Childs Nerv Syst (2006) 22: 1063–1064DOI 10.1007/s00381-006-0147-y LETTER TO THE EDITOR

P. Steinbok

Received: 14 March 2006Published online: 15 July 2006# Springer-Verlag 2006

Isolated diastasis of cranial sutures: unusualpresentation of a blocked shunt in an infant

Dear Editor:Gnanalingham et al. [1] have describedwhat they consider an unusual situation,where there was diastasis of the cranialsutures as the indicator of underlyingshunt malfunction in a patient in whomthe ventricular size did not indicate thediagnosis. I compliment the authorsfor reporting this case, but venture tosuggest that this is probably morecommon than might be indicated by thelack of reports in the literature. Whereasone might anticipate such a phenome-non in infants and very young children,where the sutures can become diastaticreadily, we have seen the same phe-nomenon in older children. At BCChildren’s Hospital the neurosurgicalteam and our sonologists are nowattuned to this particular finding. Indeed,we teach that the nature of the calvarialsutures should be reviewed on the scoutfilm of the skull done for a CT scan,on the CT scan films, or on radiographsof the shunt system. If there is a sug-gestion of diastasis this should becompared with prior films, if available.

An example of this phenomenon in a3-year-old child, presenting with head-aches but with no increase in the size ofthe small ventricles on a CT head scan,is presented (Fig. 1a,b). The suturaldiastasis in this case precipitated shuntrevision, at which time the shunt wasfound to be blocked. Another exampleoccurring in a 12-year-old girl isdescribed in more detail, because itdemonstrates that this phenomenon canalso occur at an older age. This girl with

a ventriculo-peritoneal shunt forDandy–Walker malformation and noprior shunt revision presented withmigraine-like headaches for the firsttime at age 12.0 years. She wasinvestigated for possible shunt mal-function with a CT head scan andradiographs of the shunt system. TheCTscan showed small ventricles similarto a prior well CT scan, and shuntradiographs were normal. The skullradiographs showed no evidence ofsutural diastasis (Fig. 2a). Nine monthslater (age 12.9 years), she returnedwith more severe headaches and newataxia. A CT scan showed mildincrease in ventricular size, and a skullradiograph, done as part of a series ofshunt radiographs, showed new dia-stasis of the coronal sutures (Fig. 2b).At surgery the shunt was blocked andthe intracranial pressure was markedlyelevated.

I think that sutural diastasis is auseful finding that should be lookedfor, and this can be helpful in caseswhere the clinical findings plus the CTscan findings are equivocal. I con-gratulate the authors on bringing thisto everyone’s attention.

Reference

1. Gnanalingham KK, Lafuente D, ChengD, Harkness W, Thompson D (2005)Isolated diastasis of cranial sutures:unusual presentation of a blocked shuntin an infant. Childs Nerv Syst21:936–938

P. Steinbok (*)Division of Neurosurgery,British Columbia’s Children’s Hospital,4480 Oak Street, K3-159,Vancouver, BC, V6H 3V4, Canadae-mail: psteinbok@cw.bc.caTel.: +1-604-8752094Fax: +1-604-8753109

Fig. 1 Three year old child withheadaches but with no increasein size of small ventricles on aCT head scan. a Prior to shuntrevision the skull radiographsdone to assess the continuity ofthe shunt show diastasis of thecalvarial sutures. b Threemonths after shunt revision, theskull radiographs show that thecalvarial sutures have returnedto normal

Fig. 2 A 12-year-old girl withshunted hydrocephalus and newonset of headache. a Skullradiographs done shortly afteronset of headaches show normalcoronal sutures. b Skull radio-graphs done 9 months latershow diastasis of the coronalsutures

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