scholarly journals Intracranial pressure monitoring in pediatric and adult patients with hydrocephalus and tentative shunt failure: a single-center experience over 10 years in 146 patients

2015 ◽  
Vol 122 (5) ◽  
pp. 1076-1086 ◽  
Author(s):  
Terje Sæhle ◽  
Per Kristian Eide
Keyword(s):  
Intracranial Pressure ◽  
Adult Patients ◽  
Shunt Revision ◽  
Shunt Failure ◽  
Icp Monitoring ◽  
Shunt Valve ◽  
Single Center Experience ◽  
Study Population ◽  
The Mean ◽  
A Minor

OBJECT In patients with hydrocephalus and shunts, lasting symptoms such as headache and dizziness may be indicative of shunt failure, which may necessitate shunt revision. In cases of doubt, the authors monitor intracranial pressure (ICP) to determine the presence of over- or underdrainage of CSF to tailor management. In this study, the authors reviewed their experience of ICP monitoring in shunt failure. The aims of the study were to identify the complications and impact of ICP monitoring, as well as to determine the mean ICP and characteristics of the cardiac-induced ICP waves in pediatric versus adult over- and underdrainage. METHODS The study population included all pediatric and adult patients with hydrocephalus and shunts undergoing diagnostic ICP monitoring for tentative shunt failure during the 10-year period from 2002 to 2011. The patients were allocated into 3 groups depending on how they were managed following ICP monitoring: no drainage failure, overdrainage, or underdrainage. While patients with no drainage failure were managed conservatively without further actions, over- or underdrainage cases were managed with shunt revision or shunt valve adjustment. The ICP and ICP wave scores were determined from the continuous ICP waveforms. RESULTS The study population included 71 pediatric and 75 adult patients. There were no major complications related to ICP monitoring, but 1 patient was treated for a postoperative superficial wound infection and another experienced a minor bleed at the tip of the ICP sensor. Following ICP monitoring, shunt revision was performed in 74 (51%) of 146 patients, while valve adjustment was conducted in 17 (12%) and conservative measures without any actions in 55 (38%). Overdrainage was characterized by a higher percentage of episodes with negative mean ICP less than −5 to −10 mm Hg. The ICP wave scores, in particular the mean ICP wave amplitude (MWA), best differentiated underdrainage. Neither mean ICP nor MWA levels showed any significant association with age. CONCLUSIONS In this cohort of pediatric and adult patients with hydrocephalus and tentative shunt failure, the risk of ICP monitoring was very low, and helped the authors avoid shunt revision in 49% of the patients. Mean ICP best differentiated overdrainage, which was characterized by a higher percentage of episodes with negative mean ICP less than −5 to −10 mm Hg. Underdrainage was best characterized by elevated MWA values, indicative of impaired intracranial compliance.

MO291RITUXIMAB IS EFFECTIVE AND SAFE IN ADULTS WITH STEROID-DEPENDENT NEPHROTIC SYNDROME: A LONG-TERM, SINGLE-CENTER EXPERIENCE

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Gemma Patella ◽  
Alessandro Comi ◽  
Giuseppe Coppolino ◽  
Nicolino Comi ◽  
Giorgio Fuiano ◽  
...  
Keyword(s):  
Nephrotic Syndrome ◽  
Case Series ◽  
Adult Patients ◽  
Single Center ◽  
Single Center Experience ◽  
Steroid Dependent ◽  
The Mean ◽  
Steroid Dependent Nephrotic Syndrome

Abstract Background and Aims Steroid-dependent nephrotic syndrome (SDNS) may require a prolonged multi-drug therapy with risk of drug toxicity and renal failure. Rituximab (RTX) treatment has been found to be helpful in reducing the steroid dosage and the need for immunosuppressants (ISs), but little data are currently available regarding very long-term outcomes in adults. We herein describe a long-term, single-center experience of RTX use in a large series of adults with SDNS. Method We studied 23 adult patients with SDNS (mean age 54.2±17.1 y; 65% male; BMI 28.5±4.7), mostly consequent to membranous (47.8%) or focal glomerulonephritis (30.2 %) who were eligible to start a RTX regimen. Before entering the RTX protocol, proteinuria and eGFR were 7.06±3.87 g/24h and 65.9±28.2 ml/min/1.73 m2, respectively; albumin and CD19/CD20 ratio were 2.9±0.9 g/L and 0.99±0.01 respectively; the mean number of ISs was 2.39±0.89 and the mean annual rate of relapses was 2.2±0.9. Results Patients were followed over a mean follow-up of 64 months (range: 12-144). After RTX (mean dose: 1202.1±372.4 mg) the rate of relapses was virtually nullified (p<0.001). eGFR remained roughly stable (62.1±19.8 ml/min/1.73 m2, p=NS), while proteinuria, albumin, CD19/CD20 and BMI all significantly improved (p ranging from 0.01 to 0.001). The mean number of additional ISs was also reduced (0.44±0.12; p<0.001) and RTX enabled discontinuation of steroids in 13/23 (56.5%) patients. No major adverse events related to therapy were recorded. Conclusion Findings from this large case-series with a remarkable very long follow-up reinforce the role of RTX as an efficient and safe weapon to improve outcomes in adult patients suffering from SDNS.

Management of Adult Hydrocephalus With Ventriculoperitoneal Shunts: Long-term Single-Institution Experience

Neurosurgery ◽  
2011 ◽  
Vol 69 (4) ◽  
pp. 774-781 ◽  
Author(s):  
G Kesava Reddy ◽  
Papireddy Bollam ◽  
Runhua Shi ◽  
Bharat Guthikonda ◽  
Anil Nanda
Keyword(s):  
Median Time ◽  
Adult Patients ◽  
Shunt Revision ◽  
Shunt Failure ◽  
Single Institution ◽  
Ventriculoperitoneal Shunts ◽  
Shunt Placement ◽  
Ventriculoperitoneal Shunting

Abstract BACKGROUND: Ventriculoperitoneal shunting is the most widely used neurosurgical procedure for the management of hydrocephalus. OBJECTIVE: To evaluate our long-term single-institution experience in the management of adult hydrocephalus patients with ventriculoperitoneal shunts. METHODS: Adult patients who underwent ventriculoperitoneal shunt placement for hydrocephalus from October 1990 to October 2009 were included. Medical charts, operative reports, imaging studies, and clinical follow-up evaluations were reviewed and analyzed retrospectively for clinical outcome in adult hydrocephalus patients. RESULTS: A total of 683 adult patients were included in the study. The most common etiologies of hydrocephalus include idiopathic (29%), tumors and cysts (20%), postcraniotomy (13%), and subarachnoid hemorrhage (13%). The overall shunt failure rate was 32%, and the majority (74%) of shunt revisions occurred within the first 6 months. The median time to first shunt revision was 9.31 months. Etiology of hydrocephalus showed a significant impact on the incidence of shunt revision/failure and on the median time to shunt revision. Similarly, the type of hydrocephalus had a significant effect on the incidence of shunt failure and the median time to shunt revision. CONCLUSION: A large proportion of patients (32%) experience shunt failure after shunt placement for hydrocephalus. Although the overall incidence of shunt revision was comparable to previously reported studies, the fact that a large proportion of adult populations with shunt placement experience shunt failure is a concern.

Simultaneous measurements of intracranial pressure parameters in the epidural space and in brain parenchyma in patients with hydrocephalus

2010 ◽  
Vol 113 (6) ◽  
pp. 1317-1325 ◽  
Author(s):  
Per Kristian Eide ◽  
Wilhelm Sorteberg
Keyword(s):  
Intracranial Pressure ◽  
Epidural Space ◽  
Pulse Pressure ◽  
Brain Parenchyma ◽  
Pressure Amplitude ◽  
Icp Monitoring ◽  
Simultaneous Measurements ◽  
Pulsatile Pressure ◽  
The Mean ◽  
The Brain

Object In this study, the authors compare simultaneous measurements of static and pulsatile pressure parameters in the epidural space and brain parenchyma of hydrocephalic patients. Methods Simultaneous intracranial pressure (ICP) signals from the epidural space (ICPEPI) and the brain parenchyma (ICPPAR) were compared in 12 patients undergoing continuous ICP monitoring as part of their diagnostic workup for hydrocephalus. The static ICP was characterized by mean ICP and the frequency of B waves quantified in the time domain, while the pulsatile ICP was determined from the cardiac beat–induced single ICP waves and expressed by the ICP pulse pressure amplitude (dP) and latency (dT; that is, rise time). Results The 12 patients underwent a median of 22.5 hours (range 5.9–24.8 hours) of ICP monitoring. Considering the total recording period of each patient, the mean ICP (static ICP) differed between the 2 compartments by ≥ 5 mm Hg in 8 patients (67%) and by ≥ 10 mm Hg in 4 patients (33%). In contrast, for every patient the ICP pulse pressure readings from the 2 compartments showed near-identical results. Consequently, when sorting patients to shunt/no shunt treatment according to pulsatile ICP values, selection was independent of sensor placement. The frequency of B waves also compared well between the 2 compartments. Conclusions The pulsatile ICP is measured with equal confidence from the ICPEPI and ICPPAR signals. When using the pulsatile ICP for evaluation of hydrocephalic patients, valid measurements may thus be obtained from pressure monitoring in the epidural space. Recorded differences in the mean ICP between the epidural space and the brain parenchyma are best explained by differences in the zero setting of different sensors.

Investigating shunt function using continuous intracranial pressure monitoring in adults: single center experience

2010 ◽  
Vol 113 (6) ◽  
pp. 1326-1330 ◽  
Author(s):  
Ahmed K. Toma ◽  
Andrew Tarnaris ◽  
Neil D. Kitchen ◽  
Laurence D. Watkins
Keyword(s):  
High Pressure ◽  
Intracranial Pressure ◽  
Medical Treatment ◽  
Shunt Malfunction ◽  
Icp Monitoring ◽  
Single Center ◽  
Pressure Monitoring ◽  
Surgical Exploration ◽  
Ventriculoperitoneal Shunts ◽  
Single Center Experience

Object Managing symptomatic ventriculoperitoneal shunts with no clear evidence of shunt malfunction either clinically or radiologically can be a difficult task. The aim of this study was to assess intracranial pressure (ICP) monitoring as a method of investigating shunt function. Methods The authors performed a retrospective analysis of 38 continuous ICP monitoring procedures done in patients with ventriculoperitoneal shunts and suspected shunt malfunction. Results Thirty-eight procedures were performed in 31 patients between January 2005 and October 2008. Sixteen recordings were normal, 6 revealed overdrainage or low pressure, 11 indicated underdrainage or high pressure, and 5 showed variable shunt function. Based on the findings after 20 procedures (53%), patients were treated conservatively: 4 by readjusting the valve setting and 16 by referral to the headache neurologist for medical treatment. Forty-five percent of the conservatively treated patients improved. Surgical exploration was undertaken following 18 procedures (47%); 72% of the surgically treated patients improved. Conclusions Continuous ICP monitoring using an intraparenchymal probe is a safe and effective method of investigating adult hydrocephalus.

scholarly journals Continuous intracranial pressure monitoring via the shunt reservoir to assess suspected shunt malfunction in adults with hydrocephalus

2007 ◽  
Vol 22 (4) ◽  
pp. 1-6 ◽  
Author(s):  
Romergryko G. Geocadin ◽  
Panayiotis N. Varelas ◽  
Daniele Rigamonti ◽  
Michael A. Williams
Keyword(s):  
Intracranial Pressure ◽  
Medical Therapy ◽  
Shunt Malfunction ◽  
Shunt Revision ◽  
Symptom Improvement ◽  
Icp Monitoring ◽  
Pressure Monitoring ◽  
Shunt System ◽  
Vp Shunt

Object The authors attempted to determine whether continuous intracrnial pressure monitoring via the shunt resevoir identifies ventriculoperitoneal (VP) shunt malfunctions that are not identified by radionuclide shunt patency study or shunt tap in adults with hydrocephalus. Methods During a 2-year period, 26 adults underwent 32 in-hospital continuous intracranial pressure (ICP) monitoring evaluations via needle access of a shunt reservoir. Monitoring was performed for 26.8 ± 13.8 hours (mean ± standard deviation). No ICP waveform abnormality was detected in 31% of the evaluations (10 of 32). In contrast, abnormalities were detected in 69% (22 of 32 evaluations), including B waves (nine of 22 evaluations), siphoning (nine of 22 evaluations), and variable ICP (two of 22 evaluations). In 20 (91%) of these 22 evaluations, the ICP abnormality was detected only after continuous ICP monitoring; in the other two evaluations, ICP became abnormal immediately on accessing the shunt reservoir. On the basis of the ICP monitoring results, shunt revision was performed in 66% (21 of 32 evaluations) and medical therapy was administered in 34% (11 of 32 evaluations). Shunt revision led to symptom improvement in 82% (18 of 22 patients) and no change in 18% (four of 22 patients); medical therapy led to improvement in 18% (two of 11 patients), worsening in 18% (two of 11 patients), and no change in 64% (seven of 11 patients; p < 0.05). Conclusions Continuous ICP monitoring via the shunt reservoir provides a more accurate assessment of shunt malfunction than transient ICP monitoring with a shunt tap or a radionuclide shunt patency study. It is a safe method for evaluating patients with suspected VP shunt malfunction, provides in vivo assessment of the effect of the shunt system on a patient's ICP, and can lead to more effective shunt revision.

Intracranial Pressure during Wakefulness and Sleep in 55 Adult Patients with Chronic Hydrocephalus

Neurosurgery ◽  
2006 ◽  
Vol 59 (2) ◽  
pp. 326-332 ◽  
Author(s):  
Hannes Stephensen ◽  
Magnus Tisell ◽  
Carsten Wikkelsö
Keyword(s):  
Surgical Treatment ◽  
Intracranial Pressure ◽  
Clinical Symptoms ◽  
Adult Patients ◽  
Communicating Hydrocephalus ◽  
Sitting Position ◽  
Chronic Hydrocephalus ◽  
Continuous Scale ◽  
Noncommunicating Hydrocephalus ◽  
The Mean

Abstract OBJECTIVE: To record the levels of intracranial pressure (ICP) during wakefulness and sleep in hydrocephalic adults and to correlate the ICP levels with symptoms and degree of improvement after surgical treatment. METHODS: ICP and patient behavior were registered overnight (17–26 h) in 29 patients with noncommunicating and 26 with communicating hydrocephalus. Mean ICP was calculated during wakefulness (sitting or lying supine) and during sleep. Clinical symptoms and changes after surgery were scored on a continuous scale. RESULTS: Mean ICP during sleep was 13.4 mmHg (11.1–15.7 mmHg) in noncommunicating hydrocephalus versus 10.1 mmHg (8.8–11.4 mmHg) in communicating hydrocephalus (P &lt; 0.001). Patients with idiopathic communicating hydrocephalus had higher ICP, 11.4 mmHg (9.9–12.9 mmHg), than patients with secondary communicating hydrocephalus, 8.6 mmHg (6.5–10.6 mmHg). ICP was higher during sleep than when the patients were awake lying supine, 10.9 mmHg (8.7–13.1 mmHg) in noncommunicating versus 6.8 mmHg (5.3–8.3 mmHg) in communicating hydrocephalus (P &lt; 0.0001). The mean ICP in the sitting position was 2.4 mmHg (0.5–4.3 mmHg) in noncommunicating versus 0.5 mmHg (-0.7–1.8 mmHg) in communicating hydrocephalus. All but one patient with communicating hydrocephalus had a normal ICP (≤ 15 mmHg) versus 20 of the 29 patients with noncommunicating hydrocephalus. ICP levels showed no correlation with either symptoms or improvement after surgery. CONCLUSION: ICP is higher during sleep than during periods of awake lying supine (P &lt; 0.001) and is not correlated with either symptoms or the rate of improvement after surgery. ICP is normal in most adults with hydrocephalus.

A 12-year single-center retrospective analysis of antisiphon devices to prevent proximal ventricular shunt obstruction for hydrocephalus

2019 ◽  
Vol 24 (6) ◽  
pp. 642-651
Author(s):  
Joyce Koueik ◽  
Mark R. Kraemer ◽  
David Hsu ◽  
Elias Rizk ◽  
Ryan Zea ◽  
...  
Keyword(s):  
Shunt Revision ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Shunt System ◽  
Shunt Valve ◽  
Catheter Obstruction ◽  
Before And After ◽  
Observational Cohort ◽  
Shunt Obstruction

OBJECTIVERecent evidence points to gravity-dependent chronic shunt overdrainage as a significant, if not leading, cause of proximal shunt failure. Yet, shunt overdrainage or siphoning persists despite innovations in valve technology. The authors examined the effectiveness of adding resistance to flow in shunt systems via antisiphon devices (ASDs) in preventing proximal shunt obstruction.METHODSA retrospective observational cohort study was completed on patients who had an ASD (or additional valve) added to their shunt system between 2004 and 2016. Detailed clinical, radiographic, and surgical findings were examined. Shunt failure rates were compared before and after ASD addition.RESULTSSeventy-eight patients with shunted hydrocephalus were treated with placement of an ASD several centimeters distal to the primary valve. The records of 12 of these patients were analyzed separately due to a complex shunt revision history (i.e., > 10 lifetime shunt revisions). The authors found that adding an ASD decreased the 1-year ventricular catheter obstruction rates in the “simple” and “complex” groups by 67.3% and 75.8%, respectively, and the 5-year rates by 43.3% and 65.6%, respectively. The main long-term ASD complication was ASD removal for presumed valve pressure intolerance in 5 patients.CONCLUSIONSUsing an ASD may result in significant reductions in ventricular catheter shunt obstruction rates. If confirmed with prospective studies, this observation would lend further evidence that chronic shunt overdrainage is a central cause of shunt malfunction, and provide pilot data to establish clinical and laboratory studies that assess optimal ASD type, number, and position, and eventually develop shunt valve systems that are altogether resistant to siphoning.

scholarly journals Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

2015 ◽  
Vol 122 (1) ◽  
pp. 202-210 ◽  
Author(s):  
Halinder S. Mangat ◽  
Ya-Lin Chiu ◽  
Linda M. Gerber ◽  
Marjan Alimi ◽  
Jamshid Ghajar ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Mortality Rate ◽  
Hypertonic Saline ◽  
New York State ◽  
Mortality Rates ◽  
Icp Monitoring ◽  
Severe Tbi ◽  
The Mean

OBJECT Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. METHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. RESULTS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). CONCLUSIONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.

scholarly journals Population Pharmacokinetics of Vancomycin in Adult Patients with Long Bones’ Fractures

2019 ◽  
Vol 0 (0) ◽  
Author(s):  
Jasmina Milovanovic ◽  
Radica Živković Zaric ◽  
Nikola Rosic ◽  
Dejana Ruzić Zecevic ◽  
Dragan Milovanovic ◽  
...  
Keyword(s):  
Bone Fractures ◽  
Laboratory Data ◽  
Compartment Model ◽  
Adult Patients ◽  
Population Pharmacokinetic ◽  
Final Model ◽  
Two Compartment Model ◽  
Daily Dose ◽  
Study Population ◽  
The Mean

Abstract Vancomycin is a tricyclic glycopeptide antibiotic, mostly used in the treatment of severe staphylococcal and enterococcal infections, especially in orthopedic surgery. The purpose of this analysis was to develop a population pharmacokinetic (PPK) model of vancomycine in hospitalized patients with bone fractures and identify important factors which influence its clearance (CL). A total of ninety-nine measurements of vancomycin serum concentrations were used in our population modeling. A two-compartment model was applied to describe the pharmacokinetics of vancomycin using subroutines ADVAN3 and TRANS4. The study population included patients of both sexes, with the mean age of 62.12±14.69 years and body weight of 80.32±12.44kg. Vancomycin was administered as intravenous infusion with average daily dose of 1772.73±521.34mg. Out of twenty different factors evaluated in the study (including demographic, clinical and laboratory data), only daily dose of vancomycin (DD) and co-medication with piperacillin/tazobactam (PT) showed significant effect on clearance of vancomycin. The final model was described by the following equation: CL (l/h) = 0.03 + 0.000468 x DD + 0.675 x PT. Bootstrapping was used for validation of the final model. In conclusion, the main causes of variability in the clearance of vancomycin among adult patients with bone fractures are daily dose of vancomycin and co-medication with piperacillin/tazobactam.

scholarly journals Intraoperative Measurement of Intracranial Pressure During Cranial Vault Remodeling in Children with Craniosynostosis

2022 ◽  
Author(s):  
Sonia Bansal ◽  
Subhas Konar ◽  
Dhaval Shukla ◽  
Dwarakanath Srinivas ◽  
Vishram Pandey ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Intraoperative Monitoring ◽  
External Ventricular Drainage ◽  
Cranial Vault ◽  
Icp Monitoring ◽  
Height Reduction ◽  
Csf Diversion ◽  
The Mean ◽  
Entire Procedure ◽  
Cranial Vault Remodeling

Abstract Purpose In this study, we analyzed the utility of intracranial pressure (ICP) monitoring intraoperatively for deciding height reduction and need for cerebrospinal fluid (CSF) diversion during cranial vault remodeling in children with multisutural craniosynostosis (CS). Methods This is a retrospective observational study of children who underwent surgery for CS and ICP monitoring during surgery. The ICP was monitored using an external ventricular drainage catheter. The ICP monitoring was continued during the entire procedure. Results A total of 28 (19 boys) children with the involvement of two or more sutures underwent ICP monitoring during surgery. The commonest pattern of suture involvement was bicoronal seen in 16 (57.1%) children followed by pancraniosynostoses in eight (28.6%) cases. The mean opening ICP was 23 mm Hg, which dropped to 10.9 mm Hg after craniotomy. The ICP increased transiently to 19.5 mm Hg after height reduction, and the mean ICP at closure was 16.2 mm Hg. The ICP recordings helped in undoing the height reduction in two children and ventriculoperitoneal shunt after surgery in two children. Conclusions Intraoperative monitoring of ICP helps in deciding the type of cranial vault remodeling and the need for CSF diversion after surgery.

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