History of Management of Central Nervous System Tumors Occurring During Infancy

Understanding of Disease

• Improved care of infants: Several parallel factors have allowed better understanding of tumors in infants. Advances in neonatal critical care and intraoperative technique have allowed these physiologically vulnerable patients to survive the presenting episode, and therefore investigative and treatment paradigms have evolved.

Technological Development

• Imaging of neonate: Neuroimaging advances such as high-resolution antenatal ultrasonography and fetal MRI have transformed the neurosurgical information base for often highly complex congenital tumors. The term ‘conatal’ has been used to reflect tumors diagnosed within 2 weeks of birth, and this is increasingly realized with antenatal diagnosis.
• Imaging of infant: Postnatal assessment has similarly been transformed with imaging advances such as diffusion tensor tractography, MR spectrographic assessment of cellular metabolism, and subsequent operative integration of navigational data, all of which contribute to increased efficacy of decision making and operative safety for these patients.
• Subtyping of tumors: Immunochemical and molecular analysis of resected tissue have demonstrated subtypes and on occasion required reclassification of tumors for this patient group.

Surgical Technique

• Minimally invasive surgery: The difficulty with operative manipulation because of the immaturity of brain parenchyma has been reduced by operative innovation such as minimal craniotomy realized by real-time image guidance. Other minimally invasive techniques such as neuroendoscopy have improved with enhanced optics and high-resolution image processing.
• Ultrasonic aspirator: The ultrasonic aspirator has allowed improved tissue resection by reduced tissue manipulation and minimal blood loss, and simple but effective innovations such as heated air blankets, heated fluids for irrigation, and advances in neuroanesthesia have all contributed to the success in operative intervention for infants.