Slit Ventricle Syndrome.

Slit ventricle syndrome (SVS) is a complication after ventriculoperitoneal shunt (VPS) or cystoperitoneal shunt(CPS), mostly due to excessive drainage of cerebrospinal. The disease is most often seen in children and has a complex pathogenesis. Clinical manifestations are mainly intermittent headache, slow refilling of the shunt reservoir, and slit-like ventricles on imaging. Surgery is the main treatment. We present a 22-year-old female patient with a previous 14-year history of CPS. The patient recently presented with typical symptoms but her ventricular morphology was normal. We performed VPS after diagnosis of SVS. After the surgery, the patient's symptoms improved and her condition was stable.

Novel Endoscopic Technique for Inserting a Sheath into a Slit Ventricle: The Water-Slide Technique.

BACKGROUND: The efficacy and safety of endoscopic procedures for slit ventricle syndrome (SVS) have been presented in recent studies. However, inserting a sheath into a target ventricle is essential in the beginning of endoscopic procedures for SVS, and this maneuver is challenging owing to the quite narrow ventricular space. We report a novel flexible endoscopic technique, the water-slide technique, that can effectively guide a sheath into a slit ventricle without the use of other adjunctive devices, such as a neuronavigation system and an ultrasound machine. METHODS: Ten endoscopic procedures using the water-slide technique were performed in 9 patients with SVS. All patients had undergone ventriculoperitoneal shunt placement. Using the technique, the sheath was first placed on the flexible endoscope. The endoscope was then inserted into the lateral ventricle along the tract around the pre-existing ventricular catheter with irrigation of artificial cerebrospinal fluid via the working channel of the endoscope. After the endoscope reached the ventricle, the sheath was inserted into the ventricle along the endoscope. The endoscope was then used as a stylet. The endoscopic procedure was performed afterward. Continuous irrigation of artificial cerebrospinal fluid via the working channel is important when using this technique. RESULTS: In all cases, the sheath was successfully introduced to the slit ventricle without the use of adjunctive devices. There were no postoperative complications correlated with the maneuver. CONCLUSIONS: This novel endoscopic technique is effective and safe for inserting a sheath into a target ventricle in the management of SVS.

Predictors of fast and ultrafast shunt failure in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study.

OBJECTIVE: The primary objective of this study was to use the prospective Hydrocephalus Clinical Research Network (HCRN) registry to determine clinical predictors of fast time to shunt failure (≤ 30 days from last revision) and ultrafast time to failure (≤ 7 days from last revision). METHODS: Revisions (including those due to infection) to permanent shunt placements that occurred between April 2008 and November 2017 for patients whose entire shunt experience was recorded in the registry were analyzed. All registry data provided at the time of initial shunt placement and subsequent revision were reviewed. Key variables analyzed included etiology of hydrocephalus, age at time of initial shunt placement, presence of slit ventricles on imaging at revision, whether the ventricles were enlarged at the time of revision, and presence of prior fast failure events. Univariable and multivariable analyses were performed to find key predictors of fast and ultrafast failure events. RESULTS: A cohort of 1030 patients with initial shunt insertions experienced a total of 1995 revisions. Of the 1978 revision events with complete records, 1216 (61.5%) shunts remained functional for more than 1 year, and 762 (38.5%) failed within 1 year of the procedure date. Of those that failed within 1 year, 423 (55.5%) failed slowly (31-365 days) and 339 (44.5%) failed fast (≤ 30 days). Of the fast failures, 131 (38.6%) were ultrafast (≤ 7 days). In the multivariable analysis specified a priori, etiology of hydrocephalus (p = 0.005) and previous failure history (p = 0.011) were independently associated with fast failure. Age at time of procedure (p = 0.042) and etiology of hydrocephalus (p = 0.004) were independently associated with ultrafast failure. These relationships in both a priori models were supported by the data-driven multivariable models as well. CONCLUSIONS: Neither the presence of slit ventricle syndrome nor ventricular enlargement at the time of shunt failure appears to be a significant predictor of repeated, rapid shunt revisions. Age at the time of procedure, etiology of hydrocephalus, and the history of previous failure events seem to be important predictors of fast and ultrafast shunt failure. Further work is required to understand the mechanisms of these risk factors as well as mitigation strategies.

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 Total Calvarial Transsutural Distraction Osteogenesis for 26 Children with Slit Ventricle, Craniosynostosis, or Microcephaly After Shunt Operation.

OBJECTIVE: Among shunt complications, the postshunt slit ventricle (PSSV) and the postshunt craniosynostosis (PSCS) may be managed by shunt valve upgrade and/or cranial expansion surgery. Here, we analyzed 26 children with PSSV, PSCS, or microcephaly who received simple generalized cranial expansion (ie, total calvarial transsutural distraction osteogenesis [TC-TSuDO]). METHODS: Among 254 children with shunt surgery, 26 children received TC-TSuDO. These 26 children included 14 with PSSV, 4 with PSCS, and 8 with both PSSV and PSCS. The mean age of patients who underwent shunt procedures was 8.2 ± 10.6 months, and the mean time interval from shunt surgery to TC-TSuDO was 26.8 ± 29.5 months. The mean age of children at the time of TC-TSuDO was 33.3 ± 30.2 months. We analyzed head circumferences, lumbar puncture pressures, development status, operative factors, and postoperative complications. RESULTS: The mean preoperative head circumference was -2.1 ± 1.9, which increased to -1.4 ± 2.1 (P < 0.001) postsurgically. The mean preoperative lumbar puncture pressure was 26.2 ± 10.7 cm H2O which decreased to 11.9 ± 3.5 cm H2O (P < 0.001) after surgery. The mean operation time was 138 ± 66 minutes. The mean intensive care unit stay was 0.27 ± 0.53 days. There were no mortalities but 2 patients suffered from distractor malfunction and 1 patient showed wound discharge. CONCLUSIONS: We suggest that postshunt complications such as PSSV or PSCS, especially those that are accompanied by increased intracranial pressure or postshunt microcephaly, may be managed for patients with TC-TSuDO, which has been shown to be safe, simple, and effective.

Treatment of cephalocranial disproportion in shunt-induced slit ventricle syndrome with cranial vault distraction osteogenesis.

BACKGROUND: Slit ventricle syndrome (SVS) is a known late complication of shunting procedures. Some patients develop cephalocranial disproportion (CCD) that will require surgical treatment to increase craniocerebral compliance. METHODS: We performed cranial vault distraction osteogenesis to treat 2 teenage patients who presented with SVS, increased intracranial pressure and CCD. Bilateral temporo-parieto-occipital craniotomies were performed. RESULTS: Both patients successfully completed distraction and consolidated without the need for bone grafting. Postoperatively, both patients showed an increase in intracranial and intraventricular volume, as well as decreased shunt revisions. One patient had improvement of her headaches, while the other continues to have chronic headaches. CONCLUSION: Distraction osteogenesis is an option to expand the cranial vault in older children with SVS and CCD, in which the traditional cranial vault expansion would be a challenge and may or may not provide adequate expansion.

Acute cranial decompression in Meckel-Gruber syndrome and slit-ventricle syndrome with craniocephalic disproportion.

Slit-ventricle syndrome (SVS) is characterized by headaches associated with subnormal ventricular size in patients with shunt-treated hydrocephalus. It commonly occurs in children who have had shunts placed at an early age and is diagnosed when computed tomography scans are carried out to investigate suspected shunt obstruction with an accompanying rise in intracranial pressure (ICP). Overdrainage of cerebrospinal fluid may additionally result in craniocephalic disproportion, potentially by dampening the normal expansile pulsations of the dura against the skull, which leads to craniostenosis. Management is controversial because many strategies have only short-term benefit, and surgical intervention is understandably often seen as a last resort.We present a case of a child with SVS and craniocephalic disproportion who was treated with urgent cranial expansion due to rising ICP. Intraoperative ICP monitoring demonstrates a rapid and sustained drop in ICP, and the patient made an uneventful return to his premorbid condition. We conclude that cranial vault expansion should be considered as an effective treatment for postshunt craniocephalic disproportion in patients with SVS.