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Research Article | DOI: https://doi.org/10.31579/2578-8868/321
1Dr. Md. Rezaul Amin. Associate Professor, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka.
2DR. K. M. Tarikul Islam. Associate Professor, Pediatric Neurosurgery, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka.
3Dr. ABM Manwar Hossain, Neurosurgeon, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka.
4Professor Moududul Haque, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka.
*Corresponding Author: Md. Rezaul Amin, Associate Professor, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical Dhaka, Bangladesh.
Citation: Amin MR, Islam KMT, Hossain ABM, Haque M, (2024), Outcome of Midline Posterior Cranial Fossa Tumor Surgery with Preoperative Ventriculo - Peritoneal (V-P) Shunt in Children, J. Neuroscience and Neurological Surgery, 14(4); DOI:10.31579/2578-8868/321
Copyright: © 2024, Md. Rezaul Amin. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 13 May 2024 | Accepted: 28 May 2024 | Published: 12 June 2024
Keywords: midline posterior fossa tumor; ventriculo-peritoneal shunt; children; obstructive hydrocephalus
Introduction: Pediatric patients with midline posterior cranial fossa tumors present with features of raised intracranial pressure due to development of hydrocephalus. Due to the big size tumour and lack of facility we did Ventriculoperitoneal shunt before definitive surgery for all patients.
Material and Methods: This cross-sectional experimental study was carried out on 55 consecutive patients with midline posterior cranial fossa brain tumors with obstructive hydrocephalus with age ranged from 3 to 15 years got admitted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University from March 2021 to April 2023. We did preoperative ventriculoperitoneal shunt before definitive surgery but didn’t do the Endoscopic third ventriculostomy.
Results: In this study, the age of the patients was 3-15 years, the mean age was 9.47+_3.18 and the peak incidence was 11-15 years which was 20(36.36%). Majority of the patients was male (56%), male female ratio was 1.27:1. Most of the children were presented with headache 51(92.73%) followed by papilloedema 47(85.45%), vomiting 46(83.64%), gait disturbance 37(67.27%), diminution of vision 31(56.36%), swallowing difficulty 12(21.82%), cranial nerve palsy 12(21.82%). 19 patients developed postoperative complications among them 15(27.27%) was meningitis followed by wound infection 7(12.73%), pseudomeningocele 8(14.55%), csf leakage 4(7.27%), hydrocephalous 3(5.45%). Logistic regression analysis was non-significant statistically in my study.
Discussion and Conclusion: In conclusion we found satisfactory outcome of doing pr-operative VP Shunt in posterior fossa midline tumor causing obstructive Hydrocephalus in children, however major postoperative complications were development of hydrocephalus, CSF leak, pseudo meningocele, wound infection and meningitis. Future prospective studies with sufficient sample size are warranted to reach a definitive conclusion.
VP Shunt; Ventriculoperitoneal Shunt
CSF: Cerebrospinal Fluid
ETV: Endoscopic Third Ventriculostomy
ICP: Intracranial Pressure
CT: Computer tomography
MRI: Magnetic resonance imaging
Posterior fossa tumors are the most frequent primary neoplasms in children. Tumors in the posterior fossa are considered critical brain lesions, due to the risks involved like brainstem compression, herniation, and death.1
Hydrocephalus and subsequent need for cerebrovascular fluid (CSF) diversion following posterior fossa tumor excision in the pediatric age group is the most common clinical comorbidity. Despite advances in surgical techniques, up to 30% (18%–40%) of patients need CSF diversion as ventriculoperitoneal shunt (VP shunt) or endoscopic third ventriculostomy (ETV) after tumor excision.2
The evolution of surgical technique reflects the maturation of modern neurosurgery. The majority of patients with posterior fossa tumors have hydrocephalus at the time of presentation. The management of hydrocephalus with posterior fossa tumors remains controversial.3
Moreover, postoperative elevations of intracranial pressure (ICP) are reduced with a lower incidence of pseudomeningocele formation and CSF leakage, and hence shortened hospitals stay.4
Ventriculo-peritoneal shunting may decrease operative mortality by affording time to perform diagnostic tests, prepare the patient and schedule a major neurosurgical procedure electively. Reduction in intracranial pressure also permits safer resection.5.
Several complications have been associated with CSF diversion including: supratentorial intracranial hematomas (e.g., extradural, subdural, intracerebral, and intraventricular hemorrhage). Many shunts associated complications such as malfunction, infection, multiple abdominal complications, long-term shunt dependence and infratentorial complications e.g., intratumoral hemorrhage and upward transtentorial herniation.6
Several case reports have been published describing the serious infratentorial complications that may occur because of pre-resectional CSF diversion, either by ventricular shunting or ETV in patients with posterior cranial fossa tumors. Therefore, the actual incidence of such complications is unknown.7
This cross-sectional experimental study was carried out on 55 consecutive patients with midline posterior cranial fossa brain tumors with obstructive hydrocephalus with age 3 to 15 years got admitted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University from March 2021 to April 2023 who underwent preoperative ventriculoperitoneal shunt before definitive surgery. On admission, a detailed history of the illness was taken from the patient and/or his/her attendant, after that thorough neurological examination was carried out. Preoperative and postoperative clinical features for raised intracranial pressure (ICP) and findings of Computer Tomography (CT) scan and Magnetic Resonance Imaging (MRI) of brain were recorded. A data collection sheet was used to collect the necessary information. Informed written consent was taken from each participant and or guardian. Ventriculoperitoneal shunt was done by using medium pressure Chhabra shunt. Later, definitive surgery was performed. Follow-up of these patients was done up to7 th postoperative day. We assessed the patient in respect to the development of postoperative hydrocephalus, cerebrospinal fluid leakage, pseudomeningocele, wound infection and meningitis within 7th postoperative day after definitive surgery. Datas were processed and analyzed. Demographic data were expressed in number and percentage. Development of postoperative hydrocephalus, cerebrospinal fluid leakage, pseudomeningocele, wound infection and meningitis were expressed in number and percentage. Logistic regression analysis was done to predict the relationship between dependent variable (development of hydrocephalous) and independent variables (age, sex and the extent of tumor removal). Odds ratio (OR) was calculated by using Chi-square test. Chi-square test gave a wald statistic by observing at the 95% CI of the odds ratio. Statistical significance was set to p-value < 0>
The age of the patients was 3-15 years, the mean age was 9.47±3.18, and the peak incidence was 11-15 years which was 20 (36.36%).
Majority of the patient was male (56%), male female ratio was 1.27:1.
Characteristic | n=55 (%) | |
|---|---|---|
| Age (years) | 3-15 (Mean 9.47±3.18) | |
| Sex | Male | 56 (Ratio was 1.27:1) |
| Female | 44 | |
| Symptoms before surgery | Vomiting | 46 (83.64) |
| Hydrocephalus | 55 (100) | |
| Headache | 51 (92.73) | |
| Papilloedema | 47 (85.45) | |
| Gait disturbance | 37 (67.27) | |
| Diminution of vision | 31 (56.36) | |
| Cranial nerve disorders (except papilledema) | 12 (21.82) | |
| Decreased level of consciousness | 4 (7.27) | |
Extend of removal (according to CT scan of brain after definitive surgery) | Gross Total | 41 (74.55) |
| Sub Total | 6 (10.91) | |
| Near Total | 8 (14.55) | |
| Post-operative complication | Development of hydrocephalus | 3 (5.45%) |
| Wound infection | 7 (12.73%) | |
| CSF leakage | 4 (7.27%) | |
| Pseudomeningocele | 8 (14.55%) | |
| Meningitis | 15 (27.27) | |
Tumour Histopathology |
Astrocytoma |
20 (36.36) |
| Meduloblastoma | 16 (29.09) | |
| Ependymoma | 13 (23.64) | |
| Choroid plexus papilloma | 2 (3.64) | |
| Dermoid | 2 (3.64) | |
| Meningioma | 2 (3.64) | |
Table 1 shows preoperative clinical features of the study subject. Headache 51(92.73%), papilledema 47(85.45%), vomiting 46(83.64%), gait disturbance 37(67.27%), visual 31(56.36%), swallowing 12(21.82%), cranial nerve palsy 12(21.82%).
Table 1: Characteristics of the patient of posterior fossa tumour with hydrocephalus (n=55)
Out of 55 patients 31 patients developed complications, among them hydrocephalus was 3(5.45%), CSF leakage 4(7.27%), pseudomeningocele 11(20%), wound infection 12(21.82%) and meningitis 19(34.55%) (Table 1).
In CT scan of brain after definitive surgery, gross total removal of tumor was done in 41(74.55%) patients, near total removal in 6 (10.91%) patients and subtotal removal in 8(14.55%) patients (Table 1).
In histopathological findings, 20(36.36%) patients were found to have astrocytoma, 16(29.09%) medulloblastoma, 13(23.64%) ependymoma, 2(3.64%) choroid plexus papilloma, 2(3.64%) dermoid and 2(3.64%) meningioma (Table 1).
| Outcome | Gross total removal | Near total removal | Subtotal removal | |||
| n | % | n | % | n | % | |
| Development of hydrocephalus | 3 | 5.45 | 0 | 0.00 | 0 | 0.00 |
| CSF leakage | 4 | 7.27 | 0 | 0.00 | 0 | 0.00 |
| Pseudomeningocele | 8 | 14.55 | 3 | 5.45 | 0 | 0.00 |
| Wound infection | 7 | 12.73 | 3 | 5.45 | 2 | 3.64 |
| Meningitis | 15 | 27.27 | 2 | 3.64 | 2 | 3.64 |
Table 2: Outcome of the study subject according to the extent of tumor removal during postoperative follow up (n=55)
Development of hydrocephalus was 3 (5.45%) and CSF leakage was 4(7.27%) in gross total removal. Pseudomeningocele was found 8(14.55%) in gross total removal and 3(5.45%) in near total removal. Wound infection was found 7(12.73%) in gross total removal, 3(5.45%) in near total removal and 2(3.64%) in subtotal removal. Meningitis was found 15(27.27%) in gross total removal, 2(3.64%) in near total removal and 2(3.64%) in subtotal removal.
| B | P value | OR | 95% CI for OR | ||
| Lower | Upper | ||||
| Age (11-15 years) | -0.123 | 0.934 | 0.886 | 0.063 | 10.018 |
| Male | 1.831 | 0.161 | 6.023 | 0.489 | 76.653 |
| Near total removal | -19.088 | 0.998 | 0.001 | 0.000 | - |
| Subtotal removal | -1.254 | 0.999 | 0.002 | 0.000 | - |
OR=Odds ratio, CI= Confidence interval
Multivariable logistic regression analysis was performed.
Table 3: Logistic regression of development of hydrocephalus
Age (11-15 years) had 0.886 (95% CI 0.063 to 10.018) times increase in odds having development of hydrocephalus. Male had 6.023 (95% CI 0.489 to 76.653) times increase in odds having development of hydrocephalus. Age, male, near total removal and subtotal removal were not significantly associated with development of hydrocephalus.
In this study the age of the patients was 3-15 years, the mean age was 9.47±3.18, and the peak incidence was 11-15 years which was 20 (36.36%). Emara et al.8 reported the mean age was 17.5±14.2 years with an age range from 2 to 30 years. Moussalem et al.9 observed mean age of 6.19±4.42 years. Ghani et al.3 reported mean age was 61.45±30.37 months. Gopalakrishnan et al.10 found the ages ranged from 1.5 to 18 years and mean age 8 years at the time of diagnosis. Helmbold et al.11 found that significant number of patients was between ages 0.4-20.8 years (mean, 8.5; median, 8.2). 15 out of 70 patients (21.4%) required shunt placement over the post-operative course. Patients in the shunt group (n = 15; mean, 5.4 median, 3.0) were younger than in the non – shunt group (n=55; mean, 9.3; median, 9.0). An age < 3>
Current study observed majority of the patient were male (56%), male female ratio was 1.27:1. Emara et al.8 reported out of 44 patients, 28 (63.6%) patients were males and 16 (36.4%) were females. Moussalem et al.9 observed 59.37% patients were males. Habib13 found in his study that 29 (69%) were males and 13 (31%) were females, with a male to female ratio of 2.2:1. Our study has similarity with the study of de Oliveira et al.12; Habib.13
In this study observed preoperative clinical features of the study subject were headache 51(92.73%), papilloedema 47(85.45%), vomiting 46(83.64%), gait disturbance 37(67.27%), diminution of vision 31(56.36%), swallowing difficulty 12(21.82%) and cranial nerve palsy 12(21.82%). Emara et al.8 reported most common presentation in (90.9%) of cases followed by vomiting (77.3%), then ataxia (22.7%) and cranial nerve palsy (18.2%). Patients with severe hydrocephalus caused by posterior fossa lesions were characterized by headache, nausea, vomiting, diplopia, ventricular collapse, intracranial hypertension, papilloedema and somnolence which has also mentioned by Arriada and Sotelo.14 According to de Oliveira et al.12 preoperative clinical features were headaches 89%, cerebellar ataxia 61%, papilloedema 41%, vomiting 77% and also found some typical signs and symptoms in patients namely headaches (89%), ataxia (61%), papilloedema (41%). vomiting (77%), cranial nerve palsy (28%), motor deficits (11%), full anterior fontanelle in infants, and torticollis (27%). Habib13 found in the pediatric group, headache was the most common presentation in 75.7% of patients, followed by vomiting 51.5% and 45.5% with papilledema, diminution of vision and diplopia was noted in 15.1% and 12.1% respectively.
Uddin et al.1 it indicates that preoperative V-P shunt was less required in 11-15 years age groups. Our findings are similar to the findings of other authors and in close agreement with de Oliveira et al.12 It can be interpreted that elderly children with preoperative hydrocephalus due to posterior fossa midline tumor have less chance of requirement of VP shunt. Though ETV (endoscpic 3rd ventriculostomy) is an alternative procedure of Ventriculoperitoneal shunt procedure but due to unavailability of the instrument in our centre this procedure can’t be done.
Present study observed post-operative complication of the study population CSF leakage 4(7.27%), pseudomeningocele 11(20%), wound infection 12(21.82%) and meningitis 19(34.55%). Emara et al.8 reported the most common complications are as follows: shunt obstruction 8 cases (18.2%), haemorrhage 6 cases (13.6%), cerebrospinal fluid leakage ± pseudomeningocele 6 cases (13.6%), wound infection 4 cases (9.1%), mutism 2 cases (4.55%), cranial nerve palsy 4 cases (9.1%) and seizures 2 cases (4.55%).
EI Molla and Hamza (2016) found their study that failure of V-P shunt was 5 (50%), infection 3 (30 5), CSF leak 2 (20%), upward herniation 1 (10%), subdural collection 2 (20%) and mortality 1 (10%) among 10 patients with pre insertion V-P shunt and 12 patients of direct tumor surgery, 5 (41.6%) showed recurrence of hydrocephalus within two weeks and all were treated with V-P shunt, pseudomeningocele was 3 (25%) and mortality was 2(16.7%) patients15.
A study of Islam et al.16 of 32 patients concluded that cerebrospinal fluid leakage was the most common complication which occurred in 26.7% of cases followed by pseudomeningocele in 23.5% of cases. Charles and Morgan17, complication rate 19% with a single case mortality. An uneventful postoperative period in 31% of cases and only 19% had neurological complications at long-term.18 Moussalem et al.9 reported 12.28 % of the patients developed hydrocephalus postoperatively. In our study postoperative hydrocephalous was in 3(5.45%) patients which was statistically significant with comparison of the study of Helmbold et al. 201911. CSF leak was found in 4 (7.27%) patients of this study which was statistically significant with comparison of the published literature of Sainte-Rose et al.19. Pseudomeningocele was found in 11 (20.0%) patients which was statistically significant in comparison to the study of Gopalakrishnan et al.10; Aljubour et al.20; Marx et al.21. Meningitis was found in 19 (34.55%) patient which was statistically significant with comparison of the published literature of Fritsch et al.22; Abou-Madawi23; Due-Tonnessen and Helseth24; de Oliveria et al.12; Aljubour et al.20; Marx et al.21; Helmbold et al.11.
Current study showed in CT scan of brain after definitive surgery, gross total removal of tumor was done 41(74.55%), near total removal 6(10.91%) and subtotal removal 8(14.55%). Helmbold et al.11 found in their study that within the shunt group, gross total resection was achieved in 9 (60%) and a subtotal resection in 6 patients (40%). There was no significance found between postoperative shunt placement and gross total tumor resection according to the postoperative neuroradiological report.
In histopathological findings, 20(36.36%) patients were astrocytoma, 16 (29.09%) medulloblastoma, 13(23.64%) ependymoma, 2(3.64%) choroid plexus papilloma, 2(3.64%) dermoid and 2(3.64%) meningioma. Emara et al.8 observed the most common is astrocytoma in 16 cases (36.3%) which its variants are pilocytic and anaplastic in 14 and 2 cases of them respectively, then medulloblastoma 12 cases (27.3%), ependymoma 10 cases (22.7%), metastatic tumour 4 cases (9.1%), ganglioglioma one case (2.3%) and dermoid tumour one case (2.3%). A case study was represented a rare intracranial dermoid tumour with its uncommon location in the posterior fossa.26 Moussalem et al.9 reported the most common tumor pathology was pilocytic astrocytoma (40.62 %) followed by medulloblastoma (35.93 %) and ependymoma.
Present study observed 31 patients developed post-operative complications. Development of hydrocephalus was 3 (5.45%) and CSF leakage was 4(7.27%) in gross total removal. Pseudomeningocle was found 8(14.55%) in gross total removal and 3(5.45%) in near total removal. Wound infection was found 7(12.73%) in gross total removal, 3(5.45%) in near total removal and 2(3.64%) in subtotal removal. Meningitis was found 15(27.27%) in gross total removal, 2(3.64%) in near total removal and 2(3.64%) in subtotal removal. Ghani et al.3 reported 81.58% patients were found in gross total and 18.42% in subtotal. Aljubour et al.20 reported patients who had a gross total excision of their tumor have significantly lower risk to need a VP- shunt insertion.
In this study showed age (11-15 years) had 0.886 (95% CI 0.063 to 10.018) times increase in odds having development of hydrocephalus. Male had 6.023 (95% CI 0.489 to 76.653) times increase in odds having development of hydrocephalus. Near total removal and subtotal removal were not significantly associated with development of hydrocephalus. Moussalem et al.9 reported midline tumors were more associated with the development of mutism (OR = 4.632, p = 0.306) and hydrocephalus (OR = 5.056, p = 0.135) postoperatively, a bit not statistically significant. The presence of a preoperative shunt was shown to be protective against the development of CSF leak (OR = 0.636, p = 0.767), as none of the patients that came in with CSF diversion developed a CSF leak after their surgery. Morelli et al.25 found in their study that tumor removal can restore CSF circulation, obstructive hydrocephalus persists or progresses postoperatively in approximately 15 to 30% of cases in which patients need postoperative treatment. Authors of many studies have suggested that a young age and an incomplete tumor resection could be related to a higher incidence of persistent hydrocephalus. de Oliveira et al.12 described that chronic arachnoiditis after posterior fossa surgery, leading to adhesions, may have been responsible for the higher rate of shunt requirements.
In conclusion we found satisfactory outcome of doing pr-operative VP Shunt in posterior fossa midline tumor causing obstructive Hydrocephalus in children, however major postoperative complications were development of hydrocephalus, CSF leak, pseudo meningocele, wound infection and meningitis. Future prospective studies with sufficient sample size are warranted to reach a definitive conclusion.
1. Sample size was very small.
2. The study was conducted within a short period of time
3. Outcome of the study varies with benign and malignant tumor as well as with different age groups.
4. Postoperative outcome depends on the extent of tumor removal.
1. Further study should be carried out incorporating large numbers of patients for a better conclusion.
2. Study should be done for a longer period for a better result.
3. A lifesaving operation should be performed in case of acute hydrocephalus.
Authors Contributions:
Conception, Diagnosis and Design, Radiological Diagnosis and Final approval of manuscript:
Dr Md Rezaul Amin, Dr KM Tarikul Islam, Dr ABM Manwar Hossain, Prof. Moududul Haque
Manuscript Preparation, Technical Revision, and Manuscript editing and revision:
Dr Md Rezaul Amin, Dr KM Tarikul Islam, Dr ABM Manwar Hossain
Literature Review: Dr Md Rezaul Amin, Dr KM Tarikul Islam
Ethical Approval:
Not applicable, in our country no ethical committee has been established.
Competing Interest: There is no interest in financial and personal nature.
Acknowledgements: None
Funding Support and Sponsorship: This research didn’t receive any specific grant from funding agencies in the public, commercial or not for profit sector.
Conflict of Interest: There is no conflict of interest.
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“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
