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

Report of 2 cases

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  • 1 Department of Neurological Surgery, Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center, Bronx, New York;
  • 2 Division of Pediatric Neurological Surgery, Albert Einstein College of Medicine of Yeshiva University/The Children's Hospital at Montefiore, Bronx, New York;
  • 3 Division of Pediatric Neurosurgery, The Children's Hospital of Philadelphia, Pennsylvania; and
  • 4 Division of Pediatric Plastic Surgery, New York University Medical Center, New York, New York
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A subset of hydrocephalic patients in whom shunts are placed at an early age will develop craniocerebral disproportion (CCD), an iatrogenic mismatch between the fixed intracranial volume and the growing brain. The lack of a reliable, reproducible method to diagnose this condition, however, has hampered attempts to treat it appropriately. For those practitioners who acknowledge the need to create more intracranial space in these patients, the lack of agreed-upon therapeutic end points for cranial vault expansion has limited the use of such techniques and has sometimes led to problems of underexpansion. Here, the authors present a definition of CCD based primarily on the temporal correlation of plateau waves on intracranial pressure (ICP) monitoring and headache exacerbation. The authors describe a technique of exploiting continued ICP monitoring during progressive cranial expansion in which the goal of distraction is the cessation of plateau waves. Previously encountered problems of underexpansion may be mitigated through the simultaneous use of ICP monitors and gradual cranial expansion over time.

Abbreviations used in this paper:CCD = craniocerebal disproportion; ICP = intracranial pressure; RED = rigid external distraction.

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Contributor Notes

Address correspondence to: Adam L. Sandler, M.D., Department of Neurological Surgery, Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center, 3316 Rochambeau Avenue, Bronx, New York 10467. email: adamlsandler@gmail.com.

Please include this information when citing this paper: published online March 29, 2013; DOI: 10.3171/2013.2.PEDS12404.

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