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J Neurosurg (4 Suppl Pediatrics) 107:330331, 2007
330 J. Neurosurg: Pediatrics / Volume 107 / October, 2007
In this issue, Mathews and colleagues provide an excel-lent
historical review of cranial vault reduction for
severehydrocephalic macrocephaly. This review follows theirrecent
report on a series of four patients published in theJournal of
Craniofacial Surgery.2 Overall, I agree with theirstatements, but
it would be appropriate to reiterate someunique aspects of this
rarely utilized surgery. The mostimportant is that the operation is
indeed a very extensiveprocedure for small children and carries
with it serious risks,including the risk of death. Thus the
operation should be
limited to young children who suffer extreme hydrocepha-lus and
present great difficulties in care due to gigantic headsize. When
recommending the procedure for a child, sur-geons must be sure that
the childs parents understand thatinfants with extreme
hydrocephalus can have surprisinglygood cognitive and motor
development and that reductioncranioplasty involves risk of injury
to brain tissue.
With respect to surgical techniques and patient position-ing,
the modified prone position is a good alternative be-cause it
allows for exposure of the entire vault and a one-stage operation.1
Blood loss during surgery is a potentiallylethal complication, and
the main source of bleeding is thecalvaria. To reduce blood loss
during surgery, one shouldleave the pericranium attached to the
calvaria, and the bone
flaps should be removed in large pieces.There are significant
limitations of the procedure that de-
serve particular emphasis. The operation can reduce onlythe
cranial vault but not the skull base. Thus the anteropos-terior
diameter is not reduced at all, and the skull base re-mains
elongated. While reducing the cranial vault, it maybe necessary to
plicate the dura over the anterior fossa, en-tailing the danger of
occlusion of the sagittal sinus and con-sequent venous infarct. The
brain can become infolded asthe calvaria is reduced, thus causing
additional brain injury.Moreover, removal of a large volume of
cerebrospinal fluidis necessary to achieve the vault reduction, and
shunt func-tion must be closely monitored postoperatively.
I commend the authors for providing a detailed compar-
ison of different cranial reduction procedures heretofore
re-ported. This review article will be an excellent reference
formany years.
References
1. Park TS, Grady MS, Persing JA, Delashaw JB: One-stage
re-duction cranioplasty for macrocephaly associated with
advancedhydrocephalus. Neurosurgery 17:506509, 1985
2. Sundine MJ, Wirth GA, Brenner KA, Loudon WG, MuhonenMG,
Greene CS, et al: Cranial vault reduction cranioplasty in chil-
dren with hydrocephalic macrocephaly. J Craniofac Surg
17:645655, 2006
RESPONSE: Dr. Parks points are well taken. We complete-ly concur
with his recommendation of restricting total vaultreconstruction to
only the most extreme cases; the surgeryis a major undertaking
requiring prolonged surgical stressand risks of intraoperative and
perioperative complications,as well as significant hospital stays
and use of resources. Wehave been fortunate in our experience to
have thus faravoided significant negative consequences, including
death(especially during our earlier experiences), but we
discussthese potential outcomes fully with parents on different
oc-casions in the sincere effort to obtain truly informed con-
sent.With the assistance of members of the physical therapy,
occupational therapy, and neuropsychology departments,we are
monitoring our patients progress following surgeryin order to more
objectively define a population that reapsconcrete benefits from
vault reconstruction.
Dr. Park offers excellent advice concerning hemostasis,our
primary concern during this long surgery. Intraopera-tive blood
loss is meticulously monitored, and the samecare is applied to
serial measurement of intraoperative andpostoperative hematocrit
and coagulation parameters. Thepostoperative measurements are
important because a sig-nificant amount of blood may be lost
through the surgicaldrains during the first 48 hours after surgery.
With multiple
Editorial
Vault reduction cranioplasty
TAE SUNG PARK, M.D.
Department of Neurosurgery, St. Louis Childrens Hospital,
Washington University, St. Louis,Missouri
See the corresponding article in this issue, pp 332337.
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J. Neurosurg: Pediatrics / Volume 107 / October, 2007
Editorial
331
surgeons operating simultaneously, sustained vigilance
andaggressive management of even minor bleeding can trans-late into
significant reductions in blood loss.
Planning for redundant dura mater is undertaken
duringreconstruction. Dural plication and attachment to
recon-toured skull is performed with care to avoid potential
com-pression of the sagittal or transverse sinuses or the
conflu-
ence of sinuses. We completely agree that recognition
ofpotential intracranial pressure issues is extremely impor-tant.
We routinely externalize the ventriculoperitoneal shuntat the time
of vault reconstruction to soften the brain. Inmany cases, we
recommend replacing the shunt during asecond surgical procedure,
which allows for the safety ben-efit of controlled cerebrospinal
fluid diversion during theinitial recovery period. Although it
requires significant timeexpenditure, we have had positive
experience addressing
the anteroposterior diameter by removing and reconstruct-ing the
anterior skull up to and including the orbits and byremoving all
occipital bone and opening the aspect of theforamen magnum. In
summary, with appropriate planning,participation of team members
from multiple specialties,and appropriate education of patients and
their parents, totalvault reconstruction can be safely performed
and can result
in excellent outcomes, albeit with much effort!(DOI:
10.3171/PED-07/10/330)
MARLON S. MATHEWS, M.D.University of California, Irvine
Irvine, CaliforniaWILLIAM G. LOUDON, M.D., PH.D.
Neurosciences InstituteChildrens Hospital of Orange County
Orange, California
