Kelsey Cobourn1,2, Fares Marayati1,3, Deki Tsering1, Owen Ayers1,3, John S Myseros1,4, Suresh N Magge1,4, Chima O Oluigbo1,4, Robert F Keating5,6. 1. Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA. 2. Georgetown University School of Medicine, Washington, DC, USA. 3. Princeton University, Princeton, NJ, USA. 4. George Washington University School of Medicine, Washington, DC, USA. 5. Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA. rkeating@cnmc.org. 6. George Washington University School of Medicine, Washington, DC, USA. rkeating@cnmc.org.
Abstract
PURPOSE: Cerebellar mutism syndrome (CMS) is a serious source of morbidity following posterior fossa surgery in the pediatric population. However, methods for effectively decreasing its incidence and impact remain unclear. It is our aim to examine the impact of adjusting surgical factors, namely the use of a telovelar approach and avoidance of cavitronic ultrasonic aspirator, on the incidence of CMS in our population as well as outlining potential pre-, intra-, and postoperative factors that may contribute to its development. METHODS: Retrospective review was performed to identify patients undergoing posterior fossa surgery for resection of a medulloblastoma. Demographic, surgical, and postoperative data were collected. These data were analyzed for possible correlations to the risk of developing CMS via univariate analysis. For factors found to be significant, a multivariate analysis was performed to assess their independence. RESULTS: Seven of 65 patients (10.8%) developed CMS postoperatively. Factors found to be significantly associated with a higher risk of CMS were the degree of retraction utilized during the procedure (p = 0.0000) and incision of the vermis (p = 0.0294). Although they did not reach the threshold of statistical significance, tumor vascularity (p = 0.19), adoption of a transvermian approach (p = 0.19), and lack of intraoperative imaging (p = 0.17) exhibited strongly suggestive trends towards a correlation with CMS. DISCUSSION: In an effort to reduce the incidence and severity of CMS in our population, our institution adopted surgical practices that minimize tissue trauma and mitigate postoperative edema. This included the use of a telovelar over a transvermian approach to obviate the need for vermian incision, avoidance of the CUSA, and minimization of heavy retraction during surgery. This was successful in reducing the incidence of CMS from 39% in our medulloblastoma patients to 10.8%. The development of CMS after posterior fossa surgery appears to be a "two-hit" phenomenon requiring a combination of existing predisposition, surgical injury, and postoperative exacerbation. Therefore, it is critical to identify the factors involved at each stage and investigate treatments to target them appropriately.
PURPOSE:Cerebellar mutism syndrome (CMS) is a serious source of morbidity following posterior fossa surgery in the pediatric population. However, methods for effectively decreasing its incidence and impact remain unclear. It is our aim to examine the impact of adjusting surgical factors, namely the use of a telovelar approach and avoidance of cavitronic ultrasonic aspirator, on the incidence of CMS in our population as well as outlining potential pre-, intra-, and postoperative factors that may contribute to its development. METHODS: Retrospective review was performed to identify patients undergoing posterior fossa surgery for resection of a medulloblastoma. Demographic, surgical, and postoperative data were collected. These data were analyzed for possible correlations to the risk of developing CMS via univariate analysis. For factors found to be significant, a multivariate analysis was performed to assess their independence. RESULTS: Seven of 65 patients (10.8%) developed CMS postoperatively. Factors found to be significantly associated with a higher risk of CMS were the degree of retraction utilized during the procedure (p = 0.0000) and incision of the vermis (p = 0.0294). Although they did not reach the threshold of statistical significance, tumor vascularity (p = 0.19), adoption of a transvermian approach (p = 0.19), and lack of intraoperative imaging (p = 0.17) exhibited strongly suggestive trends towards a correlation with CMS. DISCUSSION: In an effort to reduce the incidence and severity of CMS in our population, our institution adopted surgical practices that minimize tissue trauma and mitigate postoperative edema. This included the use of a telovelar over a transvermian approach to obviate the need for vermian incision, avoidance of the CUSA, and minimization of heavy retraction during surgery. This was successful in reducing the incidence of CMS from 39% in our medulloblastomapatients to 10.8%. The development of CMS after posterior fossa surgery appears to be a "two-hit" phenomenon requiring a combination of existing predisposition, surgical injury, and postoperative exacerbation. Therefore, it is critical to identify the factors involved at each stage and investigate treatments to target them appropriately.
Authors: J Kjær Grønbæk; S Toescu; R Frič; P Nilsson; C Castor; C Mallucci; B Pizer; K Aquilina; E Molinari; M Aasved Hjort; A Karppinen; G Rutkauskiene; K Mudra; B Markia; K van Baarsen; E Hoving; J Zipfel; M Wibroe; K Nysom; K Schmiegelow; A Sehested; R Mathiasen; M Juhler Journal: Childs Nerv Syst Date: 2022-02-14 Impact factor: 1.475
Authors: Camilla de Laurentis; Paola M F Cristaldi; Paola Rebora; Maria Grazia Valsecchi; Veronica Biassoni; Elisabetta Schiavello; Giorgio G Carrabba; Andrea Trezza; Francesco DiMeco; Paolo Ferroli; Giuseppe Cinalli; Marco Locatelli; Marco Cenzato; Giuseppe Talamonti; Marco M Fontanella; Giannatonio Spena; Roberto Stefini; Claudio Bernucci; Silvio Bellocchi; Davide Locatelli; Maura Massimino; Carlo Giussani Journal: J Neurooncol Date: 2022-06-29 Impact factor: 4.506