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Background: Decompressive craniectomy (DC) is used in cases of severe intracranial hypertension or impending intracranial herniation. DC effectively lowers intracranial pressure (ICP) but carries a risk of severe complications related to abnormal ICP and/or cerebrospinal fluid (CSF) circulation, eg, hygroma formation, hydrocephalus, and "syndrome of the trephined.", Objective: To study the long-term effect of DC on ICP, postural ICP regulation, and intracranial pulse wave amplitude (PWA)., Methods: Prospective observational study including patients undergoing DC during a 12-mo period. Telemetric ICP sensors (Neurovent-P-tel; Raumedic, Helmbrechts, Germany) were implanted in all patients. Following discharge from the neuro intensive care unit (NICU), scheduled weekly ICP monitoring sessions were performed during the rehabilitation phase., Results: A total of 16 patients (traumatic brain injury: 7, stroke: 9) were included (median age: 55 yr, range: 19-71 yr). Median time from NICU discharge to cranioplasty was 48 d (range: 16-98 d) and during this period, mean ICP gradually decreased from 7.8 ± 2.0 mm Hg to -1.8 ± 3.3 mm Hg (P = .02). The most pronounced decrease occurred during the first month. Normal postural ICP change was abolished after DC for the entire follow-up period, ie, there was no difference between ICP in supine and sitting position (P = .67). PWA was markedly reduced and decreased from initially 1.2 ± 0.7 mm Hg to 0.4 ± 0.3 mm Hg (P = .05)., Conclusion: Following NICU discharge, ICP decreases to negative values within 4 wk, normal postural ICP regulation is lost and intracranial PWA is diminished significantly. These abnormalities might have implications for intracranial fluid movements (eg, CSF and/or glymphatic flow) following DC and warrants further investigations., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: Multimodal treatment approaches for children with tumors of the central nervous system (CNS) have markedly contributed to improved survival. Before 1970, the survival rate among children with medulloblastoma, the most common malignant CNS tumor in children, was about 20%. At present, in contrast, cure can be achieved in more than 75% of children with a favorable constellation of risk factors. In this review article for clinicians, we give an overview of the current understanding of the pathology, presenting manifestations, early diagnosis, and treatment of CNS tumors in children and adolescents., Methods: We report the research findings of the German Treatment Network "HIT" and selectively review the pertinent literature., Results: Treatment-optimizing clinical trials have improved survival from all types of CNS tumors in children and adolescents. Biological features of the tumors now serve as the basis for improved stratification for multimodal, risk-adapted treatment. Targeted biological strategies are being developed. Difficulties remain, however, in the care of infants with CNS tumors and in the treatment of metastatic disease, tumors of certain histological types, and tumors in certain anatomical sites. Many of the affected children suffer from late effects of their disease and its treatment that can irreversibly impair their development., Conclusion: Children with a suspected or confirmed diagnosis of brain tumor should be referred early to a center with the relevant experience. Standardized diagnostic and therapeutic methods have markedly improved the chance of cure. Current research on molecular signaling pathways seems likely to lead to the development of new treatments, particularly for tumors currently associated with lower rates of survival. The long-term side effects of treatment must be systematically monitored so that they can be avoided in future, and so that appropriate support measures can be provided to the affected children.

Within 27 months 122 patients with severe head injury were treated at our clinic. Of these patients twelve (9.8%) were categorized as having a primary brain stem lesion (9 male and 3 female, mean age 28.3 years (17 to 73 years). Their injuries were caused primarily by traffic accidents. Initial and follow-up CT ruled out mass lesions or other causes for transtentorial herniation, supporting the diagnosis of primary brain stem lesion. Respiratory insufficiency and control of vegetative function demanded artificial ventilation and analog-sedation for up to 32 days (mean 18 days) on our Intensive Care Unit. In all patients we performed initial and follow-up CT scans, ICP monitoring, evoked potentials (AEP, SSEP) and TCD. MRI was carried out in four patients. One patient died during the acute hospital phase, 7 were transferred in poor and four in good condition. During rehabilitation one patient died, two, one in a vegetative state and one in poor condition were transferred to a caring facility. Eight patients with a good or moderate recovery were dismissed home, subsequently regaining their prior social function. The primary traumatic brain stem lesion presents as a dramatic clinical picture. As shown in our series the prognosis is good independent of the duration of coma. The important prognostic factors were the primary neurological state according to the Gerstenbrand and Luecking classification, the degree of the brain stem lesion in CT scan and MRI, and normal evoked potentials, indicating a favourable outcome.