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.

[Dopplerographic assessment of the autoregulation of the blood supply to the brain in neurosurgical pathology]

The development of an informative, noninvasive technique for evaluating the reserve of the cerebral circulatory system is a topical task of clinical angioneurology. The authors developed methods of Doppler evaluation of an autoregulatory response from hyperemic changes after short-term regional hypotension caused by digital compression of the cervical carotid. They calculated the indices acceptable in routine clinical practice, defined the range of their values in health and in typical variants of cerebral circulatory insufficiency in patients with disseminated neurosurgical pathology. The carotid compression test by recording linear blood flow velocity in the cerebral arteries is a safe, valid, and reproducible method of semiquantitative assessment of the autoregulation reserve which may be used to determine the tension of resistive vessels in the middle cerebral arterial bed as an important index of the functional status of the cerebral circulatory system.

Surgical treatment of benign intracranial hypertension--subtemporal decompression revisited

BACKGROUND

Subtemporal decompression, first advocated by Dandy for the treatment of benign intracranial hypertension or pseudotumor cerebri, has been replaced as a treatment mainstay by medical management using diuretics, steroids, and lumbar puncture. Failure of these forms of treatment has frequently led to insertion of cerebrospinal fluid shunts.

METHODS

We have retrospectively reviewed the long term outcome of eight patients who were treated by subtemporal decompression (STD) for classical presentations of refractory benign intracranial hypertension. The follow-up period ranged from 8 to 26 years.

RESULTS

Within 1 month of STD, deterioration in visual fields and acuity resolved in all eight patients. Five of eight patients required CSF diversion procedures after subtemporal decompression to control headaches. No patient experienced recurrent permanent visual deterioration after STD.

CONCLUSION

STD may be the most effective treatment in both long and short term follow-up to provide lasting relief and prevention of visual morbidity caused by refractory benign intracranial hypertension.

Posterior fossa tumors in children--indications for ventricular drainage and for V-P shunting

A clinical analysis of 95 patients with posterior fossa tumors treated in the Department of Neurosurgery of the Medical University in Gdansk over a period of 16 years (1979-1995) is presented. The following preoperative factors were studied: localization, size and suspected type of tumor, size of the ventricular system, and presence or absence of the "halo" symptom. The indications for ventricular drainage (Fisher) versus V-P shunting as a preliminary treatment are discussed. Finally, the advantages of each of these procedures are emphasized.

[Measuring epidural intracranial pressure in patients with severe craniocerebral trauma]

In 30 patients with severe head injury (SHI), intracranial pressure (ICP) was monitored using epidural transducers. In 22 patients, the measurements were reliable, with average values of 19.4 mmHg in the survivors and 64.6 mmHg in those who died. It is concluded that epidural measurement of ICP provides a helpful method for the management of SHI and to control the indication for CT scans.

Effects of weight loss on the course of idiopathic intracranial hypertension in women

OBJECTIVE

To determine the role of weight loss in the treatment of idiopathic intracranial hypertension (IIH) in obese women.

METHODS

Chart review of 250 patients with suspected IIH revealed 58 women who met our criteria, did not undergo early surgical intervention, and had adequate documentation of visual status, papilledema, and weight at the baseline evaluation and at 6 months or longer. Patients were divided into two groups based on whether weight loss > or = 2.5 kg occurred during any 3-month interval. Papilledema grade, visual acuity, and visual field grade at 6 months or longer and the time to improve each were recorded.

RESULTS

Mean time in months to improve one grade for papilledema and visual field in one eye was 4.0 versus 6.7 (p = 0.013) and 4.6 versus 12.2 (p = 0.032), respectively, for the 38 patients with weight loss compared with the 20 patients with no weight loss. Papilledema resolved in 28/38 with weight loss (mean, 7.6 months) and 8/20 without weight loss (mean, 10.2 months; p = 0.352). There were no differences in final visual acuity or visual field between the two groups, but the papilledema grade was slightly better in the worst eye in each patient at baseline in the weight loss group (p = 0.03).

CONCLUSIONS

Weight reduction is associated with more rapid recovery of both papilledema and visual field dysfunction in patients with IIH compared with those who do not lose weight.

Controlled external lumbar drain as treatment for therapy resistant intracranial hypertension--case report

We report the case of an eleven year old male with a history of severe head injury who had manifested high intracranial pressure refractory to aggressive medical therapy, including ventriculostomy, controlled hyperventilation, mannitol and barbiturate application. The insertion of an external lumbar drain in this patient resulted in rapid permanent control of the intracranial hypertension. No transtentorial or tonsillar herniation occurred.

Ventricular shunt removal: the ultimate treatment of the slit ventricle syndrome

OBJECT

The aim of this study was to assess the effectiveness of an algorithm used to evaluate and prescribe treatment for patients having slit ventricle syndrome (SVS).

METHODS

All patients included in this protocol underwent fiberoptic intracranial pressure monitoring after removal or externalization of their ventricular shunt systems. A significant number of patients did not need extracranial cerebrospinal fluid (CSF) diversion and tolerated removal of their shunt systems without requiring further intervention. Patients who demonstrated a need for CSF drainage underwent an endoscopic third ventriculostomy, regardless of the putative cause of their hydrocephalus. Sixteen (72.7%) of 22 patients experienced resolution of or significant improvement in their SVS complaints after their inclusion in the protocol. Concomitantly, 14 (64%) of 22 patients were no longer shunt dependent after a mean follow-up period of 21.4 months.

CONCLUSIONS

A significant number of patients debilitated by SVS may experience improvement in their symptoms and undergo shunt removal according to this protocol, improving their quality of life and simplifying their medical follow up.

Multiple suture synostosis and increased intracranial pressure following repair of single suture, nonsyndromal craniosynostosis

OBJECTIVE

Increased intracranial pressure, frequently associated with closure of multiple cranial sutures, has been reported to occur in 36% of cases following correction of syndromal craniosynostosis. Although much less common, multiple suture closure may occur following repair of single suture, nonsyndromal craniosynostosis and we present cases that concern two such children.

RESULTS

Two children with nonsyndromal craniosynostosis, one metopic and one left-coronal, underwent fronto-orbital advancement at age 3 months. At age 19 months and at age 5 years, respectively, both patients re-presented with headaches, decrease in head circumference percentile, and acceptable cosmetic outcome. Both had computerized tomographic evidence of multiple closed cranial sutures and increased intracranial pressure (ICP) (determined by monitoring). Both patients improved following a cranial expansion procedure.

CONCLUSION

Delayed closure of multiple sutures and resultant increased ICP may occur following correction of nonsyndromal, single suture craniosynostosis. This may be more likely when the initial suture is contiguous with the facial sutures. Children should be followed for many years following craniosynostosis repair with cranial, neurologic, and possibly funduscopic examinations as well as head circumference measurements to detect delayed closure of cranial sutures.

Use of cerebrospinal fluid shunts in patients having acquired immunodeficiency syndrome with cryptococcal meningitis and uncontrollable intracranial hypertension

OBJECTIVE

To evaluate the treatment of serious and uncontrollable intracranial hypertension in patients with acquired immunodeficiency syndrome who developed cryptococcal meningitis.

METHODS

All cases of cryptococcal meningitis with elevated pressure and acquired immunodeficiency syndrome were reviewed in detail and described.

RESULTS

Cerebrospinal fluid shunting dramatically improved these critically ill patients and was much more successful than serial lumbar punctures or the use of high-dose dexamethasone.

CONCLUSION

Patients with acquired immunodeficiency syndrome who develop cryptococcal meningitis and who suffer serious visual loss or ocular palsies with elevated pressures should be considered for cerebrospinal fluid shunting at an early stage.

Combined use of stereotactic aspiration and intracerebral streptokinase infusion in the surgical treatment of hypertensive intracerebral hemorrhage

Stereotactic aspiration is well known for its simplicity and safety in the surgical treatment of hypertensive intracerebral hemorrhage. Postoperative fibrinolytic infusion with urokinase or recombinant tissue plasminogen activator and drainage of liquified hematoma are often used to improve the removal of hematoma. We evaluated the safety and effectiveness of streptokinase in this treatment modality in patients with hypertensive intracerebral hemorrhage or cerebellar hemorrhage. Twelve patients with hypertensive intracerebral hemorrhage underwent stereotactic aspiration using streptokinase as a fibrinolytic agent. There were six cases of putaminal hemorrhage, three of thalamic hemorrhage, and three of cerebellar hemorrhage. All but one patient had a large hematoma and presented with intracranial hypertension. Stereotactic aspiration was undertaken to remove the hematoma. Postoperatively, streptokinase was infused into the residual hematoma every 6 to 12 hours via a catheter implanted during the operation. Liquified hematoma was aspirated by syringe manually just before each infusion of streptokinase. The average duration of the entire treatment was 6 days (range 1-7). The residual hematoma at the end of treatment was less than 10 mL in all patients. Intracranial hypertension also subsided significantly in all patients. Only one patient had aspiration-induced bleeding during the operation. We conclude that stereotactic aspiration of hypertensive intracerebral hemorrhage is relatively safe and simple. Streptokinase can be infused intracerebrally to drain residual hematoma without severe side-effects.

Favorable visual outcome in cryptococcal meningitis

PURPOSE

To describe an unusual, favorable visual outcome in a patient with lupus erythematosus and cryptococcal meningitis and to present bilateral superior oblique muscle paresis.

METHODS

Case report. A 15-year-old girl with lupus erythematosus and cryptococcal meningitis had bilateral superior oblique paresis, bilateral optic nerve head swelling, and increased intracranial pressure. She developed a visual acuity of no light perception in the right eye.

RESULTS

Treatment with oral fluconazole, acetazolamide, and dexamethasone, as well as repeated lumbar punctures to reduce intracranial pressure, was followed by recovery to a visual acuity of 20/20 in both eyes and normal ocular motility.

CONCLUSION

With appropriate treatment, visual loss associated with cryptococcal meningitis may have a favorable outcome.

Arachnoid cyst rupture producing subdural hygroma and intracranial hypertension: case reports

OBJECTIVE

To analyze the association between arachnoid cysts and subdural hygromas.

METHODS

We reviewed five cases of arachnoid cysts that ruptured, producing acute subdural hygromas. The surgical management and diagnostic methods used are assessed.

RESULTS

Five male patients ranging in age from 6 to 25 years sustained the rupture of arachnoid cysts, which produced acute subdural hygromas. Four of the patients had incurred blunt head trauma. All patients presented with symptoms referable to intracranial hypertension. The pathognomonic features of a middle fossa arachnoid cyst (MFAC) were noted on the computed tomographic scans and/or magnetic resonance images of each patient. The hygroma exerted mass effect on the ipsilateral hemisphere and was noted to be under significant pressure at the time of surgical intervention in each case. Two of the five cases are unique in the literature. In one, a coexisting quadrigeminal cyst ruptured, producing a subdural hygroma ipsilateral to the MFAC and dilating the basal cisterns. In the other, the MFAC ruptured into the basal cisterns as well as into the subdural space. The MFAC in each of the remaining three patients ruptured into the subdural space alone. All patients were treated with drainage of the subdural space. In the two patients in whom the basal cisterns were involved, both the hygromas and the MFACs failed to change significantly in size. The hygromas resolved completely and the MFACs decreased in size considerably in the three patients without cisternal involvement.

CONCLUSION

The rupture of an arachnoid cyst can produce a subdural hygroma and intracranial hypertension. The latter mandates emergent drainage of the subdural space. In patients in whom the basal cisterns are not dilated by cyst rupture, both the MFACs and hygromas resolve after subdural drainage.

[Endoscopic ventriculostomy in the treatment of obstructive forms of hydrocephalus]

Third ventriculostomy creating a pathway for the CSF from the third ventricle to the interpeduncular cistern is a rational and sound alternative to the implantation of the shunting system, including Torkildsen shunts in managing obstructive hydrocephalus. Twenty four patients with hydrocephalus aged from 6 to 46 (mean 21 year) were operated. In 20 patients the occlusion was caused by small tumors in the aqueduct area, in 4 cases the occlusion was due to non-neoplastic process. In the majority of cases (19 patients) third ventriculostomy was the first operation for hydrocephalus. A rigid ventriculoscope (K. Storz, Germany) with an external diameter of 6 mm was used in all procedures. In 23 patients a rapid clinical improvement was observed along with resolution of intracranial hypertension. Median follow-up of 7 months duration was possible in 18 cases. 16 patients remain stable with no signs of hydrocephalus. Control MRI studies showed patent ventriculostomy. 5 patients after an endoscopic procedure were treated with irradiation for tumors. In 2 patients the opening in the ventricular floor fused and became nonfunctional. It happened 4 months after fenestration followed by surgical removal of tumors of the pineal region which caused occlusion. Complications were observed in 2 cases. In one patient ventriculitis developed shortly after the procedure and resolved completely by the end of the second postoperative week. Another patient was noted to have signs of transitory moderate diabetes insipidus.

Consequences of cranial vault expansion surgery for craniosynostosis

Remodelling the cranial vault in an attempt to increase the intracranial volume and thus control intracranial hypertension, whilst at the same time improving the patient's appearance, has been the mainstay of surgery for syndromic craniosynostosis. We report a case of craniosynostosis in whom cranial vault expansion was followed by the development of hind-brain herniation and hydrocephalus. This prompted a review of our other cases of craniosynostosis who had been evaluated by magnetic resonance imaging following surgery in order to assess the frequency of hind-brain herniation and hydrocephalus in these children. Magnetic resonance imaging had been performed in the postoperative evaluation of 34 cases of craniosynostosis who had undergone procedures intended to increase the intracranial volume. The position of the cerebellar tonsils and the presence or otherwise of hydrocephalus was recorded for all cases. The effectiveness of surgery in treating raised intracranial pressure (ICP) was evaluated by means of postoperative ICP monitoring and had been performed in 22 cases. Herniation of the hind-brain below the level of the foramen magnum was observed in 18 cases (53%). Hydrocephalus, requiring the insertion of a ventriculoperitoneal shunt, was present in 14 cases (41%) and had developed after the cranial vault procedure in 9. The mean sleeping ICP measured postoperatively was normal (<10 mm Hg) in 5, borderline (10-15) in 7, and raised (>15 mm Hg) in 10 cases. Cranial vault expansion in complex craniosynostosis may fail to address the underlying aetiology of intracranial hypertension. Furthermore, both hydrocephalus and hind-brain herniation may develop following such surgery. Neither the increase in intracranial volume afforded by cranial vault expansion nor the shunting of hydrocephalus precludes the persistence of abnormal ICP. These findings are discussed in the light of possible mechanisms, in addition to cephalocranial disproportion responsible for intracranial hypertension in complex craniosynostosis. The implications for the surgical management of complex craniosynostosis are reviewed.

Jugular foraminal stenosis in Crouzon syndrome

We describe a 4-year-old boy with Crouzon syndrome, with associated acanthosis nigricans and Chiari-I malformation, who developed increased intracranial pressure necessitating posterior cranial expansion. Postoperatively, an arteriovenous fistula appeared over the mastoid region. Cerebral angiography demonstrated bilateral atresia of the jugular veins and occlusion of the left sigmoid and right transverse sinuses. We propose that increased intracranial venous pressure, secondary to bilateral jugular foraminal stenosis, caused hydrocephaly and venous dilation in the scalp vasculature. The latter set the stage for a traumatic arteriovenous fistula of the scalp, probably resulting from laceration of an adjacent artery and vein. Jugular atresia is a basilar malformation common to achondroplasia and certain eponymous syndromic craniosynostoses. Our patient has a mutation in fibroblast growth factor receptor 3, a different locus in the same gene mutated in achondroplasia.