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Introduction: We present a very rare case of ruptured superior hypophyseal artery (SHA) aneurysm that presented as an acute subdural hematoma (SDH) discussing its initial presentation, diagnosis, and treatment modalities. To our knowledge it is one of very few if any cases of a ruptured aneurysm in infants regarding that specific vascular location. Case Report: A 5-month-old boy was referred to our department due to acute SDH over the right cerebral hemisphere without significant mass effect nor hydrocephalus. Further evaluation revealed a right internal carotid artery (ICA) aneurysm arising from the SHA segment. Microsurgical clip ligation using a fenestrated, angled clip was performed with simultaneous subdural clot removal and proximal control of the ICA dissected in the neck. Our patient made an excellent recovery without any complicating features. Conclusion: Surgical management seems to be a better option in this subgroup of patients given the long life expectancy and durability of microsurgical clip ligation. We believe that our brief case report would add some insight into the management of this rare subgroup of patients, leading to better decision-making and outcome.

Introduction Hydrocephalus is a common disorder of the central nervous system (CNS) in the pediatric population. Surgical treatment options involve ventriculoperitoneal shunt (VPS) placement. VPS infection is the most common complication of surgically treated hydrocephalus in pediatric patients [1, 2],which may lead to neuronal damage. Myelin basic protein (MBP) has been proposed as a marker of neuronal injury in a variety of contexts, and MBP levels in the cerebrospinal fluid (CSF) may be used to assess the severity of neuronal damage [1, 3, 4]. Therefore, the aim of this study was to evaluate the CSF level of myelin basic protein (MBP) in a group of pediatric patients with VPS infection. Material and methods Thirty CSF samples were collected from pediatric patients with VPS infection. CSF levels of MBP were measured at three time points, marked by contamination detection, obtention of the first sterile CSF culture, and VPS shunt implantation. The collected data were compared with those of the control group composed of children with active congenital hydrocephalus and valid CSF values. Results The MBP level in the study group was higher than the corresponding control values in the second and third measurements. The highest MBP level was reached in the study group in the second and third measurements. Conclusions The lack of normalization of MBP level in the CSF of children with shunt infection could be connected with ongoing brain damage. It takes longer than the normalization of CSF protein level and pleocytosis. The delay is associated with a prolonged reaction of the immunological system.

Introduction Severe fetal cerebral ventriculomegaly, observed in about 1 in 1000 newborns, is associated with a high risk of perinatal death and neurodevelopmental delay in survivors. The objective of this study was to evaluate the efficiency of ventriculo-amniotic shunting for drainage of severe fetal cerebral ventriculomegaly and the neurodevelopment of survivors at the age of 2 years. Material and methods This was a retrospective study of 44 fetuses with severe bilateral ventriculomegaly treated with ventriculo-amniotic shunting in a tertiary fetal therapy center between 2010 and 2015. Results Shunt insertion was successfully carried out at a median gestational age of 25 weeks (range 20-33 weeks). There were three fetal deaths within 24 hours of the procedure and 41 live births at a median gestational age of 37 weeks (range 28-39 weeks). Neurodevelopment at 2 years of age was evaluated using the Bayley scale in the 38 survivors. In the 27 cases with isolated ventriculomegaly 19 (70.4%; 95% confidence interval [95% CI] 51.5%-84.2%) had normal or mild neurodevelopmental delay and 8 (29.6%; 95% CI 15.6%-48.5%) were moderately or severely delayed. In the 11 with non-isolated ventriculomegaly 2 (18.2%; 95% CI 5.1%-4.8%) had normal or mild neurodevelopmental delay and 9 (81.8%; 95% CI 52.3%-94.9%) babies were moderately or severely delayed. Conclusions Ventriculo-amniotic shunting is an option for the management of severe ventriculomegaly and results in normalization of the ventricular diameter. However, a high proportion of survivors have neurodevelopmental delay and the possible beneficial effect of ventriculo-amniotic shunting needs to be assessed by randomized studies.

Objective The aim of this paper was to evaluate the outcomes of surgical treatment for post-inflammatory hydrocephalus in pediatric patients. The patient’s age, surgical technique and type of implants, revision rate (depending on the cause for revision and shunt type), and final outcome measured with Neurologic Outcome Scale for Infants and Children (NOSIC) scale were evaluated. Methods We performed a retrospective analysis of 101 patients with post-inflammatory hydrocephalus, treated in Polish Mother’s Memorial Hospital Research Institute since 2005. Children with comorbidities (e.g., tumors or hemorrhages) were excluded from the study. The assessment included patient age, surgical technique (ventriculoperitoneal shunt (VPS) or neuroendoscopy) and type of implant, revision rate (considering its cause), and final outcome measured in Neurologic Outcome Scale for Infants and Children (NOSIC) scale. Results VPS implantation was the most common surgical technique. It was performed in 66.33% (n = 67) of cases. Neuroendoscopic procedure was used in 33.66% of cases (n = 34). Revision rate of VPS was 52.23% (n = 35). Endoscopic third ventricle ventriculostomy (ETV) was efficient only in 5 cases (14.7%), whereas in 29 cases (85.3%), it was followed by VPS implantation. Revision rate in VPS implantation after ETV reached 55.17% (n = 16). In all age groups, VPS implantation was the most frequently used procedure. Revisions of the shunt systems occurred most frequently in the 1–3 (n = 21 41.18%) and

Purpose The aim of the study is to use Raman spectroscopy to analyze the biochemical composition of medulloblastoma and normal tissues from the safety margin of the CNS and to find specific Raman biomarkers capable of differentiating between tumorous and normal tissues. Methods The tissue samples consisted of medulloblastoma (grade IV) (n = 11). The tissues from the negative margins were used as normal controls. Raman images were generated by a confocal Raman microscope—WITec alpha 300 RSA. Results Raman vibrational signatures can predict which tissue has tumorous biochemistry and can identify medulloblastoma. The Raman technique makes use of the fact that tumors contain large amounts of protein and far less lipids (fatty compounds), while healthy tissue is rich in both. Conclusion The ability of Raman spectroscopy and imaging to detect medulloblastoma tumors fills the niche in diagnostics. These powerful analytical techniques are capable of monitoring tissue morphology and biochemistry. Our results demonstrate that RS can be used to discriminate between normal and medulloblastoma tissues.

Introduction Recognizing patients with ventriculomegaly who are at risk of developing acute hydrocephalus presents a challenge for the clinician. The association between disturbed cerebrospinal fluid flow (CSF) and impaired brain compliance may play a role in the pathogenesis of hydrocephalus. Phase contrast MRI is a noninvasive technique which can be used to assess CSF parameters. The aim of the work is to evaluate the effectiveness of phase contrast MRI in recognizing patients at risk of acute hydrocephalus, based on measuring the pulsatile CSF flow parameters in the Sylvian aqueduct and prepontine cistern in children with ventriculomegaly. Aim The aim of the work is to characterize the parameters of cerebrospinal fluid (CSF) flow in the Sylvian aqueduct and prepontine cistern in children with ventriculomegaly with regard to patient age and symptoms. We hypothesize that the relationship between CSF flow parameters in these two regions will vary according to analyzed factors and it will allow to recognize children at risk of hydrocephalus. Materials and methods A group of 26 children with ventriculomegaly (five girls and 21 boys) underwent phase contrast MRI examinations (Philips 3T Achieva with Q-flow integral application). Amplitudes of average and peak velocities of the CSF flow through the Sylvian aqueduct and prepontine cistern were used to calculate ratios of oscillation and peak velocities, respectively. The relationship between the oscillation coefficient, the peak velocity coefficient, and stroke volume was then assessed in accordance with age and clinical symptoms. Results The peak velocity coefficient was significantly higher in patients with hyper-oscillating flow through the Sylvian aqueduct (3.04 ± 3.37 vs. 0.54 ± 0.28; p = 0.0094). Moreover, these patients tended to develop symptoms more often (p = 0.0612). No significant age-related changes were observed in CSF flow parameters. Conclusion Phase contrast MRI is a useful tool for noninvasive assessment of CSF flow parameters. The application of coefficients instead of direct values seems to better represent hemodynamic conditions in the ventricular system. However, further studies are required to evaluate their clinical significance and normal limits.

Collagenous scaffolds provide good conditions for embryonic nerve cell growth. The aim of the current study was to assess the brains reaction to the implantation of 3D sponge-shaped scaffolds. These scaffolds consisted of collagen (Col) and Col with chondroitin sulphate, which is modified by carbodiimide, or Col crosslinked with dialdehyde cellulose. The current study also evaluated the expression of integrins α2 and β1 in embryonic nerve cells. Embryonic nerve cells were isolated from the brains of rat embryos. Acellular scaffolds, or scaffolds populated with embryonic nerve cells, were implanted into the rats brain. The fibers of all the implanted scaffolds remained intact and served as a template for cell infiltration. The implants induced minimal to moderate inflammatory responses and minimal glial scar formations. Immunohistochemical studies did not indicate any microtubule-associated protein 2 or glial fibrillary acidic protein-positive cells inside the scaffolds. Acellular and cell-populated scaffolds yielded similar responses in the brain. The expression of integrin α2 and β1 was observed in embryonic nervous cells. TC-I15, the integrin α2β1 inhibitor, was not demonstrated to modify cell entrapment within the collagenous scaffolds. All applied scaffolds were well tolerated by the tissue and were indicated to support blood vessel formation. Therefore, all tested biomaterials are recommended for further studies. Additional chemical modifications of the material are suggested to protect the seeded cells from apoptosis after implantation into the brain.

The aim of the article is to present the new hybrid technique for ventriculoatrial shunt implantation.Two-and-a-half-year-old boy needed ventriculoatrial shunt implantation due to communicating hydrocephalus and impaired absorptive ability of the peritoneum. Because of a complete occlusion of the right internal jugular vein and critical stenosis of a distal part of the left internal jugular vein, the procedure was performed under fluoroscopy guidance in the catheterisation laboratory equipped with a 3-dimensional single plane angiography machine (Philips Allura--The Netherlands). At the level of critical stenosis of the left jugular vein, it was decided to perform a percutaneous venous balloon angioplasty. This procedure allowed inserting the ventriculoatrial shunt into the right atrium.The whole postoperative period was uneventful. Now, the child is free from symptoms of increased intracranial pressure. The boy has been followed for 9 months. In the control MRI examination, the ventricular system did not change as compared with the previous study.The disadvantage of the hemodynamic technique is a higher dose of X-ray irradiation in comparison to other techniques. The hybrid technique should be reserved only to very complicated cases.

Objective: The aim of the study was to establish optimal diagnostic and therapeutic scheme and to assess the efficacy of intrauterine therapy of hydrocephalus. Material and methods: The study was carried out between 1992-2012 on the total of 222 fetuses with hydrocephalus, using Orbis-Sigma and ACCU-Flow valves (168 cases) and Cook’s shunts, according to a strictly defined diagnostic and therapeutic scheme. Results: In the first stage of the study (between 1992-2001), a total of 168 fetuses with prenatally diagnosed hydrocephalus received intrauterine therapy. In 91.6% of the cases the therapy resulted in a decreased size of cerebral ventricles. The valve dislocated in 23 cases (13.6%). Preterm delivery occurred in 44% of the affected neonates. Severe mental impairment occurred in 17.76%, average in 36.8%, and slight in 32.9% of the infants. Normal mental development at the age of 3 was observed in 12.5% of the children. A total of 11.2% of children did not require further neurosurgical reatment. In the second stage of the study (between 2006-2012) after therapy, the size of the right lateral cerebral ventricle decreased by 54.76% (average of 27.54 mm to 12.46 mm) and the left lateral cerebral ventricle decreased by 53.12% (average of 26.41 mm to 12.38 mm ) (p=0.0018). The maximum and minimum width of the cerebral cortex increased by 23.06% and 27% (average of 9.04 mm to 11.75 mm vs. 3.65 mm to 5mm), respectively. Early complications were observed in 22% of the cases: PROM (6), intrauterine fetal death (4), intrauterine infection (1), and premature detachment of the placenta (1). Average gestational age at delivery was 34 weeks, and 24% of the patients delivered at term. Conclusions: • Implantation of ventriculo- amniotic shunts proved to be an effective form of therapy, resulting in normalization of intracranial pressure. • In both stages of therapy, reduction of ventricular size in patients with hydrocephalus and good neurological outcome (45.4% in I stage, 60% in II stage) were observed • In the second stage of therapy, the size of lateral brain ventricles after fetal therapy was significantly lower (54%). A total of 18% of the neonates did not require neurosurgical treatment.

Objective: The authors intended to evaluate the application of neuroendoscopic techniques for the treatment of arachnoid cysts in children and compare it with other operative methods. Methods: The analysis covered the results of treatment of 44 children with arachnoid cysts who were subjected to neuroendoscopic procedures and 62 patients who underwent other operations. Results: The neuroendoscopic treatment of arachnoid cysts was very effective because of low rate of reoperative treatment (six out of 44 patients), no need to change the operative method (40 effective out of total 44 operative procedures), and low rate of persistent worsening (none of 44 patients worsened). Conclusions: Summing up all the mentioned aspects of neuroendoscopic techniques, the neuroendoscopic techniques were the most suitable operative procedures in the treatment of arachnoid cysts in the presented group of patients, providing that the connection between the lumen of the arachnoid cyst and the cerebrospinal fluid cisterns was of good quality.

Hydrocephalus, which is the most common disease of the central nervous system in children, has a diverse etiology and clinical picture. Children suffering from hydrocephalus are often treated either by using a neuroendoscopic procedure or by Orbis Sigma shunt implantation.To evaluate the long-term psychological effects of neuroendoscopic surgical treatment on the mental development and cognitive abilities of children suffering from hydrocephalus, in comparison with the results following Orbis Sigma shunt implantation, and to assess the impact of the kind of hydrocephalus on the outcome of the treatment.The study involved 78 patients treated surgically for chronic noncommunicating hydrocephalus: 39 patients who had undergone neuroendoscopic surgery (average age: 12 years, SD +/- 7 years), and 39 who had undergone implantation of a ventriculo-peritoneal shunt (average age: 14 years +/- 5 years). The psychomotor development of the two groups was analyzed using psychomotor development tests including the Brunet-Lezine test, the Terman-Merrill test, Raven's Standard Progressive Matrices, Raven's Colored Progressive Matrices, the Benton Visual Retention Test, the Bender Visual Motor Gestalt Test, the Rey Fifteen-Item Memory Test, lateralization tests and a questionnaire.In the shunt group there were statistically significant prevalences hydrocephalus diagnosed perinatally and in the first year of life (p = 0.0291), epileptic seizures (p = 0.0181), intellectual disability (p = 0.0049) and gait disturbances (p = 0.006). There were statistically significant differences between two groups in the relative changes of linear measurements of the cerebral ventricle depending on the type of treatment: Relative Frontal Horn Index (RFHI): 0.93 following endoscopy and 0.64 following shunt implantation; Relative Evans' ratio (RER): 0.93 following endoscopy and 0.62 after shunt implantation; Relative Frontal and Occipital Horn Ratio (RFOHR): 0.89 after endoscopy and 0.69 after shunt implantation. The time treatment was undertaken and the incidence of mental retardation did not differ significantly between the two groups.The analysis of cerebral ventricle enlargement expressed in linear ventricular enlargement measurements revealed statistically important differences in the intellectual, cognitive and motor development between the groups treated with the two neurosurgical techniques.

Introduction The amount of spine surgeries grow each year. Spine diseases usually associated with advanced age start to appear in much younger patients. The matter of sagittal balance plays a crucial role in modern spine surgery. Knowledge of pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and spino-sacral angle (SSA) is mandatory in any modern spine procedure. However, so well understood spine parameters are almost never associated with pregnancy. Materials and Methods In our study, we decided to measure all the important spine parameters in a group of young women before pregnancy (healthy and women after spine surgical procedures on L4–S1) and after delivery. One of the most important questions is how to operate a young women properly in the reproductive period (discectomy vs. posterior transpedicular stabilization and PLIF/TLIF fusion). The study includes 90 women (30 in each group). Overall, 30 healthy with no syndromes before and after surgery, 30 who underwent microdiscectomy on L4–S1 level, and 30 who underwent posterior transpedicular and TLIF/PLIF fusion on L4–S1 level. All women had a sagittal balance spine measurements before and after pregnancy (pelvic incidence, pelvic tilt, sacral slope, and spino-sacral angle). The parameters have been comprised and proper conclusions were drawn. Results In all operated women before the surgical procedure, sagittal balance was changed. After pregnancy only in fused group, proper sagittal balance was retained. In the other groups (discectomy and healthy), sagittal balance was impaired after delivery. Conclusions Sagittal balance changes during natural pregnancy course. Posterior transpedicular stabilization with PLIF/TLIF fusion performed before pregnancy characterized better long-term follow-up than pure discectomy. Also, reoperation proportion was significantly lower in the fused group. In women in reproductive period, surgical procedures based on fusion and sagittal balance correction seems to be a method of choice.

Purpose The aim of the article is to present the new extrapedicular percutaneous technique for posttraumatic vertebral column fracture. Methods A 15-year-old boy needed a surgical Th8 posttraumatic vertebral body (VB) compressive fracture reduction due to insufficient conservative treatment and consistent severe clinical symptoms. After 6 months of external Jevett long-roll brace stabilization, progressive sagittal balance disturbance of thoracic kyphosis was measured and persistent clinical symptoms were observed. It was decided to present a surgical technique method allowing to attempt to reduce VB fracture, rebalance the vertebral column (VC) without any motion limitation, and decrease clinical symptoms. The procedure was performed percutaneously from extrapedicular approach with intravertebral implant (Spine Jack®—Vexim™) and cement (Interface®—Vexim™) under fluoroscopic imaging (Ziehm™ 8000®). Results The whole procedure was uneventful. Now, the child is free from clinical symptoms and the partial reduction of VB fracture was achieved. The patient has been followed for 3 months. In the control CT scans, the VB fracture reduction is stable and no progression of thoracic kyphosis angle is observed. Furthermore since the surgical procedure, the patient is clinical symptom free. Conclusion The extrapedicular percutaneus technique of VB fracture reduction with intravertebral fixation allowed to partially reduce the VB compressive fracture, rebalance the VC without any motion limitation, avoid external long-roll brace, and eliminate clinical symptoms. The procedure is minimally invasive, fast, and clinically effective. However, the technique should be restricted only to carefully selected clinical cases.