Dynamic Chess-Table Cranial Expansion for Treatment of Craniocerebral Disproportion: Technical Note and Volumetric Results

Endoscopy-Assisted Craniosynostosis Surgery without Postoperative Helmet Molding Therapy

OBJECTIVE

Endoscopy-assisted craniosynostosis surgery (EACS) yields excellent surgical outcomes by minimizing blood loss, operative time, and hospital stays. Postoperative helmet therapy (PHT), commonly employed for head shape correction, involves frequent adjustments, potential complications, and high costs. Given the rising cost of helmet therapy, reduced insurance coverage, and limited availability in low- and middle-income countries, understanding success rates without helmet use is crucial. The present study analyses the anthropometric results of the first EACS series without PHT.

METHODS

A retrospective analysis of a single-center series involving 90 consecutive patients who underwent EACS without PHT from 2012 to 2022 was conducted, with a follow-up exceeding 3 years. The study exclusively included patients with nonsyndromic isolated sagittal synostosis, with 33 meeting the criteria. Craniometric measurements were obtained from preoperative, 1-year postoperative, and the latest computed tomography scans. For isolated sagittal synostosis cases, the cephalic index (CI) was calculated (CI >75 for excellent results, CI 70-75 for good results, and <70 for poor results). Collected data encompassed patient sex, age, and follow-up time.

RESULTS

The mean age was 84.8 ± 45.3 days (2.79 ± 1.49 months) within a range of 3-172 days. The preoperative mean CI was 68 ± 42, increasing to 76 ± 6 1 year postoperatively (mean difference +8 ± 6.3; P = 0.0001). Seventy-one percent of patients achieved excellent results, 23% good (CI = 70-75), and 6% poor. Reintervention was unnecessary.

CONCLUSIONS

EACS without PHT demonstrates favorable anthropometric results, cost reduction, and simplified postoperative management.

Cranial expansion and aqueductoplasty for combined isolated fourth ventricle and slit-ventricle syndrome: a surgical alternative

INTRODUCTION

An isolated fourth ventricle (IFV) is a rare entity observed in shunted patients and its treatment is still uncertain. Endoscopic aqueductoplasty has shown good results for restoring CSF flux between the third and fourth ventricles. However, it needs some grade of ventricular dilation to be performed. Some patients affected by IFV show slit-ventricle morphology in CT/MRI. Usually, the rise of opening pressure or the shunt externalization gets enough ventricular dilation. However, the lack of intracranial compliance in some patients makes these options unsuitable and high-ICP symptoms are developed without ventricular dilation.

METHODS

We present a two cases series affected by IFV with no ventricular dilation in radiological exams. ICP sensors were implanted, observing high-ICP and establishing the diagnosis of craniocerebral disproportion. A two-stage surgical plan based on a dynamic cranial expansion followed by a supratentorial endoscopic aqueductoplasty was performed. A physical and mathematical model explaining our approach was also provided.

RESULTS

Chess-table cranial expansion technique was performed in both patients. Six/seven days after the first surgery, respectively, ventricular dilation was observed in CT. Endoscopic precoronal aqueductoplasty was then performed. No postoperative complications were described. IFV symptoms improved in both patients. Eighteen and 12 months after the two-stage surgical plan, the patients remain symptom-free and void of flow is still observed between the third and the fourth ventricles in MRI.

CONCLUSION

The two-stage approach was a suitable option for the treatment of these complex patients affected by both craniocerebral disproportion and isolated fourth ventricle.