Correction of hydrocephalic macrocephaly with total cranial vault remodeling and molding helmet therapy

Reduction Cranioplasty in Cases of Hydrocephalic Macrocephaly: Pearls and Pitfalls of Computer-Assisted Surgery

Reduction cranioplasty may be indicated to address functional or cosmetic sequelae of hydrocephalic macrocephaly. With the advent of CAD/CAM digital workflow, surgeons can design and fabricate craniotomy guides, templates, and models that allow for precise cranial reconstruction. Although there are several advantages of virtual planning, pre-determined surgical plans may limit intraoperative flexibility, requiring surgeons to troubleshoot errors in pre-operative planning or model design. The purpose of this report is to present a series of cases demonstrating our institution's technique for single-stage reduction cranioplasty using a CAD/CAM workflow. This report will highlight the benefits and challenges associated with a contemporary digital workflow for reduction cranioplasty.

Cranial vault reduction cranioplasty for severe macrocephaly due to holoprosencephaly and subdural hygroma: a case report

BACKGROUND

Severe macrocephaly can still be found in developing countries. This condition is usually caused by neglected hydrocephalus and can cause a lot of morbidities. Cranial vault reconstruction cranioplasty is the main treatment option for severe macrocephaly. Holoprosencephaly is often seen with features of microcephaly. Hydrocephalus should be considered as the main cause in HPE patients with features of macrocephaly. In this report, we present a rare case of cranial vault reduction cranioplasty procedure in patient with severe macrocephaly due to holoprosencephaly and subdural hygroma.

CASE DESCRIPTION

A 4-year-10-month-old Indonesian boy was admitted with head enlargement since birth. He had a history of VP shunt placement when he was 3 months old. But the condition was neglected. Preoperative head CT showed massive bilateral subdural hygroma that compressed brain parenchyma caudally. From the craniometric calculation, the occipital frontal circumference was 70.5 cm with prominent vertex expansion, the distance between nasion to inion was 11.91 cm and the vertical height was 25.59 cm. The preoperative cranial volume was 24.611 cc. The patient underwent subdural hygroma evacuation and cranial vault reduction cranioplasty. The postoperative cranial volume was 10.468 cc.

CONCLUSION

Subdural hygroma can be a rare cause of severe macrocephaly in holoprosencephaly patients. Cranial vault reduction cranioplasty and subdural hygroma evacuation is still the main treatment option. Our procedure successfully reduces significant cranial volume (57.46% volume reduction).

[Reduction cranioplasty for hydrocephalic macrocephaly: clinical observations and literature review]

Reduction cranioplasty for extreme hydrocephalic macrocephaly is performed for acquiring motor skills (head holding, sitting, moving), aesthetic correction and social adaptation of children. The authors analyze literature data and describe 2 patients with congenital hydrocephalic macrocephaly who underwent shunting surgery followed by reduction cranioplasty in early age using resorbable mini-plates. Reduction cranioplasty decreased skull volume, improved social adaptation of children and ensured favorable aesthetic outcome.

Cranial Vault Remodeling in Children With Ventricular Shunts

INTRODUCTION

Cranial vault surgery in children with ventricular shunts is more complex due to the possible interference of shunt location with surgical planning and increased risk of shunt related complications. The study evaluated the management of ventricular shunts during cranial vault remodeling (CVR) and subsequent outcomes and complications following CVR.

METHODS

An IRB-approved retrospective chart review was performed including patients who underwent CVR in presence of a ventricular shunt. Measured outcomes were number of shunt revisions following CVR, 30-day complication rate, 3-month complication rate, and post-CVR Whitaker classification. Finally, a review of the literature was performed, and our results were compared to previous reports.

RESULTS

Eleven patients met the inclusion criteria. Ventricular shunt was not exposed in 18%; exposed and not revised in 54%; exposed and left on a bone peninsula in 18% and simultaneously exposed and revised in 18%. Two patients experienced complications within 30-days. Three additional patients experienced complications within 3-months. An average of 2.2 shunt revisions per patient were performed following CVR. Whitaker classification was I in 7 patients, II in 1 patient and III in 2 patients. Shunt revision rate for patients undergoing CVR for hydrocephalic macrocephaly was on average of 1.2 and 1.9 for shunt-induced craniosynostosis in literature.

CONCLUSIONS

Cranial vault abnormalities in the presence of a ventricular shunt can be effectively treated with CVR. The presence of a shunt does not seem to interfere with final head shape. While leaving the shunt unexposed may appear less morbid, shunt related complications can still occur with this approach.

The Use of Virtual Surgical Planning for Reduction Cranioplasty

Hydrocephalic macrocephaly may occur as a result of untreated hydrocephalus. Reduction cranioplasty is the treatment of choice for these patients when the weight of their head interferes with normal development and negatively impacts quality of life. However, this procedure has several associated risks, including prolonged anesthesia, significant blood loss, and death. Virtual surgical planning (VSP) has been shown to be a useful adjunct for orthognathic and craniofacial surgery. The following report details the application and advantages of this technology in the setting of a reduction cranioplasty. We report the case of a 2-year-old girl with severe hydrocephalic macrocephaly who underwent a reduction cranioplasty guided by VSP with computer-aided design and manufacturing (CAD/CAM). Prefabricated cutting guides and a concave assembly bowl were used for precise fixation of bony segments. Our patient underwent a successful reduction cranioplasty using VSP and CAD/CAM. This technology allowed precise remodeling of the cranial vault with minimal bony gaps in the final construct. Head circumference and intracranial volume were reduced from 70 cm and 4,575 cm³ to 62 cm and 2,645 cm³, respectively. VSP with CAD/CAM can serve as a useful adjunct in complex cases of cranioplasty allowing for an increase in the precision, the efficacy, and the esthetic result.

Early postnatal cranial vault reduction and fixation surgery for severe hydrocephalic macrocephaly

OBJECTIVE Infants with severe hydrocephalus and extreme macrocephaly typically undergo CSF diversion early in life, which can result in significant cranial deformity due to CSF overdrainage. In this scenario, overlap of the cranial plates can precede the development of secondary synostosis and/or severe, permanent cranial deformity. As a result, extensive cranial vault remodeling is sometimes undertaken later in life, which is often challenging and has been associated with mortality and a high morbidity rate. The authors have previously described a technique for early postnatal cranial vault reduction and fixation (CVRF), in which the calvarial bones are stabilized using absorbable fixation plates in the neonatal period, in an attempt to facilitate patient positioning, simplify hydrocephalus management, and improve cosmesis. Here, the authors describe their institutional experience managing patients with extreme neonatal hydrocephalus with CSF diversion, with and without CVRF, over the past 12 years. METHODS The authors retrospectively reviewed the charts of infants with extreme hydrocephalus (head circumference > 49 cm) treated at their children's hospital with ventriculoperitoneal shunting, with or without CVRF, between 2005 and 2017. Data collected included age, sex, etiology of hydrocephalus, type of CVRF performed (anterior, posterior, or combined), follow-up duration, orbitofrontal circumference, craniometric measurements, intraoperative blood loss, operative duration, and postoperative complications. Developmental data were collected using the third edition of the Ages and Stages Questionnaire. Photographic imaging was used to demonstrate esthetic outcomes, and family questionnaires were used to evaluate satisfaction with the esthetic outcome. RESULTS Eleven patients with extreme neonatal hydrocephalus underwent CSF shunting; 5 underwent shunting alone and 6 patients underwent shunting and CVRF. For patients who underwent shunting and CVRF, the median age at CVRF was 6 days and the median interval between shunt placement and CVRF was 2.5 days. The mean extent of calvarial vault volume reduction was 44.5% (± 3.9%). The mean duration of the CVRF procedure was 108 minutes, and 5 of 6 patients required intraoperative transfusion. Of the 5 patients who underwent shunting alone, 3 developed severe cranial deformities. Of 6 patients who underwent shunting and CVRF, 1 had a poor cosmetic outcome. In the shunting-alone group, 2 patients died and 1 required extensive cranial vault correction at 10 years of age. One patient in the shunting and CVRF group also died. CONCLUSIONS CVRF in combination with CSF shunting in the neonatal period can simplify the treatment of the rare case of severe hydrocephalic macrocephaly and leads to cosmetic outcomes that are considered good by their families.

Endoscopic Lavage of Extensive Chronic Subdural Hematoma in an Infant After Abusive Head Trauma: Adaptation of a Technique From Ventricular Neuroendoscopy

Subdural fluid collections are frequently encountered in young children after non-accidental injury. In a subset of patients, these collections progress in size and ultimately require permanent drainage, which is commonly achieved with subdural-peritoneal shunts. However, excessive protein and cellular contents in the fluid are potential risk factors for shunt failure. Here, we describe the adaptation of an endoscopic lavage technique established for ventricular endoscopy with the aim of improving fluid condition prior to shunting. We present a case of subdural fluid collections secondary to non-accidental injury, where permanent shunting was required but could not be performed due to excessive protein and cellular levels in the subdural fluid despite conventional burr hole drainage. A two-month-old male infant presented with a bulging and tense fontanel, a reduced level of consciousness, bradycardia, and significant macrocephaly. Computed tomography (CT) demonstrated massive bilateral, low attenuation subdural fluid collections, reaching a diameter of 4.5 cm. Emergency burr hole washout and insertion of subdural drains was performed. Despite prolonged drainage over 10 days, the protein level remained at 544 mg/dl and the mean erythrocyte count at 6,493/µl. Continuous drainage was required to avoid clinical deterioration due to raised intracranial pressure; however, the fluid condition was still considered incompatible with permanent subdural-peritoneal shunting. We, therefore, performed an endoscopic subdural lavage with a careful evacuation of residual blood deposits. No complications were encountered. Postoperatively, mean protein level was 292 mg/dl and mean erythrocyte count was 101/µl. Endoscopic lavage could be safely performed in a case of extensive subdural low attenuation fluid collections, where conventional burr hole drainage failed to improve protein and cellular contents as a prerequisite for successful permanent shunting. We conclude that adaptation of this technique can be helpful in selected cases as an alternative procedure.

Reverse Distraction Cranioplasty for Treatment of Hydrocephalic Megalocephaly

Macrocephaly resulting from untreated hydrocephalus is a rare but difficult condition to treat. The patient presented is a 6-year-old boy who had progressively increasing head size since birth secondary to untreated hydrocephalus with associated developmental delay. His initial head circumference was 69 cm, and computed tomography scan showed evidence of obstructive hydrocephalus. For the first stage of the procedure, bicoronal and circumferential strip craniectomies were performed, 5 fully open 3.5 mm midface distractors were placed to facilitate vault reduction, and absorbable plates were placed in the frontoorbital region. Neurosurgery also performed an endoscopic third ventriculostomy and placed an external ventricular drain. Reverse distraction was completed over 5 days and tolerated well by the patient. Three months after the first procedure, the distractors were removed and frontoorbital reduction and additional cranial vault reduction and reshaping were performed. At 1 month following this operation he was noted to have excellent forehead contour and dramatic improvement of his macrocephaly with some remaining mid-vault asymmetry. His head circumference was measured at 61.5 cm with bicoronal distance of 39.5 cm. He demonstrated improvement in head control and ability to sit. This patient demonstrates a new technique for reduction cranioplasty involving the use of reverse distraction to facilitate gradual and controlled reduction prior to extensive cranial vault remodeling. The challenges associated with managing hydrocephalus in cranial vault reduction patients are also addressed.

Reduction cranioplasty for macrocephaly caused by giant occipital cystic lesion

Reduction cranioplasty for macrocephaly improves patients' quality of life both functionally and aesthetically. However, it is indicated for only a small number of patients because of the risks of complications. Thus, it is rarely performed, and not many reports have been published. In Dandy-Walker syndrome, there is often a posterior fossa cyst continuous with the fourth ventricle. We report here a case of scaphocephalic macrocephaly because of such a cystic lesion. The patient underwent a single-stage surgery with plication of the cyst wall and posterior reduction cranioplasty. This procedure achieved good results.

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

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.