The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea?

Abstract

Introduction:Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly.Materials and Methods:All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis.Results:There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion.Conclusions:Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.

Postdecompressive Craniectomy Surgery, Ventriculomegaly, or Hydrocephalus Development: Imaging, Prevention, and Management

“…[ 8 ] Hence, stringent patient selection criteria can drastically reduce the need for CSF diversion surgery, and surgery should be offered to selected cases showing significant clinicoradiological concordant and the judicious use of CSF pressure monitoring, if feasible and facility exist for such monitoring values. [ 5 7 ] As it is evident with a study by Rahme et al . observed 0% incidence of hydrocephalus after DCS with the application of stringent diagnostic criteria for labelling the diagnosis of hydrocephalus.…”

“…In addition, intrcranial pressure was monitored in five cases in the ventricular tapping group, who were managed with ventricular drain for assisting cranioplasty and noted it was also proven to be helpful. [ 7 ]…”

Simultaneous Cranioplasty and External Ventricular Drain Implantation in Patients with Hydrocephalus: Case Series and Literature Review

“…In this regard, progressive neurological decline can be mentioned, 10,13 in addition to hemorrhages, infections, inflammations and, also, disorders of the ventricular system, 14 where the CSF flows. Among the latter complications, there is HC, which, according to the literature, is triggered by changes in pulse wave pressure through the convexity of the brain 15,16 and by a reduction in venous flow in the medial margin of the craniectomy. [16][17][18] Some studies also point to the extension of the craniectomy as a predisposing factor for HC.…”

Endoscopic-assisted surgery for skull defects with subdural effusion.

“…Staged surgical treatment can reduce the infection factors of shunt operations, such as skin flap effusion (cerebrospinal fluid fistula), and infection at the surgical incision [ 25 ]. Although only 2 patients with hydrocephalus were relieved after repair, this suggests that repair may reduce hydrocephalus and even enable shunt operations to be avoided, which is one of the significance factors of staging [ 26 ].…”