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Fronto-orbital advancement as a treatment for recurrent VPS failure

Alyssa Brisbin, Lucas A. Dvoracek, Joseph E. Losee, Stephanie Greene, Jesse A. Goldstein
University of Pittsburgh Department of Plastic Surgery
2019-02-13

Presenter: Alyssa Brisbin

Affidavit:
I certify that the material proposed for presentation in this abstract has not been published in any scientific journal or previously presented at a major meeting. The program director is responsible for making a statement within the confines of the box below specific to how much of the work on this project represents the original work of the resident. All authors/submitters of each abstract should discuss this with their respective program director for accurate submission of information as well as the program director's approval for inclusion of his/her electronic signature.

Director Name: Vu Nguyen

Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: Craniomaxillofacial

Background
Ventriculoperitoneal shunt (VPS) placement is a common treatment for hydrocephalus. However, shunt failure often occurs, and can require multiple VPS revisions. We share our experience with a 6-year-old girl who underwent numerous VPS revisions before a fronto-orbital advancement cranial vault expansion was performed to improve ventricular compliance and eliminate the need for further VPS revisions.

Methods
A 4-year-old girl with a history of Dandy-Walker Malformation, recurrent seizures, and 12 VPS revisions presented to our clinic for evaluation. The patient was overall normocephalic, with mild retrusion of the supraorbital rims bilaterally, and posterior occipital flattening. A fronto-orbital advancement cranial vault expansion was performed electively in an attempt to avoid further shunt failure. A standard bicoronal approach was used and the bandeau was advanced bilaterally. An EVD was also placed at this time.

Results
Postoperatively, unsuccessful weaning of the EVD mandated the placement of a VPS. Following this, the patient was discharged without evidence of neurological deficits. At 18 months follow-up, the patient had not required further surgical revisions of her shunt, which is the single longest amount of time she has gone without a revision.

Conclusions
While cranial vault expansion has been used to prevent further shunt failure and manage elevated ICP in pediatric patients, these cases involved either syndromic or iatrogenic craniosynostosis, not patients who were overall normocephalic. In patients with a history of recurrent shunt failure, cranial vault expansion could be considered to improve compliance of the ventricles and reduce the need for VPS revision.

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