Reduction cranioplasty with the aid of simulated computer imaging for the treatment of hydrocephalic macrocephaly

Clinical article

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Object

The occurrence of hydrocephalic macrocephaly is uncommon. When the condition does occur, it is usually seen in infants and young children. Patients with this disorder have an excessively enlarged head and weak physical conditions. Various surgical techniques of reduction cranioplasty for the treatment of these patients have been reported. In this study, a revised surgical procedure with the aid of simulated computer imaging for the treatment of hydrocephalic macrocephaly is presented.

Methods

Five cases of hydrocephalic macrocephaly in children ranging in age from 16 to 97 months were reviewed. These patients underwent surgical treatment at The First Affiliated Hospital of Xiamen University over a period of 4 years from January 2007 to January 2011. After physical examination, a 3D computer imaging system to simulate the patient's postoperative head appearance and bone reconstruction was established. Afterward, for each case an appropriate surgical plan was designed to select the best remodeling method and cranial shape. Then, prior to performing reduction remodeling surgery in the patient according to the computer-simulated procedures, the surgeon practiced the bone reconstruction technique on a plaster head model made in proportion to the patient's head. In addition, a sagittal bandeau was used to achieve stability and bilateral symmetry of the remodeled cranial vault. Each patient underwent follow-up for 6–32 months.

Results

Medium-pressure ventriculoperitoneal shunt surgery or shunt revision procedures were performed in each patient for treating hydrocephalus, and all patients underwent total cranial vault remodeling to reduce the cranial cavity space. Three of the 5 patients underwent a single-stage surgery, while the other 2 patients underwent total cranial vault remodeling in the first stage and the ventriculoperitoneal shunt operation 2 weeks later because of unrecovered hydrocephalus. All patients had good outcome with regard to hydrocephalus and macrocephaly.

Conclusions

There are still no standard surgical strategies for the treatment of hydrocephalic macrocephaly. Based on their experience, the authors suggest using a computer imaging system to simulate a patient's postoperative head appearance and bone reconstruction together with total cranial vault remodeling with shunt surgery in a single-stage or 2-stage procedure for the successful treatment of hydrocephalic macrocephaly.

Abbreviation used in this paper:VP = ventriculoperitoneal.

Object

The occurrence of hydrocephalic macrocephaly is uncommon. When the condition does occur, it is usually seen in infants and young children. Patients with this disorder have an excessively enlarged head and weak physical conditions. Various surgical techniques of reduction cranioplasty for the treatment of these patients have been reported. In this study, a revised surgical procedure with the aid of simulated computer imaging for the treatment of hydrocephalic macrocephaly is presented.

Methods

Five cases of hydrocephalic macrocephaly in children ranging in age from 16 to 97 months were reviewed. These patients underwent surgical treatment at The First Affiliated Hospital of Xiamen University over a period of 4 years from January 2007 to January 2011. After physical examination, a 3D computer imaging system to simulate the patient's postoperative head appearance and bone reconstruction was established. Afterward, for each case an appropriate surgical plan was designed to select the best remodeling method and cranial shape. Then, prior to performing reduction remodeling surgery in the patient according to the computer-simulated procedures, the surgeon practiced the bone reconstruction technique on a plaster head model made in proportion to the patient's head. In addition, a sagittal bandeau was used to achieve stability and bilateral symmetry of the remodeled cranial vault. Each patient underwent follow-up for 6–32 months.

Results

Medium-pressure ventriculoperitoneal shunt surgery or shunt revision procedures were performed in each patient for treating hydrocephalus, and all patients underwent total cranial vault remodeling to reduce the cranial cavity space. Three of the 5 patients underwent a single-stage surgery, while the other 2 patients underwent total cranial vault remodeling in the first stage and the ventriculoperitoneal shunt operation 2 weeks later because of unrecovered hydrocephalus. All patients had good outcome with regard to hydrocephalus and macrocephaly.

Conclusions

There are still no standard surgical strategies for the treatment of hydrocephalic macrocephaly. Based on their experience, the authors suggest using a computer imaging system to simulate a patient's postoperative head appearance and bone reconstruction together with total cranial vault remodeling with shunt surgery in a single-stage or 2-stage procedure for the successful treatment of hydrocephalic macrocephaly.

Macrocephaly is defined as a head circumference of greater than 2 standard deviations above the mean.6 There are many causes of macrocephaly, including growing, chronic subdural hematomas, familial megalocephaly, pseudotumor cerebri, benign extracerebral collections of infancy, hydrocephalus, various genetic conditions, and metabolic and dysplastic diseases.2,5,9 Among these causes, untreated hydrocephalus is the most common for developing macrocephaly, leading to a condition termed hydrocephalic macrocephaly.6,10,15,16

Hydrocephalic macrocephaly is a relatively rare condition and may result in many complications such as hemorrhage due to cranial vault instability.6,7 In addition, massive cranial size could hinder neurological development because of increased intracranial pressure, difficulties with posture and movement, and aesthetic problems.5,6,9 Because extrathecal CSF shunts can be used to treat all types of hydrocephalus, most hydrocephalic children respond to shunt surgery alone, especially ventriculoperitoneal (VP) shunt placement, and nearly normal neurological development can be ensured in most.1,12 However, there are hydrocephalic children whose conditions either could not be completely corrected through shunt surgeries or the patient did not receive effective treatment in time. Unfortunately, some of these children could develop extreme hydrocephalic macrocephaly. To date, the technical details and outcomes of using surgical methods for the treatment of hydrocephalic macrocephaly remain the focus of intensive discussions.3,4,6,7,11,15,16,18

In this study, the clinical profile and outcome of the children with hydrocephalic macrocephaly who had undergone shunt surgeries with 1-stage total cranial vault remodeling were analyzed retrospectively. In addition, the feasibility of surgery for total cranial vault remodeling in children with hydrocephalic macrocephaly is discussed.

Methods

Patient Population

Between January 2007 and January 2011, 5 children (3 males and 2 females; age range 16–97 months, mean 54 months) with head circumferences of greater than 2 standard deviations above the mean for their respective ages were diagnosed as having hydrocephalic macrocephaly at the Department of Neurosurgery of the First Affiliated Hospital of Xiamen University. Upon detailed investigation and after obtaining properly informed consent, surgical treatment for each child was planned by the neurosurgical team. All patients underwent VP shunting or shunt revision procedures and corrective cranial vault surgery. None of the patients had craniosynostosis. This retrospective study was approved by the First Affiliated Hospital of Xiamen University Institutional Review Board.

Operative Technique

Prior to the single-stage total cranial vault remodeling surgery, we simulated the most probable postoperative appearance of each patient's head and bone reconstruction using computer imaging software prepared by our group with 3D CT (Siemens) data to select the best method for remodeling and final cranial shape. A specific program was designed for each patient to remodel his or her head into the ideal shape using his or her own cranial vault bone (Fig. 1). A plaster head model with the same proportions of the patient's head was made, and bone reconstruction was simulated on the computer (Fig. 2). The appropriate operative time was then chosen after evaluating the patient's physical conditions and meeting with the patient's family members.

Fig. 1.
Fig. 1.

Computer simulation of single-stage vault remodeling surgery. The most probable appearance of each patient's postoperative head and bone reconstruction was simulated based on preoperative computer images of the 3D CT data of the patient's head. Preoperative calvaria (A), model of postoperative excepted calvarial shape (B), simulation in splitting the calvarial bone (C and D), and simulation in reconstructing the calvaria (E and F).

Fig. 2.
Fig. 2.

Plaster head models before and after surgery. Left: A plaster head model in proportion with the patient's head before surgery was built and the lines of incision were indicated. Right: Simulation of bone reconstruction after surgery for the same patient is shown on a plaster model. A sagittal bandeau was made to support the bilateral bone flap in the single-stage total cranial vault remodeling.

On the day of surgery, the patient underwent induction of general anesthesia and was placed in the supine position with the head in 40°–45° ventral flexion. Adrenaline (1:200,000) (Fuzhou Neptunus Fuyao Pharma) was infused subcutaneously, and a coronal incision was made within the hair-bearing scalp halfway between the apex of the skull and the anterior hairline. Scalp flaps were undermined to the eyebrow anteriorly and to the transverse sinus posteriorly in a subperiosteal plane to expose the entire cranial vault (Fig. 3). All calvarial bones were removed according to the preoperative computer simulation plan, and a ventricular shunt catheter was introduced into the lateral ventricle to drain the CSF slowly. The length and width of the dural envelope were reduced by coagulating the dura mater with bipolar forceps in selected areas under continuous irrigation. Coagulation of the vessels of the dura and veins draining into the sagittal sinus was carefully avoided. To determine if there was any subarachnoid or subdural bleeding caused by the operation, a small incision was made in the dura, and the color of the CSF was checked to see if there were signs of subarachnoid bleeding. Furthermore, a small amount of saline was also added to the subdural space to determine if there was subdural bleeding after surgery. This examination was followed by closing the incision in a watertight manner. The fragmented bones were cut into ideal shapes, placed to form a new cranial vault shape, and fixed with titanium plates and screws (both Medtronic) under a sagittal bandeau as designed preoperatively (Fig. 4). A shunt valve was connected to the ventricular catheter, and the remaining VP shunt surgery was then performed. It should be noted that 2 patients continued to undergo external drainage and underwent VP shunt surgery approximately 2 weeks after the corrective cranial vault surgery. After placement of 2 subperiosteal catheters to drain the postoperative bleeding, the remodeled calvaria was entirely covered by intact periosteum. The scalp was closed in a way that would result in a favorable cosmetic appearance with less tension of the redundant areas after resection.

Fig. 3.
Fig. 3.

Case 3. The calvaria of a 97-month-old boy with macrocephaly before, during, and after the single-stage total cranial vault remodeling surgery. A and B: Intraoperative photographs. Scalp flaps were undermined to the eyebrow anteriorly and to the transverse sinus posteriorly in a subperiosteal plane to expose the entire cranial vault. A sagittal bandeau was built. C and D: The head circumference of this patient decreased from 65 cm preoperatively (C) to 54 cm after a single-stage total cranioplasty (D). The patient stayed in the ICU for 22 days due to a lung infection.

Fig. 4.
Fig. 4.

Preoperative (A–C) and postoperative (D–F) 3D CT scans (coronal [A and D], sagittal [B and E], and axial [C and F] views). The fragmented bones were cut into ideal shapes, placed to form a new shape of cranial vault, and fixed with titanium plates and screws under a sagittal bandeau.

During the operation, bipolar forceps were used to coagulate slight bleeding in the dura mater beside the superior sagittal sinus and the sagittal sinus. This operation allowed appropriate shortening of the superior sagittal sinus. The dura beside the superior sagittal sinus was then sutured and hung to the reconstructed sagittal bandeau to tack the sagittal sinus onto the bandeau. Proper bipolar electrocoagulation was also performed on various areas to construct the dura mater. This was followed by suturing and hanging the dura mater to the reconstructed skull to reduce the epidural space as much as possible.

Analysis of Outcome

Clinical evaluations included the comparative preoperative and postoperative examinations of head circumference, nasion-inion distance, and bitragal distance as well as postoperative complications. In addition, subjective postoperative neurological change and parent satisfaction were also evaluated. Patients' functional outcomes, such as the ability to support the weight of the head, to sit, and to stand and walk, were assessed according to a previously published method.4

Results

Two girls and 3 boys with a median age of 35 months (range 16–97 months), at the time of surgery were included in this study. All patients had undergone at least one VP shunt operation at other institutions before coming to our institution, and the average number of shunt procedures performed was 1.4. There were no episodes of air embolism and no deaths associated with any of the procedures. Furthermore, no brain tissue was resected and no significant perioperative complications were found in this group of patients.

During surgery, preventive steps were taken to determine if there were any signs of subarachnoid or subdural bleeding caused by surgery; no subarachnoid or subdural bleeding was found. The average ICU time for these 5 patients was 10.4 days, and the average length of hospital stay was 23 days. One patient had a prolonged stay of 22 days in the ICU due to a postoperative lung infection (Fig. 3). Except for the 2 patients who underwent one-time postoperative shunt revision procedures approximately 2 weeks after the remodeling surgery, no patient underwent any other postoperative surgery for hydrocephalus or macrocephaly. In addition, no other severe postoperative complications were observed in any of the patients during an average of 22 months (range 6–32 months) of follow-up. All patients had a significant reduction in macrocephaly (Table 1) and a better appearance than before the operation (Fig. 5). The median head circumference decreased from 64 cm preoperatively to 53 cm postoperatively (Table 1 and Fig. 5). Likewise, the median nasioninion distance decreased from 42 cm preoperatively to 34 cm postoperatively, while the median bitragal distance was reduced from 41 cm preoperatively to 34 cm postoperatively (Table 1).

The global neurological change was assessed by a score from 0 to 3: a score of 0 was assigned to permanent decrement while scores of 1, 2, and 3 were given to transient decrement, no change from baseline, and improvement from baseline, respectively. All patients received a score of 3 (Table 1). In addition, parent satisfaction was surveyed, and scores of 0, 1, and 2 were recorded if parents were dissatisfied, satisfied, and very satisfied, respectively. The results showed that all parents were very satisfied and were uniformly pleased with the improvement in their child's appearance after surgery (Table 1). Moreover, motor function, including head control, sitting, and walking/standing, was assessed in patients before and after surgery using the scoring system shown in Table 2. The median total score postoperatively was 7, which was significantly higher than the preoperative score of 5 (Table 3).

TABLE 1:

Postoperative measurements and subjective outcome assessment

Case No.Age (mos), SexHead Circumference (cm)Nasion-Inion Distance (cm)Bitragal Distance (cm)Neurological Change*Parent Satisfaction
PreopPostopPreopPostopPreopPostop
193, M64534635453532
216, F64544234413332
397, M65544335423432
435, F63534234403332
529, M62524134403432

A score of 3 indicates improvement from baseline.

A score of 2 indicates very satisfied.

Fig. 5.
Fig. 5.

Patient appearance and recovery of macrocephaly before and after single-stage total cranial vault remodeling surgery. A–C: Case 1. Photographs obtained in a 93-month-old boy before surgery (A), on Day 6 after surgery (B), and at 25 months postsurgery (C). His head circumference was reduced from 64 to 53 cm by single-stage cranioplasty. D–F: Case 2. Photographs obtained in a 16-month-old girl before surgery (D), on Day 15 after surgery (E), and at 20 months postsurgery (F). Her head circumference decreased from 64 to 54 cm. G–I: Case 5. Photographs obtained in a 29-month-old boy before surgery (G), at 2 weeks after surgery (H), and at 32 months postsurgery (I). His head circumference was reduced from 62 to 52 cm.

TABLE 2:

Scoring system used for functional assessment*

Motor FunctionBehaviorScore
head controlcannot support weight of head unassisted0
supports weight of head w/ some assistance1
supports weight of head unassisted2
dorsiflexion of head unassisted3
sittingcannot sit unassisted0
sits w/ some assistance1
able to sit unassisted2
walking/standingcannot stand0
can stand & slightly move w/ some assistance1
able to stand & slightly move unassisted2
able to stand & walk unassisted3

Based on the scoring method of Gage et al.

TABLE 3:

Comparison of functional outcome before and after surgery*

Case No.Age (mos)Head ControlSittingStanding & WalkingTotal Score
preop
1932226
2162103
3972226
4352215
5292215
median352215
postop
1943238
2172215
3983238
4363227
5302226
median363227

Refer to Table 2 for definitions of functional assessment scores.

p < 0.05 versus the preoperative value.

Discussion

The occurrence of hydrocephalic macrocephaly is uncommon. As hydrocephalus is often neglected and/or treated ineffectively, defects in neurological function and physical development together with a cosmetic deformity of the calvaria are frequently seen in these patients. Reduction cranioplasty is required in certain cases of hydrocephalic macrocephaly to decrease the size, weight, and contour of the significantly enlarged head.3,6,15,16 In our study, 5 patients with an average age of 54 months (range 16–97 months) underwent reduction cranioplasty and all had improvement in motor function, including head control, sitting, and walking/standing. In addition, all parents were very satisfied and were uniformly pleased with the improvement in their child's appearance after surgery. Thus, reduction cranioplasty is a very effective treatment to correct hydrocephalic macrocephaly.

Various surgical methods of reduction cranioplasty for the treatment of hydrocephalic macrocephaly have been described in the literature.3,4,6,7,10,13–17 Takahashi et al. considered that aesthetics were important but not as important as neurological function; they performed multistage reduction cranioplasty to treat 2 cases of hydrocephalic macrocephaly to decrease the associated risks.14 In addition, Gage et al. described a limited cranioplasty technique that was shown to be associated with a shorter hospitalization and lower shunt revision rate.4 This technique focused on the posterior turricephaly but did not address any anterior frontal bossing. Other surgeons reported that a single-stage total cranial vault reduction cranioplasty is safe and effective for the treatment of macrocephaly due to hydrocephalus and that improvement of patient functioning and aesthetics could be achieved after surgery.6,7,10,13,17 We reasoned that a simulated computer program to reconstruct the head prior to surgery should be used and, together with the aforementioned surgical techniques, could provide good aesthetic outcomes postoperatively. We also used a sagittal bandeau as described by Sundine et al.13 in all of our total cranial vault remodeling procedures for the correction of hydrocephalic macrocephaly (Figs. 3 and 4). All patients survived and had good outcomes in terms of neurological function and aesthetics. We conclude that a sagittal bandeau is important in achieving the stability and bilateral symmetry of the remodeled cranial vault.

Hydrocephalic macrocephaly is rare. In general, each patient with this condition has a different head deformity. Therefore, each total cranial vault reduction cranioplasty is unique. From our experience, we recommend the following steps for a successful reduction cranioplasty. First, a computer imaging system should be used to simulate the patient's postoperative head appearance and bone reconstruction followed by selection of the best method for remodeling and cranial shape in every case. Second, an operative plan should be designed around remodeling the patient's head to an ideal shape using the patient's cranial vault bones (Fig. 1). Third, the techniques of bone reconstruction should be practiced according to the computer-simulated procedures using a plaster head model made in proportion to the patient's head before performing the total cranial vault reduction remodeling surgery (Fig. 2).

Hydrocephalic macrocephaly is usually only found in infants and young children. Kohan et al. performed total cranial vault remodeling in 8 children with a mean age of 18 months (range 9–26 months) at the time of surgery, and a high satisfaction rate with appearance and ease of caring for the child were noted after surgery.6 Likewise, Gage et al. performed reduction cranioplasty for macrocephaly in 10 patients with an average age of 17.9 months (range 6–53 months), and all patients showed good outcomes at an average of 41.5 months of follow-up.4 However, Mathews et al. suggested that the reduction cranioplasty should be avoided in patients younger than 3 years.8 Obviously, the minimum age at the time of reduction cranioplasty for hydrocephalic macrocephaly is still under debate. In our study, the mean age of patients undergoing total vault reduction remodeling surgery was 54 months (range 16–97 months). It should be noted that patients with hydrocephalic macrocephaly usually have significant growth retardation in the body and limbs, and some of them have very weak physical conditions that may not be suitable for a lengthy reduction cranioplasty. For these reasons, we offered this surgery to appropriate patients regardless of their age.

There are no reports about long-term follow-up after cranial vault remodeling in patients with hydrocephalic macrocephaly. Therefore, it would be difficult to predict the outcome of our patients 5 or 10 years after surgery. More cases and a longer follow-up time are needed to evaluate this surgical treatment.

Conclusions

From our experience, single-stage total cranial vault remodeling with shunt surgery for patients with hydrocephalic macrocephaly who are older than 1 year is safe and effective. The strategic goal of total cranial vault reduction cranioplasty is to improve the patient's quality of life and to correct the deformity, which requires meticulous preoperative evaluation and planning. We suggest using a computer 3D imaging system to simulate the patient's bone reconstruction before surgery for better aesthetic outcome.

Acknowledgment

We would like to thank John Jane Jr., M.D., (Department of Neurosurgery, University of Virginia, Charlottesville, VA) for his valuable advice throughout the study and for his critical reading of the manuscript.

Disclosure

This work was supported by the Natural Science Foundation of China (81271332). The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Z Wang, Shen. Acquisition of data: Shen. Analysis and interpretation of data: Z Wang, Kwan, Cai. Drafting the article: Shen. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Z Wang. Statistical analysis: Guo, Tan. Administrative/technical/material support: Chen. Study supervision: X Liu, F Liu.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

References

  • 1

    Di Rocco CMassimi LTamburrini G: Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review. Childs Nerv Syst 22:157315892006

    • Search Google Scholar
    • Export Citation
  • 2

    Dias MSLi V: Pediatric neurosurgical disease. Pediatr Clin North Am 45:15391578x1998

  • 3

    Ehni G: Reduction of head size in advanced hydrocephalus: a case report. Neurosurgery 11:2232281982

  • 4

    Gage EAPrice AVSwift DMSacco DJFearon JA: Limited reduction cranioplasty for the treatment of hydrocephalic macrocephaly. Plast Reconstr Surg 128:127212802011

    • Search Google Scholar
    • Export Citation
  • 5

    Gutierrez FAMcLone DGRaimondi AJ: Physiopathology and a new treatment of chronic subdural hematoma in children. Childs Brain 5:2162321979

    • Search Google Scholar
    • Export Citation
  • 6

    Kohan EJackson EHeller JLazareff JBradley JP: Correction of hydrocephalic macrocephaly with total cranial vault remodeling and molding helmet therapy. Plast Reconstr Surg 125:176317702010

    • Search Google Scholar
    • Export Citation
  • 7

    Mansour NSobel LLee MLarumbe JStelnicki E: A new method for the treatment of macrocephaly caused by hydrocephalus. Cleft Palate Craniofac J 42:162005

    • Search Google Scholar
    • Export Citation
  • 8

    Mathews MSLoudon WGMuhonen MGSundine MJ: Vault reduction cranioplasty for extreme hydrocephalic macrocephaly. J Neurosurg 107:4 Suppl3323372007

    • Search Google Scholar
    • Export Citation
  • 9

    Matsui TTsutsumi KKaizu HAsano T: Reduction cranioplasty for craniocerebral disproportion due to chronic subdural hematoma in infants. A technical report. Neurol Res 23:67712001

    • Search Google Scholar
    • Export Citation
  • 10

    Park TSGrady MSPersing JADelashaw JB: One-stage reduction cranioplasty for macrocephaly associated with advanced hydrocephalus. Neurosurgery 17:5065091985

    • Search Google Scholar
    • Export Citation
  • 11

    Parsons DSamuels SISteinberg GShuer L: Reduction cranioplasty and severe hypotension. Anesthesiology 68:1451461988

  • 12

    Shooman DPortess HSparrow O: A review of the current treatment methods for posthaemorrhagic hydrocephalus of infants. Cerebrospinal Fluid Res 6:12009

    • Search Google Scholar
    • Export Citation
  • 13

    Sundine MJWirth GABrenner KALoudon WGMuhonen MGGreene CS: Cranial vault reduction cranioplasty in children with hydrocephalic macrocephaly. J Craniofac Surg 17:6456552006

    • Search Google Scholar
    • Export Citation
  • 14

    Takahashi YTajima YOkura ATokutomi TShigemori MKiyokawa K: Reduction cranioplasty for macrocephaly. Two case reports. Neurol Med Chir (Tokyo) 39:4594621999

    • Search Google Scholar
    • Export Citation
  • 15

    Ventureyra ECDa Silva VF: Reduction cranioplasty for neglected hydrocephalus. Surg Neurol 15:2362381981

  • 16

    Vries JKHabal MB: Cranio-orbital correction for massive enlargement of the cranial vault. Plast Reconstr Surg 63:4664721979

  • 17

    Winston KROgilvy CSMcGrail K: Reduction cranioplasty. Pediatr Neurosurg 22:2282341995

  • 18

    Yano HTanaka KSueyoshi OTakahashi KHirata RHirano A: Cranial vault distraction: its illusionary effect and limitation. Plast Reconstr Surg 117:1932012006

    • Search Google Scholar
    • Export Citation

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Article Information

Address correspondence to: Zhan-Xiang Wang, M.D., Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, 55 Zhenhai Rd., Xiamen 361003, Fujian, People's Republic of China. email: sjwk123@yahoo.com.cn.

Please include this information when citing this paper: published online November 29, 2013; DOI: 10.3171/2013.10.PEDS12573.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Computer simulation of single-stage vault remodeling surgery. The most probable appearance of each patient's postoperative head and bone reconstruction was simulated based on preoperative computer images of the 3D CT data of the patient's head. Preoperative calvaria (A), model of postoperative excepted calvarial shape (B), simulation in splitting the calvarial bone (C and D), and simulation in reconstructing the calvaria (E and F).

  • View in gallery

    Plaster head models before and after surgery. Left: A plaster head model in proportion with the patient's head before surgery was built and the lines of incision were indicated. Right: Simulation of bone reconstruction after surgery for the same patient is shown on a plaster model. A sagittal bandeau was made to support the bilateral bone flap in the single-stage total cranial vault remodeling.

  • View in gallery

    Case 3. The calvaria of a 97-month-old boy with macrocephaly before, during, and after the single-stage total cranial vault remodeling surgery. A and B: Intraoperative photographs. Scalp flaps were undermined to the eyebrow anteriorly and to the transverse sinus posteriorly in a subperiosteal plane to expose the entire cranial vault. A sagittal bandeau was built. C and D: The head circumference of this patient decreased from 65 cm preoperatively (C) to 54 cm after a single-stage total cranioplasty (D). The patient stayed in the ICU for 22 days due to a lung infection.

  • View in gallery

    Preoperative (A–C) and postoperative (D–F) 3D CT scans (coronal [A and D], sagittal [B and E], and axial [C and F] views). The fragmented bones were cut into ideal shapes, placed to form a new shape of cranial vault, and fixed with titanium plates and screws under a sagittal bandeau.

  • View in gallery

    Patient appearance and recovery of macrocephaly before and after single-stage total cranial vault remodeling surgery. A–C: Case 1. Photographs obtained in a 93-month-old boy before surgery (A), on Day 6 after surgery (B), and at 25 months postsurgery (C). His head circumference was reduced from 64 to 53 cm by single-stage cranioplasty. D–F: Case 2. Photographs obtained in a 16-month-old girl before surgery (D), on Day 15 after surgery (E), and at 20 months postsurgery (F). Her head circumference decreased from 64 to 54 cm. G–I: Case 5. Photographs obtained in a 29-month-old boy before surgery (G), at 2 weeks after surgery (H), and at 32 months postsurgery (I). His head circumference was reduced from 62 to 52 cm.

References

  • 1

    Di Rocco CMassimi LTamburrini G: Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review. Childs Nerv Syst 22:157315892006

    • Search Google Scholar
    • Export Citation
  • 2

    Dias MSLi V: Pediatric neurosurgical disease. Pediatr Clin North Am 45:15391578x1998

  • 3

    Ehni G: Reduction of head size in advanced hydrocephalus: a case report. Neurosurgery 11:2232281982

  • 4

    Gage EAPrice AVSwift DMSacco DJFearon JA: Limited reduction cranioplasty for the treatment of hydrocephalic macrocephaly. Plast Reconstr Surg 128:127212802011

    • Search Google Scholar
    • Export Citation
  • 5

    Gutierrez FAMcLone DGRaimondi AJ: Physiopathology and a new treatment of chronic subdural hematoma in children. Childs Brain 5:2162321979

    • Search Google Scholar
    • Export Citation
  • 6

    Kohan EJackson EHeller JLazareff JBradley JP: Correction of hydrocephalic macrocephaly with total cranial vault remodeling and molding helmet therapy. Plast Reconstr Surg 125:176317702010

    • Search Google Scholar
    • Export Citation
  • 7

    Mansour NSobel LLee MLarumbe JStelnicki E: A new method for the treatment of macrocephaly caused by hydrocephalus. Cleft Palate Craniofac J 42:162005

    • Search Google Scholar
    • Export Citation
  • 8

    Mathews MSLoudon WGMuhonen MGSundine MJ: Vault reduction cranioplasty for extreme hydrocephalic macrocephaly. J Neurosurg 107:4 Suppl3323372007

    • Search Google Scholar
    • Export Citation
  • 9

    Matsui TTsutsumi KKaizu HAsano T: Reduction cranioplasty for craniocerebral disproportion due to chronic subdural hematoma in infants. A technical report. Neurol Res 23:67712001

    • Search Google Scholar
    • Export Citation
  • 10

    Park TSGrady MSPersing JADelashaw JB: One-stage reduction cranioplasty for macrocephaly associated with advanced hydrocephalus. Neurosurgery 17:5065091985

    • Search Google Scholar
    • Export Citation
  • 11

    Parsons DSamuels SISteinberg GShuer L: Reduction cranioplasty and severe hypotension. Anesthesiology 68:1451461988

  • 12

    Shooman DPortess HSparrow O: A review of the current treatment methods for posthaemorrhagic hydrocephalus of infants. Cerebrospinal Fluid Res 6:12009

    • Search Google Scholar
    • Export Citation
  • 13

    Sundine MJWirth GABrenner KALoudon WGMuhonen MGGreene CS: Cranial vault reduction cranioplasty in children with hydrocephalic macrocephaly. J Craniofac Surg 17:6456552006

    • Search Google Scholar
    • Export Citation
  • 14

    Takahashi YTajima YOkura ATokutomi TShigemori MKiyokawa K: Reduction cranioplasty for macrocephaly. Two case reports. Neurol Med Chir (Tokyo) 39:4594621999

    • Search Google Scholar
    • Export Citation
  • 15

    Ventureyra ECDa Silva VF: Reduction cranioplasty for neglected hydrocephalus. Surg Neurol 15:2362381981

  • 16

    Vries JKHabal MB: Cranio-orbital correction for massive enlargement of the cranial vault. Plast Reconstr Surg 63:4664721979

  • 17

    Winston KROgilvy CSMcGrail K: Reduction cranioplasty. Pediatr Neurosurg 22:2282341995

  • 18

    Yano HTanaka KSueyoshi OTakahashi KHirata RHirano A: Cranial vault distraction: its illusionary effect and limitation. Plast Reconstr Surg 117:1932012006

    • Search Google Scholar
    • Export Citation

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