You decide to place a ventriculoperitoneal (VP) shunt.

You manage to insert a VP shunt and use a medium pressure valve.

The patient does well and gets discharged home within a few days. You see him in clinic at 2 and 6 weeks postoperatively and he seems to be doing fine. Three months after discharge he presented to the clinic with a fluctuant subgaleal collection that is increasing in size upon coughing, crying, or simply laying in the supine position. You opt for observation for one week, but it continues to grow.

You admit this child and decide to revise the shunt, downgrade the pressure setting, and repair the leak site (from the original burr hole) with fascia and tissue sealant. The patient does very well postoperatively. He is discharged home without leakage or fluid collection. Along with his follow-up with the pediatrics service for delayed milestones, he follows up with you for the VP shunt. You notice that he has started to develop progressively significant positional plagiocephaly.

Despite multipositional stimulation the head continues to deform upward; the parietal bones grow and override the flattened occipital and frontal bones (Fig. 56.2). This deformity worsens with time. The fontanel remains soft. There are no associated neurologic sequelae.

At the age of one year, the parents are offered surgery, which they opt for. Multiple cranial osteotomies and reconstruction (cranial reduction procedure) are performed to reduce the towering of the cranium and expand the anteroposterior and bilateral diameter and to correct the left-sided occipitoparietal flattening.

• This study depicts severe hydrocephalus with significantly thinned out cortical mantle.
  
• The 4th ventricle is small, and this represents a case of aqueductal stenosis.
  
• There is interhemispheric transcallosal schizencephaly.

• Surgical options include^1,2
  
  
  
  
  • Extracranial cerebrospinal fluid (CSF) diversion procedures:
    
    
    
    
    • VP shunt
      
    • Ventriculoatrial shunt
    
    
  • Third ventriculostomy with or without choroid plexus coagulation³

• Shunt types include programmable vs. fixed (low or medium) pressure valves, with or without an antisiphon device.1,2
  
• The pressure to be used will be determined during surgery from the opening pressure of the ventricle.

• Specific complications include^4–6
  
  
  
  
  • CSF leakage around the ventricular catheter, as the cortical mantle is very thin in this case. The CSF can track through the burr hole. In addition, Laplace’s law describing pressure difference over an interface in a sphere will dictate that the greater pressure in a larger skull will tend to drive further CSF out of the burr hole.
    
  • Overdrainage from the shunt
    
  • Shunt infection
    
  • Pressure sores, valve erosion through the skin, skin abrasions at the overriding bone edges
    
  • Cranial deformities due to the overriding of the floating bones that were much larger than needed preshunting.
    
  • Fluid and electrolyte imbalance due to the CSF shifts during surgery.
    
  • Occult subdural hemorrhage postoperatively: Always beware of subdural hematomas developing postshunting, especially in patients with mega-hydrocephalus. These patients will not show signs of high intracranial pressure. They may lose a large portion of their blood volume intracranially and present with hypovolemic shock.
    
  • General shunt complications and complications of neonatal anesthesia

• CSF is leaking from the burr hole site around the ventricular catheter insertion site due to a lower resistance than that at the shunt valve.

• Management of a subgaleal collection postshunting:
  
  
  
  
  • Revise the shunt reservoir to a lower setting and repair the CSF leak site.
    
  • Repair the CSF site without revising the valve pressure. In this case, there is a risk of recurrence.

• Postshunting plagiocephaly treatment options include^7,8
  
  
  
  
  • Conservative options:
    
    
    
    
    • Multipositional stimulation
      
    • Frequent position changes – special care not to lie on the flat areas
      
    • Correction bands and helmets
  
  
• Special care not to develop abrasions from overriding skull edges
  
• Pressure sores at the valve and catheter sites – tailored openings in helmets at these sites
  
  
  
  
  • Surgical: Correction of deformities and remodeling

• The purpose of surgery is to improve and ease han dling, hygiene, cosmesis, and possibly mobility.^9–11

• Limitations include^9–11
  
  
  
  
  • Incapability to reconstruct or change the skull base
    
  • Presence of a long superior sagittal sinus
    
  • Risk of infolding of the thinned-out cortex leading to congestion or venous infarct

• Complications of cranial reduction in craniofacial reconstruction procedures include^9,10
  
  
  
  
  • Hemorrhage and complications of massive transfusion
    
    
    
    
    • Disseminated intravascular coagulation and other coagulopathies.
      
    • Acute respiratory distress syndrome
    
    
  • Postoperative prolonged edema that may threaten the airway and prolong the intubation period
    
  • Extradural collections
    
  • Complications of prolonged open surgical procedure
    
    
    
    
    • Anesthesia issues
      
    • Pressure sores
      
    • Infection
      
    • Electrolyte imbalances
    
    
  • Risk of brain injury
    
    
    
    
    • Enfolding of excess cortex causing venous infarcts
      
    • Manipulation of the superior sagittal sinus and risk of thrombosis or hemorrhage
      
    • Direct brain injury