Cranial reduction and fixation with a resorbable plate combined with cerebrospinal fluid shunting for difficult-to-manage macrocephaly related to hydrocephalus

Manwaring, Jotham; Truong, Devon; Deukmedjian, Armen R.; Carey, Carolyn M.; Storrs, Bruce B.; Rodríguez, L. F.; Tetreault, Lisa; Tuite, Gerald F.

doi:10.3171/2012.10.peds12340

Cited by 6 publications

(6 citation statements)

References 12 publications

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“…1). 8 In brief, patients with extreme forms of macrocephalic shunted hydrocephalus undergo surgery to approximate and fixate the widely separated cranial sutures. The primary goals of each CVRF operation are to reduce the volume of the cranial vault so as to better appose the calvarial bones and create a rounder, less dysmorphic head shape and to stabilize the intracranial volume so as to simplify management of CSF flow dynamics and minimize the need for VPS reprogramming and/or revision.…”

Section: Surgical Techniquementioning

confidence: 99%

“…We have previously described a novel approach to cranial reduction in a neonate with severe hydrocephalic macrocephaly, in whom the mobile and overlapping cranial bones that develop after shunt placement are stabilized by connecting adjacent cranial bones with a resorbable plate placed in the epidural space. 8 Here, we report our institutional experience with the management of cases of extreme neonatal hydrocephalus using CSF diversion, with and without cranial vault reduction and fixation (CVRF), over the 12-year period.…”

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confidence: 99%

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Early postnatal cranial vault reduction and fixation surgery for severe hydrocephalic macrocephaly

Iyer¹,

Carey

Rottgers³

et al. 2018

Journal of Neurosurgery: Pediatrics

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OBJECTIVEInfants with severe hydrocephalus and extreme macrocephaly typically undergo CSF diversion early in life, which can result in significant cranial deformity due to CSF overdrainage. In this scenario, overlap of the cranial plates can precede the development of secondary synostosis and/or severe, permanent cranial deformity. As a result, extensive cranial vault remodeling is sometimes undertaken later in life, which is often challenging and has been associated with mortality and a high morbidity rate. The authors have previously described a technique for early postnatal cranial vault reduction and fixation (CVRF), in which the calvarial bones are stabilized using absorbable fixation plates in the neonatal period, in an attempt to facilitate patient positioning, simplify hydrocephalus management, and improve cosmesis. Here, the authors describe their institutional experience managing patients with extreme neonatal hydrocephalus with CSF diversion, with and without CVRF, over the past 12 years.METHODSThe authors retrospectively reviewed the charts of infants with extreme hydrocephalus (head circumference > 49 cm) treated at their children’s hospital with ventriculoperitoneal shunting, with or without CVRF, between 2005 and 2017. Data collected included age, sex, etiology of hydrocephalus, type of CVRF performed (anterior, posterior, or combined), follow-up duration, orbitofrontal circumference, craniometric measurements, intraoperative blood loss, operative duration, and postoperative complications. Developmental data were collected using the third edition of the Ages and Stages Questionnaire. Photographic imaging was used to demonstrate esthetic outcomes, and family questionnaires were used to evaluate satisfaction with the esthetic outcome.RESULTSEleven patients with extreme neonatal hydrocephalus underwent CSF shunting; 5 underwent shunting alone and 6 patients underwent shunting and CVRF. For patients who underwent shunting and CVRF, the median age at CVRF was 6 days and the median interval between shunt placement and CVRF was 2.5 days. The mean extent of calvarial vault volume reduction was 44.5% (± 3.9%). The mean duration of the CVRF procedure was 108 minutes, and 5 of 6 patients required intraoperative transfusion. Of the 5 patients who underwent shunting alone, 3 developed severe cranial deformities. Of 6 patients who underwent shunting and CVRF, 1 had a poor cosmetic outcome. In the shunting-alone group, 2 patients died and 1 required extensive cranial vault correction at 10 years of age. One patient in the shunting and CVRF group also died.CONCLUSIONSCVRF in combination with CSF shunting in the neonatal period can simplify the treatment of the rare case of severe hydrocephalic macrocephaly and leads to cosmetic outcomes that are considered good by their families.

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Section: Surgical Techniquementioning

confidence: 99%

mentioning

confidence: 99%

Early postnatal cranial vault reduction and fixation surgery for severe hydrocephalic macrocephaly

Iyer¹,

Carey

Rottgers³

et al. 2018

Journal of Neurosurgery: Pediatrics

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“…Neglected or partially treated hydrocephalus in infant may cause rapid enlargement of the head (Manwaring et al 2013). Diagnosis of macrocephaly is made when rapid enlargement of the head is greater than two standard deviations above mean of given age (Mathews et al 2007).…”

Section: Introductionmentioning

confidence: 99%

Case Report: Cranial Vault Reduction Cranioplasty for Severe Hydrocephalus

Suryaningtyas

Parenrengi

2020

FMI

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Extreme hydrocephalic macrocephaly is still encountered in developing countries due to delayed treatment, rapidly progressing hydrocephalus and family socioeconomic problems. Reduction cranioplasty was used with several techniques to address the issue. The study aimed to determine the safety and feasibility of barrel-stave technique for reducing the size of extreme hydrocephalic macrocephaly. Three post-diversion patients underwent surgical reconstruction. Children with head circumference more or equal to two standard deviation above mean on given age, no active wound at the area of surgery, presentation of sufficient “potential removable fluid” that allows dura reduction and no active shunt infection were eligible. The surgical procedure includes modified pi, barrel-stave technique, and diversion of the cerebrospinal fluid and subdural collection. Clinical data were recorded. Three patients with age range of 2 month to 2 years old underwent the surgery. Two patients had shunt implanted at least 1 month before the surgery and 1 patient had an ETV procedure 3 months before the reduction. The frontal-occipital circumference before surgery ranged from 50 to 63 cm. The maximum reduction that could be achieved was 15 cm. One patient (2 months old) died within 24 hour due to failure to cope with excessive blood loss. Two patients were followed up for 3 months and 6 months without complications. Reduction cranioplasty using barrel-stave techniques is an option for children with extreme large head that poses a mechanical or cosmetic problem. Risk and pitfalls should be considered and taken care meticulously, especially the age and blood loss.

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“…Newer reported techniques include limited reduction cranioplasty focused on correcting posterior turricephaly, 7 single-stage total cranial vault remodeling with the addition of prolonged helmet therapy, 8 and use of resorbable plating systems to aid in reconstruction. 9,10 Distraction osteogenesis (DO) was first utilized in craniofacial surgery as a technique for mandibular lengthening and later expanded upon as a technique for midface advancement and cranial vault remodeling. 11 In the cranial vault, DO is often used for posterior vault remodeling in the treatment of craniosynostosis, as the gradual expansion minimizes dead space and allows for concomitant expansion of the dura and soft tissues.…”

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Reverse Distraction Cranioplasty for Treatment of Hydrocephalic Megalocephaly

Saad

Kanack

McIntyre

et al. 2015

Journal of Craniofacial Surgery

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Macrocephaly resulting from untreated hydrocephalus is a rare but difficult condition to treat. The patient presented is a 6-year-old boy who had progressively increasing head size since birth secondary to untreated hydrocephalus with associated developmental delay. His initial head circumference was 69 cm, and computed tomography scan showed evidence of obstructive hydrocephalus. For the first stage of the procedure, bicoronal and circumferential strip craniectomies were performed, 5 fully open 3.5 mm midface distractors were placed to facilitate vault reduction, and absorbable plates were placed in the frontoorbital region. Neurosurgery also performed an endoscopic third ventriculostomy and placed an external ventricular drain. Reverse distraction was completed over 5 days and tolerated well by the patient. Three months after the first procedure, the distractors were removed and frontoorbital reduction and additional cranial vault reduction and reshaping were performed. At 1 month following this operation he was noted to have excellent forehead contour and dramatic improvement of his macrocephaly with some remaining mid-vault asymmetry. His head circumference was measured at 61.5 cm with bicoronal distance of 39.5 cm. He demonstrated improvement in head control and ability to sit. This patient demonstrates a new technique for reduction cranioplasty involving the use of reverse distraction to facilitate gradual and controlled reduction prior to extensive cranial vault remodeling. The challenges associated with managing hydrocephalus in cranial vault reduction patients are also addressed.

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Cranial reduction and fixation with a resorbable plate combined with cerebrospinal fluid shunting for difficult-to-manage macrocephaly related to hydrocephalus

Cited by 6 publications

References 12 publications

Early postnatal cranial vault reduction and fixation surgery for severe hydrocephalic macrocephaly

Early postnatal cranial vault reduction and fixation surgery for severe hydrocephalic macrocephaly

Case Report: Cranial Vault Reduction Cranioplasty for Severe Hydrocephalus

Reverse Distraction Cranioplasty for Treatment of Hydrocephalic Megalocephaly

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