Pediatric Neurology and Neurosurgery

When it comes to neurosurgical disorders in children, medical expertise matters.

Since 1991, Acıbadem Pediatric Neurosurgery Center sets an example in this medical field, serving as a reference center for complex cases from Turkey and abroad. It was established as a comprehensive center where experts from various medical specialties work in collaboration for the treatment of all neurological pathologies in children, including congenital anomalies, epilepsy, spasticity, and brain tumors. Today, it is an internationally recognized center, providing exceptional care for still-developing children’s brains, with more than 25% of our patients coming from all over the world.

“A child is not a miniature version of an adult. The difference between a child and an adult is as vast as the difference between a mouse and a giraffe. It is not just in size but also in shape, anatomy and function. Function centers of an adult brain are well established, but unlike adult brains, the brains of children are still in the process of development.  Which means some of the safe zones that we can easily operate on adults, are forbidden in children.”

Prof. Dr. Memet Özek, Pediatric Neurosurgeon, ACIBADEM Healthcare Group

Acıbadem Pediatric Neurosurgery team consists of experienced and dedicated physicians, nurses and technicians. Physical therapy and rehabilitation, pediatric neurosurgery, orthopedics, pediatric neurology, pediatric surgery, oncology, radiology, dental departments are available, and therefore, a multidisciplinary approach is adopted for all our patients. Multidisciplinary approach ensures that medical experts of all related specialties examine the patient together, to determine the treatment plan and its stages, considering all existing options.

Prof. Dr. Memet Özek compares a good surgery team to a string quartet. “These four musicians can be virtuosos in their own but playing together in harmony is what makes them a string quartet. And to achieve that, they have to practice day and night for months, even years. We have been working with the same surgical nurses and technicians for 10 years and  27 years with the same pediatric anesthesiologist. This brings harmony to our work, meaning better outcomes for our tiny patients.”

Diagnosis of Neurosurgical Disorders

Each successful treatment starts with the accurate diagnosis. Acıbadem Pediatric Nerosurgery Center is equipped with all the latest technologies for correct diagnosis of neurosurgical conditions in children. PET, SPECT, EEG, CT, USG can be used for precise diagnosis.

Acıbadem has some of the most advanced 3 Tesla MRI models available today: Siemens Vida and GE Premier. The 70 cm patient bore allows children with claustrophobia to be scanned comfortably. The devices provide higher efficiency and enhanced workflow, and improve the image quality up to eight times. Current MRI technology is so advanced that it can show all brain disorders in the MRI scan. It makes visible the location of vessels and their course in the tumor. Moreover, it can show the extent of how much the vessels feed centers responsible for a certain function. A well-equipped radiology unit using a high-resolution 3 Tesla MRI can set a precise diagnosis with MRI scan alone in most of the cases, and this is a routine procedure in Acıbadem.

Computer-assisted Three-Dimensional Gait Analysis Device is used to detect and determine gait disorders, especially those related to neurologic, orthopedic, and rheumatologic problems.

Conditions We Treat

The multidisciplinary team of Acıbadem Pediatric Neurosurgery Center treats all neurosurgical pathologies in children, with special expertise in:

• Deep-seated brain tumors (located in the brain stem and thalamus)
• Epilepsy surgery
• Spasticity surgery
• Endoscopic treatment of hydrocephalus (an alternative to shunt surgery)

Congenital Brain Abnormalities

Congenital abnormalities mean that a child is born with malformations of the brain or spine. There are five types of congenital anomalies in pediatric neurosurgery: hydrocephalus, brain cysts, encephalocele, craniosynostosis, and cerebral vascular malformations.

• Hydrocephalus is a term that is derived from the words “hydro = water” and “cephalus = head”. It is defined as “accumulation of water in human brain and increased pressure”. It is colloquially called “excessive water accumulation in brain”. Here, the word “water” is used for the cerebrospinal fluid (CSF). There are chambers in our brain, which are interconnected by ducts and vary in size. These chambers are called “ventricles”. There are four ventricles in total (two lateral ventricles, the 3rd ventricle and the 4th ventricle). Hydrocephalus may develop due to excessive accumulation of CSF in one or more chambers, and results in elevation of pressure. As expected, this condition harms the brain tissue.
• Congenital cysts can develop all over the brain. If they cause pressure on brain tissue, these cysts should be operated after birth. The most common type are arachnoid cysts that occur as a result of the splitting of the arachnoid membrane. The cysts are not tumors; they are fluid-filled sacs, appearing in one of the three layers of tissue covering the central nervous system.
• Encephalocele is a type of congenital abnormality of the neural tube that affects the brain. It occurs when part of the skull has not formed well, and a portion of brain tissue and associated structures protrude outside the skull.
• Craniosynostosis implies premature closure of the skull sutures. As a result, a deformity develops in the skull of the child. If skull bones cannot keep pace with the quick growth of brain in preliminary phases of infant’s life, a clinical condition develops that is called increased intracranial pressure. This condition implies that brain cannot enlarge and gets stuck in the skull. If the condition is not diagnosed and treated at an early stage, it may result in irreversible neurological, cognitive and behavioral damages.
• Cerebral vascular malformations are localized tangles of abnormal blood vessels that cause alternations in blood flow. These vascular masses are not tumors but sometimes they can grow and provoke various symptoms. Unlike other abnormalities, they do not require urgent treatment. However, cerebral vascular malformations must be diagnosed and monitored because of higher risk of brain hemorrhage.

Symptoms of Congenital Abnormalities

Hydrocephalus

Newborns (0-1 month): Overgrowth of head, bulging fontanelle, thin scalp, dilatation of blood vessels in head, vomiting, restlessness, downward deviation of eyes and sunsetting of the eyes are potential symptoms.

Children (1 month or older): Overgrowth of head, headache, nausea, vomiting, fever, diplopia, restlessness, delay in walking or talking, communication disorders, loss or sensor and motor functions, seizures. Difficulty in staying awake or waking up in older children.

Congenital cysts

• Headache
• Nausea and vomiting
• Developmental delays
• Excessive fatigue or low energy
• Seizures
• Hydrocephalus due to obstruction of normal cerebrospinal fluid circulation
• Vision problems

Encephalocele

• Hydrocephalus: Cerebrospinal fluid accumulated in the brain
• Vision problems
• Microcephaly: An abnormally small head
• Spastic quadriplegia: Paralysis of the limbs
• Mental and growth retardation
• Ataxia: Uncoordinated muscle movement
• Developmental delay
• Seizures

Craniosynostosis

Changes in the shape of the head and face are usually visible and they are usually the first and only symptom. Another sign is a small or absent fontanelle. In rare cases, synostosis can lead to increased pressure within the skull. When multiple cranial sutures are fused prematurely, this is particularly true.

How are Congenital Abnormalities Diagnosed?

During pregnancy,  a perinatologist follows up the patient by ultrasound scans, watching out for any abnormality in the brain tissue. Depending on ultrasound findings, a fetal MRI may be required. In fetal MRI, the pregnant woman undergoes an MRI scan to screen the fetus. Thereby, congenital anomaly can be detected and accurate prenatal diagnosis can be set. After birth, the pediatric neurosurgery department is to perform surgery.

Surgical Treatments for Congenital Abnormalities

In congenital brain abnormalities, surgery is the main treatment option for children. Especially in some malformations, an operation has to be performed within the first 36 hours of birth.

Hydrocephalus

• Neuroendoscopic Procedures (Endoscopic Third Ventriculostomy): If anatomical pathways are blocked due to any reason, a new duct is created by using an endoscope and thus, circulation of the cerebrospinal fluid is restored. Endoscopes are high-tech camera systems that measure 2 to 4 mm in diameter. If the anatomy allows and there is no contraindication, our clinic primarily prefers this surgical technique and the children can continue living without a foreign body.
• Ventriculoperitoneal (V/P) Shunt Surgery: Shunt surgery is an option for patients who are not eligible for endoscopic procedures. Thus, the fluid is drained from the brain to another body cavity (usually the abdomen). A thin and long elastic silicone tube called “shunt” is used for the drainage. The system has a “pump (valve)” beneath the scalp to ensure unidirectional flow at a controlled rate. Thus, elevation of pressure in the brain is eliminated. However, this system should function continuously, as cerebrospinal fluid is constantly produced in the brain. Since the shunt is placed in subcutaneous tissue, it can be seen only in babies. In children and adults, the tube can be felt in the subcutaneous tissue by palpation.

Congenital brain cysts

• Craniotomy: In this treatment, a portion of the skull is removed to provide the neurosurgeons with access to the cyst. This is a more invasive treatment method but allows the neurosurgeons to precisely inspect and address the cyst.
• Shunt: Neurosurgeons insert a tube into the cyst, which remains in place and allows the fluid to drain away and be absorbed into the abdominal cavity.

Encephalocele

Surgery is an inevitable treatment method for encephalocele. Moreover, it should be performed during the first 3 months after birth. If there is a layer of skin covering the tissue, surgical intervention can be delayed for a few months. But if there is no skin to protects an encephalocele, surgery should be performed soon after birth.

Craniosynostosis

In Acıbadem, neurosurgeons generally apply minimally-invasive endoscopic surgery for treatment of craniosynostosis, but in some cases endoscopic surgery may not work well. For instance, in older babies or babies with more than one closed suture, different surgery methods can be applied. In endoscopic craniosynostosis surgery, physicians open small incisions, just enough to insert the surgical instruments, and use a small camera to perform the surgery.

Before surgery, the child is put under general anesthesia. Neurosurgeons make one or two small cuts in the scalp. Then, a thin tube with an added video camera and other tools are inserted through the incision. The camera allows the surgeons to see inside the child’s head while they perform surgery. During the surgery, the neurosurgeons remove a narrow strip of bone along the closed suture. Patients generally stay in the hospital between two and three days after the operation. After surgery, babies may need to wear a special helmet to help mold the shape of their head. This helmet may be worn anywhere from a few months to one year.

Cerebral vascular malformations

Surgery of cerebral vascular malformations is usually aided by computer-assisted navigation and microscope. Neurosurgeons  endeavor to entirely remove the vascular malformation and avoid the risk of rupture. The optimal surgical method is determined based on the size, shape, location of the defect, and patient’s general health.

Pediatric Brain Tumors

Brain tumors in children are very different from those in adults. Some of the tumors seen in children are almost never seen in adults. Acıbadem Pediatric Neurosurgery team mainly focuses on tumors of the brain stem and thalamus, or deep-seated brain tumors.  These thumb-sized vital areas are localized right in the very center of the brain. Without them, a human being would not be able to breathe on its own, move its extremities, use face mimics, or even swallow food. Being so vital, tumors of this area require serious expertise. Putting the surgical expertise aside, preoperative preparation of the case is fundamental.

In ACIBADEM, with a state-of-the-art, 3 Tesla powered, high-resolution MRI device, our expert team precisely knows the locations of the tumors and also the structures responsible for vital functions, thus performing surgeries without harming them. Brain mapping and monitorization techniques are also utilized for precise surgery. 

All brain tumors, malignant or benign, have major impacts on patients’ lives. There is a spectrum of malignancy in pediatric brain tumors. But whatever the tumor type is, an experienced multidisciplinary team consisting of radiologists, radiation oncologists, medical oncologists and pediatric neurosurgeons is needed. The team discusses all new patient files in a weekly council and plans preoperative, intraoperative and postoperative phases, as well as any additional treatment options. Brain tumors, even if they are benign, have the potential to reoccur, or malignant ones to metastasize and spread to other organs. Acıbadem physicians collaborate and discuss all scenarios, and plan on how to keep the disease under control.

Symptoms of Brain Tumors

The first and the most common sign of pediatric brain tumor is Persistent headache. In addition to headache, the following symptoms can be seen in these patients;

• Vomiting (projectile vomiting especially after getting out of the bed in the morning)
• Slowed down movements, loss of strength and plegia in arms and feet
• Facial paralysis
• Seizure (epileptic seizure, foam discharge from mouth, loss of consciousness)
• Deviation of eyes, limited right or left gaze
• Inability to look upward
• Decreased visual acuity
• Difficulty swallowing
• Speech disorder
• Restlessness, lack of appetite, continuous cry (in babies)
• Bulging fontanelle
• Continuous sleepiness
• Neck stiffness

Surgical treatment of brain tumors

Pediatric brain tumors treatment will be quite likely surgical. However, monitoring or biopsy alone can be recommended instead of surgery for certain tumors with a slow growth rate.

At Acıbadem Pediatric Neurosurgery Center, physicians use the thinnest endoscopes and can operate the patients and discharge them the next day.

An ultrasound-guided aspirator is also used during surgery. It helps to treat tumors in ventricles with endoscopic closed method. Moreover, as one of the most advanced technologies, laser can be used through an endoscope. In Acıbadem, rather than operating the tumors in those gaps called ventricles with an open method, surgeons use this specialized endoscope to excise a tumor. The aspirator is inserted through an endoscope with this advanced technology. It makes small fragments, like flour, in the brain tissue and absorbs it. Therefore, grinding it into powder and sucking is preferred rather than pulling and pushing on brain tissue. Thus, the surgery is performed cleanly and without harming the patient.

Gamma-Knife

Gamma Knife therapy can be considered for pediatric brain tumors that are smaller than 3 cm in size. For malignant brain tumors that require radiotherapy, the treatment strategy involves surgical removal of the tumor tissue at the maximum extent followed by conventional radiotherapy. However, Gamma Knife can be used in selected cases for small tumors that relapse after routine surgery and radiotherapy.

Spasticity

Spasticity is abnormal muscle tightness, caused by an imbalance of signals from the brain and spinal cord to the muscles. It usually causes problems in motion. The main reason for spasticity in children is cerebral palsy. Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. Signs and symptoms vary among patients and over time. Often, symptoms include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, swallowing, and speaking as well. In short, CP means brain damage. This damage usually happens during birth or in the following month, because of the lack of blood flow to the brain.  If this lack of blood flow continues for 3 minutes or more, brain damage is inevitable and irreparable.

At Acıbadem, however, doctors have the opportunity to intervene, treating the movement disorders caused by CP.  About 60% of patients with CP have spasticity. Previously, the only treatment for spasticity used to be physical therapy, but today, several different interventions are possible.  Treatment options for each specific case are evaluated by our multidisciplinary counsels, where physicians discuss every patient in detail with specialists in physical therapy and rehabilitation, pediatric neurosurgery, orthopedics, pediatric neurology, and many more experts. The Pediatric Neurosurgery Center of Acıbadem has performed over 1500 operations and helped patients from all over the world.

Symptoms of Spasticity

• Newborn to 2 months old infant: Clinical picture of seizures, difficulty in suckling, severely irregular sleep pattern, prolonged crying
• 3 months old infant: Immobility or failure to coordinate movements of arms and legs
• 4 months old infant: Curling hands into a fist – failure of dorsiflexion in fingers; inability to hold the head up
• 8 months old infant: Crossed/scissor legs when the baby is picked up, stepping on toes, inability to grasp toys
• 10 months or older infants: Delay in crawling and standing on their own, lack of response to some visual or audible stimulus

Spasticity treatments

Pediatric Rehabilitation: In spasticity treatment, physicians can apply to physiotherapy and rehabilitation. It may be useful to patients for:

• Prevention of physical disorders secondary to spasticity;
• Relieving the spasticity with various techniques;
• Increasing functional capacity to boost independency of the child in daily life;
• Selecting medical aids that the child needs and education on their usage.

There is also a movement analysis unit with an expert team at Acıbadem. The movement analysis laboratory is utilized to understand the exact situation of every muscle of each patient. Gait analysis is one of the important evaluation stages in the assessment of muscles, joints and skeletal system. Computer-assisted 3D gait analysis helps for the objective identification of gait disorders, shows action and contraction time of muscles, demonstrates range-of-motion of joints, and supports physicians in their planning of treatment stages. In this unit, movement abilities of the child are documented, and treatment is planned. Day by day, the movement ability of the child is enhanced and measured by specialists.

Spasticity surgery: Spasticity surgery should be considered, if rehabilitation does not help the condition, daily care of the child is difficult due to spasticity, and the child suffers from pain due to abnormal muscle contractions. Relevant surgeries are as follows:

• Botulinum toxin injection
• Selective Dorsal Rhizotomy (SDR)
• Selective Neurotomy (Selective Fasciculotomy)
• Deep Brain Stimulation (DBS)
• Implantation of Baclofen Pump
• Pallidotomy

Epilepsy

Epilepsy is a disorder of the central nervous system, with abnormal brain activity that causes recurrent epileptic seizures. Epileptic seizures are episodes that can vary from brief and nearly undetectable blank periods to long periods of vigorous shaking.  These episodes can result in physical injuries, but also irreversible brain damage, especially in children, whose brains are still under development. In most of the cases, epilepsy can be treated successfully by a pediatric neurologist with medication. But in 25% of cases medication is not sufficient and patients keep suffering from seizures. In these patients, neurosurgeons intervene with different techniques.

Symptoms of Epilepsy

• Stiffening of the body
• Consciousness problem
• Loss in bladder control
• Stopping breathing
• Not responding to words or noise
• Staring
• Jerking movements of the legs and arms
• Nodding head as rhythmic
• Falling suddenly for no reason (it is associated with loss of consciousness)

Epilepsy surgery

In epilepsy patients, a tumor or cyst is not present in the brain but certain region develops abnormally; or MRI scan is completely normal but it is detected through other tests that seizures originate from a certain part of the brain. X-ray may be normal but a part of the brain may dysfunction. That is when the patient becomes a candidate for epilepsy surgery.

Unlike other brain disorders, medication is the first-line treatment in epilepsy. But if a patient is refractory to medication treatment (drug-resistant epilepsy), neurosurgery may help, since human brain is the source of epilepsy. For such patients, surgical techniques include focal resection (removal of the diseased area of brain), orpus callosotomy (disconnecting both halves of the brain), hemispherotomy (disconnecting the diseased hemisphere from the healthy hemisphere, if the damage is confined to one hemisphere) and stimulators (vagal nerve stimulation). Eligibility for surgery and the type of epilepsy surgery to be applied should be determined by a specialized team, capable of achieving effective results while protecting the delicate brain functions.