pISSN 2234-8999 / eISSN 2288-2243 CLINICAL ARTICLE Korean J Neurotrauma 2015;11(2):93-99 http://dx.doi.org/10.13004/kjnt.2015.11.2.93 An Improved One-Stage Operation of Cranioplasty and Ventriculoperitoneal Shunt in Patient with Hydrocephalus and Large Cranial Defect Young Taek Jung, MD, Sang Pyung Lee, MD, PhD, and Jae Ik Cho, MD Department of Neurosurgery, Cheju Halla General Hospital, Jeju, Korea Objective: The risk of complications is high for patients with a large cranial defect and hydrocephalus, undergoing cranio- plasty and ventriculoperitoneal (VP) shunt operation. The purpose of this study is to examine retrospectively such cases with complications and contrive an operative technique to reduce complications. Methods: Nineteen patients underwent cranioplasty and VP shunt operation due to large cranial defects and hydrocephalus. These patients were divided into two groups: Group A with 10 patients who underwent staged-operations, and Group B with 9 patients who underwent one-stage operation. Their complications in each group were retrospectively reviewed. Another five patients underwent a one-stage operation with temporary occlusion of the distal shunt catheter to improve on the tech- nique and were categorized as Group C. Complications in these groups were compared and analyzed. Results: The results of the data analysis revealed that complications related to anesthesia (40%) and those related to antibiot- ic prophylaxis (30%) were high in Group A, while non-infectious delayed complications (45%) and perioperative complica- tions such as intracranial hematoma (33%) were high in Group B. However, for patients in Group C, it showed less compli- cation with the operative technique devised by these authors, as opposed to two previous procedures. Conclusion: In patients with hydrocephalus and a large cranial defect, complications arising from existing one-stage oper- ation or staged-operations can be reduced by implementing the technique of “one-stage operation with temporary occlusion of the distal shunt catheter.” (Korean J Neurotrauma 2015;11(2):93-99) KEY WORDS: Decompressive craniectomy ㆍCranioplasty ㆍCranial defect ㆍVentriculoperitoneal shunt ㆍ Hydrocephalus ㆍOne-stage operation. Introduction to improve cerebral compliance, cerebral oxygen supply, and cerebral perfusion pressure (CPP).4,12,15,27,29) With respect Decompressive craniectomy (DC) is one of the widely to operative technique, DC is a simple procedure. Never- utilized imperative methods in the treatment of refractory theless, there are numerous reported complications such intracranial hypertension. The benefits of DC, in the aspect as postoperative herniation through the cranial defect, sub- of decreasing intracranial pressure (ICP), are well-docu- dural fluid collection, postoperative intracranial bleeding,1) mented in several studies.1,3-5,8,22) Furthermore, DC is known postoperative infection, “syndrome of the trephined,” and 3,8,11,15,19,24,27,29) Received: June 29, 2015 / Revised: September 11, 2015 hydrocephalus. Accepted: October 5, 2015 In addition to the etiology that leads to having DC, a cra- Address for correspondence: Jae Ik Cho, MD nial defect alone may cause neurologic symptoms referred Department of Neurosurgery, Cheju Halla General Hospital, 65 Doryeong-ro, Jeju 63127, Korea to as the “syndrome of the trephined” or “sinking skin flap Tel: +82-64-740-5036, Fax: +82-64-740-5000 syndrome.” It is known to occur due to changes in the hydro- E-mail: [email protected] dynamics of cerebrospinal fluid (CSF) in association with cc This is an Open Access article distributed under the terms of Cre- 3,8,27,29) ative Attributions Non-Commercial License (http://creativecommons. a postoperative cranial defect. The “syndrome of the org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, trephined” and hydrocephalus are the most frequent com- distribution, and reproduction in any medium, provided the original work is properly cited. plications that develop after DC.3) It has been reported that Copyright © 2015 Korean Neurotraumatology Society 93 Improved Simultaneous Operation of Cranioplasty and VP Shunt the incidence rates of post-traumatic hydrocephalus, second- operation (Group B). Their complications in each group ary to a head trauma, are in the range of 0.7% to 86%.6,11) It were retrospectively reviewed. From April 2013 through is known that the incidence rate of hydrocephalus, which December 2014, another 5 patients underwent a one-staged may develop following DC, is about 10% to 40%.1,14,28) The operation with temporary occlusion of the distal shunt cath- etiology of the hydrocephalus following DC may be not only eter to improve on the technique, and therefore were cate- post-traumatic but also original disease related hydrocepha- gorized as Group C. The complications in each group were lus, such as post spontaneous subarachnoidal hemorrhagic compared and analyzed. This study also examined the hydrocephalus. In cases with hydrocephalus secondary to following parameters: 1) age and sex, 2) size and laterality large craniectomy, they may require cranioplasty with a of cranial defects, and 3) clinical condition after surgery ventriculoperitoneal (VP) or a subdural-peritoneal (S-P) (Glasgow Outcome Scale). In this study, the hydrocephalus shunt. Patients would have a higher risk of complications by criteria were established as follows: 1) Evan’s index ＞0.3, undergoing two procedures simultaneously than by under- 2) bicaudate ratio ＞0.25 (means significant ventriculomeg- going each procedure in staged operations.18) However, pa- aly), 3) enlargement of the temporal horn or the third ven- tients undergoing staged operations also are imposed with tricle, 4) presence of periventricular low density, 5) clini- considerable complications, such as having more chances cal features, and 6) responses to preoperative continuous of undergoing general anesthesia and surgical procedure, lumbar drainage (＞150 mL/day). All patients underwent higher cost of surgery, longer hospital stay, and adverse re- early cranioplasty (5 to 8 weeks after DC), while an autol- actions of antibiotic prophylaxis. In this study, these authors ogous bone flap, which was kept at -80°C in the bone bank, report an improved one-stage operation with minimization was utilized as the material for cranioplasty. After cranio- of complications associated with the aforementioned com- plasty, using the ipsilateral Kocher’s point or Keen’s point plications of one-stage or staged operations. (in case of bilateral cranioplasty, we used the right side), a VP shunt was performed. Only a programmable shunt valve Materials and Methods type (Codman-Medos programmable VP shunt, Medos SA, Le Loche, Switzerland) was used in VP shunt implanta- From May 2006 through December 2012, 91 patients tion.6) Prior to surgery, owing to the possibility of tempo- underwent DC, due to refractory intracranial hypertension rary occlusion with the device affecting the mechanical after they had suffered a traumatic brain injury or a vascu- structure of the shunt catheter wall, an experiment was car- lar lesion, in our hospital. Furthermore, cranioplasty and ried out to find out whether any structural change of the CSF shunting operation were carried out for those patients shunt catheter wall could occur after occlusion. Complete that developed hydrocephalus. Of these 91 patients who occlusion was verified by infusing 10 mL of normal saline underwent cranioplasty after DC, 23 received both cranio- in a syringe into each of the following: 1) a case of occlu- plasty and CSF shunt operation, and were reviewed, but 4 sion with a Yasargil aneurysm clip (Aesculap Inc., South cases with an S-P shunt were excluded. The medical re- San Francisco, CA, USA), 2) a case of occlusion with a bull- cords of these 19 subjects were retrospectively investigated. dog clamp (Lawton, Fridingen, Germany), and 3) a case of These 19 patients were divided into two groups: the group occlusion by making a direct tie of the shunt catheter with of 10 patients who underwent staged-operations (Group a black silk 4-0 suture material. Complete occlusion was A), and the group of 9 patients who underwent one-stage verified in the above 2 cases, where saline passage was A B C FIGURE 1. Photographs of occluded distal shunt catheter by using different occlusion devices. A: By making a direct tie of the shunt catheter with a black silk 4-0 suture material. B: By applying a Yasargil aneurysm clip. Note that the distal end of the clip blades is reinforced with a black silk tie to increase the ending force. C: With a bulldog clamp. 94 Korean J Neurotrauma 2015;11(2):93-99 Young Taek Jung, et al. not observed even though strong positive pressure was ap- initial pressure of the programmable shunt valve was set plied with a syringe. Nevertheless, slight saline passage was at 200 mm H2O and the ICP was allowed to drop gradually evident when occlusion was carried out with an aneurysm as these patients were followed up by brain computed tomog- clip. Then, the distal end of the clip blades was reinforced raphy (CT). with a black silk tie, increasing the ending force, which re- sulted in complete occlusion (Figure 1). The distal shunt Results catheter was occluded by using 1) an aneurysm clip, 2) a bulldog clamp, and 3) by making a direct tie using a black There were 11 males and 13 females while the mean age silk 4-0 suture material. The slides of thin sections of the of these subjects was 53.1 years old with a range of 22 to region, which had been occluded for 7 days in each case, 74 years. The etiologies of DC and CSF disorder included were observed under an optical microscope (×100) and a traumatic brain injury (13 cases), complicated clinical out- surgical microscope (×13). These were compared with that come after spontaneous subarachnoid hemorrhage sec- of the normal shunt catheter for which nothing had been ondary to cerebral aneurysmal rupture (9), malignant brain done. There was no difference between the wall structure of swelling following cerebral infarction (1), and spontaneous the above 3 shunt catheters and that of a normal shunt cath- intracerebral hemorrhage (1).