The Conundrum of Ventricular Dilatations Following ...€¦ · profile, etiology, and Glasgow coma...

232 © 2018 Journal of Neurosciences in Rural Practice | Published by Wolters Kluwer - Medknow

Introduction: Ventriculomegaly and hydrocephalus (HCP) are sometimes abewildering sequela of decompressive craniectomy (DC). The distinguishingcriteria between both are less well defined. Majority of the studies quoted in theliterature have defined HCP radiologically, rather than considering the clinicalstatus of the patient.Accordingly, these patients have been treated with permanentcerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomaticventriculomegaly following DC should undergo aspiration with cranioplasty andbe followed up regularly. Materials and Methods: All patients with post‑DCwhowere scheduled for cranioplasty and satisfied the radiological criteria for HCPwere included. These patients were categorized into two groups. Group 1 includedventriculomegaly with clinical signs attributable to HCP and Group 2 constitutedventriculomegaly but no clinical signs attributable to HCP.All patients in Group 1underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patientsin Group 2 underwent cranioplasty along with simultaneous ventriculostomy andtemporary aspiration of the lateral ventricle.All patientswere regularly followed astheoutpatientbasis.Results:Therewere21patientswhodevelopedventriculomegalyfollowingDC.Therewere 10 patients inGroup 1 and 11 patients inGroup 2.Theaveragedurationoffollow‑upwasfrom6monthsto2years.Twopatientsintheshuntgroup ‑ (group1)hadoverdrainageand required revision.Onepatient inaspirationgroup ‑ (group 2) required permanent CSF diversion. Conclusions: Cranioplastywith aspiration is a viable option in selected group of patients in whom there isventriculomegalybutnosignsorsymptomsattributabletoHCP.

Keywords: Decompressive craniectomy, hydrocephalus, ventriculoperitoneal shunt, ventriculostomy

The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea?Raja K. Kutty, Sunilkumar Balakrishnan Sreemathyamma, Jyothish Sivanandapanicker, Prasanth Asher, Rajmohan Bhanu Prabhakar, Anilkumar Peethambaran, Gnanaseelan Kanakamma Libu1

Address for correspondence: Dr. Sunilkumar Balakrishnan Sreemathyamma,

Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India.

E‑mail: [email protected]

ventriculomegaly (PDCV). Patientswho had ventricularenlargement and clinical manifestations of HCP, viz.,poor MMSE, gait disturbances, and papilledema,underwent ventriculoperitoneal shunt (VPS), whileotherswhodidnothavesymptomsandpapilledemabuthad ventriculomegaly underwent a ventricular puncture

Original Article

Introduction

T he occurrence of ventriculomegaly/hydrocephalus(HCP) followingdecompressive craniectomy (DC)

estimates a wide range around 10%–45%.[1‑4] Thesefigures vary widely because of the different criteriachosenforthedeterminationofHCPfollowingDC.Moststudies have set radiological parameters to determinethe onset of HCP following DC.[1,5] However, thisalone alongwith clinicalmanifestations ofHCP shoulddeterminethecourseoftreatment.We,inourinstitution,have followed a treatment protocol for managementof patients who have post‑DC HCP (PDCH)/post‑DC

DepartmentsofNeurosurgeryand1CommunityMedicine,GovernmentMedicalCollege,Thiruvananthapuram,Kerala,India A

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DOI: 10.4103/jnrp.jnrp_395_17

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How to cite this article: Kutty RK, Sreemathyamma SB, Sivanandapanicker J, Asher P, Prabhakar RB, Peethambaran A, et al. The conundrum of ventricular dilatations following decompressive craniectomy: Is ventriculoperitoneal shunt, the only panacea? J Neurosci Rural Pract 2018;9:232-9.

Published online: 2019-09-02

Kutty, et al.: Conundrum of post decompressive craniotomy hydrocephalus

233Journal of Neurosciences in Rural Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2018

and aspiration of the lateral ventricle at the time ofcranioplasty. By this ventriculostomy, the brain shrunkbackintotheconfinesofthecranialdefectandfacilitatedtoanchortheboneflapaccuratelyinthecranialdefect.

Materials and MethodsAll patients who developed brain swelling andradiologically confirmed ventricular dilatation followingDCwereincludedinthestudy.ThestudywasdoneafterobtainingclearancefromtheInstitutionalReviewBoardand theEthicsCommittee.The studywas aprospectiveobservational study conducted in accordance with theEthical Standards on Human Experimentation of theHelsinkiDeclarationof1975,asrevisedin2000.Evan’sindex >30% was used as the limit to define HCP. Thepatientsweredividedintotwogroups.Patientswhohadclinical signs of HCP and papilledema were assignedGroup 1 and patients who did not have clinical signsof HCP and papilledema constituted Group 2. Patientsin Group 1 underwent cranioplasty with VPS eitheras a staged or concurrent procedure, whereas patientin Group 2 underwent simple aspiration of ventriclesfollowed by cranioplasty. The mean follow‑up periodwas6monthsto2years.Allpatientswereexaminedfordevelopment of papilledema and signs of neurologicaldeterioration. All patients underwent DC in a uniformmannerasfollows.

Decompressive hemicraniectomyAtypicalsurgeryperformedinourinstitutionisbymarkinga large bone flap covering the frontal, parietal, temporal,and occipital region.We usually keep ourmedialmargin2.5 cm away from themidline.The dural is opened in astellate fashion and the etiology, i.e., hematoma/contusionis let out. After attaining the hemostasis, the brain isusually covered with a double layer of dural substitute,G‑Patch(G.SurgiwearLtd.).Adrainiskeptandwoundisclosed in two layers.Theboneflap is usuallykept in theleftupperquadrantintheabdomen.

Ventriculoperitoneal shunt and cranioplastyVPS and cranioplasty was done as a staged procedurein eight patients and concurrently in two patients. Thesiteusuallychosenfortheshuntinsertionwasipsilateral

to the side of craniectomy in patients who underwentshunt concurrently and contralateral to craniectomy sitewhendoneasastagedprocedure.Aburrholewasmadejustbehindposterior‑mostedgeofthecraniectomywhendone concurrently, whereas the site of entry in stagedprocedurewaskeen’spoint.Theventricularcatheterwasguidedintotheoccipitalhornofthelateralventricleandadvancedfurthertoreachthefrontalhorns.Themediumpressure Chhabra VPS shunt was the most commonlychosen shunt for the procedure. The abdomen incisionwas put over the lumbar or hypochondrium regiondependingonthesurgeon’spreferenceandsubcutaneoustunneling was done, and the procedure was completedas with the standard VPS. Timeline of events on acomputedtomography(CT)scanofapatientundergoingthe procedure is illustrated in Figure 1. The clinicalprofile, etiology, and Glasgow coma scale GCS atpresentation, during the procedure, and at discharge aresummarizedinTable1.

Aspiration and cranioplastyAtypicalprocedureisillustratedinFigure2.Thepatientis supine with head turned to the side opposite to thecraniectomy. The bone flap is harvested first and theabdominalwound isclosedby theassistant.Thecranialwould is opened in the line of the previous incisionundersterileprecautions.Theskinflap is raisedand thebony edges are defined. The Paine’s point was usuallychosen as the entry site for ventricular catheterizationbutwasleft to thediscretionofasurgeon.Aventricularend of aVPS catheter is inserted into the ventricle andthecerebrospinalfluid (CSF) isaspirateduntil thebrainbecomes lax. In the latter part of the study, we startedto measure the intracranial pressure (ICP) to rule outhigh‑pressure HCP.When adequately lax and the boneflap fits in snuggly to the defect, it is anchored to thecraniectomy site with plate and screws. At the end oftheprocedure,theventricularcatheterisremoved.Therewere cases where the neuro‑ophthalmic findings wereequivocal. In such patients, ICP was measured to ruleout high‑pressure HCP. Timeline of events in CT scanof a patient undergoing the procedure is illustratedin Figure 3. The clinical profile, etiology, and GCS at

Figure 1:TimelineofeventsonacomputedtomographyscanofatypicalpatientwhodevelopedventriculomegalyfollowingacutesubduralhematomaandunderwentVentriculoperitonealshunt.POD:Postoperativeday,Cplsty:Cranioplasty


234 Journal of Neurosciences in Rural Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2018

presentation, during the procedure, and at discharge aresummarisedinTable2.

ResultsTwo hundred and ten patients underwent decompressivecraniotomies between 2014 and 2016. Majority of thepatients comprised of traumatic brain injury, middlecerebral artery infarct, and intracerebral hematoma.Twenty‑six patients died and were excluded from thisstudy. Of the remaining 174 patients who were followedup and scheduled for cranioplasty, 21 (12.07%) patientsdeveloped ventricular dilatations. There were 14 malesand 7 females in the study.Therewere 12 cases of acutesubdural hematoma, 4 cases ofmalignantmiddle cerebralartery infarct, and 5 cases of intracerebral hematoma.Themean age of the patientswas 37.1 ± 13.4 years.The

meanEvan’s index in the shuntgroup (38.58±1.69)washigherthanintheaspirationgroup(33.75±1.46),andthisdifferencewasfoundtobestatisticallysignificant.Figure4illustratestheboxplotforEvan’sindexinthetwogroups.

Ten patients with ventriculomegaly had poor GCSand had papilledema. These patients underwent a VPSfollowed by cranioplasty. The rest of the 11 patientsunderwent aspiration of lateral ventricles along withcranioplasty. ICP was measured in five patients inGroup 2 [Table 3]. The mean ICP was 50 mm ofCSF. The average duration of time elapsed betweencranioplasty and initial injury was not uniform due topoor follow‑up in the initial period. The mean time tocranioplasty was 4.2 months in the shunt group and7.1monthsintheaspirationgroup.Theboxplotfortimeto cranioplasty in the aspiration group and the shuntgroup is shown in Figure 5. The aspiration group hadhigherGCSthantheshuntgroup.

ComplicationsThere were no procedure‑related complications in theVPS group. One patient in the aspiration group hadcomplication wherein his brain became suddenly tensewhile doing the ventricular puncture at the keens point.Anticipatinganintracranialbleed,anexternalventriculardrain (EVD) was inserted at the Paine’s point whilethe procedure was abandoned. Emergency CT scanwas done which revealed an intracerebral hematoma atthe initial puncture site [Figure 6]. He was ventilatedwithout evacuating the hematoma, and he was back tohis preoperative status after 48 h after which the EVDwas removed. This patient was not willing for anyfurther procedures while he is still in follow‑up withgoodneurologicalstatus.

Follow‑upAll patients in both groups recovered well, and theywere discharged with regular follow‑up on outpatient

Table 1: Clinical profile, etiology, Glasgow Coma Scale at admission, cranioplasty and discharge along with time to cranioplasty of patients who underwent ventriculoperitoneal shunt and cranioplasty (Group 1)

Age Sex Etiology GCS at admission GCS at procedure GCS at discharge Time to cranioplasty (months)31 Female ASDH 6 8 9 560 Female ICH 10 10 11 242 Female ICH 9 10 11 425 Male ASDH 10 12 13 535 Female ASDH 12 13 14 361 Female ASDH 12 12 12 122 Male ICH 10 10 12 636 Male ICH 13 13 14 1450 Male ASDH 10 11 12 138 Male ASDH 10 12 14 2ProfileofpatientswhounderwentVPshuntalongwithcranioplasty(Group1).GCS:GlasgowComaScale,ASDH:Acutesubduralhematoma,ICH:Intracerebralhemorrhage,VP:Ventriculoperitoneal

Figure 2:Intraoperativeimagesofapatientwithacutesubduralhematomaandcoronalsuturaldiastasis3monthsafterdecompressivecraniectomy.Patientisundergoingaspirationwithcranioplasty.(a)Themildlytensebrain is visualized after raising of skinflap. (b) Intracranial pressurebeingmeasuredaftercannulationventriclesatthePaine’spoint.(c)Thebrainbecomingverylaxaftersufficientamountofcerebrospinalfluidisletoff.(d)Thebonepiecesbeinganchoredatthecraniectomysitewithplateandscrews

dc

ba



basis.The improvement inwasmore pronounced in theaspiration group compared to theVPSgroup.Themeanduration of follow‑up period of patients in both groupswas22months.Onepatient in theshuntgroupdiedduetocausesunrelated to theprocedure.Twopatients in theshuntgroupdevelopedoverdrainageoftheventricle,andconsequently, theirVPSwas tiedoff.These twopatientsunderwentaprogrammableshuntatalaterstage.

One patient in the aspiration group developed mildaphasiaandheadacheatafollow‑upof12months.Thispatienthadmild increase inventricular sizewith regardto previous CT findings and fundus showed evidence

of papilledema; hence, he underwent VPS. The patientimprovedsymptomaticallyaftertheCSFdiversion.

DiscussionDC has become cornerstone in the management ofintractable raised intracranial hypertension, particularlyin places where there are no ICP monitors available.Mostlyreservedfortrauma‑relatedcauses,theindicationsfor DC have been broadened to include a variety ofetiologies such as spontaneous intracerebral hematoma,cerebral venous sinus thrombosis, malignant middlecerebralarteryinfarct,andsubarachnoidhemorrhage.[2,6‑9]The growing acceptance of this technique for variousetiologies began to expose the different complicationsassociated with it. PDCH is one peculiar complicationassociatedwith this technique.Thepopular postulationscitedas to thecauseof thisetiologyaredisturbances inthepulsewavepressureacrosstheconvexityofthebrainfollowingDC[10] aswell asdecreasedvenousoutflowatthe medial margin of the craniectomy.[1,4] Studies alsodescribe the size of the craniectomy to be an incitingfactorinthedevelopmentofHCP.[4,11,12]

The incidenceofPDCH in the literaturevariesbetween0.7%and86%.[11]Thiswide range ismost likelydue tothe difference in criteria adopted for defining HCP invariousstudies.Conventionally,thishastobeassociated

Table 3: Clinical profile of patients with etiology, cerebrospinal fluid pressure, and fundus examination

Age Sex Primary injury

MMSE CSF pressure mm of CSF

Fundus

19 Male ASDH 28 46 Temporalpallor+42 Male ASDH 30 52 Normal43 Male MMCAI 29 54 Normal50 Male MMCAI 28 42 Normal36 Male ICH 26 56 NormalDemography of patients, etiology, clinical profile, and theirCSFpressuremeasuredduringaspirationwithcranioplasty.ASDH:Acutesubdural hematoma,MMCAI:Malignantmiddle cerebral arteryinfarct,ICH:Intracerebralhematoma,CSF:Cerebrospinalfluid,+:meansthatTemporalPallorwaspresent

Table 2: Clinical profile, etiology, Glasgow Coma Scale at admission, cranioplasty and discharge along with time to cranioplasty of patients who underwent aspiration and cranioplasty (Group 2)

Age Sex Etiology GCS at admission GCS at procedure GCS at discharge Time to cranioplasty (months)40 Male ASDH 12 14 14 260 Male MMCAI 13 15 15 740 Female ASDH 11 15 15 419 Male ASDH 9 15 15 1043 Male MMCAI 9 15 15 442 Female ASDH 11 15 15 250 Male MMCAI 10 14 14 942 Male MMCAI 12 15 15 638 Male ASDH 9 10 12 722 Male ASDH 10 14 14 1536 Male ICH 12 14 14 13Profileofpatientswhounderwentaspirationwithcranioplasty(Group2).ASDH:Acutesubduralhematoma,MMCAI:Malignantmiddlecerebralarteryinfarct,ICH:Intracerebralhematoma,GCS:GlasgowComaScale

Figure 3:Timelineofeventsonacomputedtomographyscanofatypicalpatientwhodevelopedventriculomegalyfollowingamalignantmiddlecerebralarteryinfarctandunderwentaspirationwithcranioplasty.POD:Postoperativeday,Asp+Cplsty:Aspirationwithcranioplasty



withclinicalmanifestationsofHCP.Sincethesesignsandsymptoms are difficult to be elicited in the backgroundofclinicaldecline following trauma,manyauthorshavedefinedthisonlybythesizeofventriclesonCTscan.[1,13]Consequently, there has been exponential increase inreporting this entity.[11] In this study, Evan’s indexof>30%waschosenasthecriteriaforventriculomegaly.Inour series, the incidenceofHCPwas10%.Thiswasin spite of the margins of craniectomy being 2.5 cmaway from the midline. This controllable etiology hasbeen postulated to be an important inciting factor forthe development of PDCH.[1,4] On the contrary, thereare studies refuting these hypotheses.[3,14,15] The primaryindication for DC in our patients was mainly stroke,intracerebral hematoma, and acute subdural hematoma.Interestingly, none of our patients who underwent DCfor malignant middle cerebral artery infarct developeda shunt‑dependant HCP. The finding whether DC forstroke causes shunt‑dependant HCP is a matter ofdispute. Rahme et al. noted 0% shunting rates in theircohort of 12 patients who underwent DC for middlecerebral artery infarction.[16] Various other authors whohavecontradictedthisfindingbyreportingtheincidenceofHCP followingDC formiddle cerebral artery infarctin the range of 29%[17]–71%.[10]As the total number ofpatients who undergo DC for traumatic brain injury inour center fairly outnumbers patients who undergo DCforstroke,nothingconclusivelycanbederivedfromourfinding.

Owing to the higher incidence of complicationsfollowing a DC, researchers have investigated andfound that by doing a cisternostomy and replacing thebone flap back after craniotomy, the incidence of HCPhas decreased.[18,19] In this method, the authors havedescribedwideopeningofthebasalcisternsofthebrain,whereby adequate CSF is drained until optimal brainrelaxationisachieved.Thisfacilitatesthereplacementofboneflapeasilycontrary toconventionaldecompressivehemicraniectomywherethisisnotpossible.

We have noted that there are a subset of patients whohave post DC ventriculomegaly and aslo satify theradiological criteria for hydrocephalus but are clinicallyasymptomatic.Hence,webelievethatinsuch,subgroupof a permanent CSF diversion is unnecessary. It wouldbe wiser to call it PDCV. Authors have estimatedthat such ventriculomegaly to be very common andaround 45%, but only a third of this require anyform of CSF diversion.[3] Lin et al. in their studynoted ventriculomegaly in all their 13 patients whounderwent a DC for malignant middle cerebral arteryinfarct.[20] They noted that the neurologic findings weredisproportionate to the degree of ventriculomegaly in

Figure 6: Computed tomography brain plain showing intracerebralhematomaalongthetractontheposteriorparietalregion.Theexternalventricular drain has been pulled out in transit to the computedtomographyscanwhichwasreinsertedlater

Figure 5:Boxplotshowingtimetocranioplastybetweentwogroups.Themedian time tocranioplasty in theshuntgroupwasmuchearlierthantheaspirationgroup

Figure 4: Boxplot showingEvan’s index for the two groups.ThemedianEvan’sindexwashigherintheshuntgroupthantheaspirationgroup



their patients. However, a mildly bulging brain willhinder the proper placement of bone flap back into thecraniotomy defect during cranioplasty. To circumventthis,wedoaventriculostomyatdefinedentrypoints tillthe brain regresses back into the confines of the cranialvault. This will facilitate the placement of bone flap tobeaccuratelyplaced into thecraniotomydefect.Havingsaid this, we do acknowledge the presence of patientswho have PDCH and are symptomatic. Such patientstend tohave tensebrainbulgingoutside the confinesofthe skull defectwith associatedpapilledema.Theyneeda permanentCSF diversion procedure.We generally dothisat thetimeofcranioplastyorasastagedprocedure.Wehadonlyonecomplicationduringcannulationoftheventricle in the aspiration group with the developmentof intraparenchymalhematoma.Sinceitwasonthesideof the gliotic brain, we did not anticipate any furtherdeficits.AnimmediateinsertionofEVDintothePaine’spoint negated the temporary rise of ICP. Some authorshave advocated the use of external lumbar drains forpost‑DC brain swellings.Although notwidely reported,thistechniqueisavalidalternativetoEVDs.[21,22]

Alternatively, Yang and Pirouzmand have described aninnovativemethod tomitigate theeffectofbrainbulgesdue tounderlyingpsuedomeningoceles followingDC.[23]Inthismethod,theyhavedescribedcontrolledreductionduroplasty with radial coagulation of dura, akin tospokes of wheel pattern using a bipolar cautery underlowcurrent.Thishaseffectively lessened theprotrusioncaused by underlying psuedomeningoceles by shrinkingoftheoverlyingduraaidingintheboneflapreplacementinto the desired craniectomy defect. We had tried thismethod in the above patient in whom the complicationofintracerebralhematomaoccurredbeforetheaspirationtechnique, but the reduction achievedwasnot sufficienttoanchortheboneflapsuccessfully.

Postcraniotomy bulges have been classified by differentauthors.[12,24,25]Accordingtothemwhenthebrainistenseandherniatingoutside, theskullneedscranioplastywithpermanent CSF diversion. In cases where the brain isflaccid and not tense, a cranioplasty may be sufficient.NoneofourpatientsinGroup2hadtensebulgingbrain.

The disappearance of ventriculomegaly aftercranioplasty is well documented.[26‑28] This has beenshown in various case series of patients who werewaitingtoundergostagedoperationforcranioplastyandVPS. The return of the CSF and hemodynamic withinthe brain after the placement of the bone flap mayplay a role in the resolution of HCP.[29,30] Pachatouridiset al. from Greece studied the patients with PDCHwithVPSas a single aswell as stagedprocedure alongwith cranioplasty.[28] The single‑staged surgery was

accomplished with programmable shunt while stagedsurgery included insertion of ventricular catheter andmeasurement of ICP and choosing themost appropriateshuntaccordingtothepressure.Inthatstudy,theauthordescribesthreepatients,onefromconcomitantgroupandtwofromstagedgroupwhodidnoteventuallyrequireaVPS forHCP followingcranioplasty. In their respectivestudies of PDCH following DC for middle cerebralartery infarction, Lee etal.[17] and Lin etal.[20] reportedtwo out of seven and nine out of thirteen patients whodidnotrequireaVPS.

InanotherseriesbyTsangetal.,theauthorsreportedthatfive out of 21 patientswho had undergone cranioplastywithVPS in situ were eventually found to be nonshuntdependent after their shunts were exteriorized formalfunction.[31] In these patients, CSF dynamics mighthave returned to normal following cranioplasty, leadingthemtoliveashuntindependentlife.[31]

PatientswhohadsuchresolutionofHCPalsoneed tobefollowed up as it has been documented in the literaturethat HCP can develop even as a late sequelae followinghead injury.[32] An ophthalmologic follow‑up to lookfor papilledema is a good test to screen patients for theevidence of developingHCP.This has been validated inthe literature in patients who have undergoneDC.[33]Allour patients in Group 2 were screened for developmentofpapilledema in the follow‑upperiod,but thisoccurredonly in one patient.As he also developed mild aphasia,the possibility of late high‑pressure HCP was thoughtof, and he underwent VPS. Insertion of VPS in notwithout complications which are well described in theliterature.[34‑36]Bydoingaspirationalongwithcranioplasty,wecouldavoidaVPSin10outof11patients.

TwopatientsintheshuntgrouphadoverdrainageoftheCSF and required a revision with programmable shunt.The incidenceofoverdrainageandsubduralcollectionshasbeenreportedtobemoreinpatientsundergoingVPSfor PDCH.[20] This happened around 3 months in onepatient and in the 5th month in the second patient. Theuse of programmable shunts has been very effectivelyprovenforthePDCHinvariouscaseseries.[25,28,37,38]Thefeasibility to titrate the pressure of the programmablevalve is prominent advantage over fixed pressure valvein this situation as the blood and CSF dynamic maytake time to return to normal following cranioplasty.Since this studywasdone ina tertiarycaregovernmenthospital, the socioeconomic status of the patients is notwelldevelopedtoaffordaprogrammableshunt.

Limitations of the studyOnly ten patients underwent aspiration and cranioplastyinGroup2.This cohort samplewas too small toderive



a definitive conclusion. ICPs were not measured inall cases to select the appropriate pressure for fixedpressure shunt. Marmarou et al.[39] studied the CSFdynamics in posttraumatic patients and showed that themere presence of ventriculomegaly does not indicatehigh‑pressureHCP.Itcanalsooccurincasesofatrophyand normal pressure HCP. In our study, we did notmeasure ICP in all cases, and hence, this might haveled to failure to identify cases of normal pressureHCPwhichcanoccurincasesoftrauma.

ConclusionsNotallcasesofPDCHwarrantpermanentCSFdiversionsurgery such as VPS. The strategy of aspiration withcranioplasty is a valid option in the management ofPDCV. By the described procedure, a permanent VPSmay be avoided in a selected group of patients withcraniectomy‑related HCP who undergo cranioplasty.However,thesepatientsneedtobefolloweduptodetectthepossibilityofdevelopmentoflateHCP.

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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