Skip to main content

Advertisement

SpringerLink
Log in

Predictors of postoperative complications and functional outcomes in pediatric patients with surgically treated fourth ventricle tumors

  • Original Article
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Tumors of the fourth ventricle are frequently treated pathologies in pediatric neurosurgery. Data regarding predictors for permanent neurological deficits, long-term functional outcomes, cerebellar mutism (CM), the extent of resection (EOR), and oncological outcomes are scarce. We attempt to contribute to this topic with an analysis of our institutional cohort.

Methods

A retrospective single-center study of patients aged ≤ 19 years who underwent primary surgical resection of a fourth ventricular tumor over a 15-year period (2006–2021). Predictors analyzed included age, gender, surgical approach, anatomical pattern, tumor grade, EOR, tumor volume, and others as appropriate.

Results

One hundred six patients were included (64 males, mean age 7.3 years). The rate of permanent neurological deficit was 24.2%; lateral tumor extension (p = 0.036) and tumor volume greater than 38 cm3 (p = 0.020) were significant predictors. The presence of a deficit was the only significant predictor of reduced (less than 90) Lansky score (p = 0.005). CM occurred in 20.8% of patients and was influenced by medulloblastoma histology (p = 0.011), lateral tumor extension (p = 0.017), and male gender (p = 0.021). No significant difference between the transvermian and telovelar approach in the development of CM was detected (p = 0.478). No significant predictor was found for the EOR. EOR was not found to be a significant predictor of overall survival for both low-grade and high-grade tumors; however, gross total resection (GTR) was protective against tumor recurrence compared to near-total or subtotal resection (p < 0.001). In addition, survival was found to be better in older patients (≥ 7.0 years, p = 0.019).

Conclusion

The overall rate of postoperative complications remains high due to the eloquent localization. Older patients (> 7 years) have been found to have better outcomes and prognosis. Achieving GTR whenever feasible and safe has been shown to be critical for tumor recurrence. CM was more common in patients with medulloblastoma and in patients with tumors extending through the foramen of Luschka. The telovelar approach uses a safe and anatomically sparing corridor; however, it has not been associated with a lower incidence of CM and neurological sequelae in our series, showing that each case should be assessed on an individual basis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

Available from the corresponding author upon reasonable request.

Code availability

Not applicable.

Abbreviations

BAEP:

Brainstem evoked potentials

CI:

Confidence interval

CM:

Cerebellar mutism

CN:

Cranial nerve

CPA:

Cerebellopontine angle

EOR:

Extent of resection

EVD:

External ventricular drain

FLAIR:

Fluid-attenuated inversion recovery

GTR:

Gross total resection

IQR:

Interquartile range

MEP:

Motor evoked potentials

MRI:

Magnetic resonance imaging

NTR:

Near-total resection

OR:

Odds ratio

SD:

Standard deviation

SSEP:

Somatosensory evoked potentials

STR:

Subtotal resection

VPS:

Ventriculoperitoneal shunt

WHO:

World Health Organization

References

  1. Ashida R, Nazar N, Edwards R, Teo M (2021) Cerebellar mutism syndrome: an overview of the pathophysiology in relation to the cerebrocerebellar anatomy, risk factors, potential treatments, and outcomes. World Neurosurg 153:63–74. https://doi.org/10.1016/j.wneu.2021.06.065

    Article  PubMed  Google Scholar 

  2. Atallah A, Rady MR, Kamal HM, El-Mansy N, Alsawy MFM, Hegazy A, Zaghloul M (2019) Telovelar approach to pediatric fourth ventricle tumors: feasibility and outcome. Turk Neurosurg 29:497–505. https://doi.org/10.5137/1019-5149.Jtn.24078-18.3

    Article  PubMed  Google Scholar 

  3. Beneš V, Zápotocký M, Libý P, Táborský J, Blažková J, Blažková J, Sumerauer D, Mišove A, Perníková I, Kynčl M et al (2022) Survival and functional outcomes in paediatric thalamic and thalamopeduncular low grade gliomas. Acta Neurochir 164:1459–1472. https://doi.org/10.1007/s00701-021-05106-5

    Article  PubMed  Google Scholar 

  4. Catsman-Berrevoets CE, Van Dongen HR, Mulder PGH, Y Geuze DP, Paquier PF, Lequin MH (1999) Tumour type and size are high risk factors for the syndrome of “cerebellar” mutism and subsequent dysarthria. J Neurol Neurosurg Psychiatry 67:755–757. https://doi.org/10.1136/jnnp.67.6.755

    Article  CAS  PubMed  Google Scholar 

  5. Dandy WE (1932) The practice of surgery. The Brain. Hagerstwon, MD: WF Prior 12

  6. Duffner PK, Horowitz ME, Krischer JP, Friedman HS, Burger PC, Cohen ME, Sanford RA, Mulhern RK, James HE, Freeman CR et al (1993) Postoperative chemotherapy and delayed radiation in children less than three years of age with malignant brain tumors. N Engl J Med 328:1725–1731. https://doi.org/10.1056/nejm199306173282401

    Article  CAS  PubMed  Google Scholar 

  7. Eissa E (2017) The role of telovelar approach in fourth ventricular surgery: a new perspective. Turk Neurosurg. https://doi.org/10.5137/1019-5149.jtn.21209-17.1

    Article  Google Scholar 

  8. El-Bahy K (2005) Telovelar approach to the fourth ventricle: operative findings and results in 16 cases. Acta Neurochir 147:137–142. https://doi.org/10.1007/s00701-004-0407-0

    Article  CAS  PubMed  Google Scholar 

  9. Fabozzi F, Margoni S, Andreozzi B, Musci MS, Del Baldo G, Boccuto L, Mastronuzzi A, Carai A (2022) Cerebellar mutism syndrome: from pathophysiology to rehabilitation. Front Cell Dev Biol 10:1082947. https://doi.org/10.3389/fcell.2022.1082947

    Article  PubMed  PubMed Central  Google Scholar 

  10. Ferguson SD, Levine NB, Suki D, Tsung AJ, Lang FF, Sawaya R, Weinberg JS, McCutcheon IE (2018) The surgical treatment of tumors of the fourth ventricle: a single-institution experience. J Neurosurg 128:339–351. https://doi.org/10.3171/2016.11.jns161167

    Article  PubMed  Google Scholar 

  11. Grønbæk JK, Wibroe M, Toescu S, Frič R, Thomsen BL, Møller LN, Grillner P, Gustavsson B, Mallucci C, Aquilina K et al (2021) Postoperative speech impairment and surgical approach to posterior fossa tumours in children: a prospective European multicentre cohort study. Lancet Child Adolesc Health 5:814–824. https://doi.org/10.1016/s2352-4642(21)00274-1

    Article  PubMed  Google Scholar 

  12. Gudrunardottir T, Morgan AT, Lux AL, Walker DA, Walsh KS, Wells EM, Wisoff JH, Juhler M, Schmahmann JD, Keating RF et al (2016) Consensus paper on post-operative pediatric cerebellar mutism syndrome: the Iceland Delphi results. Child’s Nerv Syst 32:1195–1203. https://doi.org/10.1007/s00381-016-3093-3

    Article  Google Scholar 

  13. Jabarkheel R, Amayiri N, Yecies D, Huang Y, Toescu S, Nobre L, Mabbott DJ, Sudhakar SV, Malik P, Laughlin S et al (2020) Molecular correlates of cerebellar mutism syndrome in medulloblastoma. Neuro Oncol 22:290–297. https://doi.org/10.1093/neuonc/noz158

    Article  PubMed  Google Scholar 

  14. Jaju A, Yeom KW, Ryan ME (2022) MR imaging of pediatric brain tumors. Diagnostics 12:961. https://doi.org/10.3390/diagnostics12040961

    Article  PubMed  PubMed Central  Google Scholar 

  15. Jiang T, Zhang Y, Wang J, Du J, Ma Z, Li C, Liu R, Zhang Y (2016) Impact of tumor location and fourth ventricle infiltration in medulloblastoma. Acta Neurochir 158:1187–1195. https://doi.org/10.1007/s00701-016-2779-3

    Article  PubMed  Google Scholar 

  16. Kellogg JX, Piatt JH Jr (1997) Resection of fourth ventricle tumors without splitting the vermis: the cerebellomedullary fissure approach. Pediatr Neurosurg 27:28–33. https://doi.org/10.1159/000121221

    Article  CAS  PubMed  Google Scholar 

  17. Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J (1996) The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27:1304–1305. https://doi.org/10.1161/01.str.27.8.1304

    Article  CAS  PubMed  Google Scholar 

  18. Lansky SB, List MA, Lansky LL, Ritter-Sterr C, Miller DR (1987) The measurement of performance in childhood cancer patients. Cancer 60:1651–1656. https://doi.org/10.1002/1097-0142

    Article  CAS  PubMed  Google Scholar 

  19. Louis DN, Wesseling P, Aldape K, Brat DJ, Capper D, Cree IA, Eberhart C, Figarella-Branger D, Fouladi M, Fuller GN et al (2020) cIMPACT-NOW update 6: new entity and diagnostic principle recommendations of the cIMPACT-Utrecht meeting on future CNS tumor classification and grading. Brain Pathol 30:844–856. https://doi.org/10.1111/bpa.12832

    Article  PubMed  PubMed Central  Google Scholar 

  20. Louis DN, Perry A, Wesseling P, Brat DJ, Cree IA, Figarella-Branger D, Hawkins C, Ng HK, Pfister SM, Reifenberger G et al (2021) The 2021 WHO classification of tumors of the central nervous system: a summary. Neuro Oncol 23:1231–1251. https://doi.org/10.1093/neuonc/noab106

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Maloumeh EN, Khoshnoud RJ, Ebrahimzadeh K, Tavassol HH, Salari S, Mousavinejad A, Kargari A, Samadian M, Rezaei O (2021) Surgical management of the fourth ventricular tumors using telovelar approach and the role of neuroendoscopy: post-operative outcome and long-term results in a series of 52 cases. Clin Neurol Neurosurg 201:106419. https://doi.org/10.1016/j.clineuro.2020.106419

    Article  PubMed  Google Scholar 

  22. Mariën P, De Smet HJ, Wijgerde E, Verhoeven J, Crols R, De Deyn PP (2013) Posterior fossa syndrome in adults: a new case and comprehensive survey of the literature. Cortex 49:284–300. https://doi.org/10.1016/j.cortex.2011.06.018

    Article  PubMed  Google Scholar 

  23. Matsushima T, Rhoton AL Jr, Lenkey C (1982) Microsurgery of the fourth ventricle: part 1. Microsurgical anatomy. Neurosurgery 11:631–667. https://doi.org/10.1227/00006123-198211000-00008

    Article  CAS  PubMed  Google Scholar 

  24. Morris EB, Phillips NS, Laningham FH, Patay Z, Gajjar A, Wallace D, Boop F, Sanford R, Ness KK, Ogg RJ (2009) Proximal dentatothalamocortical tract involvement in posterior fossa syndrome. Brain 132:3087–3095. https://doi.org/10.1093/brain/awp241

    Article  PubMed  PubMed Central  Google Scholar 

  25. Morrissy AS, Cavalli FMG, Remke M, Ramaswamy V, Shih DJH, Holgado BL, Farooq H, Donovan LK, Garzia L, Agnihotri S et al (2017) Spatial heterogeneity in medulloblastoma. Nat Genet 49:780–788. https://doi.org/10.1038/ng.3838

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Northcott PA, Korshunov A, Witt H, Hielscher T, Eberhart CG, Mack S, Bouffet E, Clifford SC, Hawkins CE, French P et al (2011) Medulloblastoma comprises four distinct molecular variants. J Clin Oncol 29:1408–1414. https://doi.org/10.1200/jco.2009.27.4324

    Article  PubMed  Google Scholar 

  27. Onorini N, Spennato P, Orlando V, Savoia F, Calì C, Russo C, De Martino L, de Santi MS, Mirone G, Ruggiero C et al (2022) The clinical and prognostic impact of the choice of surgical approach to fourth ventricular tumors in a single-center, single-surgeon cohort of 92 consecutive pediatric patients. Front Oncol 12:821738. https://doi.org/10.3389/fonc.2022.821738

    Article  PubMed  PubMed Central  Google Scholar 

  28. Pettersson SD, Kitlinski M, Miękisiak G, Ali S, Krakowiak M, Szmuda T (2022) Risk factors for postoperative cerebellar mutism syndrome in pediatric patients: a systematic review and meta-analysis. J Neurosurg: Pediatr 29:467–475. https://doi.org/10.3171/2021.11.peds21445

    Article  PubMed  Google Scholar 

  29. Pols SYCV, Van Veelen MLC, Aarsen FK, Gonzalez Candel A, Catsman-Berrevoets CE (2017) Risk factors for development of postoperative cerebellar mutism syndrome in children after medulloblastoma surgery. J Neurosurg: Pediatr 20:35–41. https://doi.org/10.3171/2017.2.peds16605

    Article  PubMed  Google Scholar 

  30. Rajesh BJ, Rao BRM, Menon G, Abraham M, Easwer HV, Nair S (2007) Telovelar approach: technical issues for large fourth ventricle tumors. Child’s Nerv Syst 23:555–558. https://doi.org/10.1007/s00381-006-0295-0

    Article  CAS  Google Scholar 

  31. Resende LL, Alves CSAPF (2021) Imaging of brain tumors in children: the basics—a narrative review. Transl Pediatr 10:1138–1168. https://doi.org/10.21037/tp-20-285

    Article  PubMed  PubMed Central  Google Scholar 

  32. Tamburrini G, Frassanito P, Chieffo D, Massimi L, Caldarelli M, Di Rocco C (2015) Cerebellar mutism. Child’s Nerv Syst 31:1841–1851. https://doi.org/10.1007/s00381-015-2803-6

    Article  CAS  Google Scholar 

  33. Thomale UW, Driever PH (2013) Inconsistent terminology for cerebellar mutism. Childs Nerv Syst 29:717–718. https://doi.org/10.1007/s00381-013-2074-z

    Article  PubMed  Google Scholar 

  34. Toescu SM, Samarth G, Layard Horsfall H, Issitt R, Margetts B, Phipps KP, Jeelani NU, Thompson DNP, Aquilina K (2020) Fourth ventricle tumors in children: complications and influence of surgical approach. J Neurosurg Pediatr 27:52–61. https://doi.org/10.3171/2020.6.Peds2089

    Article  PubMed  Google Scholar 

  35. Tomasello F, Conti A, Cardali S, La Torre D, Angileri FF (2015) Telovelar approach to fourth ventricle tumors: highlights and limitations. World Neurosurg 83:1141–1147. https://doi.org/10.1016/j.wneu.2015.01.039

    Article  PubMed  Google Scholar 

  36. Yang W, Cai Y, Chen J, Yang P, Ying Z, Liang Y, Ling M, Zhu K, Sun H, Ji Y et al (2023) Epidemiological characteristics, clinical presentations, and prognoses of pediatric brain tumors: experiences of national center for children’s health. Front Oncol 13:1067858. https://doi.org/10.3389/fonc.2023.1067858

    Article  PubMed  PubMed Central  Google Scholar 

  37. Yaşargil MG, Abdulrauf SI (2008) Surgery of intraventricular tumors. Neurosurgery 62:1029–1040. https://doi.org/10.1227/01.neu.0000333768.12951.9a. (discussion 1040–1021)

    Article  PubMed  Google Scholar 

  38. Zaheer SN, Wood M (2010) Experiences with the telovelar approach to fourth ventricular tumors in children. Pediatr Neurosurg 46:340–343. https://doi.org/10.1159/000321539

    Article  PubMed  Google Scholar 

Download references

Funding

Supported by the Ministry of Health of the Czech Republic Grant No. NU23-08–00460.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic

    Kryštof Haratek, Adéla Bubeníková, Martin Tomášek, Petr Libý, Michal Tichý, Ondřej Bradáč & Vladimír Beneš 3rd

  2. Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic

    Adéla Bubeníková & Ondřej Bradáč

  3. Department of Neurosurgery, Charité – Universitätsmedizin Berlin, Berlin, Germany

    Christian Joachim Entenmann

  4. Center for Pediatric Neuro-Oncology, University Hospital Motol, V Úvalu 84, 150 06, Prague 5, Prague, Czech Republic

    Martin Tomášek, Michal Zápotocký, David Sumerauer, Martin Kynčl, Miroslav Koblížek, Petr Libý, Michal Tichý, Ondřej Bradáč & Vladimír Beneš 3rd

  5. Department of Pediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic

    Michal Zápotocký & David Sumerauer

  6. Department of Radiology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic

    Martin Kynčl

  7. Department of Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic

    Miroslav Koblížek

Authors
  1. Kryštof Haratek
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Adéla Bubeníková
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christian Joachim Entenmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Martin Tomášek
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michal Zápotocký
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. David Sumerauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Martin Kynčl
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Miroslav Koblížek
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Petr Libý
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Michal Tichý
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Ondřej Bradáč
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Vladimír Beneš 3rd
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study’s conception and design. Material preparation and data collection were performed by K. H., A. B., C. E., and V. B. A. B. performed the statistical analysis. The first draft of the manuscript was written by K. H., A. B., and V. B. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Vladimír Beneš 3rd.

Ethics declarations

Ethics approval

Ethical approval was waived by the local Ethics Committee of the Second Faculty of Medicine, Charles University and Motol University Hospital, in view of the retrospective nature of the study, and all the procedures being performed were part of the routine care.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The abstract has been submitted for the EANS 2023 congress as a part of the oral presentation section.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Haratek, K., Bubeníková, A., Entenmann, C.J. et al. Predictors of postoperative complications and functional outcomes in pediatric patients with surgically treated fourth ventricle tumors. Acta Neurochir 165, 4279–4292 (2023). https://doi.org/10.1007/s00701-023-05729-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-023-05729-w

Keywords

Search

Navigation