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Serial, consistent, and well-documented neurological assessments are the most important aspect of nursing care for the pediatric neurosurgical patient. Subtle changes in the neurological assessment may first be noted by a bedside nurse. Keen observation skills and the ability to extract information about a patient’s baseline level of neurological function from the parents or primary caregivers are essential. The nurse’s response to assessment changes is essential to the prevention of secondary neurological sequelae and other complications associated with neurological disorders [11]. These potential complications include, among others, inability to protect the airway, immobility, endocrine disorders related to central hormonal dysregulation, impaired communication, and behavioral issues [20].

Hydrocephalus is a condition resulting from an imbalance between the production and absorption of cerebral spinal fluid (CSF). This imbalance results in an increased volume of spinal fluid, dilation of the ventricular system, and often increased intracranial pressure. Hydrocephalus can be acute and occur over hours or days. It may also be chronic and occur over months or years. Hydrocephalus can occur as an isolated condition or one associated with numerous other neurological conditions and diseases.

Craniosynostosis is the premature closure of one or more cranial sutures. Sometimes the entire suture is fused, but even a partial fusion can cause a deformity, as the skull growth is restricted. Although the clinical condition of craniosynostosis was described by Hippocrates in BC 400, effective treatments have only been developed in the last century [9]. In 1800, Sömmering described the anatomic structures of calvarial sutures and the results of premature closure [54]. However, the German pathologist Rudolf Virchow first used the term craniostenosis and proposed that “outward growth of the skull is restricted in a direction perpendicular to the prematurely fused suture and compensatory growth occurs in the patent sutures” [58]. This restriction of growth in one direction and compensatory growth in others accounts for the classic skull deformities seen in craniosynostosis.

Neural tube defects are a common birth defect, with an incidence rate in the United States of 1 in 1000 live births [1,9,11,29]. They are caused by abnormal embryological formation of the neural tube during the early weeks of pregnancy. Clinical outcomes are dependent on the characteristics of the defect; whether it is open or closed, the anatomic level and if there are associated brain abnormalities. The clinical deficit can range from a mild to severe disability or paralysis, and possibly death. There are several terms used to describe the open or closed forms of a neural tube defect (Table 4.1).

Chiari malformations are a group of abnormalities of the hindbrain that were originally described in 1891 by Hans Chiari, a German professor. His work, based on autopsy results, created the classic definitions of hindbrain herniation now described as Chiari type I (CIM), Chiari type II (CIIM), and Chiari type III (CIIIM) malformations. CIM consists of displacement of the cerebellar tonsils below the foramen magnum (FM). CIIM, usually associated with myelomeningocele (MM), includes caudal displacement of the inferior cerebellar vermis, the fourth ventricle, and the medulla into the cervical canal. CIIIM, a rare and severe form, includes a low occipital or high cervical encephalocele in combination with downward displacement of most of the cerebellum, the fourth ventricle, and possibly portions of the brainstem [3, 10, 19].

Brain tumors are the most common solid tumor in childhood. For example, there are approximately 2000 brain tumors diagnosed in children each year in the United States. The incidence of brain tumors is higher among males than females, and higher among white children than any other group. While the incidence of reported pediatric brain tumors has been increasing over the past few decades, this is probably because of improvements in diagnostic capabilities and reporting. Recent advances in diagnostic capabilities, aggressive surgical techniques, and multimodal therapy, including radiation and/or chemotherapy, have lead to longer survival and even cure of some classifications of pediatric brain tumors [17].

Despite prevention efforts, pediatric head trauma remains the most common cause of serious injury and death in children. Seventy-five percent of children who are hospitalized secondary to trauma, sustain head trauma. Most pediatric head trauma is mild in severity, although central nervous system (CNS) injury is the most common cause of pediatric traumatic death [22]. The overall incidence is 200–300 cases per 100,000 in the population annually. Deaths from severe traumatic brain injury (TBI) occur at an alarming rate of 7,000 annually [20]. This is especially concerning when considering that upwards of 20–40% of the injuries are preventable. The financial burden on individuals and society is immense, and is estimated at $7.5 billion annually in the United States. Many childhood survivors of severe TBI are left with varying degrees of permanent disability.

The immature pediatric spinal column has unique features that increase the spinal cord’s susceptibility to injury without obvious evidence of abnormality in alignment or bony integrity. The pediatric spine does not reach adult characteristics until after the age of 8 years and may not reach full maturity until age 16–18 years [8, 21]. The anatomic features of the immature pediatric cervical spine increase the mobility of the spinal column, causing it to be hypermobile and susceptible to flexion and extension type injuries. The vertebral bodies are wedge-shaped, allowing for slippage of the vertebral bodies anteriorly during flexion. The facet joints are much more horizontally oriented in the pediatric spine in comparison to the adult spine. This again allows for translation of the vertebral bodies as the spine is flexed forward or extended back.

Neurovascular malformations are generally congenital lesions that have the potential to produce symptoms at any time. Vascular malformations are a rare occurrence in children but can be quite complex in this population [47]. The vast majority of pediatric malformations fall into one of the following groups: aneurysms, arteriovenous malformations (AVM), cavernous malformations, vein of Galen malformations, venous angiomas, and moyamoya. Vessels within the vascular blood supply are composed of arteries, veins, and capillaries. Table 9.1 describes the characteristics of these three types of vessel.

Epilepsy affects approximately 0.5–1% of the world’s population, with initial onset most frequently occurring during childhood [1]. Prior to initiating treatment, it is important to determine whether or not the described behaviors are epileptic seizures. A detailed and thorough history will help confirm whether the described behaviors include periods of unresponsiveness, altered awareness, interruption in the child’s activity, or a period of postictal depression. Additionally, an electroencephalogram (EEG) is performed to provide further formation about the seizure type.