Posterior Cranial Vault Remodeling for Shunt-Induced Crainiocerebral Disporpotion (CCD)

Contributors: Kumar Patel, PA-C and Gregory W. Albert

Posterior cranial vault remodeling post shunt induced Crainiocerebral Disporpotion (CCD)  Patient is a 5 y/o boy having frequent headaches which may be indicative of increased intra-cranial pressure in addition to a step-off deformity of his posterior calvarium.

DOI#: http://dx.doi.org/10.17797/d03zxkvg2h

Procedure cranial vault remodeling.
Frequent headaches, visual changes, hydrocephalus, craniosynostosis, increased intracranial pressure seen on eye-exam with optic disc swelling (ie papilledema) with deformation of the skull, or other evidence of symptoms that may be related to the skull being too small for the brain to adequately grow. Other indications beyond these can be for head shape alone.
Active shunt infection, absence of symptoms or increased intra-cranial pressure and acceptable head shape.
Intubation with oral ray secured down the midline to chin, 2 large bore IVs, arterial line, foley cath, prone positioning, padding to avoid pressure to orbit, bone-wax and thrombin available, blood & FFP available.
History & physical, CBC, basic metabolic panel, PT/PTT, anesthesiology evaluation for ASA class, shunt evaluation, 3D CT 1mm cut head-to-hyoid, ophthalmology exam to evaluate for papilledema.
Posterior vault flattening noted, coronal incision from ear to ear, wavy incision to hide in hairline and realign scalp. scalp anatomy: skin, subcutaneous tissue, galea, periosteum, skull bone. Incision down to bone through periosteum must be mindful of any thin bone or cranial defects where dura is exposed. Identify cranial sutures: coronal sagittal and lambdoid. Sterile pencil (or marker) is used to mark the area of bone to be removed, striving to avoid damaging what is a �¢ï¿½ï¿½normal�¢ï¿½ï¿½ contour--; the major cerebral sinuses must be avoided and the dura is more adherent to bone over a open suture, care must be taken when dissecting in this area; once the bone is off it can be split and plated back in a such a way as to increase intra-cranial volume.
Advantages: increases space posteriorly to allow for adequate brain growth. Disadvantages: does not increase space for anterior brain growth, because the child with a VP shunt has reduced cerebral expansion, there is a risk of creating dead space in the newly remodeled vault. Attention to the age of the child and potential for brain growth must guide the surgeon more towards a remodeling for skull shape rather than volume expansion.
Bleeding, infection, damage to dura mater lead to CSF leak, structural instability of plates and/or screws.
Bleeding, infection, damage to dura mater lead to CSF leak, structural instability of plates and/or screws.
Jessica Boswell
a. Ong J, Harshbarger RJ, Kelley P, George T. Posterior Cranial Vault Distraction Osteogenesis: Evolution of Technique. Seminars in Plastic Surgery. 2014;28(4):163-178. doi:10.1055/s-0034-1390169. b. Nilsson, D., Svensson, J., Korkmaz, B. A., Nelvig, H., & Tisell, M. (2013). Decreased head circumference in shunt-treated compared with healthy children. Journal of Neurosurgery: Pediatrics, 12(5), 483-490

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