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Up to 20% of victims from skull fractures are represented by the pediatric population, and 50% of these lesions are depressed skull fractures. The treatment is multimodal in nature, ranging from conservative treatment to open surgical repair. The last one is associated, although in a small proportion, to complications, such as infections, hematomas and even death, besides the risks of the anesthetic procedure itself. The authors of the present article present a case report of the successful treatment of a depressed skull fracture in a newborn patient, using the vacuum-suction technique. The use of vacuum-suction may be beneficial for the pediatric patients, as it is a quick, non-invasive procedure, without the need for general anesthesia.

Abstract EPNs comprise a heterogeneous group of neuroepithelial tumors, accounting for about 10% of all intracranial tumors in children and up to 30% of brain tumors in those younger than 3 years. Actually, the pattern therapy for low-grade EPNs includes complete surgical resection followed by radiation therapy. Total surgical excision is often not possible due to tumor location. The aim of this study was to evaluate, for the first time, the anti-tumor activity of Amblyomin-X in 4 primary cultures derived from pediatric anaplastic posterior fossa EPN, Group A (anaplastic, WHO grade III) and one primary culture of a high grade neuroepithelial tumor with MN1 alteration, which was initially misdiagnosed as EPN: i) by in vitro assays: comparisons of temozolomide and cisplatin; ii) by intracranial xenograft model. Amblyomin-X was able to induce cell death in EPN cells in a more significant percentage compared to cisplatin. The cytotoxic effects of Amblyomin-X were not detected on hFSCs used as control, as opposed to cisplatin-treatment, which promoted a substantial effect in the hAFSCs viability. TEM analysis showed ultrastructural alterations related to the process of cell death: mitochondrial degeneration, autophagosomes and aggregate-like structures. MRI and histopathological analyzes demonstrated significant tumor mass regression. Our results suggest that Amblyomin-X has a selective effect on tumor cells by inducing apoptotic cell death and may be a therapeutic option for Group AEPNs.

Background: The syndrome of the trephined was described in 1939 by Grant and Norcross and is defined as a progressive neurological deterioration after craniectomy. Commonly, it is associated with sinking of the skin near the bone-free area. The symptoms and signs improve after cranioplasty. This report intends to describe an uncommon case of a patient who presented to the hospital with the syndrome of the trephined and was temporarily treated with a plastered helmet. Case description: 45-year old male was submitted to a decompressive craniectomy due to severe traumatic brain injury. After one month, he was diagnosed with the syndrome of the trephined. Once he was in sepsis, cranioplasty could not be done. An alternative treatment was proposed and the patient improved in both clinical and radiological cenarios. Conclusion: The external cranioplasty made with plastered helmet proved to be an effective technique that can be safely applied to patients with the syndrome of the trephined who cannot be promptly treated with surgery.

The neuroendoscopy is supported by three pivotal pillars: training, planning, and prudence. The training consists of attending practical courses with synthetic head models for immersion in the intricate ventricular anatomy and practice in handling the neuroendoscope. The planning begins with the choice of the entry point, usually performed at the Kocher's point, and measurement of this to the ventricle. Neuroendoscopy in intraventricular hemorrhage or ventriculitis is always challenging due to low visibility, thus, copious irrigation with a heated solution at 37°C, like plasma type, is mandatory, often reaching 6L of solution. Narrow spaces between the clivus and basilar artery can be very dangerous, therefore we prefer a "Sputnik" fórceps rather than blunt instruments to open the floor of the III ventricle and subsequently widen it with Fogarty n°3. Sometimes it is necessary to mechanically remove the larger clots that do not come off the ventricle walls only with irrigation; in these cases, we aspirate them through the neuroendoscope until we see the structures that allow us to perform ETV and guarantee its patency. Navigating inside the ventricle when the complex anatomy is distorted, such as cases of myelomeningoceles with large interthalamic masses, can be very difficult; for these cases, we use the optics inversion technique to access different locations with the same field of view. The innovation in neuroendoscope models allowed us to associate techniques, such as the concomitant use of an ultrasonic aspirator to remove intraventricular lesions. Another field of great development was fetal surgery for hydrocephalus; initially with cephalocenteses passing through the ventriculo-aminiotic shunt until the fetal ETV. For complex cases of the second look of ETV, we can still associate techniques such as aqueductoplasty and implantation of stents in the third ventricular floor and cerebral aqueduct to keep them patent. Last but not least, we have the pillar of prudence. Any neuroendoscopy, regardless of the surgeon's experience or the apparent simplicity of the case, must be done with the utmost caution, avoiding minimal bleeding, avoiding touching structures that are not vital to the procedure, and be objective.

Next month, it will have been 9 months since the emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19), that is, the length of a full-term pregnancy. What can be expected? Perhaps favorable outcomes, such as the following: 1) there is a lack of viral transmission to the fetus; 2) there is a failure to produce malformations in the fetal central nervous system during the "fetal moment," that is, the period when the fetus or its parent becomes infected; 3) the fetus is immune to the virus; and 4) the fetus inherits acquired immunity from its mother during the infection period. These questions are pertinent, and the ability to address them is attributable to the speed at which our Chinese colleagues identified this new mutated virus. Their efforts in this regard are much appreciated. The same was not achieved when we encountered the Zika virus epidemic, during which it took us a considerable time to correlate microcephaly with congenital viral infection. To date, we have counted more than 18 million confirmed cases on the planet, including over 680,000 deaths. Will the fetuses of infected pregnant mothers be spared? On reviewing works published in English and Chinese languages, we managed to identify only four cases of probable mother-to-child vertical transmission, one of which was identified at 30 h of life. However, in most of these cases, maternal contamination occurred in the third trimester of pregnancy. What is the real damage to the fetus' central nervous system when contamination occurs during embryogenesis? Such questions will surely be addressed in the imminent months. This pandemic has also revealed to us the fragility of our health service, considering the relatively high mortality rates obtained in well-equipped intensive care units (ICUs) with well-trained medical staff, facilities which are scarce in many regions of our country. Two groups of patients have been of major concern to us: pregnant women and newborns. First, results have already revealed that pregnant Brazilian women who became infected with the new coronavirus had a mortality rate 3.4 times higher than that of uninfected pregnant women. Could genetic factors, immunological factors, or failure to follow up during the puerperal period have contributed to this outcome? However, newborns seem to be protected. Due to the vaccine load they receive, they can build immunity against coronavirus; even a small amount of angiotensin-converting enzyme 2 (ACE-2), which is a co-receptor for the entry of the virus into cells (located mainly in the lungs, intestine, and heart) may block the early stages of infection by binding to the spike protein, preventing it from entering the cells. Alternatively, even a repeated number of viral infections could cause natural immunity. Nonetheless, this protection has not manifested in indigenous children, who are often malnourished and extremely vulnerable to respiratory infections. The mortality rate in the indigenous child and adolescent population is 7.5 per 100,000 inhabitants, which is 10 times higher than that in the same age group for other Brazilians. Therefore, the decimation of our indigenous population can be anticipated. Inevitably, the Indian population appeals for help (figure 1). A new multisystem inflammatory syndrome has recently been identified as a long-term effect of COVID-19, where, due to an imbalance of the inflammatory response, several tissues are affected, such as those of the gastrointestinal system as well as cardiovascular, hematological, cutaneous, respiratory, and neurological tissues. Overall, 2% of affected children have died. Population growth, lack of basic sanitation, deforestation of our forest reserves, and the increase in global temperatures have contributed to the emergence of new infectious epidemics and pandemics. Yellow fever, Ebola, Dengue fever, Chikungunya, Zika, H1N1, H1N2, Middle East respiratory syndrome (MERS), and SARS are simply precursors of what lies ahead. This presents yet another great challenge for humanity, especially those who survive the next 4 million years on Earth.

Abstract Background Previous studies have demonstrated remarkable tropism of mesenchymal stem cells (MSCs) toward malignant gliomas, making these cells a potential vehicle for delivery of therapeutic agents to disseminated glioblastoma (GBM) cells. However, the potential contribution of MSCs to tumor progression is a matter of concern. It has been suggested that CD133+ GBM stem cells secrete a variety of chemokines, including monocytes chemoattractant protein-1 (MCP-1/CCL2) and stromal cell-derived factor-1(SDF-1/CXCL12), which could act in this tropism. However, the role in the modulation of this tropism of the subpopulation of CD133+ cells, which initiate GBM and the mechanisms underlying the tropism of MSCs to CD133+ GBM cells and their effects on tumor development, remains poorly defined. Methods/results We found that isolated and cultured MSCs (human umbilical cord blood MSCs) express CCR2 and CXCR4, the respective receptors for MCP-1/CCL2 and SDF-1/CXCL12, and demonstrated, in vitro, that MCP-1/CCL2 and SDF-1/CXC12, secreted by CD133+ GBM cells from primary cell cultures, induce the migration of MSCs. In addition, we confirmed that after in vivo GBM tumor establishment, by stereotaxic implantation of the CD133+ GBM cells labeled with Qdots (705 nm), MSCs labeled with multimodal iron oxide nanoparticles (MION) conjugated to rhodamine-B (Rh-B) (MION-Rh), infused by caudal vein, were able to cross the blood-brain barrier of the animal and migrate to the tumor region. Evaluation GBM tumors histology showed that groups that received MSC demonstrated tumor development, glial invasiveness, and detection of a high number of cycling cells. Conclusions Therefore, in this study, we validated the chemotactic effect of MCP-1/CCL2 and SDF-1/CXCL12 in mediating the migration of MSCs toward CD133+ GBM cells. However, we observed that, after infiltrating the tumor, MSCs promote tumor growth in vivo probably by release of exosomes. Thus, the use of these cells as a therapeutic carrier strategy to target GBM cells must be approached with caution.

Abstract Introduction Neurological and neurosurgical disorders are highly prevalent in Brazil. The initial management is performed by general practitioners, showing the importance of theoretical and practical studies of neurology and neurosurgery during undergraduate medical courses. Objective Describe the choices of medical specialty by members of a neurosurgery student league and investigate the existence and composition of neurology and/or neurosurgery courses and neuro-leagues in medical schools in Brazil. Methods We surveyed, in person or through social networks, all medical students who were members of the Neurosurgery Student League of Escola Paulista de Medicina (EPM) from 2007 to 2015 on the completion of their course and residency chosen. An online form was also submitted to all the medical schools registered with the Federal Council of Medicine (Conselho Federal de Medicina [CFM]) Results and Discussion Fifty-seven medical graduates had participated in the Neurosurgery Student League of EPM. Out of these, 45 have completed their undergraduate courses; 6 have undergone neurosurgery and 5 neurology. We obtained responses from 128 out of the 173 medical schools affiliated with the CFM. A total of 91% of the schools responded that they have a structured neurology course. These courses are divided as into: 32 exclusively theoretical, with 12 addressing neurosurgery and 84 are theoretical-practical, with 51 addressing neurosurgery. Structured neurosurgery courses were only present in 19% of the faculties, half of which are theoretical only. Neurosciences leagues were present in 66% of the universities. Conclusions It was noted that neurology and neurosurgery student leagues in 66% of the medical schools in Brazil is, many times, used to supplement theoretical-practical content that should have been addressed at undergraduate level. Unfortunately, only 9.5% of the medical schools include a theoretical-practical neurosurgery course in their curriculum, a fact that is concerning due to the high prevalence of neurologic diseases in the Brazilian population.

Objective: To evaluate the height of normal intervertebral discs and describe their differences after analyzing anterior and posterior height. Methods: Retrospective study based on analysis of analysis of lumbar spine magnetic resonance imaging. We included male and female patients who underwent lumbar spine resonance, most of them for investigation of low back pain. Patients with previous surgeries, advanced degenerative disc disease, suspected infection, deformities were excluded from the study. Results: 300 patients had their images analyzed for the anterior and posterior height of the L3-L4, L4-L5 and L5-S1 discs, totaling 900 intervertebral discs. The mean age of the patients was 46,2 ± 15,1 years. The mean anterior disc height of L3-L4 was 9.30 mm, L4-L5 10.94 mm and L5-S1 12.41 mm. About 7% of the patients have a L3-L4 anterior height 0,05). Conclusions: L3 to L5 discs present greater anterior height than posterior and this difference tends to decrease with aging. The L5-S1 disc is that most contributes for lumbar lordosis, followed by L4-L5. Populations with lower average height should have their disc dimensions carefully studied during surgical planning, especially in L3-L4 segment. Keywords: Intervertebral disc, Spinal curvatures, Spinal fusion, Sagittal balance

Amniotic fluid has been investigated as new cell source for stem cells in the development of future cell-based transplantation. This study reports isolation of viable human amniotic fluid-derived stem cells, labeled with multimodal iron oxide nanoparticles, and its effect on focal cerebral ischemia–reperfusion injury in Wistar rats. Middle cerebral artery occlusion of 60 min followed by reperfusion for 1 h, 6 h, and 24 h was employed in the present study to produce ischemia and reperfusion-induced cerebral injury in rats. Tests were employed to assess the functional outcome of the sensorimotor center activity in the brain, through a set of modified neurological severity scores used to assess motor and exploratory capacity 24 h, 14, and 28 days after receiving cellular therapy via tail vein. In our animal model of stroke, transplanted cells migrated to the ischemic focus, infarct volume decreased, and motor deficits improved. Therefore, we concluded that these cells appear to have beneficial effects on the ischemic brain, possibly based on their ability to enhance endogenous repair mechanisms.

Introdução: A síndrome diencefálica é uma doença pediátrica rara, decorrente de tumores hipotalâmicos, caracterizada por failure to thrive. Objetivo: Descrever o estado nutricional e a terapia nutricional por meio de sonda nasoenteral de pacientes com tumores cerebrais com a síndrome diencefálica. Método: Sete pacientes foram acompanhados de julho/1999 a abril/2002 e analisados retrospectivamente, usando os escores-z de peso para idade (P/I), peso para estatura (P/E) e estatura para idade (E/I) no diagnóstico da desnutrição. Todos foram avaliados por meio de composição corporal: prega cutânea triciptal (PCT) e circunferências do braço e muscular do braço (CB e CMB) e receberam alimentação por sonda nasoenteral ou gastrostomia após o diagnóstico da neoplasia. Resultados: A idade variou de 2 meses a 13 anos, cinco do sexo masculino. A duração média da nutrição enteral foi de 7 meses (1,1-18,5) após o diagnóstico, sem diferença estatística significante na evolução dos escores-z, apesar do aumento nas médias de P/I (-4,42 para -3,50) e P/E (-3,06 para -1,99), e dos indicadores de composição corporal (PCT: 2,85 para 4,88; CB: 9,81 para 11,84 e CMB: 8,91 para 10,31). Houve redução na média da E/I, caracterizando o atraso no crescimento dessas crianças. Conclusão: A nutrição enteral demonstrou garantir a oferta nutricional e recuperar em parte os indicadores nutricionais de desnutrição aguda; principalmente a gordura corporal, mais do que massa magra. Entretanto, manteve-se o déficit de crescimento, agravado na maioria dos casos. A terapia nutricional deve ser implantada durante o tratamento oncológico, assegurando sua continuidade.

ABSTRACT The anterior cervical discectomy and fusion is considered an established technique in cervical degenerative disease treatment, in which the final goal is the fusion of the segments involved. There are options for spacer grafts, such as bone grafts and synthetic bone substitutes like hydroxyapatite and tricalcium phosphate. This technical note describes the combination of the stand-alone anchored intervertebral spacer and iliac graft, which is used as a pillar between the vertebrae. The iliac crest removal is performed with a 10 mm or 12 mm diameter trephine. The trephine is employed to make a graft in the same format as the inner portion of the intervertebral spacer. The cylindrical bone graft removed must be 1 millimeter higher than the cage that will be implanted so that it is 0.5 mm above and below the upper and lower edges of the cage. The objective is to establish support between the vertebral plateaus and the bone cylinder, as they present similar resistance and biological aspects, which are fundamental characteristics for proper osseointegration and fusion. When the conventional technique is used, the interaction between the cage and the plateaus occurs more intensely, and a plateau fracture may occur, a phenomenon known as subsidence. This technical note describes a feasible way to obtain autograft bone to be used in ACDF stand-alone surgery. This type of graft may be associated with lower rates of pseudoarthrosis. Level of Evidence IV; Case Series.

BackgroundNon-germinomatous germ cell tumors (NGGCT) accounts for one third of intracranial GCT. While the germinoma group have an excellent overall survival, the standard of practice for children with NGGCT is still under evaluation.AimsDescribe the results of the of the Brazilian consortium protocol.MethodsSince 2013, 15 patients with a diagnosis of NGGCT by histopathology and/or serum/cerebrospinal fluid (CSF) tumor markers, βHCG >200mlU/ml and/or positive alpha-fetoprotein were treated with neoadjuvant chemotherapy with carboplatin, cyclophosphamide and etoposide followed by ventricular radiotherapy (RTV) of 18Gy with boost (32Gy) to the primary site. Metastatic patients underwent craniospinal irradiation (CSI) and “slow responders” to the four initial cycles of CT, to autologous stem cell transplantation (ASCT) followed by CSI.ResultsMean age, 13.1 years. Thirteen males. Primary sites: pineal (n=12), suprasellar (n=2) and bifocal (n=1). Four patients were metastatic at diagnosis. Eight patients had CSF and/or serum alpha-fetoprotein levels > 1,000ng/ml. Tumor responses after chemotherapy demonstrated complete in six cases and partial in seven, with “second-look” surgery being performed in five cases, and two patients presenting viable lesions being referred to ASCT. The main toxicity observed was hematological grades 3/4. Two patients with metastatic disease, one with Down Syndrome and AFP > 1,000ng/ml and the other with choriocarcinoma and pulmonary metastases, developed progressive disease resulting in death, as well as two other patients without evidence of disease, due to endocrinological disorders. Event-free and overall survival at 2 and 5 years were 80% and 72.7%, respectively, with a mean follow-up of 48 months (range, 7-107).ConclusionsDespite the small number of patients, in our series, treatment with six cycles of chemotherapy and RTV with focal boost for localized disease (n=11) and ACST for identified slow responders (n=2) seem to be effective strategies contributing to the overall effort to improve outcomes of this group of patients.

Background Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management. Objective Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements. Methods Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan. Results We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42–68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6–77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours. Conclusion In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.

Background: Infratentorial choroid plexus tumors are rare lesions in the pediatric population. At diagnosis, they most often present with signs of intracranial hypertension and cranial nerve deficits. The main objective of the surgery is total resection and the prognosis is favorable in most cases. Case Report: A 16-year-old boy with gait disturbance, headaches and left side hypoacusia had a diagnosis of posterior fossa tumor with hypertensive hydrocephalus. He underwent urgent placement of a ventriculoperitoneal shunt and subsequently microsurgery with gross total resection. At follow up, the patient was asymptomatic and without deficits. Conclusion: Choroid plexus tumors should be included in the differential diagnosis of posterior fossa tumors in childhood. Preoperative planning, choosing the best surgical approach and interruption of the lesion's vascular supply as the initial step of surgery are fundamental strategies for successful treatment.

Introduction/Background: Central nervous system (CNS) tumors in infants are rare, ranging between 1 and 10% of all pediatric CNS tumors. The infratentorial location is a challenge to neuro-oncologist and -surgeons due their subtle clinical presentation, different histopathological types, biological behaviors, and anesthetic-surgery difficulties. Methods: Single center retrospective study of infants diagnosed with posterior fossa tumors between 2010 and 2023. Results: Nineteen patients were included. Mean age 8.8 months; eight males. The most common presenting symptom was torticollis (n-6, 31.6%), followed by vomiting (n-3, 15.8%) and increased head circumference (n-3, 15.8%). Atypical Teratoid Rhabdoid Tumor (AT/RT) was the most common subtype (n-11, 57.9%), followed by Medulloblastoma (MB). Metastatic disease at diagnosis was evident in five cases. Seventeen patients initially underwent correction of hydrocephalus. Regarding surgical resection, one (5.3%) patient underwent biopsy, 13 (68.4%) complete resection, four (21%) partial resection. Only one patient, diagnosed with ependymoma, did not receive chemotherapy after surgery, 14/19 received high-dose chemotherapy, eight of these followed by autologous bone marrow transplantation (ABMT). Focal radiotherapy (RT) was performed in four patients with AT/RT and in one ependymoma, following ABMT and complete resection, respectively. Event-free survival at 2 and 5 years was 64.9% and overall survival 63.2% and 54.2% respectively. Conclusion: Despite aggressive histological subtypes, neurosurgical challenges, and limitation of adjuvant therapy, we have shown acceptable survival rates in this challenging group of patients showing the importance of appropriate supportive care, improvement in surgical techniques and a multi-professional approach.

Central nervous system tumors in pediatric patients represent the most frequent solid tumor type in this age group, especially ependymomas, which comprise 5% of childhood intracranial tumors, and occur mainly in the posterior fossa. The MEDLINE and ClinicalTrials databases were searched for studies on posterior fossa ependymomas, 64 studies met the search criteria. Symptoms include ataxia, vertigo, headache, vomiting, cranial nerve palsies, or papilledema, resulting from intracranial hypertension due to obstruction of CSF circulation. Imaging examination often reveals posterior fossa ependymomas in the fourth ventricle or cerebellopontine angle; they may extend through the foramina of Luschka, Magendie, and/or magnum. These tumors cause a significant mass effect, displacing rather than invading the hidbrain, and may involve vessels or cranial nerves, making surgical resection difficult. Various radiological features have been studied to distinguish between ependymomas and other histological types, as well as between ependymoma subtypes. The 2021 WHO classification of central nervous system tumors classifies ependymomas by location. Three types occur in the posterior fossa: subependymomas, PF-A, and PF-B. These are differentiated by the degree of DNA methylation and CpG islands, which can be assessed by immunohistochemical analysis with H3K27me3. The consensus on the treatment of posterior fossa ependymomas in children advocates the maximum possible surgical resection, followed by radiotherapy in patients >1 year. Chemotherapy remains controversial, with no survival gain. Recent studies suggest molecular subgroups as an independent prognostic factor in posterior fossa ependymomas. The therapeutic challenge of ependymomas requires new treatment options, based on new technologies and molecular discoveries.

This edition of APN is entirely dedicated to posterior fossa tumors. Very common in the daily routine of pediatric neurosurgeons, these tumors remain one of the most challenging pathologies we must face. The importance and complexity of the anatomical structures of the posterior fossa, associated with the enormous histological variety of neoplastic lesions in this region, make its therapeutic approach difficult and even more challenging. The degree of surgical resection plays a determining role in the prognosis and cure possibilities for the children with posterior fossa tumors; on the other hand, gross total resection is related to the much feared cerebellar mutism syndrome, related to serious cognitive and behavioral sequelae. Every pediatric neurosurgeon's nightmare, this subject deserves special attention in our edition. Ballestero and Juca review the literature, discuss the concepts of mutism, predisposing factors, pathophysiology, and available treatments. However, mutism prevention after surgical resection is essential. In addition to excellent mastery of microneurosurgery techniques and in-depth anatomical knowledge of the structures of the posterior fossa, pediatric neurosurgeons must use all the most advanced technologies to protect their patients and obtain the best results. Therefore, Kodangeski and Pinheiro discuss the use of electrophysiological monitoring during resection surgeries for posterior fossa tumors. Ahmed also emphasizes the importance of neuronavigation in these surgeries, as a significant tool to reduce morbidity and mortality. Around 70 to 90% of posterior fossa tumors present with hydrocephalus. The treatment of hydrocephalus before, during or after tumor resection is a very controversial subject, with different approaches among groups. Mandic retrospectively applies the success scores of endoscopic third ventriculocysternostomy in a group of patients with posterior fossa tumors and analyzes its efficiency. Costa pays special attention to posterior fossa ependymomas. Despite the explosion of genomic and epigenomic knowledge of these tumors in recent decades, surgery still plays an essential role in their treatment because the main objective as gross total resection represents a great technical challenge for the neurosurgeon. Besides to medulloblastomas, astrocytoma and ependymomas, more rarely other histological types can involve the posterior fossa and should be considered as differential diagnosis of these lesions. Therefore, Lopez presents clinical cases of choroid plexus papilloma and Rabelo Rodrigues reviews the cases of hemangioblastomas found in the literature. Even though posterior fossa tumors are predominant in children of preschool and school age, Dassi presents a series of cases in patients under two years of age, highlighting the histological characteristics and treatment strategies in this age group. The final result of this edition is a set of articles that highlight the complexity of posterior fossa tumors and the challenges of their treatment. Although these are the most common intracranial tumors in childhood and are part of the routine of every pediatric neurosurgery service, the war against those tumors has not been definitively won. We still lack greater understanding, and the exchange of experiences is increasingly necessary. We hope these articles can help all readers in their daily battles. Our special thanks to all the authors who worked on this edition and to the editorial staff who, with all their dedication, made it possible. Have an excellent read!

PURPOSEThis prospective Brazilian single-arm trial was conducted to determine response to chemotherapy and survival after response-based radiotherapy in children with intracranial germinomas, in the setting of a multi-institutional study in a middle-income country (MIC) with significant disparity of subspecialty care.PATIENTS AND METHODSSince 2013, 58 patients with histologic and/or serum and CSF tumor marker evaluations of primary intracranial germ cell tumors were diagnosed; 43 were germinoma with HCGβ levels ≤200 mIU/mL and five between 100 and 200 mIU/mL. The treatment plan consisted of four cycles of carboplatin and etoposide followed by 18 Gy whole-ventricular field irradiation (WVFI) and primary site(s) boost up to 30 Gy; 24 Gy craniospinal was prescribed for disseminated disease.RESULTSMean age 13.2 years (range, 4.7-25.5 years); 29 were males. Diagnosis was made by tumor markers (n = 6), surgery (n = 25), or both (n = 10). Two bifocal cases with negative tumor markers were treated as germinoma. Primary tumor location was pineal (n = 18), suprasellar (n = 14), bifocal (n = 10), and basal ganglia/thalamus (n = 1). Fourteen had ventricular/spinal spread documented by imaging studies. Second-look surgery occurred in three patients after chemotherapy. Thirty-five patients achieved complete responses after chemotherapy, and eight showed residual teratoma/scar. Toxicity was mostly grade 3/4 neutropenia/thrombocytopenia during chemotherapy. At a median follow-up of 44.5 months, overall and event-free survivals were 100%.CONCLUSIONThe treatment is tolerable, and WVFI dose reduction to 18 Gy preserves efficacy; we have demonstrated the feasibility of successfully conducting a prospective multicenter trial in a large MIC despite resource disparity.

A scientific journal’s greatest responsibility is to ensure that all contributions accepted for publications are rigorously but fairly reviewed. The Editor-in-Chief and Archives of Pediatric Neurosurgery gratefully acknowledge the qualified and regular collaboration of renowned medical doctors and scientists who kindly devoted their time to constructively review the submitted articles. Their expertise and invaluable assistance contributed to maintain a high scientific standard for APN. We are thus indebted to the Editorial Board members and the following experts who reviewed papers and completed the peer-reviewing process within 2022.

Introduction: Posterior Fossa arachnoid cysts (PFAC) are rare lesions in the childhood. Owing to the wide variety of cystic malformations within the posterior cranial fossa, PFAC have long attracted the attention of pediatric neurosurgeons because they can produce not only neurological symptons but also behaviro and learning deficts, in addition to presenting major surgical challenges. Surgical treatment is warranted in symptomatic patients. Nowadays, neuroendoscopic techniques have established themselves as the treatment of choice of these lesions. Patients and Methods: We present four cases of symptomatic PFAC which were treated using endoscopic neurosurgery. Endoscopic approaches were defined by the presence of hydrocephalus, and discussed in each case. Results : Two cases of quadrigeminal plate cysts, predominantly occupying the infratentorial compartment , one case of supracerebellar cyst and one case of cerebellopontine angle were treated with good results. However, one case of quadrigeminal plate cyst developed a communicating hydrocephalus, requiring placement of cyst-ventricle peritoneal shunt, guided by the neuroendoscope. Discussion and Conclusion : A literature review was performed. The clinical features, the advantages and disadvantages of several surgical treatments are discussed. Symptomatic PFAC should be treated. The relatively good results using endoscopic fenestration buttresses our use as a first-line surgery.

The first edition of the Archives of Pediatric Neurosurgery (APN) was released in September 2019. Since then we have completed the 10th edition. There were 108 submissions receives (44/year), with a rejection rate of 20%. Archives of Pediatric Neurosurgery is the first open access electronic-only journal in pediatric neurosurgery, and also we are on social media as Facebook, Instagram and Tweeter. APN is the only journal specialized in Pediatric Neurosurgery in Latin America and Mexico. We have different types of publication highlighted the original papers, review, clinical case, video clinical case, and clinical video lecture. The Archives of Pediatric Neurosurgery is a triannual peer-reviewed medical online journal and was recognized in September 2020 as the official publication of the Brazilian Society for Pediatric Neurosurgery. In addition, the internal regulation (by-laws) was approved during the 2021 SBNPed Business Meeting. Some statistics related to APN (2019-2022): MOST DOWNLOADED PDF ARTICLE: Dezena et al. Anatomy of the ventricular system: Historical and morphological aspects MOST READ ABSTRACT: De Paula et al. Shaken Baby Syndrome: literature review in the last 5 years MOST CITED ARTICLE: de Oliveira RS, Ballestero MFM. The Covid-19 Outbreak and Pediatric Neurosurgery guidelines All articles are available online and free license to open access and download. All the papers were peer-reviewed (Figure 1). During this period, we included a specialized consultancy and we were able to index the APN in several indexing bases: DOAJ, Google Scholar, Cengage, REDIB, Crossref, Dimensions, J-Gate, and BASE. DOAJ is the most important community-driven, open access service in the world and has a reputation for advocating best practices and standards in open access. DOAJ indexing has brought recognition of a correct and well-structured work On this special occasion the editorial office would like to extend their greatest appreciation to all editors, and reviewers who have been supportive, and devoted much of their time and effort in nurturing APN. The journal, in particular, would like to thank the authors for submitting their papers to APN. We organized two editions in 2022 focusing on craniofacial and arachnoid cysts. Based on data from Google Analytics, APN is gaining momentum and attracting interest from readers. The number of accesses to abstracts has been increasing progressively since 2019 (Figure 1). The editorial board thanks you and the work continues so that we can reach new indexing bases and consolidate as a reference in pediatric neurosurgery. Recently, the Brazilian Neurosurgery Society recognized the importance of APN by supporting the project. Happy Birthday Archives of Pediatric Neurosurgery! A long life for everyone!

ABSTRACT A systematic review of the literature was performed in order to organize, evaluate, and select evidences available about the safety and efficacy of minimally invasive percutaneous arthrodesis with percutaneous pedicle screws in the treatment of patients with degenerative disc disease (and other spinal pathologies) as compared to conventional arthrodesis. PubMed, EMBASE and Cochrane Library databases were consulted to locate clinical trials and case reports/case series published in English between 2014 and 2019. After selection according to the inclusion/exclusion criteria, 21 of the 197 articles identified were chosen for a complete reading and used for the present review. Although the level of evidence of most of the studies included made the demonstration of efficacy and superiority among the surgical techniques reviewed difficult, the findings related to the minimally invasive procedure indicate a safe and reliable approach for the treatment of lumbar diseases. Level of evidence II; Systematic review of literature.

Much controversy remains on the current management of Chiari I deformity (CID) in children, with many clinical, surgical and ethic-legal implications. The Brazilian Society of Pediatric Neurosurgery (SBNPed, in the Portuguese acronym) has put together a panel of experts to analyze updated published data on the medical literature about this matter and come up with several recommendations for pediatric neurosurgeons and allied health professionals when dealing with CID. Their conclusions are reported herein, along with the respective scientific background.

A scientific journal’s greatest responsibility is to ensure that all contributions accepted for publications are rigorously but fairly reviewed. The Editor-in-Chief and Archives of Pediatric Neurosurgery gratefully acknowledge the qualified and regular collaboration of renowned medical doctors and scientists who kindly devoted their time to constructively review the submitted articles. Their expertise and invaluable assistance contributed to maintain a high scientific standard for APN. We are thus indebted to the Editorial Board members and the following experts who reviewed papers and completed the peer-reviewing process within 2021.

An unlikely idea became a reality in June 2019 when we gathered an enthusiastic group and started testing the platform & workflow by OJS/PKP thus turning an idea into something concrete. The next step would be choosing the name of the journal and creating the website. Finally, the choice of the national and international editorial board based on academic and scientific criteria. Archives of Pediatric Neurosurgery (APN) was born. We published the very first issue of the APN in September 2019. The decision was to use of the Internet and related technologies as an enabler and infrastructure for health innovations. The use of information and communication technologies and the web helps to empower patients (not least through peer-to-peer communications), provides a platform for communication, clinical information and telemedicine (these days often through mobile devices), and revolutionizes information access and medical education [1]. We were not only innovating on content, but also on form. We were the first open access electronic-only journal in pediatric neurosurgery, and also, we are on social media as Facebook, Instagram and tweeter. We have different types of publication highlighted the clinical case, video clinical case, and clinical video lecture. Our YouTube channel, together with SBNPed, has a total of 48 videos and more than a thousand inscriptions. The Archives of Pediatric Neurosurgery is a triannual peer-reviewed medical online journal and was recognized in September 2020 as the official publication of the Brazilian Society for Pediatric Neurosurgery. We believe APN will contribute in furthering efforts to make our dream a reality getting a pediatric neurosurgery medical journal to be recognize in the world as option to publish original papers, clinical case, video clinical case, and others. Some statistics related to APN: MOST DOWNLOADED PDF ARTICLE: Dezena et al. Anatomy of the ventricular system: Historical and morphological aspects MOST READ ABSTRACT: Furlanetti et al. Shunt Technology in Pediatric Neurosurgery: Current options and Scientific Evidence MOST CITED ARTICLE: de Oliveira RS, Ballestero MFM. The Covid-19 Outbreak and Pediatric Neurosurgery guidelines Submissions Received 112 In two years, APN has published 62 international peer-review medical journals in 5 issues from September, 2019 to August, 2021. All articles are available online and free license to open access and download. All the papers were peer-reviewed (Figure 1). During this period, we included a specialized consultancy and we were able to index the APN in several indexing bases: Google Scholar, Cengage, REDIB, Crossref, Dimensions, and the most recent J-Gate. On this special occasion the editorial office would like to extend their greatest appreciation to all editors, and reviewers who have been supportive, and devoted much of their time and effort in nurturing APN. The journal, in particular, would like to thank the authors for placing their faith in this new, bold journal when it was still in its beginning stages. This continuous support has been pivotal to the development of the journal. In the times to come, APN will remain committed to publishing novel, high-quality, and valuable content. APN endeavors to bring readers the most up-to-date information in a wide variety of fields in the hopes of ultimately benefiting patients, all while ensuring the largest possible readership for all articles published in the journal. In our modern globalized academic community, APN recognizes the importance of international collaborations, and seeks to promote itself as an international journal. We have organized a series of articles focusing on important topics in various fields, and invited international prominent experts to co-author. Based on data from Google Analytics, APN is gaining momentum and attracting interest from readers. The number of accesses to abstracts has been increasing progressively since 2019 (Figure 2). As Section Editors, they keep track of the latest and significant research in their areas and recommend international key opinion leaders to review and write editorial comments on those important topics. We will pursue the serious work and include the APN in more indexing databases, expanding its importance in pediatric neurosurgery. Yes, it's time to celebrate this incredible achievement! but continue the professional work. Happy Birthday Archives of Pediatric Neurosurgery! A long life for everyone!

A scientific journal’s greatest responsibility is to ensure that all contributions accepted for publications are rigorously but fairly reviewed. The Editor-in-Chief and Archives of Pediatric Neurosurgery gratefully acknowledge the qualified and regular collaboration of renowned medical doctors and scientists who kindly devoted their time to constructively review the submitted articles. Their expertise and invaluable assistance contributed to maintain a high scientific standard for APN. We are thus indebted to the Editorial Board members and the following experts who reviewed papers and completed the peer-reviewing process within 2020.

Introduction: Dandy Walker malformation (DWM) is characterized by agenesis or hypoplasia of the cerebellar vermis, cystic dilatation of the fourth ventricle leading to an increase of the posterior fossa and superior dislocation of the lateral sinus, tentorium and torcula. Although it is the commonest posterior fossa malformation, its pathogenesis is still not fully understood, making the differential diagnosis with other posterior fossa malformations difficult and as a result the choice of therapeutic strategy. Material and methods: An extensive review of the literature relating to Dandy Walker malformation was performed. Historical, genetic, embryologic, epidemiologic, clinical and radiological presentation, treatment and prognosis were revised. Conclusion: The correct diagnosis of Dandy Walker malformation can be made through careful interpretation of magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) flow studies. The choice of hydrocephalus treatment depends on whether there is aqueduct stenosis. And, although ventriculoperitoneal (VP) shunts have been the treatment of choice for many years, neuroendoscopic techniques such as endoscopic thirdventriculostomy and stent placement are being frequently performed lately.

Dear Reader, You are receiving the second volume of Archives of Pediatric Neurosurgery. This is an electronic journal from the Brazilian Society of Pediatric Neurosurgery, which is published quarterly. We are dedicating this volume to hydrocephalus-related topics. Hydrocephalus is one of the most important topics in pediatric neurosurgery and is related to up to 40% of the activities performed in many specialized services. With its multiple etiologies and variety of proposed treatment modalities, this disease presents a huge challenge, and many questions have not been answered. When focusing on fetal hydrocephalus, we still cannot determine which fetuses will benefit from treatment during the fetal period. The answers are also unclear as to why surgery for myelomeningocele correction performed under 27 weeks of gestation decreases the prevalence of hydrocephalus. What is the best treatment for intraventricular hemorrhage in premature infants: Brain Washing, external ventricular drainage, ventriculosubgaleal shunt, reservoir placement and repeated punctures or lumbar punctures? Furthermore, what is the best treatment for hydrocephalus in cases of posterior fossa tumor: Placing an external ventricular drain and resecting the tumor, performing a third ventriculostomy or placing a ventriculoperitoneal shunt, considering that in cases of giant tumors in each of these situations, ascending herniations can occur? Of course, the procedure selected will be related to the dynamics, volume and expertise of the treatment center. Regarding valves, we know that the number of shunts implanted annually is enormous and that the market for valves is divided among several companies that manufacture these prostheses. Which valve is the best? An anti-gravitational one, a programmable one, one with an anti-siphon mechanism? Fixed-pressure valves, valves that produce fewer MRI artifacts, those that do not experience pressure changes due to MRI, or those impregnated with antibiotics? How can a simple valve work as well as a valve with a complex system? Why does a valve system cost $1,000 in one country but costs ten times more in another country? Why are some types of valves sold only in underdeveloped countries? How can we avoid or minimize biological and mechanical complications after valve placement? Even neuroendoscopic procedures that have been performed for more than 25 years in Brazil are not free of complications such as bleeding, infection and technical incapacity of the professional. Nevertheless, we believe that all services that treat children with hydrocephalus should be able to provide neuroendoscopic procedures, thus decreasing the number of shunts placed. We hope that this volume can answer some of these questions. I invite you to participate in Archives of Pediatric Neurosurgery by contributing scientific articles focusing on pediatric neurosurgery. This volume was compiled during the coronavirus (COVID-19) pandemic. We hope that this disease will be controlled quickly, allowing us to return to our normal activities. We also hope that pregnant women will not transmit the disease to their fetuses, causing hydrocephalus, as was observed in the last Zika virus epidemic. Sincerely, Sergio Cavalheiro Editor-in-chief, Archives of Pediatric Neurosurgery

ABSTRACTThe central sulcus region is an eloquent area situated between the frontal and parietal lobes. During neurosurgical procedures, it is sometimes difficult to understand the cortical anatomy of this region.Objective Find alternative ways to anatomically navigate in this region during neurosurgical procedures.Method We analyzed eighty two human hemispheres using a surgical microscope and completed a review of the literature about central sulcus region.Results In 68/82 hemispheres, the central sulcus did not reach the posterior ramus of the lateral sulcus. A knob on the second curve of the precentral gyrus was reliably identified in only 64/82 hemispheres.Conclusion The morphometric data presented in this article can be useful as supplementary method to identify the central sulcus region landmarks.

The anatomical characterization of the orbitofrontal cortex in human is limited in literature instead of many functional and clinical studies involving it. Objective Anatomically define the orbitofrontal region aiming to possible neurosurgical treatments and unify the scientific nomenclature as well. Method We analyze eighty four human hemispheres using a surgical microscope. Then we chose four hemispheres and dissect them according to Klinger’ technique. Results We found five main sulcus: olfatory sulcus, orbital medial sulcus, orbital lateral sulcus, orbital transverse sulcus and orbital intermediate sulcus. These sulcus, excluding the intermediate sulcus, delimit five gyrus: rectus gurys, orbital medial gyrus, orbital anterior gyrus, orbital lateral gyrus and orbital posterior gyrus. The main sulcal configuration can be divided on four more frequently patterns. Conclusion Orbitofrontal cortex is associated with many psychiatric disorders. Better anatomical and functional characterization of the orbitofrontal cortex and its connections will improve our knowledge about these diseases.

Abstract Background Although germ cell tumors and pineal cell tumors account for most of the histologic tumor subtypes, > 17 different tumors can arise in this location. We report a rare case of a low-grade oligodendroglioma that arose in the pineal region. Clinical Presentation A young woman complaining of a headache underwent magnetic resonance imaging that showed a mass in the pineal region and mild hydrocephalus. A ventriculoperitoneal shunt was performed followed by a near-total tumor removal, due to tumor invasion of the tectal plate and thalamus. The histologic examination confirmed the diagnosis of a low-grade oligodendroglioma. The patient then underwent chemotherapy and radiotherapy as adjuvant therapies. Conclusion Although the pineal region is a common place for a large number of tumoral lesions, low-grade oligodendrogliomas are extremely rare in this location. This case is only the second account of a benign oligodendroglioma of the pineal region reported in the literature.