Continuing experience with subgaleal shunting

OBJECTIVE

To evaluate subgaleal shunting--the diversion of cerebrospinal fluid into the subgaleal space for temporary absorption by the membranes of the scalp.

METHOD

Eighty-one (81) patients were treated over a 20-year period. There were 22 cases of hypertensive hydrocephalus, 52 cases of acute head trauma, and 7 cases of chronic subdural hematoma. The simple surgical technique is described.

RESULTS

Of the eight-one patients, 33 improved, 27 did not change, and 21 expired within 72 hours. Intracranial pressure was monitored directly in 22 cases and demonstrated that subgaleal shunting provided effective short-term treatment.

CONCLUSIONS

This simple, closed method for drainage of cerebrospinal fluid avoids the complications of open ventriculostomy or open drainage of the subdural space.

Cryptococcal meningitis in the immunocompromised host: intracranial hypertension and other complications

Cryptococcosis as a complication of the immunocompromised host has dramatically increased in frequency since the start of the AIDS epidemic. This trend has heightened awareness of the complications of cryptococcal meningitis; of these, intracranial hypertension is common, severe, and life-threatening, as exemplified by three cases in our institutions presented here in detail. An aggressive approach to management of this complication has not been the standard of care, but neurosurgical interventional studies combined with physiologic observations suggest early intervention may reduce the devastating morbidity and mortality.

Traumatic brain injury: patterns of failure of nonoperative management

OBJECTIVE

The circumstances of failure for nonoperative management of blunt traumatic brain injury have been poorly defined. In this study, all trauma patients identified over a 12-year period with progression of neurologic injury requiring craniotomy were retrospectively reviewed.

METHODS

Data collected included demographic information, mechanism of injury, field and admission vital signs, and Glasgow Coma Scale score, medications, associated injuries, and coagulopathy. Head computed tomographic scans were reviewed, and anatomic findings were correlated with clinical changes (change in mental status or elevation of intracranial pressure) that led to subsequent CT scan and craniotomy.

RESULTS

Of 20,100 patients, there were 852 who had computed tomographic scans with acute intracranial injuries on admission; 462 patients were managed nonoperatively. Fifty-seven patients had progression of neurologic injury (34 < 24 hours = early; 23 > 24 hours = late) that required surgery.

CONCLUSION

Of the variables investigated, only anatomic location of injury was found to be predictive of early failure of nonoperative management. Frontal intraparenchymal hematomas are particularly prone to early failure. Clinical examination and intracranial pressure monitoring are equally important in detecting failure and should be an integral part of nonoperative management.

State of the art in craniofacial surgery: nonsyndromic craniosynostosis

Craniosynostosis refers to the premature fusion of one of the six major sutures of the cranial vault. Functionally, craniosynostosis may be defined as the premature conversion of the dynamic region of growth and resorption between two adjacent bones of the cranium into a static region of bony union. Molecular analysis has blurred the traditional categories of nonsyndromic and syndromic synostosis to some extent, but, in general, the distinctions between the two groups still hold true. The complexity of the congenital anomalies may be limited with the former, whereas the latter usually requires reoperations and correction of the facial skeleton. This article briefly outlines the characteristic deformities produced from nonsyndromic craniosynostosis. Various approaches to surgical correction of the deformities are described. Finally, new biomaterials that are used in the correction of nonsyndromic craniosynostosis are reviewed.

Extrinsic cerebral venous sinus obstruction resulting in intracranial hypertension

We report the case of a 70-year-old man reporting with headache and visual disturbances who was being treated for prostate cancer. Investigations showed him to have intracranial hypertension caused by venous sinus obstruction. Patients with metastatic disease and raised intracranial pressure in the absence of focal signs should be considered as possible cases of venous outflow obstruction.

Idiopathic intracranial hypertension: a case report with optic nerve histopathology

We present the clinical and pathologic findings in an atypical case of idiopathic intracranial hypertension. A 51-year-old man had headaches, visual deterioration, papilloedema, and deafness. Neuroimaging was normal, and cerebrospinal fluid pressure monitoring confirmed increased intracranial pressure. The patient was treated with a ventriculo-peritoneal shunt. Histopathology revealed grossly atrophic optic nerves with almost complete axonal loss. The prelaminar portion of the optic nerves was thickened by gliosis and hyalinized capillaries, which have not been described previously.

Cranial vault deformity and intracranial hypertension secondary to cephalic molding at delivery: a case and its management

Cephalic molding at birth has been traditionally felt to be benign, resulting in only a transient and self-correcting cranial deformity. However, we report a 6-month-old infant who presented with extensive cephalic molding at birth in combination with persistent brachyturricephaly from unilateral coronal synostosis and occipital deformation. Helmet therapy over a 3-month period failed despite patient compliance and numerous adjustments. Intracranial hypertension developed, as documented by multiple occipital bony erosions on computed tomographic scan and by an elevated direct intracranial pressure reading. The cranial vault asymmetry was corrected in two surgical stages: (1) occipital bar advancement, temporoparietal bone remodeling, and midline sagittal strip compression to reduce vertical height, followed in 3 months by (2) fronto-orbital advancement and remodeling.

[Clinical experience with the Sp[hy adjustable valve in the treatment of adult hydrocephalus. A series of 147 cases]

OBJECTIVE

Evaluate the advantages, results and drawbacks of the Sophy adjustable valve (SV) in the treatment of hydrocephalus in the adult.

MATERIAL AND METHODS

One-hundred and forty-seven adult hydrocephalic patients (mean age = 64.5 years) shunted with a SV between 1990 and 1997 were retrospectively reviewed. Etiologies of hydrocephalus were: "normal pressure" chronic hydrocephalus (NPH) in 124 and tumoral hydrocephalus with intracranial hypertension in 23 patients. One-hundred fifty shunts were established in 147 patients: 14 ventriculoatrial and 136 ventriculoperitoneal shunts. The initial pressure settings of the SV were: high pressure: 12 times (8%), medium pressure: 136 times (90.6%) and low pressure: 2 times (1.3%).

RESULTS

Sixteen patients were lost to follow-up. Two patients died within hours following the procedure. So, the results were analyzed in the 129 remaining patients, with a follow-up of 16.7 months (+/- 17.8). Three patients died from shunted-related causes (2.3%). Eighty-four patients had good results (65%), 25 had fair results (19.5%) and 20 failed to improve or deteriorated (15.5%) after shunting. Fifty-three reoperations were performed in 44 patients (34%), including 37 procedures for mechanical obstruction and 6 for septic complications. Subdural effusions (SDE) occurred in 16 patients (12.5%): 10 surgical evacuations were required in 7 patients; 8 patients were successfully treated using uprating of the SV pressure alone; one was managed conservatively. Fifty-eight pressure readjustments were performed in 47 patients. The pressure settings were uprated 28 times in patients showing clinical or computerized tomographic (CT) features suggesting overdrainage; 20 of those proved to be successful (71.5%). The pressure settings were lowered 30 times in patients showing a lack of improvement after shunting, attributed to underdrainage; only 12 of those proved to be successful (40%). Spontaneous changes of the pressure settings were observed in 14 patients (10.8%). After a MRI exposure, SV pressure changes were observed in 64% of patients.

DISCUSSION

The technological refinements that have been proposed to eliminate the overdrainage which occurs in most usual cerebrospinal fluid shunts are reviewed. The SV valve has allowed non-invasive adjustments of its opening pressure in patients showing complications ascribed to inappropriate drainage. The need for additional surgery was eliminated in 20% to 25% of patients of the present series. Because of frequent spontaneous and magnetic resonance-induced pressure changes, the need for repeated controls of valve pressure is to be reemphasized.

CONCLUSION

This experience suggests that the SV represents a substantial improvement over standard fixed-pressure valves.

Endovascular recanalization with balloon angioplasty and stenting of an occluded occipital sinus for treatment of intracranial venous hypertension: technical case report

OBJECTIVE AND IMPORTANCE

Dural sinus thrombosis can lead to intracranial venous hypertension and can be complicated by intracranial hemorrhage. We present a case report of a patient who underwent endovascular recanalization and stenting of a thrombosed occipital sinus.

CLINICAL PRESENTATION

A 13-year-old patient with a history of chronic sinus thrombosis refractory to anticoagulant therapy presented with acute onset of aphasia and hemiparesis. Computed tomography and magnetic resonance imaging revealed hydrocephalus and cerebral edema. Angiography delineated multiple dural arteriovenous fistulae and persistent occlusion of the posterior sagittal, occipital, and bilateral transverse dural sinuses with retrograde cortical venous drainage.

INTERVENTION

After embolization of the dural arteriovenous fistulae, a transvenous approach was used to recanalize and perform balloon angioplasty of the right internal jugular vein and the occipital and left transverse sinuses, resulting in subsequent clinical improvement. The patient's condition deteriorated 3 days later with reocclusion of both balloon-dilated sinuses. Repeat angioplasty and then deployment of an endovascular stent in the occipital sinus were performed, and reestablishment of venous outflow was achieved, resulting in a decrease of intracranial venous pressure from 41 to 14 mm Hg and neurological improvement. At the 3-month follow-up examination, the stented occipital sinus remained patent and served as the only conduit for extracranial venous outflow; the patient remained neurologically intact at the 12-month follow-up examination.

CONCLUSION

This is the first report of mechanical recanalization, balloon angioplasty, and stent deployment in the occipital sinus to provide sustained venous outflow for the treatment of venous hypertension with retrograde cortical venous drainage in a patient with dural pansinus thrombosis refractory to anticoagulant therapy.

The contribution of macular changes to visual loss in benign intracranial hypertension

PURPOSE

To describe the significance of macular changes to visual outcome in benign intracranial hypertension (BIH).

METHOD

The clinical and photographic records of 24 patients with BIH who required optic nerve sheath fenestration were analysed.

RESULTS

Macular changes were found in 21 of 48 (44%) eyes. These were: choroidal folds 9; circumferential lines (Paton's lines) 4; nerve fibre layer haemorrhage 3; macular stars 5; macular oedema 6; retinal pigment epithelial changes 4; subretinal haemorrhage leading to a macular scar 1. Significant visual loss attributable to the macular changes was found in 5 eyes in the short term and 3 in the long term. The 2 eyes that improved had macular stars. Of the 3 eyes that did not improve, 2 eyes had retinal pigment epithelial changes and 1 a large subretinal haemorrhage that led to a macular scar. These 3 cases had long-standing BIH.

CONCLUSIONS

The majority of macular changes resolve and do not add to visual loss from optic nerve damage. Patients with marked macular oedema are at most risk of permanent visual loss and should be considered for early treatment such as optic nerve sheath fenestration.

[Follow-up monitoring with magnetic resonance tomography after decompressive trephining in experimental "malignant" hemispheric infarct]

Acute ischemia in the complete territory of the carotid or the middle cerebral artery may lead to cerebral edema with raised intracranial pressure and progression to coma and death. Although clinical data suggest benefit for patients undergoing decompressive surgery for massive space occupying hemispheric stroke, little data about the effects of this procedure on morbidity and outcome is available. The experimental data support an early surgical approach. For early and probably most effective treatment of severe, space-occupying cerebral ischemia, the "malignant" character of the brain edema has to be recognized early after onset of vessel occlusion. Hereby magnetic resonance imaging (MRI) may allow to determine the clinical significance of brain edema early after onset, simultaneously allowing to monitor the evolution of ischemia. We performed serial SE-MRI in rats with acute hemispheric infarctions treated by decompressive craniectomy. Focal cerebral ischemia was induced in 36 rats using an endovascular occlusion technique. Decompressive craniectomy was performed 4 and 24 hours after vessel occlusion in groups of 12 animals each. Twelve animals were not treated by decompressive craniectomy (control group). Four, 24, 48, 72 and 168 hours after MCAO all animals were examined with conventional T1- and T2-weighted SE-MRI. Shift of the midline structures and compression of the ventricles were scored. Changes in weight and neurological performance were measured daily. The infarction volume was calculated by triphenyltetrazolium chloride staining 168 hours after MCAO. While mortality in the untreated group was 33.3%, none of the animals treated by a decompressive craniectomy died (mortality 0%). Neurological behaviour, weight loss and infarction volume were significantly better in the animals treated by early decompressive craniectomy (p < 0.05). Four hours after MCAO all untreated animals showed a massive shift of the midline structures and a massive compression of the ventricles; only 7 of 12 animals treated early by craniectomy showed mild mass effects. Correlation of the histological brain damage with T2-weighted MRI 4 hours after MCAO was poor (r = 0.41); later than 24 hours there was a good correlation (r > 0.7). Our results suggest that decompressive craniectomy in malignant cerebral ischemia reduces mortality and significantly improves outcome. If performed early after vessel occlusion, it also significantly reduces infarction size. In the acute phase of hemispheric infarction conventional SE-MRI is not sensitive in estimation of infarction size. Later than 24 hours, conventinal SE-MRI proved to be useful in monitoring brain edema and infarction size in this rat model of malignant hemispheric stroke.

Relationship between intracranial pressure and the development of vasospasm after aneurysmal subarachnoid hemorrhage

The relationship between intracranial pressure (ICP) and the development of vasospasm after subarachnoid hemorrhage caused by the rupture of an intracranial aneurysm was investigated. Eleven patients were divided into high (6 cases) and low (5 cases) ICP groups based on ICP data obtained during the perioperative period by continuous ICP monitoring. Transcranial Doppler ultrasonography was performed every 24 hours for 7 days and the severity, distribution, and duration of vasospasm were assessed. The high ICP group tended to have severe, prolonged, and diffuse vasospasm compared with the low ICP group. However, only duration of vasospasm was statistically different. The relationship between cerebral perfusion pressure (CPP) and the development of vasospasm was also examined. CPP had a less significant effect than ICP although similar tendencies for high ICP and low CPP were observed. High ICP worsens vasospasm and treatment for decreasing ICP with perioperative ICP monitoring has potential for avoiding the development of vasospasm.

[Anesthesiologic neurosurgical management of bitemporal craniectomy in patients with excessively high intracranial pressure]

A therapy refractory brain edema is causally responsible for the death of approximately 50% of patients following severe craniocerebral trauma. The development of a brain edema which cannot be controlled by conservative means is also the most frequent cause of death with cerebral emergencies not caused by trauma. The cerebral perfusion pressure (CPP), which is the decisive factor for sufficient cerebral oxygenation, can be calculated on condition that the mean arterial pressure (MAP) and the intracranial pressure (ICP) are continually monitored: (CPP = MAP-ICP). On the basis of neurological observations, the computer tomographical results and the jugular vein oxymetry, an incipient cerebral decompensation and consequently the failure of the ongoing conservative treatment becomes apparent at an early stage. At this point at the latest, a bitemporal craniectomy should be considered for treatment. A drop in CPP to below 70 mmHg for adults and 50 mmHg for children is regarded as the intervention limits. Our experience shows that the outcome can be improved if the time of the bitemporal craniectomy lies before that of the cerebral decompensation.

Traumatic subdural pneumocephalus causing rise in intracranial pressure in the early phase of head trauma: report of two cases

This paper presents two unique cases of subdural tension pneumocephalus which has deteriorated in the early phase of head trauma. Subdural pneumocephalus accounts for about 25% of all intracranial pneumocephalus cases. In the literature subdural pneumocephalus is describes as a benign and spontaneously resolving condition. Contrary to the available literature and our experience in 1341 trauma cases in the past ten years of whom 76 had subdural pneumocephalus, both cases deteriorated in the early hours following head trauma due to an increase in subdural air volume which was evacuated by craniotomy.

Decompressive craniectomy in patients with uncontrollable intracranial hypertension

There has been controversial discussion about the benefits of decompressive craniectomy in patients with critically raised intracranial pressure (ICP) after severe head injury. The aim of this retrospective study was to analyze the results of secondary decompressive craniectomy in patients with uncontrollable raised ICP after maximum aggressive medical treatment. The data of 28 patients (mean age 22 years, range 8-44 years) with severe head injury and posttraumatic cerebral edema were analyzed retrospectively. Surgery was not indicated in patients with vast primary lesions, hypoxia, ischemic infarction, brainstem injuries and central herniation. The outcome was classified according to the Glascow Outcome Scale (GOS) after one year. The decompressive crainectomy was performed an average of 68 hours after trauma, and ICP (< 25 mm Hg) decreased always while cerebral perfusion pressure (CPP > 75 mm Hg) improved as well as cerebral blood flow and microcirculation to normal values. 15 patients (56%) had a good outcome after one year (GOS 4 + 5). 5 patients (18%) were severely disabled, 4 patients (14%) remained in vegetative state and 3 patients (11%) died. Decompressive craniectomy should be kept in mind as the last therapeutic step, especially in young patients with head injury and raised ICP, which is not controllable with conservative methods.

Post-craniectomy intracranial hypotension: potential impact on rehabilitation

More aggressive neurosurgical management of intractably elevated intracranial pressure has resulted in increased survival of severely brain injured patients, many of whom are transferred for inpatient rehabilitation status post-craniectomy. Positional headache due to intracranial hypotension has been described in the literature, but is rarely reported as a complicating factor for patients receiving rehabilitation therapies. Low cerebrospinal fluid (CSF) pressure symptoms include postural headache, vertigo, nausea, vomiting, visual symptoms, auditory symptoms, and rarely cognitive changes. This report describes a patient who sustained a severe traumatic brain injury requiring craniectomy for management of increased intracranial pressure who subsequently developed intracranial hypotension. One month post-craniectomy, she developed postural headaches with cognitive and functional decline, which significantly impaired her rehabilitation. Aggressive efforts at conservative management including hydration and empiric blood patch were unsuccessful. Once the bone flap was replaced, she made rapid and dramatic functional gains, with total resolution of headache. This paper hypothesizes that the mechanism of low CSF pressure after extensive craniectomy is related to loss of hydrostatic pressure following removal of the skull vault. In rehabilitation of severely brain injured patients with craniectomies, it is important to recognize and appropriately treat this syndrome to avoid compromising patient care and prolonging hospitalization.

["Paradoxical" herniation after decompressive trephining]

The intracranial space is divided into two large compartments by the tentorium. The hydrostatic pressure of spinal fluid is responsible for buoyancy of the brain within these compartments. In patients with craniectomy this equilibrium is exposed to atmospheric pressure. We report on four cases of reversible herniation after either bilateral or unilateral decompressive craniectomy performed for increased intracranial pressure (ICP) and failure of conservative ICP treatment. All four patients had survived a severe neurological disease (encephalitis, subdural haematoma, stroke) which required craniectomy to control raised ICP. All were successfully weaned from the ventilator and awake and CT scans showed no space-occupying lesion anymore. The patients showed a typical "sunken pattern" at the trepanation site. All patients developed clinical signs of transtentorial herniation (i.e. unilateral dilated pupils, deteriorated alertness, and extensor posturing) shortly after either diagnostic or presumed therapeutic lumbar puncture. One patient developed herniation a second time while in the typical 30 degrees upright position. After craniectomy, transtentorial herniation is possible even in the absence of increased ICP. It is related to a negative gradient between atmospheric and intracranial pressure, which is enhanced by changes in the CSF compartment following lumbar puncture. Lumbar puncture should be avoided if possible and, when necessary, only be performed in the head-down position. Acute therapy in these cases is quite simple; it requires flat or even head-down positioning and early cranioplasty.

The MRI appearance of the optic nerve sheath following fenestration for benign intracranial hypertension

Optic nerve fenestration is carried out in cases of severe benign intracranial hypertension. This study aimed to monitor the optic nerve sheath appearances and orbital changes that occur following this procedure. The eight patients were all female with an average age of 37.3 years and a range of 20-58 years. The duration of symptoms was 2-6 years. Symptoms included headaches, diplopia and visual obscurations. Examination revealed severe papilledema. All investigations, including MRI, biochemical and immunological tests, were negative. Patients had fenestration of a 2 mm x 3 mm segment of the medial aspect of the optic nerve sheath. Imaging was obtained with a 1 T MRI machine using a head coil. Coronal, axial and sagittal 3 mm contiguous sections using STIR sequences with TR 4900 ms, IT 150 ms and TE 60 ms were obtained. Five patients showed clinical improvement. The post-operative MRI findings in four of these included a decreased volume of cerebrospinal fluid (CSF) around the optic nerve sheaths and a localized collection of fluid within the orbit. There were no MRI changes in the three patients with no clinical improvement. Decreased CSF volume around the optic nerve and a fluid collection within the orbit may indicate a favorable outcome in optic nerve fenestration.

Severe optic disc edema without hydrocephalus in neurofibromatosis 2

A 26-year-old man who had neurofibromatosis type-2 with symptoms of unexplained optic disc edema is reported. Magnetic resonance imaging (MRI) revealed bilateral acoustic schwannomas. Obstructive hydrocephalus, however, was not evident in spite of his severe disc edema and visual loss. After partial removal of the right acoustic schwannoma, symptoms of intracranial hypertension, such as vomiting and headache, developed and MRI demonstrated evidence of obstructive hydrocephalus. Placement of a ventricular-peritoneal shunt relieved the symptoms of intracranial hypertension, but visual acuity in his left eye was reduced to hand motion due to secondary optic atrophy. In patients with similar symptoms it is suggested that, in addition to tumor removal, early treatment to decrease intracranial pressure should be considered when visual function is progressively impaired by the symptoms of prolonged papilledema.

Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow

OBJECTIVES

A retrospective study was carried out on 13 patients with intracranial dural arteriovenous fistulas (DAVFs) who presented with isolated or associated signs of intracranial hypertension.

METHODS

Nine patients presented with symptoms of intracranial hypertension at the time of diagnosis. Ocular fundoscopy available in 12 patients showed bilateral papilloedema in eight and optic disk atrophy in four. Clinical evolution was particularly noticeable in five patients because of chronic (two patients) or acute (after lumbar shunting or puncture: three patients, one death) tonsillar herniation.

RESULTS

Two patients had a type I fistula (drainage into a sinus, with a normal antegrade flow direction). The remaining 11 had type II fistulas (drainage into a sinus, with abnormal retrograde venous drainage into sinuses or cortical veins). Stenosis or thrombosis of the sinus(es) distal to the fistula was present in five patients. The cerebral venous drainage was abnormal in all patients.

CONCLUSION

Type II (and some type I) DAVFs may present as isolated intracranial hypertension mimicking benign intracranial hypertension. Normal cerebral angiography should be added as a fifth criterion of benign intracranial hypertension. The cerebral venous drainage pattern must be carefully studied by contralateral carotid and vertebral artery injections to correctly evaluate the impairment of the cerebral venous outflow. Lumbar CSF diversion (puncture or shunting) may induce acute tonsillar herniation and should be avoided absolutely. DAVF may induce intracranial hypertension, which has a poor long term prognosis and may lead to an important loss of visual acuity and chronic tonsillar herniation. Consequently, patients with intracranial hypertension must be treated, even aggressively, to obliterate the fistula or at least to reduce the arterial flow and to restore a normal cerebral venous drainage. The endovascular treatment may associate arterial or transvenous embolisation and/or surgery. Patients in whom the fistula is not obliterated after an endovascular therapeutic procedure, need continuous clinical and angiographical follow up.

Meningo-cortical calcifying angiomatosis and celiac disease

A woman with ophthalmic migraine was found to have bilateral cerebellar and cerebral calcifications. She progressively developed severe intracranial hypertension, with swelling of the brain and downward transtentorial and tonsillar herniation. Because steroid treatment was ineffective, the right occipital pole was resected. Histological study demonstrated meningo-cortical calcifying angiomatosis. Within 2 months, brain swelling and papilledema disappeared. Subtle signs of malabsorption led to the hypothesis of celiac disease, confirmed by jejunal biopsy. Similar cerebral histological findings have been reported in the brain of two young patients affected by epilepsy and celiac disease. The association between cerebral calcifications and celiac disease is peculiar; the pathogenetic relationship is unknown.

[Nephritis following shunt operation for hydrocephalus]

The ventriculo-atrial (VA) and ventriculo-peritoneal (VP) shunts implanted due to hypertensive hydrocephalus might get infected and be complicated by shunt nephritis. We reviewed the morphological changes in kidney retrospectively in the autopsy materials of our institute for the last 15 years after shunt implantation. Histological examination of the kidney was performed in 26 of these cases having 7 cases with glomerular morphological changes. Thus, the shunt nephritis is a relatively frequent complication of VA or VP shunts implanted due to hydrocephalus. Monitorization and follow-up of kidney function in case of any dysfunction of the shunt may suggest the possibility of shunt infection, and the removal of the infected shunt may protect the development of more severe, septic complications.

Stereotactic ventriculoperitoneal shunt for idiopathic intracranial hypertension: technical note

OBJECTIVE

Lumboperitoneal shunting is the bastion of neurosurgical management for idiopathic intracranial hypertension (IIH). However, recent studies document a high failure rate for this procedure. The present study was designed to explore the feasibility of placing ventriculoperitoneal shunts under stereotactic control into patients with IIH as an alternative to lumboperitoneal shunting.

METHODS

Seven patients with IIH for whom medical management had failed underwent stereotactic implantation of ventriculoperitoneal shunts.

RESULTS

Shunt placement was successful and uncomplicated in each case. Five of seven patients experienced complete resolution of papilledema. The remaining two patients showed resolving papilledema. Six of seven patients experienced resolution of headache. The remaining patient continued to have headaches despite a radionuclide study demonstrating normal shunt function.

CONCLUSION

Our results suggest that stereotactic ventriculoperitoneal shunting may be a reasonable alternative to lumboperitoneal shunting in those patients with IIH who require surgical intervention.