See the corresponding article in this issue, pp 332337.

J Neurosurg (4 Suppl Pediatrics) 107:330331, 2007

Editorial Vault reduction cranioplasty

TAE SUNG PARK, M.D.
Department of Neurosurgery, St. Louis Childrens Hospital, Washington University, St. Louis, Missouri

In this issue, Mathews and colleagues provide an excellent historical review of cranial vault reduction for severe hydrocephalic macrocephaly. This review follows their recent report on a series of four patients published in the Journal of Craniofacial Surgery.2 Overall, I agree with their statements, but it would be appropriate to reiterate some unique aspects of this rarely utilized surgery. The most important is that the operation is indeed a very extensive procedure for small children and carries with it serious risks, including the risk of death. Thus the operation should be limited to young children who suffer extreme hydrocephalus and present great difficulties in care due to gigantic head size. When recommending the procedure for a child, surgeons must be sure that the childs parents understand that infants with extreme hydrocephalus can have surprisingly good cognitive and motor development and that reduction cranioplasty involves risk of injury to brain tissue. With respect to surgical techniques and patient positioning, the modified prone position is a good alternative because it allows for exposure of the entire vault and a onestage operation.1 Blood loss during surgery is a potentially lethal complication, and the main source of bleeding is the calvaria. To reduce blood loss during surgery, one should leave the pericranium attached to the calvaria, and the bone flaps should be removed in large pieces. There are significant limitations of the procedure that deserve particular emphasis. The operation can reduce only the cranial vault but not the skull base. Thus the anteroposterior diameter is not reduced at all, and the skull base remains elongated. While reducing the cranial vault, it may be necessary to plicate the dura over the anterior fossa, entailing the danger of occlusion of the sagittal sinus and consequent venous infarct. The brain can become infolded as the calvaria is reduced, thus causing additional brain injury. Moreover, removal of a large volume of cerebrospinal fluid is necessary to achieve the vault reduction, and shunt function must be closely monitored postoperatively. I commend the authors for providing a detailed compar330

ison of different cranial reduction procedures heretofore reported. This review article will be an excellent reference for many years.
References 1. Park TS, Grady MS, Persing JA, Delashaw JB: One-stage reduction cranioplasty for macrocephaly associated with advanced hydrocephalus. Neurosurgery 17:506509, 1985 2. Sundine MJ, Wirth GA, Brenner KA, Loudon WG, Muhonen MG, Greene CS, et al: Cranial vault reduction cranioplasty in children with hydrocephalic macrocephaly. J Craniofac Surg 17: 645655, 2006

RESPONSE: Dr. Parks points are well taken. We completely concur with his recommendation of restricting total vault reconstruction to only the most extreme cases; the surgery is a major undertaking requiring prolonged surgical stress and risks of intraoperative and perioperative complications, as well as significant hospital stays and use of resources. We have been fortunate in our experience to have thus far avoided significant negative consequences, including death (especially during our earlier experiences), but we discuss these potential outcomes fully with parents on different occasions in the sincere effort to obtain truly informed consent. With the assistance of members of the physical therapy, occupational therapy, and neuropsychology departments, we are monitoring our patients progress following surgery in order to more objectively define a population that reaps concrete benefits from vault reconstruction. Dr. Park offers excellent advice concerning hemostasis, our primary concern during this long surgery. Intraoperative blood loss is meticulously monitored, and the same care is applied to serial measurement of intraoperative and postoperative hematocrit and coagulation parameters. The postoperative measurements are important because a significant amount of blood may be lost through the surgical drains during the first 48 hours after surgery. With multiple
J. Neurosurg: Pediatrics / Volume 107 / October, 2007

Editorial
surgeons operating simultaneously, sustained vigilance and aggressive management of even minor bleeding can translate into significant reductions in blood loss. Planning for redundant dura mater is undertaken during reconstruction. Dural plication and attachment to recontoured skull is performed with care to avoid potential compression of the sagittal or transverse sinuses or the confluence of sinuses. We completely agree that recognition of potential intracranial pressure issues is extremely important. We routinely externalize the ventriculoperitoneal shunt at the time of vault reconstruction to soften the brain. In many cases, we recommend replacing the shunt during a second surgical procedure, which allows for the safety benefit of controlled cerebrospinal fluid diversion during the initial recovery period. Although it requires significant time expenditure, we have had positive experience addressing the anteroposterior diameter by removing and reconstructing the anterior skull up to and including the orbits and by removing all occipital bone and opening the aspect of the foramen magnum. In summary, with appropriate planning, participation of team members from multiple specialties, and appropriate education of patients and their parents, total vault reconstruction can be safely performed and can result in excellent outcomes, albeit with much effort! (DOI: 10.3171/PED-07/10/330)
MARLON S. MATHEWS, M.D. University of California, Irvine Irvine, California WILLIAM G. LOUDON, M.D., PH.D. Neurosciences Institute Childrens Hospital of Orange County Orange, California

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