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Aaron Mohanty, Arundhati Biswas, Satyanarayana Satish, Shanti Shankar Praharaj, and Kolluri V. R. Sastry


The aim of this study was to assess the efficacy of various treatment options available for children with Dandy–Walker malformation (DWM) and to evaluate the role of endoscopic procedures in the treatment of this disorder.


The authors conducted a retrospective review of 72 children who underwent surgical treatment for DWM during a 16-year period. All patients underwent computed tomography scanning, and 26 underwent magnetic resonance (MR) imaging. The initial surgical treatment included ventriculoperitoneal (VP) shunt placement in 21 patients, cystoperitoneal (CP) shunt placement in 24, and combined VP and CP shunt insertion in three. Twenty-one patients underwent endoscopic procedures (endoscopic third ventriculostomy [ETV] alone in 16 patients, ETV with aqueductal stent placement in three, and ETV with fenestration of the occluding membrane in two). Three patients underwent membrane excision via a posterior fossa craniectomy. In the 26 patients who had undergone preoperative MR imaging, aqueductal patency was noted in 23 and aqueductal obstruction in three. These three patients underwent placement of a stent from the third ventricle to the posterior fossa cyst in addition to the ETV procedure.

During the follow-up period, 12 patients with a CP shunt and four with a VP shunt experienced shunt malfunctions that required revision. Four patients with a CP shunt also required placement of a VP shunt. In addition, five of the 21 ETVs failed, requiring VP shunt insertion. A reduction in ventricle size noted on postoperative images occurred more frequently in patients with a VP shunt, whereas a reduction in cyst size was more appreciable in patients with a CP shunt. Successful ETV resulted in a slight decrease in ventricle size and varying degrees of reduction in cyst size.


Endoscopic procedures may be considered an acceptable alternative in children with DWM. The authors propose a treatment protocol based on preoperative MR imaging findings of associated aqueductal stenosis.

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Adam L. Sandler, Arundhati Biswas, and James Tait Goodrich

In 1915, faced with 2 patients with large skull defects, W. Wayne Babcock, an obstetrician-gynecologist-turned-general surgeon, operating in a modest North Philadelphia hospital, did something extraordinary: he went to the hospital kitchen to look for a cranial graft. Based heavily on archival and other primary sources, the authors tell the remarkable tale of the “soup bone” cranioplasties of the Samaritan Hospital and place these operations within the context of the early modern American hospital.

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Aaron Mohanty, Vani Santosh, B. Indira Devi, Satyanarayana Satish, and Arundhati Biswas


Intraventricular and paraventricular tumors resulting in hydrocephalus commonly require a CSF diversion procedure. A tumor biopsy can often be performed concurrently. Although the tissue samples obtained during endoscopic biopsy procedures are small, a diagnosis can be made in most cases. In the present study the authors analyzed the efficacy of concurrent endoscopic biopsy and CSF diversion procedures using a single bur hole and trajectory.


Eighty-seven patients with intraventricular and paraventricular tumors were treated with endoscopic biopsy and CSF diversion procedures using a rigid rod-lens endoscope or a rigid fiberscope during a 10-year period. All patients underwent a tumor biopsy and an endoscopic third ventriculostomy (ETV), aqueductal stenting (AS), or ventriculoperitoneal (VP) shunting, depending on the tumor location and site of obstruction. A single bur hole for both procedures was used in all patients.


Among the 87 patients, the biopsy was diagnostic in 72 (83%) and merely suggestive in 7 (8%); in 8 patients (9%) the sample was nondiagnostic. Among the 22 patients who underwent an initial endoscopic biopsy and subsequent procedures, the specimen obtained at the second surgery was concordant with the initial endoscopic biopsy sample in 13 patients; it was somewhat similar in 4 patients. In the other 5 patients, either a microsurgical or stereotactic approach was used to correctly diagnose the pathology. Fifty-five patients were considered for endoscopic CSF diversion procedures; an ETV was performed in 52 patients and AS in 2. An ETV could not be performed in 3 patients for technical reasons. A VP shunt was inserted in 32 patients, with 25 undergoing shunt placement at the same time as the ETV and 7 at a later date. Significant bleeding was encountered in 3 patients during the tumor biopsy and in 1 patient during the ETV. The ETV failed in 1 patient during the follow-up, and a repeat ETV was required.


Endoscopic biopsy sampling and a concurrent CSF diversion procedure through a single bur hole and trajectory can be considered for intraventricular tumors. The overall success rates of 83% for the biopsy procedure and 86% for the ETV indicate that the procedures are beneficial in the majority of cases. A concordance rate of 75% was found in patients who underwent an initial biopsy procedure and a subsequent microsurgical approach for tumor excision.

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Adam L. Sandler, Donald Sturrock, Jane Branfield, Rick Abbott, James T. Goodrich, Arundhati Biswas, Lawrence B. Daniels III, and Eugene S. Flamm

On December 5, 1960, 4-month-old Theo Dahl, the only son of best-selling author Roald Dahl (1916–1990), had his skull shattered in a horrific traffic accident. What began as a personal tragedy for the Dahl family would soon evolve into a dogged crusade by Dahl to expand upon preexisting valve technology with the goal of developing a shunt that would not become obstructed. Based upon exclusive access to private archives of the Dahl estate, as well as interviews with those involved, this article tells the intricate tale of one famous father's drive to significantly alter the natural history of pediatric hydrocephalus. Dahl's collaboration with British toymaker Stanley Wade and pioneering pediatric neurosurgeons Joseph Ransohoff, Kenneth Shulman, and Kenneth Till to create the Wade-Dahl-Till (WDT) valve is examined in detail. The ensuing rift between the American and British contingents, the valve's multiple design revisions, and the goal of creating an affordable shunt for children in developing countries are among the issues addressed. The development of the WDT valve marked a significant turning point in the surgical management of pediatric hydrocephalus in general and in shunt valve technology in particular.

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Adam L. Sandler, Oren M. Tepper, James T. Goodrich, Rani Nasser, Arundhati Biswas, and Rick Abbott

While autologous split calvaria remains the preferred material for use in pediatric cranioplasty, it may be difficult to split the bone neatly into two distinct pieces, especially in infants and young children. In this paper, the authors present a technique in which numerous split pieces of bone can be readily joined together and conformed to the shape of the specific defect using a customized template and 3D trellis-like basket.