Treatment of Cephalocranial Disproportion in Shunt-Induced Slit Ventricle Syndrome with Cranial Vault Distraction Osteogenesis

Abstract

Background: Slit ventricle syndrome (SVS) is a known late complication of shunting procedures. Some patients develop cephalocranial disproportion (CCD) that will require surgical treatment to increase craniocerebral compliance. Methods: We performed cranial vault distraction osteogenesis to treat 2 teenage patients who presented with SVS, increased intracranial pressure and CCD. Bilateral temporo-parieto-occipital craniotomies were performed. Results: Both patients successfully completed distraction and consolidated without the need for bone grafting. Postoperatively, both patients showed an increase in intracranial and intraventricular volume, as well as decreased shunt revisions. One patient had improvement of her headaches, while the other continues to have chronic headaches. Conclusion: Distraction osteogenesis is an option to expand the cranial vault in older children with SVS and CCD, in which the traditional cranial vault expansion would be a challenge and may or may not provide adequate expansion.

The Expanding Role of Posterior Vault Distraction Osteogenesis in Idiopathic Intracranial Hypertension and Slit Ventricle Syndrome

“…The authors noted 1 distractor failure that had to be replaced; however, both patients had reduction in shunt revisions and one had resolution of chronic headaches. 8 Park et al 7 used total calvarial trans-sutural distraction osteogenesis, which in short entails resection of all fused sutures followed by distraction of the sagittal, lambdoid, and bicoronal sutures in various vectors. Postoperative LPs showed significant reduction of ICP from preoperative measurements (26.2 cmH 2 O versus 11.9 cmH 2 O).…”

“…[2][3][4][5] Patients who are refractory to conventional treatments are candidates for cranial vault expansion, with a variety of expansion options having already been reported in the literature with mixed success. [5][6][7][8][9] Posterior vault distraction osteogenesis (PVDO) has gained acceptance as a part of the armament for treatment of syndromic CS, with previous literature documenting perioperative safety, reasonable complication profile, substantial expansion of intracranial volume, and potential resolution of Chiari malformation. [10][11][12][13][14][15][16] To date, the role of PVDO in primary nonsynostotic (non-CS) diagnoses such as IIH and SVS has not been established.…”

“…Reducing ICP is a cornerstone in the treatment of both SVS and IIH, with each condition managed medically or surgically in stepwise fashion according to published treatment algorithms 2–5 . Patients who are refractory to conventional treatments are candidates for cranial vault expansion, with a variety of expansion options having already been reported in the literature with mixed success 5–9 …”

Osteogenic Distraction

“…4). This could be combined with simultaneous fronto-orbital distraction (Imai et al 2002;Yonehara et al 2003;Yano et al 2006;Komuro et al 2009;de Lima et al 2013;Kim et al 2008;Mitchell et al 2015). In this technique the bone could be left attached laterally, with a monocorticotomy performed to facilitate "green stick" bending.…”

Management of Pre-existing Ventriculoperitoneal Shunt in Posterior Vault Distraction for Lambdoid Craniosynostosis: A Case Report and Technical Note

“…For patients with a parieto-occipital ventriculoperitoneal shunt (poVPS), posterior vault DO places the shunt at risk for both infection and migration. Although others have described cases of DO with pre-existing shunt, none have described operative strategies to avoid shunt migration in a rapidly expanding calvarium [8][9][10]. Here we report surgical details and follow-up results from our experience managing a posterior vault distraction patient with a poVPS in a single operative setting.…”