Recovery From Surgery for Pineal Region Tumors in Children

Postoperative Orders 

• Admit to neurosurgical ICU/observation unit: The patient should be admitted for continuous cardiac monitoring, pulse oximetry, vital signs, and neurological checks every hour.
• EVD: If an EVD is present, the drain is weaned slowly and clamped as tolerated, and ventricular imaging is obtained.  If the patient cannot tolerate drain weaning, a CSF diversion procedure may be needed. Continuous ICP monitoring can be done prior to EVD removal.
• Steroids: Dexamethasone, 4 mg PO every 6 hours, weaned over 5 days, unless plans exist for postoperative radiation therapy, in which case low-dose steroid therapy may be continued.  Patients on steroids are given a proton-pump inhibitor for gastrointestinal prophylaxis. 
• Pain: Morphine, 0.1 mg/kg IV every 1–2 hours as needed for pain. Ketorolac, 30 mg IV every 6 hours as needed for pain, may be initiated on postoperative day 1 or 2 if there is no concern about or radiographic evidence of hemorrhage.
• Imaging studies: MRI of the brain with and without gadolinium enhancement should be performed within 24 hours postoperatively. MRI of the spine should also be performed during the hospitalization for tumor staging and adjuvant treatment planning.
• Consultations: Neurooncology should be consulted for malignant pineal tumors.

Postoperative Morbidity

• General deterioration: Postoperative neurological deterioration is due to hemorrhage in the tumor resection cavity or other intracranial compartment, cerebral or cerebellar swelling, or acute hydrocephalus.  After the use of an infratentorial supracerebellar approach, retraction of the cerebellum and sectioning of the vermian veins may result in postoperative cerebral edema. These events often require surgical management.
• Visual: In cases where an occipital transtentorial approach is used, retraction of the occipital lobe may cause hemianopia, although this deficit is typically transient.  Mechanical manipulation and disruption of the vascular supply to the quadrigeminal plate may result in persistent or worsened Parinaud’s syndrome.  
• SIADH and DI: When the third ventricle is manipulated, one should carefully monitor serum sodium for detection of SIADH or DI.