Pediatric Neurosurgeon
Marine Lines , Mumbai, Maharashtra
Brain And Spinal Cord Trauma Treatment Services
Antenatal Counseling Treatment Services
Craniosynostosis Treatment Services
Hydrocephalus Treatment Services
Surgery Epilepsy Treatment Services
Brain and Spinal Cord Tumors (Pediatric Neuro-oncology)
Brain And Spinal Cord Tumors Treatments Services
Spinal Dysraphism Treatment Services
Pediatric Neurosurgeon treats infants and children with disorders affecting the central and peripheral nervous system.
Pediatric Neurosurgery is a sub-specialty of Neurosurgery and requires additional fellowship training after residency to specialize in the care of infants and children. The specialty focuses on the particular problems seen, and sometimes unique to, the pediatric age group. As such, my practice is exclusively dedicated to the care of children with neurosurgical disorders and incorporates a team approach involving many other Pediatric specialists including Paediatricians, Pediatric-Neurologist, Pediatric Intensitivist, Pediatric-Anesthesia, Neuro-radiologist, Neuro-oncologist, Pediatric-Orthopedics and Plastic-Surgeon.
I treat Infants and Children with disorders affecting the Central Nervous SystemHydrocephalus [ Including Neuroendoscopy ]Tethered Cord syndrome [Spinal Dysraphism,Spina Bifida]Brain and Spinal Cord Tumors (Pediatric Neuro-oncology)CraniosynostosisSurgery for EpilepsyBrain and Spinal Cord TraumaCranial Dysraphism Cerebrovascular Disorders (Including Moya Moya disease)Ante-natal counseling for Neurosurgical ProblemsPediatric Neurosurgery is a sub-specialty of Neurosurgery and requires additional fellowship training after residency to specialize in the care of infants and children. The specialty focuses on the particular problems seen that are unique to, the pediatric age group.My practice is exclusively dedicated to the care of children with neurosurgical disorders and incorporates a team approach involving many other Pediatric specialists including Pediatricians, Pediatric-Neurologist, Pediatric Intensitivist, Pediatric-Anesthesia, Pediatric-Orthopedics ,Plastic-Surgeon.Neuro-radiologist, and Neuro-oncologist, Some of the diseases are given as under, read more to learn about these diseases and their treatments:+ Read More
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Trauma is the second leading cause of death in children less than 15 years of age and head injury is responsible for 20% of these deaths. The outcome in the children depends on the severity of the injury as well as management. Children have a large number of productive years ahead - it is imperative that these children require utmost care and attention. The mechanism of injury in children is distinct from adults with common causes being falls (35%), recreational activities (29%) and traffic accidents (24%). There is also age specific variation with child abuse seen frequently in children less than 2 years of age. Falls are a major cause of head injury in children less than 3 years. Road traffic accidents account for larger numbers as the age of the child increases.
Children as mini adults and treat them similarly. The immature skull has different mechanical properties and the child's brain is undergoing maturation and development and. The newborn's skull has pliable thin bones which can significantly deform.The pliability of the skull makes it more vulnerable to injury especially diffuse injury. The child's brain is much larger in proportion to the body as compared to adults - the newborn's brain constitutes 15% of body weight compared to 3% in the adult. The relatively larger size of the brain of a child in comparison to the body makes it more vulnerable to injury.
Head injury could be primary or secondary. The primary injury is the immediate Contact forces may result in fractures, localized contusions and hematoma ,hemorrhages and diffuse injury. Secondary injury results from an array of reactive events which follow the primary event and can worsen the initial injury or cause new injury to brain. These events include hypoxia, hypotension, metabolic alterations, fluid and electrolyte imbalance, brain edema, seizures, local and systemic infections etc The secondary injury are preventable and this constitutes an important aim in the management of the head injured child. Various pathologies may be seen in head injured patients.
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Hydrocephalus comes from the Greek: "hydro" meanswater, "cephalus" means head. Hydrocephalus is an abnormalaccumulation of cerebrospinal fluid (CSF) within cavities called ventriclesinside the brain. CSF is produced in the ventricles, circulates through theventricular system and is absorbed into the bloodstream. CSF is in constantcirculation and has many important functions. It surrounds the brain and spinalcord and acts as a protective cushion against injury. CSF contains nutrientsand proteins necessary for the nourishment and normal function of the brain. Italso carries waste products away from surrounding tissues. Hydrocephalus occurswhen there is an imbalance between the amount of CSF that is produced and therate at which it is absorbed. As the CSF builds up, it causes the ventricles toenlarge and the pressure inside the head to increase.
CSF Pathways
The Choroid plexus is the mainsource of CSF. The CSF formed in the lateral ventricles gains access to thethird ventricle through the paired foramina of Munro. From there through theAqueduct of Sylvius it enters the fourth ventricle from which is exits throughthe foramina of Luschka and Magendie. Part of it flows down into the spinalsubarachnoid space. The bulk flows over the hemispheres and the subarachnoidpathway to be absorbed by the arachnoid villi in the superior sagittal sinus. Primary site of absorption is thearachnoid villi - by a pressuredependent process. The other sites of absorption are the parenchymalcapillaries and root sleeves of the large cranial nerves). The production,circulation and absorption of CSF is a continuous and dynamic process.
Etiopathogenesis
Hydrocephalus can result from
1. Over production of CSF
2. Under absorption of CSF
Over production
The only known condition causing hydrocephalus by overproduction is ChoroidPlexus tumor.
Underabsorption
Under absorption may result from:
1. A block in the CSF pathways interfering with the flow of CSF (i.e. obstructive hydrocephalus).
2. A defect in the absorptive mechanism itself.
Both result in an accumulation of CSF. In theformer the obstruction can be inside the ventricular system (referred to as noncommunicating hydrocephalus) or in the subarachnoid spaces (termedcommunicating hydrocephalus).
Clinical Features Infants: The skull is pliable and yielding in thisage. The common manifestations are increased head size, bulging or fullanterior fontanelle, sutural separation, sunset sign, poor feeding,irritability, vomiting, and dilated scalp veins. Cracked pot resonance is often mentioned butseldom elicited.
Hydrocephalus that is congenital (present at birth) iscaused by a complex interaction of environmental and perhaps genetic factors.Aqueductal stenosis and spinal bifida are two examples. Acquired hydrocephalusmay result from intraventricular hemorrhage, meningitis, head trauma, tumorsand cysts. Hydrocephalus is believed to occur in about 2out of 1,000 births. Hydrocephalusin infants and young children is frequently diagnosed at birth or shortlythereafter, With the advent of sophisticated imaging technologies such asmagnetic resonance imaging (MRI) and ultrasonography, hydrocephalus can bediagnosed in utero, before the baby is born.
Children: The common manifestations includeincreasing head size, vomiting, bulging fontanelles (if it is still open),irritability, poor feeding or even refusal of feeds, headache, visual deficits,abnormal ocular movements, gait disturbance, increased tone in the lowerextremities, paralysis of upward gaze and papilledema. Serial measurements ofthe head size are a good indicator of the evolution of hydrocephalus.
I offer parents of children with inuteroabnormalities prenatal counseling. This allows us to provide education toprospective parents about their child's diagnosis and prognosis, allowing themmaking important decisions about the pregnancy and new born. Disordersdiagnosed in utero include hydrocephalus, intracranial cyst, spinal dysraphism,vascular anomalies, and rarely, tumors.
What Is Prenatal Hydrocephalus?
Prenatal hydrocephalus describes hydrocephalus that is diagnosed in utero (before birth).
Hydrocephalus can be detected in a fetus as early as the latter part of the first trimester of pregnancy. Around 20 to 24 weeks of gestation, abnormal dilation of the fetus's ventricles is more clearly detectable. Prenatal ultrasound, performed by a radiologist skilled in obstetric ultrasound, is highly reliable and accurate. It will establish that there is an abnormal cerebrospinal fluid (CSF) collection but it may not show the precise site of flow obstruction. The more important question is what caused the hydrocephalus and to what degree is there other malformations within the central nervous system. Amniocentesis (needle aspiration of intrauterine fluid) can often detect the presence of open neural tube defects, such as myelomeningocele, chromosome abnormalities and in utero infections, and may indicate the severity of the fetal condition. In general, early (first trimester) development of significant hydrocephalus can be a bad prognostic sign for infant mortality and developmental progress. In some cases, mild ventricular dilation identified by ultrasound has resolved itself by the third trimester.
Prenatal hydrocephalus is generally not treated until after birth, After birth a shunt may be inserted into the baby's brain to divert CSF fluid to treat the hydrocephalus.
There are many unknowns surrounding a prenatal diagnosis of hydrocephalus. This can be very frightening, distressing and sad for expectant parents, and extremely frustrating for the medical specialists who provide care. Although the outlook and success rate for infants diagnosed at or after birth is generally very high, there are limited studies available on the long-term prognosis of those with prenatal-onset hydrocephalus. Much seems to depend on the extent of associated brain and systemic abnormalities, structural changes in the brain and the extent of the hydrocephalus. It is very difficult to accurately predict future function based on morphology or imaging. The more significant factor in the future development of children with prenatal-onset hydrocephalus is the presence of continuing care and the absence of complications such as infection or hemorrhage.
I also do antenatal counseling for cyst in brain like Dandy-Walker malformation, Arachnoid cyst and spinal dyrasphism.
Epilepsy is an intermittent derangement of the nervous system due to a sudden, excessive, disorderly electrical discharge of cerebral neurons. The term epilepsy is derived from the Greek word epilamvanein .Prevalence rate of epilepsy in India is 5.59 per 1000 population with no gender or geographical difference. More than two-thirds of all epilepsy begins in childhood, when seizures can have drastic and devastating results on the child's psyche and development. Recent advances over the past decade in the understanding of pathogenesis mechanisms and in the diagnosis of epilepsy have had a significant impact on every aspect of epilepsy management including surgical management of epilepsy.
Surgical treatment is highly effective in the treatment of many of the epilepsies that have not responded to medical therapy. Nearly 40 percent of children with partial epilepsy are candidates for surgical therapy.
I work in close association with a team. Our Pediatric Epilepsy Surgery team includes Pediatric Neurologists, Pediatric Neurosurgeons, Neuropsychologists and Neuroradiologist. Children with medically intractable epilepsy are extensive evaluations include video-EEG, Neuroimaging like MRI. and Neuropsychological assessments. We conduct monthly meetings to discuss pediatric epilepsy cases in our forum to provide the best surgical management and plan [tailored to the individual's case]and care. The department is experienced in performing temporal lobectomy, lesionectomy, corpus callostomy and hemispherectomies and placement of vagal nerve stimulator. I also conduct Awake craniotomy when appropriate.
Why epilepsy surgery?
AED is main stay in the treatment. The untoward cognitive side effects of AEDs coupled with the long-term effects of recurrent seizures, reduced quality of life and increased co-morbidities for the majority of patients. So in children with epilepsy where surgical option is available, more and more children are recruited for epilepsy surgery.
Patients with unsatisfactory seizure control often seek alternative care. The number or severity of the seizures may be unacceptable to the patient, family, or treating physician. Other reasons for referral for epilepsy surgery include the results of diagnostic tests that may show a structural focal brain lesion, unsatisfactory psychosocial adaptation due to poor seizure control, unacceptable sedation, or other drug side effects.
The morbidity and mortality of seizures include accidental injury; cognitive decline; sudden death; and psychological, social, and vocational impairment. Accidental injuries commonly include fractures, burns, dental injuries, lacerations, and head injuries. Cognitive decline over time has been demonstrated to occur in patients with certain epilepsy syndromes who have recurrent convulsive seizures or episodes of status epilepticus. Both depression and anxiety are very common among patients with medically refractory epilepsy. Vocational issues include inability to be employed or, if employed, underemployment.Prolonged anticonvulsant drug therapy also affects cognition, memory, behaviorand motor developmentin substantial number of children.
Type of surgery
Epilepsy surgery may be divided into two major categories: Resective and Functional. The aim of Functional surgery is to decrease seizure frequency.
Resective surgeries
The aim of resective surgery is to remove the epileptogenic zone and render the patient seizure free. Surgeries done are:
1. Anteromedial Temporal Resection [AMTR],
2. Selective Amygdylohippocapectomy
3. Lesionectomy [Temporal and Extra-temporal]
Skull deformities are a very common reason for referral to pediatric neurosurgery.Premature fusion of cranial suture closure is called craniosynostosis.
Incidence and Aetiology :
Isolated craniosynsostosis occurs due to the premature fusion of a single suture or multiple sutures. The overall prevalence of craniosynostosis is around 1 in 2500 live births, with ranges of 1 in 709 to 1 in 3225 of births. The wide variation seen is due to differences in the various criteria under which one labels craniosynsostosis. Isolated craniosynostosis is far more common than multiple 'syndromic' synostosis.Sagittal seems to be commonest, followed by coronal and metopic. True lambdoid synostosis appears rare and is difficult to distinguish from deformational posterior asymmetry, which is considered to be because of positional molding of the cranium.
Common Syndromic Craniosynostosis like Apert and Crouzon have prevalence of about 1 in 65000, each about 4-6 per cent of all craniosynostosis. There is evidence of FGFR2 mutation in Apert Syndrome, FGFR3 in Crouzon syndrome and FGFR1 in Pfeiffer syndrome. Almost all Aperts and about 50 per cent of Crouzons arise de novo and there is a correlation with increase in paternal age. The prevalence of Pfeiffer syndrome is lower than others but there is no definite percentage data.
Apart from this there are rarer types of single gene syndromes associated with other malformations, metabolic storage disorders and learning disabilities.There are chromosomal aberrations of which craniosynostosis may be a feature. There are teratogenic causes associated with anticonvulsants, (Valproate, Hydantoin)cytotoxic agents, (Methotraxate, Cyclophosphomide, Cytarabine) abortifacients, and nitrosatable drugs(Chlorpneramine,Nitrofurantoin, Chlordiazepoxide and Fluconazole).
Classification and Terminology
Over the years, the nomenclature for various craniofacial deformities has remained constant, but with the entry of molecular genetics, there have been additional terms given to the complex multi sutural synostosis. However, in simple terms these deformities can be classified into three different varieties.
Simple, Complex and Secondary:
The Simple anomalies include single suture or two suture involvement and are named as
Sagittal synostosis or Scaphocephaly or Dolichocephaly, is so called when the sagittal suture is singularly prematurely fused and the head attains a longish anteroposterior length with or without frontal bossing.
Unicoronal synostosis [Anterior-Plagiocephaly] when there is flattening of one side of the forehead and a mild facial scoliosis, due to premature fusion of one coronal suture.
Metopic synostosis or Trigonocephaly, when there is premature fusion of the metopic suture, and the forehead assumes a triangular shape like the keel of a boat.
Lambdoid synostosis [Posterior Plagiocephaly] when a single lambdoid suture fuses to produce asymmetric occipital flattening.
Bicoronal synostosis or Brachycephaly, where both coronal sutures fuse prematurely and the skull assume spherical shape.
Acrocephaly or Turricephaly or Oxycephaly , where both coronals and anterior Sagittal sutures fuse and the skull assumes a pointed tower like shape.
Brain tumors are second most common neoplasm of childhood after leukaemia, primary brain tumors are responsible for 20% of all cancers in children, and for 20% of childhood cancer deaths. The yearly incidence of childhood brain tumors is reported to be 24 per million children less than 15 years of age. The neurologic functional outcome and quality of life of children is goal of treatment .
Pediatric NeurosurgeonBombay Hospital, New Marine Lines, Mumbai-400012, Maharashtra, India
Naresh Biyani