Transient mutism following neuroendoscopy in children; report of two cases

Neuroendoscopy is replacing traditional craniotomy and shunting procedures, worldwide for management of hydrocephalus, brain tumors, arachnoid cysts and etc.

Several complications are mentioned for neuroendoscopic procedures for children in the literature, which include hemorrhage (intraventricular, intraparenchymal, subdural, epidural and subarachnoid), CSF leakage, CSF infections, vascular insults (basilar rupture, thalamic infarcts), hypothalamic injury, memory disturbance, focal neurologic deficits and delayed sudden death [1, 2]. Although the rate of transient morbidities is about 8 % [3, 4], only 2 % will have permanent morbidity and mortality rate of about 0.2 % is reported in different series [3, 4].

In a 2007 review by Cinalli and coworkers [5], transient akinetic mutism was seen in 1 of their 231 patients who underwent neuroendoscopic procedures. This patient suddenly passed away due to unexplained events (probably due to acute hydrocephalus following closure of stoma) 6 months after the procedure and was the only mortality presented according to their report.

To my knowledge this is the first report of two cases with transient mutism, apathy and inability to cry following neuroendoscopic procedures in children. Both cases improved after a course of 5–6 days. The pathogenesis of mutism in these cases is not well understood. However, knowledge that this phenomenon is transient is necessary and will let the pediatric neurosurgeon reassure the parents that the child will regain his pre-operative status of attention to the environment and speech milestones.

This complication may result from excessive traction on paraventricular white matter [6] and disruption of fronto-subcortical circuits [7]. This complication can be avoided with minimizing the manipulation of neural structures and avoiding repeated dilatation of ventricles during the procedure. Most of these complications are temporary and do not mandate a surgical intervention. If the symptoms persist or aggravated during the few post-operative days, dopaminergic agents may prove useful in alleviating these symptoms.

No surgery is risk-free; however, a thorough understanding of limitations and possible complications associated with a specific surgical procedure, will help the surgeon to avoid them or better manage them if they are inevitable.