Positional shunt assist for slit ventricle syndrome.

PURPOSE: Hydrocephalus is one of the most common pathologies in pediatric neurosurgery. One of the causes of recurring events of headaches among shunted children is "slit ventricle syndrome" (SVS). Several potential treatments have been proposed, yet SVS often represents a treatment challenge. The goal of the current series is to present our experience with adding a positional shunt-assist (SA) (Miethke, Aesculap) for the treatment of SVS. METHODS: Clinical data was retrospectively collected from all consecutive children with SVS that were treated with SA (Miethke, Aesculap) at our center. Surgical and clinical outcomes as expressed by hospital visits, or need for additional surgery, were evaluated. RESULTS: Nine cases were included. Hydrocephalus etiology included IVH (6), postinfectious (1), and congenital syndromes (2). Average age at first shunt was 4 months. Primary shunt type was differential-pressure-valve in all. Average age at SVS onset was 4 years. Average age at SA placement was 5.5 years. There were no perioperative complications besides a single stich abscess. A 6-month follow-up period after SA was compared to a 6-month period prior to the SA: average hospital visits decreased from 2.4 to 0.6 per patient (p < 0.0002). 4/9 patients needed an LP or shunt revision before the SA surgery, while no procedure was indicated during the immediate 6-month follow-up. At the last follow-up, there was a significant reduction in the rate of ER visits compared to prior to surgery; however, the number of neurosurgical procedures did not significantly differ. CONCLUSION: Using a SA for SVS was associated with a short-term improvement of symptoms in the majority of cases, reduction in hospital visits, and reduced need for SVS-related procedures.

Upward ballooning of the third ventricle floor in a patient with slit ventricle syndrome: A unique magnetic resonance imaging finding.

Slit ventricle syndrome (SVS) is a well-known chronic complication of ventriculoperitoneal shunt (VPS) placement. In this report, we describe a unique anatomical change that we observed on the magnetic resonance (MR) images of the brain acquired from a patient with SVS. The patient was a 40-year-old woman who had undergone VPS placement at 3 months of age. A computed tomography scan of her brain revealed a slit-like ventricle. In addition, an MR image of her brain revealed upward ballooning of the third ventricle floor, which returned to normal after a lumbar puncture. This anatomical change resulted from the pressure gradient between the intra- and extraventricular spaces. We believe our findings will further our understanding of the pathogenesis of SVS. Moreover, we hope our findings will help clinicians to select endoscopic third ventriculostomy as the primary surgical approach in patients with this particular SVS pathogenesis in order to avoid complications.

The "steppingstone" phenomenon: a new endoscopic finding in slit-ventricle syndrome.

Slit-ventricle syndrome (SVS) seems to encompass various pathophysiological abnormalities, including overdrainage of cerebrospinal fluid (CSF) and craniocerebral disproportion after extracranial CSF shunt placement. These pathologies result in small ventricle morphologically, and the ventricular catheter is obstructed by the collapsed ventricular walls. Patients with intermittent headaches, small ventricles on neuroimaging, and slow refill of the shunt reservoir are diagnosed with SVS. In this report, we present a case of SVS treated endoscopically. We detected bulges in a zigzag line on the ventricular walls according to side holes of the ventricular tube, and named them "steppingstone" phenomenon. It is a curious finding which directly shows that the intermittent obstruction of the ventricular tube occurs in patients with SVS. No previous articles have reported this phenomenon, and it indicates adequate treatment for SVS should be provided.

Modified bilateral subtemporal decompression for resistant slit ventricle syndrome.

PURPOSE: Slit ventricle syndrome (SVS) remains a major problem for early shunted children. Several conservative and surgical treatment paradigms have been suggested; however, there is no consensus on the optimal surgical treatment. We present our experience using bilateral subtemporal decompressions with dura and arachnoid opening for the treatment of a subgroup of children with severe and resistant SVS. METHODS: Fifteen children with severe and resistant SVS underwent a modified bilateral subtemporal craniectomy, with dura and arachnoid opening. Their clinical and radiological data were retrospectively reviewed. RESULTS: Seven (46.6%) patients had a complete recovery from their symptoms with a follow-up of 5.9 ± 2.6 years.The remaining eight (53.3%), underwent additional surgeries. Four (26.6%), had a single proximal shunt revision after dilatation of their ventricles. Following these procedures these four children are well and stable with a follow-up of 1.8 ± 2 years. The other four had further cranial vault expansion, one of which was followed by a proximal shunt revision. Thus, 11 of these 15 patients (73.4%) had a very good outcome, attributable to this technique, with a mean follow-up of 4.5 ± 3 years. CONCLUSIONS: Modified bilateral subtemporal decompression with dura and arachnoid opening yields a high cure rate for severe and resistant slit ventricle syndrome. Proximal shunt revision may be safely performed in a subset of patients that dilate their ventricles following the procedure. Further cranial expansion may be reserved for children with recurrent SVS symptoms who do not respond to STD and remain with very small ventricles.