colonic duplication: a rare presentation in an adult patient. J Ultrasound Med. 2006 Mar;25(3):407-11. PubMed PMID: 16495506.
6) , 25) D’Costa GF, Kirtane J, Najmi S, Shedge R. Caudal duplication. Bombay Hosp J. 2008;50(3):529–531.
8) Pang D, Dias MS, Ahab-Barmada M. Split cord malformation: Part I: A unified theory of embryogenesis for double spinal cord malformations. Neurosurgery. 1992 Sep;31(3):451-80. Review. PubMed PMID: 1407428.
10) Kroes HY. Two cases of caudal duplication anomaly including a discordant monozygotic twin. Am J Med Genet 2002; 112:390-3.
11) Seibert A. Association of cloacal anomalies, caudal duplication and twinning. Ped Dev Pathol 2005; 8:339-54.
13) , 28) Incesu L, Karaismailoglu TN, Selcuk MB. Neurologically normal complete asymmetric lumbar spine duplication. AJNR Am J Neuroradiol. 2004 May;25(5):895-6. PubMed PMID: 15140743.
15) , 23) Liu H, Che X, Wang S, Chen G. Multiple-stage correction of caudal duplication syndrome: a case report. J Pediatr Surg. 2009 Dec;44(12):2410-3. doi: 10.1016/j.jpedsurg.2009.09.018. PubMed PMID: 20006039.
16) , 20) Ramzan M, Ahmed S, Ali S. Caudal duplication syndrome. J Coll Physicians Surg Pak. 2014 Jan;24(1):64-6. doi: 01.2014/JCPSP.6466. PubMed PMID: 24411548.
18) Samuk I, Levitt M, Dlugy E, Kravarusic D, Ben-Meir D, Rajz G, Konen O, Freud E. Caudal Duplication Syndrome: the Vital Role of a Multidisciplinary Approach and Staged Correction. European J Pediatr Surg Rep. 2016 Dec;4(1):1-5. doi: 10.1055/s-0035-1570370. PubMed PMID: 28018799.
19) Hu T, Browning T, Bishop K. Caudal duplication syndrome: imaging evaluation of a rare entity in an adult patient. Radiol Case Rep. 2016 Jan 19;11(1):11-5. doi: 10.1016/j.radcr.2015.12.001. PubMed PMID: 26973727; PubMed Central PMCID: PMC4769617.
21) Sur A, Sardar SK, Paria A. Caudal duplication syndrome. J Clin Neonatol. 2013 Apr;2(2):101-2. doi: 10.4103/2249-4847.116412. PubMed PMID: 24049755; PubMed Central PMCID: PMC3775131.
22) Swaika S, Basu S, Bhadra RC, Sarkar R, Maitra SK. Caudal duplication syndrome-report of a case and review of literature. Indian J Surg. 2013 Jun;75(Suppl 1):484-7. doi: 10.1007/s12262-013-0838-z. PubMed PMID: 24426655; PubMed Central PMCID: PMC3693374.
29) Bannykh SI, Bannykh GI, Mannino FL, Jones KL, Hansen L, Benirschke K, Masliah E. Partial caudal duplication in a newborn associated with meningomyelocele and complex heart anomaly. Teratology. 2001 Feb;63(2):94-9. PubMed PMID: 11241432.

The Global Rise of Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Pediatric Hydrocephalus

Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) offers an alternative to shunt treatment for infantile hydrocephalus.

In the quest to identify the optimal means of cerebrospinal fluid diversion free of shunt dependency, endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) has been proposed as a promising procedure in select children. Supplementing traditional ETV with obliteration of the choroid plexus has been shown to decrease the likelihood of ultimate shunt dependency by roughly 20%. Originally devised to treat hydrocephalus in infants in sub-Saharan Africa, ETV/CPC has gained eager attention and cautious support in the developed world 1).

Diagnosing treatment failure is dependent on infantile hydrocephalus metrics, including head circumference, fontanel quality, and ventricle size.

Systematic review

Systematic review was performed using four electronic databases and bibliographies of relevant articles, with no language or date restrictions. Cohort studies of participants undergoing ETV/CPC that reported outcome were included using MOOSE guidelines. The outcome was time to repeat CSF diversion or death. Forest plots were created for pooled mean and its 95 % CI of outcome and morbidity.

Of 78 citations, 11 retrospective reviews (with 524 total participants) were eligible. Efficacy was achieved in 63 % participants at follow-up periods between 6 months and 8 years. Adverse events and mortality was reported in 3.7 and 0.4 % of participants, respectively. Publication bias was detected with respect to efficacy and morbidity of the procedure. A large discrepancy in success was identified between ETV/CPC in six studies from sub-Saharan Africa (71 %), compared to three studies from North America (49 %).

The reported success of ETV/CPC for infantile hydrocephalus is higher in sub-Saharan Africa than developed nations. Large long-term prospective multi-center observational studies addressing patient-important outcomes are required to further evaluate the efficacy and safety of this re-emerging procedure 2).

Case series


It is not clear to what degree these metrics should be expected to change after ETV/CPC. Using these clinical metrics, Dewan et al., present and analyze the decision making in cases of ETV/CPC failure.

Infantile hydrocephalus metrics, including bulging fontanel, head circumference z-score, and frontal and occipital horn ratio (FOHR), were compared between ETV/CPC failures and successes. Treatment outcome predictive values of metrics individually and in combination were calculated.

Forty-four patients (57% males, median age 1.2 months) underwent ETV/CPC for hydrocephalus; of these patients, 25 (57%) experienced failure at a median time of 51 days postoperatively. Patients experiencing failure were younger than those experiencing successful treatment (0.8 vs 3.9 months, p = 0.01). During outpatient follow-up, bulging anterior fontanel, progressive macrocephaly, and enlarging ventricles each demonstrated a positive predictive value (PPV) of no less than 71%, but a bulging anterior fontanel remained the most predictive indicator of ETV/CPC failure, with a PPV of 100%, negative predictive value of 73%, and sensitivity of 72%. The highest PPVs and specificities existed when the clinical metrics were present in combination, although sensitivities decreased expectedly. Only 48% of failures were diagnosed on the basis all 3 hydrocephalus metrics, while only 37% of successes were negative for all 3 metrics. In the remaining 57% of patients, a diagnosis of success or failure was made in the presence of discordant data.

Successful ETV/CPC for infantile hydrocephalus was evaluated in relation to fontanel status, head growth, and change in ventricular size. In most patients, a designation of failure or success was made in the setting of discordant data 3).


A study retrospectively reviewed medical records of 27 premature infants with intraventricular hemorrhage (IVH) and hydrocephalus treated with ETV and CPC from 2008 to 2011. All patients were evaluated using MRI before the procedure to verify the anatomical feasibility of ETV/CPC. Endoscopic treatment included third ventriculostomy, septostomy, and bilateral CPC. After ETV/CPC, all patients underwent follow-up for a period of 6-40 months (mean 16.2 months). The procedure was considered a failure if the patient subsequently required a shunt. The following factors were analyzed to determine a relationship to patient outcomes: gestational age at birth, corrected age and weight at surgery, timing of surgery after birth, grade of IVH, the status of the prepontine cistern and cerebral aqueduct on MRI, need for a ventricular access device prior to the endoscopic procedure, and scarring of the prepontine cistern noted at surgery.

Seventeen (63%) of 27 patients required a shunt after ETV/CPC, and 10 patients did not require further CSF diversion. Several factors studied were associated with a higher rate of ETV/CPC failure: Grade IV hemorrhage, weight 3 kg or less and age younger than 3 months at the time of surgery, need for reservoir placement, and presence of a normal cerebral aqueduct. Two factors were found to be statistically significant: the patient’s corrected gestational age of less than 0 weeks at surgery and a narrow prepontine cistern on MRI. The majority (83%) of ETV/CPC failures occurred in the first 3 months after the procedure. None of the patients had a complication directly related to the procedure.

Endoscopic third ventriculostomy/CPC is a safe initial procedure for hydrocephalus in premature infants with IVH and hydrocephalus, obviating the need for a shunt in selected patients. Even though the success rate is low (37%), the lower rate of complications in comparison with shunt treatment may justify this procedure in the initial management of hydrocephalus. As several of the studied factors have shown influence on the outcome, patient selection based on these observations might increase the success rate 4).


A total of 710 children underwent ventriculoscopy as candidates for ETV as the primary treatment for hydrocephalus. The ETV was accomplished in 550 children: 266 underwent a combined ETV-CPC procedure and 284 underwent ETV alone. The mean and median ages were 14 and 5 months, respectively, and 443 patients (81%) were younger than 1 year of age. The hydrocephalus was postinfectious (PIH) in 320 patients (58%), nonpostinfectious (NPIH) in 152 (28%), posthemorrhagic in five (1%), and associated with myelomeningocele in 73 (13%). The mean follow up was 19 months for ETV and 9.2 months for ETV-CPC. Overall, the success rate of ETV-CPC (66%) was superior to that of ETV alone (47%) among infants younger than 1 year of age (p < 0.0001). The ETV-CPC combined procedure was superior in patients with a myelomeningocele (76% compared with 35% success, p = 0.0045) and those with NPIH (70% compared with 38% success, p = 0.0025). Although the difference was not significant for PIH (62% compared with 52% success, p = 0.1607), a benefit was not ruled out (power = 0.3). For patients at least 1 year of age, there was no difference between the two procedures (80% success for each, p = 1.0000). The overall surgical mortality rate was 1.3%, and the infection rate was less than 1%.

The ETV-CPC was more successful than ETV alone in infants younger than 1 year of age. In developing countries in which a dependence on shunts is dangerous, ETV-CPC may be the best option for treating hydrocephalus in infants, particularly for those with NPIH and myelomeningocele 5).

1) Dewan MC, Naftel RP. The Global Rise of Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Pediatric Hydrocephalus. Pediatr Neurosurg. 2016 Dec 22. doi: 10.1159/000452809. [Epub ahead of print] PubMed PMID: 28002814.
2) Weil AG, Westwick H, Wang S, Alotaibi NM, Elkaim L, Ibrahim GM, Wang AC, Ariani RT, Crevier L, Myers B, Fallah A. Efficacy and safety of endoscopic third ventriculostomy and choroid plexus cauterization for infantile hydrocephalus: a systematic review and meta-analysis. Childs Nerv Syst. 2016 Nov;32(11):2119-2131. PubMed PMID: 27613635.
3) Dewan MC, Lim J, Morgan CD, Gannon SR, Shannon CN, Wellons JC 3rd, Naftel RP. Endoscopic third ventriculostomy with choroid plexus cauterization outcome: distinguishing success from failure. J Neurosurg Pediatr. 2016 Dec;25(6):655-662. PubMed PMID: 27564786.
4) Chamiraju P, Bhatia S, Sandberg DI, Ragheb J. Endoscopic third ventriculostomy and choroid plexus cauterization in posthemorrhagic hydrocephalus of prematurity. J Neurosurg Pediatr. 2014 Apr;13(4):433-9. doi: 10.3171/2013.12.PEDS13219. PubMed PMID: 24527862.
5) Warf BC. Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg. 2005 Dec;103(6 Suppl):475-81. PubMed PMID: 16383244.