e1 References 1 Munch TN, Rostgaard K, Rasmussen ML, Wohlfahrt J, Juhler M, Melbye M Familial aggregation of congenital hydrocephalus in a nationwide cohort Brain 2012;135(Pt 8) 2409 2415 2 Garton HJ[.]
e1 References Munch TN, Rostgaard K, Rasmussen ML, Wohlfahrt J, Juhler M, Melbye M Familial aggregation of congenital hydrocephalus in a nationwide cohort Brain 2012;135(Pt 8):2409-2415 Garton HJ The Dandy-Walker Complex and Arachnoid Cysts In: Albright AL, Pollack IF, Adelson PD, ed Principles and Practice of Pediatric Neurosurgery 3rd ed New York, NY: Thieme; 2015: 145-161 el Awad ME Infantile hydrocephalus in the south-western region of Saudi Arabia Ann Trop Paediatr 1992;12(3):335-338 Kahle KT, Kulkarni AV, Limbrick Jr DD, Warf BC Hydrocephalus in children Lancet 2016;387(10020):788-799 Simon TD, Riva-Cambrin J, Srivastava R, et al Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths J Neurosurg Pediatr 2008;1(2): 131-137 Rekate HL Treatment of Hydrocephalus In: Albright AL, Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 2nd ed New York, NY: Thieme; 2008:94-108 Kochanek PM, Carney N, Adelson PD, et al Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition Pediatr Crit Care Med 2012;13(suppl 1):S1-82 Kulkarni AV, Riva-Cambrin J, Butler J, et al Outcomes of CSF shunting in children: comparison of Hydrocephalus Clinical Research Network cohort with historical controls: clinical article J Neurosurg Pediatr 2013;12(4):334-338 Warf BC Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy J Neurosurg 2005;102(suppl 1):1-15 10 McLone DG, Czyzewski D, Raimondi AJ, Sommers RC Central nervous system infections as a limiting factor in the intelligence of children with myelomeningocele Pediatrics 1982;70:338-342 11 Kestle JR, Riva-Cambrin J, Wellons JC III, et al A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative J Neurosurg Pediatr 2011;8(1):22-29 12 Kulkarni AV, Drake JM, Kestle JR, et al Predicting who will benefit from endoscopic third ventriculostomy compared with shunt insertion in childhood hydrocephalus using the ETV Success Score J Neurosurg Pediatr 2010;6(4):310-315 13 Kulkarni AV, Drake JM, Mallucci CL, et al Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus J Pediatr 2009;155(2):254-259.e1 14 Kulkarni AV, Riva-Cambrin J, Rozzelle CJ, et al Endoscopic third ventriculostomy and choroid plexus cauterization in infant hydrocephalus: a prospective study by the Hydrocephalus Clinical Research Network J Neurosurg Pediatr 2018;21(3):214-223 15 Al-Holou WN, Yew AY, Boomsaad ZE, Garton HJ, Muraszko KM, Maher CO Prevalence and natural history of arachnoid cysts in children J Neurosurg Pediatr 2010;5(6):578-585 16 Rengachary SS, Watanabe I Ultrastructure and pathogenesis of intracranial arachnoid cysts J Neuropathol Exp Neurol 1981;40(1):61-83 17 Harsh GR, Edwards MSB, Wilson CB Intracranial Arachnoid Cysts in Children J Neurosurg 1986;64(6):835-842 18 Shaw CM “Arachnoid cysts” of the sylvian fissure versus “temporal lobe agenesis” syndrome Ann Neurol 1979;5(5):483-485 19 Pierre-Kahn A, Capelle L, Brauner R, et al Presentation and management of suprasellar arachnoid cysts Review of 20 cases J Neurosurg 1990;73(3):355-359 20 Al-Holou WN, Terman S, Kilburg C, Garton HJ, Muraszko KM, Maher CO Prevalence and natural history of arachnoid cysts in adults J Neurosurg 2013;118(2):222-231 21 Somma T, Solari D, Beer-Furlan A, et al Endoscopic Endonasal Management of Rare Sellar Lesions: Clinical and Surgical Experience of 78 Cases and Review of the Literature World Neurosurg 2017;100:369-380 22 Rizk E, Chern JJ, Tagayun C, et al Institutional experience of endoscopic suprasellar arachnoid cyst fenestration Childs Nerv Syst 2013;29(8):1345-1347 23 McLaughlin N, Vandergrift A, Ditzel Filho LF, et al Endonasal management of sellar arachnoid cysts: simple cyst obliteration technique J Neurosurg 2012;116(4):728-740 24 Gangemi M, Seneca V, Colella G, Cioffi V, Imperato A, Maiuri F Endoscopy versus microsurgical cyst excision and shunting for treating intracranial arachnoid cysts J Neurosurg Pediatr 2011;8(2):158-164 25 Tubbs RS, Griessenauer CJ, Oakes WJ Chiari malformations In: Albright AL, Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 3rd ed New York, NY: Thieme; 2015:192204 26 Azahraa Haddad F, Qaisi I, Joudeh N, et al The newer classifications of the Chiari malformations with clarifications: an anatomical review Clin Anat 2018;31(3):314-322 27 Dyste GN, Menezes AH, VanGilder JC Symptomatic Chiari malformations An analysis of presentation, management, and longterm outcome J Neurosurg 1989;71(2):159-168 28 Ivashchuk G, Loukas M, Blount JP, Tubbs RS, Oakes WJ Chiari III malformation: a comprehensive review of this enigmatic anomaly Childs Nerv Syst 2015;31(11):2035-2040 29 Tubbs RS, Demerdash A, Vahedi P, Griessenauer CJ, Oakes WJ Chiari IV malformation: correcting an over one century long historical error Childs Nerv Syst 2016;32(7):1175-1179 30 Tubbs RS, Muhleman M, Loukas M, Oakes WJ A new form of herniation: the Chiari V malformation Childs Nerv Syst 2012; 28(2):305-307 31 Paul KS, Lye RH, Strang FA, Dutton J Arnold-Chiari malformation Review of 71 cases J Neurosurg 1983;58(2):183-187 32 Pillay PK, Awad IA, Hahn JF Gardner’s hydrodynamic theory of syringomyelia revisited Cleve Clin J Med 1992;59(4):373-380 33 Williams B Cerebrospinal fluid pressure-gradients in spina bifida cystica, with special reference to the Arnold-Chiari malformation and aqueductal stenosis Dev Med Child Neurol Suppl 1975(35):138-150 34 Armonda RA, Citrin CM, Foley KT, Ellenbogen RG Quantitative cine-mode magnetic resonance imaging of Chiari I malformations: an analysis of cerebrospinal fluid dynamics Neurosurgery 1994;35(2):214-223; discussion 223-214 35 Ellenbogen RG, Armonda RA, Shaw DW, Winn HR Toward a rational treatment of Chiari I malformation and syringomyelia Neurosurg Focus 2000;8(3):E6 36 Ellenbogen RG Duraplasty: a procedure not to fear! World Neurosurg 2011;75(2):224-225 37 Pollack IF, Pang D, Albright AL, Krieger D Outcome following hindbrain decompression of symptomatic Chiari malformations in children previously treated with myelomeningocele closure and shunts J Neurosurg 1992;77(6):881-888 38 Pollack IF, Pang D, Kocoshis S, Putnam P Neurogenic dysphagia resulting from Chiari malformations Neurosurgery 1992;30(5):709-719 39 Park TS, Hoffman HJ, Hendrick EB, Humphreys RP Experience with surgical decompression of the Arnold-Chiari malformation in young infants with myelomeningocele Neurosurgery 1983;13(2): 147-152 40 Chern JJ, Gordon AJ, Mortazavi MM, Tubbs RS, Oakes WJ Pediatric Chiari malformation Type 0: a 12-year institutional experience J Neurosurg Pediatr 2011;8(1):1-5 41 Sasaki-Adams D, Elbabaa SK, Jewells V, Carter L, Campbell JW, Ritter AM The Dandy-Walker variant: a case series of 24 pediatric patients and evaluation of associated anomalies, incidence of hydrocephalus, and developmental outcomes J Neurosurg Pediatr 2008; 2(3):194-199 42 Hirsch JF, Pierre-Kahn A, Renier D, Sainte-Rose C, Hoppe-Hirsch E The Dandy-Walker malformation A review of 40 cases J Neurosurg 1984;61(3):515-522 43 Raimondi AJ, Shimoji T, Sato K Clinical experience with 37 patients In: Raimondi AJ, Shimoji T, Sato K, eds Dandy-Walker Syndrome Basel: S Karger AG; 1984:21-45 e2 44 Bindal AK, Storrs BB, McLone DG Management of the DandyWalker syndrome Pediatr Neurosurg 1990;16(3):163-169 45 Ulm B, Ulm MR, Deutinger J, Bernaschek G Dandy-Walker malformation diagnosed before 21 weeks of gestation: associated malformations and chromosomal abnormalities Ultrasound Obstet Gynecol 1997;10(3):167-170 46 Pascual-Castroviejo I, Velez A, Pascual-Pascual SI, Roche MC, Villarejo F Dandy-Walker malformation: analysis of 38 cases Childs Nerv Syst 1991;7(2):88-97 47 Sawaya R, McLaurin RL Dandy-Walker syndrome Clinical analysis of 23 cases J Neurosurg 1981;55(1):89-98 48 Naidich TP, Radkowski MA, McLone DG, Leestma J Chronic cerebral herniation in shunted Dandy-Walker malformation Radiology 1986;158(2):431-434 49 Asai A, Hoffman HJ, Hendrick EB, Humphreys RP Dandy-Walker syndrome: experience at the Hospital for Sick Children, Toronto Pediatr Neurosci 1989;15(2):66-73 50 Carmel PW, Antunes JL, Hilal SK, Gold AP Dandy-Walker syndrome: clinico-pathological features and re-evaluation of modes of treatment Surg Neurol 1977;8(2):132-138 51 Cartmill M, Jaspan T, McConachie N, Vloeberghs M Neuroendoscopic third ventriculostomy in dysmorphic brains Childs Nerv Syst 2001;17(7):391-394 52 Fischer EG Dandy-Walker syndrome: an evaluation of surgical treatment J Neurosurg 1973;39(5):615-621 53 Kumar R, Jain MK, Chhabra DK Dandy-Walker syndrome: different modalities of treatment and outcome in 42 cases Childs Nerv Syst 2001;17(6):348-352 54 Lee M, Leahu D, Weiner HL, Abbott R, Wisoff JH, Epstein FJ Complications of fourth-ventricular shunts Pediatr Neurosurg 1995; 22(6):309-313; discussion 314 55 Almeida GM, Matushita H, Mattosinho-Franca LC, Shibata MK Dandy-Walker syndrome: posterior fossa craniectomy and cyst fenestration after several shunt revisions Childs Nerv Syst 1990; 6(6):335-337 56 Liu JC, Ciacci JD, George TM Brainstem tethering in DandyWalker syndrome: a complication of cystoperitoneal shunting Case report J Neurosurg 1995;83(6):1072-1074 57 Villavicencio AT, Wellons JC III, George TM Avoiding complicated shunt systems by open fenestration of symptomatic fourth ventricular cysts associated with hydrocephalus Pediatr Neurosurg 1998; 29(6):314-319 58 Macfarlane R, Rutka JT, Armstrong D, et al Encephaloceles of the anterior cranial fossa Pediatr Neurosurg 1995;23(3):148-158 59 Richards CG Frontoethmoidal meningoencephalocele: a common and severe congenital abnormality in South East Asia Arch Dis Child 1992;67(6):717-719 60 Simpson DA, David DJ, White J Cephaloceles: treatment, outcome, and antenatal diagnosis Neurosurgery 1984;15(1):14-21 61 Jimenez DF, Barone CM Encephaloceles, Meningoceles and Dermal Sinuses In: Albright AL, Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 3rd ed New York, NY: Thieme; 2015:205-229 62 Caviness Jr VS, Evarard P Occipital encephalocele: a pathologic and anatomic analysis Acta Neuropathol 1975;32(3):245-255 63 Mealey Jr J, Dzenitis AJ, Hockey AA The prognosis of encephaloceles J Neurosurg 1970;32(2):209-218 64 Suwanwela C Geographical distribution of fronto-ethmoidal encephalomeningocele Br J Prev Soc Med 1972;26(3):193-198 65 Cohen Jr MM, Lemire RJ Syndromes with cephaloceles Teratology 1982;25(2):161-172 66 Mecke S, Passarge E Encephalocele, polycystic kidneys, and polydactyly as an autosomal recessive trait simulating certain other disorders: the Meckel syndrome Ann Genet 1971;14(2):97-103 67 Naidich TP, Altman NR, Braffman BH, McLone DG, Zimmerman RA Cephaloceles and related malformations AJNR Am J Neuroradiol 1992;13(2):655-690 68 Chapman PH, Swearingen B, Caviness VS Subtorcular occipital encephaloceles Anatomical considerations relevant to operative management J Neurosurg 1989;71(3):375-381 69 Lorber J, Schofield JK The prognosis of occipital encephalocele Z Kinderchir Grenzgeb 1979;28(4):347-351 70 Shokunbi T, Adeloye A, Olumide A Occipital encephalocoeles in 57 Nigerian children: a retrospective analysis Childs Nerv Syst 1990; 6(2):99-102 71 Strahle J, Muraszko K Spinal Meningoceles In: Albright AL, Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 3rd ed New York, NY: Thieme; 2015:286-293 72 Dias MS, McLone DG Myelomeningocele In: Albright AL, Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 2nd ed New York, NY: Thieme; 2008:338-366 73 Greenberg MS Developmental anomalies In: Greenberg MS, ed Handbook of Neurosurgery 7th ed New York, NY: Thieme; 2010: 222-261 74 Lien SC, Maher CO, Garton HJ, Kasten SJ, Muraszko KM, Buchman SR Local and regional flap closure in myelomeningocele repair: a 15-year review Childs Nerv Syst 2010;26(8):1091-1095 75 Stein SC, Schut L Hydrocephalus in myelomeningocele Childs Brain 1979;5(4):413-419 76 Adzick NS, Thom EA, Spong CY, et al A randomized trial of prenatal versus postnatal repair of myelomeningocele N Engl J Med 2011;364(11):993-1004 e3 Abstract: Congenital anomalies of the brain create unique management challenges in pediatric critical care Common conditions— including hydrocephalus, arachnoid cysts, neural tube defects, and Chiari malformations—are reviewed Key Words: Hydrocephalus, arachnoid cyst, Chiari, myelomeningocele, Dandy-Walker 60 Neurologic Assessment and Monitoring MARK S WAINWRIGHT AND SUE J HONG PEARLS • Much of the practice of brain-directed critical care in children is empiric, but studies in traumatic brain injury show that protocoldirected care with multidisciplinary teams in the intensive care unit improves outcome • Neuromonitoring incorporates the use of technologies including electroencephalography and neuroimaging but begins with a focused neurologic examination • Communication between team members, serial examinations, anticipation and early recognition of changes in the neurologic exam, or other monitoring parameters are essential • The examiner should focus both on localization of a neurologic deficit and identifying mechanism(s) of injury (or potential injury) as the first step in developing a treatment approach to reduce brain injury The goal of neuromonitoring is to identify and prevent neurologic insults in the intensive care unit (ICU) and to guide treatment of these injuries Ideally, these data and the treatments implemented using them should be linked to long-term neurologic outcomes Monitoring of brain function in children faces specific challenges, including the relative dearth of data supporting practice guidelines for management of acute brain injuries, lack of validated biomarkers of brain injury, developmental changes in the neurologic exam and physiology, and the long intervals between ICU treatment and the emergence of the full impact of neurologic insults The approach to the neurologic assessment of the patient in the pediatric ICU (PICU) or cardiac ICU (CICU) requires an interdisciplinary team involving intensivists, neurologists, neurosurgeons, nurses, and allied disciplines, including pharmacists, physiatry, and psychiatry Examples of these programs at different pediatric academic centers have been published.1–6 The practice of pediatric critical care neurology differs in important ways from the practice of adult neurocritical care.7,8 Survival is higher than in adults with comparable brain injuries, but the spectrum of neurologic recovery is broad, and recovery times are measured in decades Studies of outcomes following acute brain injuries in children use inconsistent measures of neurologic function, and long-term recovery data are sparse Although survival is higher, prognostication about the functional neurologic outcome after pediatric brain injury is based on limited data and is therefore imprecise Even for relatively common acute brain injuries—including traumatic brain injury (TBI), cardiac arrest, and status epilepticus—guidelines of management in children are based on limited data and expert consensus.9–12 Other differences involve the need to obtain testing (imaging, neurophysiology, laboratory) on patients who may appear neurologically intact, the need to intervene before a specific neurologic diagnosis has been identified or mechanism of injury confirmed, and the challenge of determining whether such interventions affect long-term outcome Effective neuromonitoring in critically ill children is possible The practice of pediatric critical care neurology combines serial neurologic examinations, clear communication between nurses and physicians, and—between multiple medical services—the need for early recognition of changes in the neurologic exam and the anticipatory management of patients with the potential for progressive neurologic deterioration The confounding effects of sedation and/or postoperative anesthesia on neurologic functioning pose an additional set of challenges to the assessment of these patients A core part of this approach is to combine the ICU neurologic examination with attention to the mechanisms of injury (present or potential) and develop a plan for ongoing monitoring and management It is prudent to regard every patient in the PICU as having the potential for neurologic complications of their illness These patients with primary diagnoses ranging from neurologic complications of solid-organ transplantation to liver failure to congenital heart disease may suffer neurologic injury from any combination of hypoxic, ischemic, inflammatory, or metabolic cerebral insults 720 Nursing Role in the Recognition of Neurologic Complications of Critical Illness The recognition of new neurologic deficit(s) relies on the ability of the medical team to recognize changes in the neurologic exam which occur in approximately 30% of children during their ICU stay.13 Nurses play a critical role in this process with their frequent physical examinations and attention to bedside monitors Interventions to treat or attenuate neurologic insults—whether seizures, ischemia, or increasing intracranial pressure (ICP)—are more likely to be successful if initiated early in the process of injury This means that effective neurologic monitoring in the PICU does not rely solely on the availability of an intensivist, neurologist, CHAPTER 60 Neurologic Assessment and Monitoring electroencephalography (EEG), or neuroimaging Standardized ICU nursing neurologic assessments using a modification of the Glasgow Coma Scale (GCS) score enables crude but reliable detection of neurologic decline.13 Anticipatory Planning for New Neurologic Deficits The ability to recognize changes in the neurologic exam is an essential component of brain-directed critical care for children Reliance on technology alone is insufficient Management should include anticipation of specific changes in the patient’s exam, an understanding of the pathophysiology causing that change, and a predetermined plan to intervene to address that mechanism Representative examples include new irritability in the patient with acute liver failure (ALF), right leg weakness in a patient with right anterior cerebral artery stroke, or hypophonia in the patient with acute inflammatory demyelinating polyneuropathy Each example (progression of hepatic encephalopathy; compression of the left anterior cerebral artery caused by increased edema in the right frontal lobe; progression to involve bulbar weakness) requires an escalation in care and cannot currently be identified by bedside monitors other than an examiner with an understanding of the disease process and the implications of these findings An improving exam despite deterioration in other modalities— such as EEG, transcranial Doppler (TCD), ICP, or neuroimaging— may change the treatment plan Similarly, deterioration in the neurologic exam may occur without changes in these other measures The ability to detect and react to such change requires a consensus on the admission neurologic exam, consensus on criteria for “decline” or “improvement” for each specific patient, and anticipatory planning for management of changes in exam The examiner should first discuss the neurologic findings with the bedside nurse and other members of the medical team If possible, abnormal findings should be demonstrated to the members of the team There should be a consensus on the key findings and the approach to be taken for evaluation and management if the neurologic exam changes The improvement in outcome for children with severe TBI associated with introduction of a multidisciplinary care team14 and adherence to management guidelines15 suggests that an emphasis on consistent care following established protocols can improve outcome without the need for additional technology (see Chapter 118) History and Assessment of Risk Factors For children in the PICU, the medical history may provide essential information about the mechanisms and timing of neurologic insult This information is needed for the interpretation of the neurologic exam and assessment of potential mechanisms of neurologic injury These data are then used to assess the risk for progression of neurologic injury, to prioritize therapeutic interventions, and to determine the need for and timing of additional evaluations, including imaging, EEG, and laboratory studies In many cases, decisions to treat (or not treat) a neurologic injury in the PICU must be empiric and based on a careful assessment of risk factors, potential mechanisms of injury, and weighing of the risks and benefits of such intervention For example, the approach to evaluation of altered mental status presenting to the PICU will be different for children with an established complex partial seizure disorder, sickle cell disease, or a stem cell transplant recipient 721 on immunosuppressive drugs Before examining the patient, knowledge of salient details of the medical history allows the examiner to begin to formulate a diagnostic approach and to prepare the early steps in management The patient with a history of epilepsy in the example presented earlier would likely require an emergent EEG to rule out nonconvulsive seizures, while the patient with sickle cell disease and risk factors of vascular injury with the same symptoms may require an imaging study and the immunosuppressed patient a lumbar puncture The presenting neurologic symptoms may be similar, but the history dictates the assessment based on the likely mechanisms producing the deficits found on neurologic examination Iatrogenic Complications of Pharmacotherapy A review of medications should be part of the neurologic assessment of any patient with new neurologic symptoms The initial assessment of the patient should include attention to medications that cross the blood-brain barrier or that may interfere with the renal or hepatic metabolism of centrally active drugs In patients in renal or liver failure, or requiring dialysis, the side effects of a centrally acting drug must be considered in the differential diagnosis for any neurologic symptom This may occur even in the presence of “normal” doses of drugs or levels of anticonvulsants, as off-target drug toxicities may be due to metabolites, not the drug itself Common examples in the PICU include immunophilin-associated seizures, encephalopathy and hypertension, oculogyric crisis, drug-induced delirium, and prolonged sedation and paralysis following neuromuscular blockade In many cases, the attribution of the symptoms to a drug side effect (excess level, too rapid withdrawal, idiosyncratic reaction, impairment of clearance) will be a diagnosis of exclusion Nevertheless, a review of medications and recent changes should be a routine component of the neurologic assessment Vital Signs Vital signs are an essential component of the neurologic exam, including recording of temperature The prevention of hyperthermia may significantly reduce secondary neurologic injury The results of randomized controlled trials of therapeutic hypothermia in children for severe TBI16,17 and out-of-hospital cardiac arrest18,19 suggest that early hypothermia, irrespective of ICP, does not improve outcome and, in the case of TBI, may increase the risk of death.17,20,21 Despite this, the prevention of hyperthermia can be regarded as a safe and effective intervention.22 Therefore, as a general principal for ICU patients with known or suspected central nervous system (CNS) injury, fever should be aggressively avoided In contrast to adults, there are limited data on the optimum ranges for blood pressure, ICP, and cerebral perfusion pressure (CPP) for children In adults, there are goal-directed protocols aimed at improving outcome following TBI The targets of ICP less than 20 mm Hg and CPP above 60 mm Hg are based on a number of studies.23–27 Data for children with TBI are limited.28,29 Guidelines suggest an ICP threshold of 20 mm Hg for all ages and a CPP threshold of 40 to 65 mm Hg as an “agerelated continuum.”30 Although children with TBI younger than years of age have a high mortality rate compared with older children, no thresholds for ICP or CPP have been established for this age group.31 Accordingly, blood pressure, temperature, and oxygenation must be interpreted in the context of the underlying ... York, NY: Thieme; 2015:286-293 72 Dias MS, McLone DG Myelomeningocele In: Albright AL, Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 2nd ed New York, NY: Thieme;... Pollack IF, Adelson PD, eds Principles and Practice of Pediatric Neurosurgery 3rd ed New York, NY: Thieme; 2015:205-229 62 Caviness Jr VS, Evarard P Occipital encephalocele: a pathologic and anatomic... Surg Neurol 1977;8(2):132-138 51 Cartmill M, Jaspan T, McConachie N, Vloeberghs M Neuroendoscopic third ventriculostomy in dysmorphic brains Childs Nerv Syst 2001;17(7):391-394 52 Fischer EG Dandy-Walker