Surgery

Despite advances in the non-surgical management of medulloblastomas, surgical resection remains the primary initial treatment of these tumors. In addition to providing histologic diagnosis and relief of tumor burden, surgical resection of medulloblastomas can provide immediate relief of neurologic signs and symptoms due to hydrocephalus and direct brain-stem compression. Because 90% of children present with hydrocephalus, and up to 30% will require chronic CSF diversion [4], an EVD is inserted prior to tumor resection, regardless of the degree of hydrocephalus present on imaging. More recently, endoscopic third ventriculostomy may be another appropriate approach to relieving the block of CSF flow at the level of the aqueduct of Sylvius. Typically arising from the roof of the fourth ventricle, medulloblastomas invade the floor of the ventricle in up to 36% of cases [5]. Unlike ependymomas (discussed later), tumor residual in the brainstem does not adversely affect outcome [6] and most pediatric neurosurgeons will resect the tumor flush with the floor of the fourth ventricle, without entering the brainstem (Fig. 28.1b). Adjuvant technology, such as the operating microscope, intraoperative cranial nerve/SSEP monitoring and post-resection intraoperative ultrasound are essential in our institution for achieving the goal of radical resection of these tumors. For staging purposes, a lumbar puncture can be performed with the child still anesthetized. In these authors' experiences, immediate lumbar puncture after tumor resection does not lead to false-positive results.

Cure Your Yeast Infection For Good

Cure Your Yeast Infection For Good

The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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