Shunt-related craniocerebral disproportion: treatment with cranial vault expanding procedures

Abstract

Two patients with intracranial arachnoid cysts, one with myelomeningocele-hydrocephalus and the other with a subdural fluid collection, were given a cerebrospinal (CSF) extracranial shunt. All four patients developed features of CSF overdrainage following shunting and were treated by cranial vault expanding procedures. Before undergoing decompressive craniotomy, the patients were treated by a variety of procedures, including changing of obstructed ventricular catheters (n=4), insertion or upgrading of programmable valves (n=3), and foramen magnum decompression (n=1). Clinical manifestations of these four patients were attributed to craniocerebral disproportion caused by chronic and progressive skull changes due to dampening of the CSF pulse pressure, which is necessary for maintaining normal cranial growth. On the basis of our previous experience with expanding craniotomies in cases of minimal forms of craniosynostosis, we treated these patients with bilateral parietal craniotomies, with satisfactory results. In conclusion, biparietal decompressive craniotomy constitutes a useful and safe procedure for relieving the clinical manifestations of some CSF overdrainage syndromes, especially in cases with slit-ventricle syndrome and craniocerebral disproportion that prove to be refractory to simpler management procedures.

Successful treatment of post-shunt craniocerebral disproportion by coupling gradual external cranial vault distraction with continuous intracranial pressure monitoring

“…3,6,8,15,17 Thus, we argue, the compromised cranial compliance inherent in patients with CCD can be clearly captured by the presence of plateau waves on ICP monitoring.…”

“…2,11,14,17,20 We define CCD as a state in which the volume of the brain exceeds the available intracranial space. The typical patient evaluated electively at our institution for CCD has undergone shunt placement at an early age (usually before 1 year of age) and has a history of multiple emergency department and/or office visits complaining of chronic severe headaches that impair his or her normal daily routine.…”

The Evolution of Cerebrospinal Fluid Shunts: Advances in Technology and Technique

“…Fixed-pressure valves may be beneficial in populations where repeated MRI is necessary and an artifact from a programmable shunt is not desirable, e.g., in patients with a history of a brain tumor, who require surveillance imaging. Programmable valves can be beneficial in younger patients, where the risk of overdrainage may lead to the development of craniocephalic disproportion, and also alterations in shunt resistance can be done without additional surgery [62] . These valves must be reprogrammed after MRI studies, secondary to adjustment by the magnet.…”

Comment on the Article by Hart et al. Entitled ‘Combined Intracranial Pressure Monitoring and Cerebrospinal Fluid Infusion Study to Guide Management of Slit Ventricle Syndrome'

“…In fact, post-shunt CCD was described by Hoffman and Tucker [7] as early as 1976 and has been confirmed in innumerable reports since then [8,9]. Furthermore, in the setting of a child with noncompliant ventricles, we remain unconvinced of the utility of a ventricular infusion study.…”