Sub-Periosteal Shunt Valve Insertion to Overcome Shunt Exposure Risks in Predisposed Pediatric Age Group

Abstract Background: Shunting procedure still represents the backbone for the treatment of hydrocephalus. To have an exposed shunt is a nightmare every neurosurgeon wish to avoid encountering in his career. However pediatric patients with hydrocephalus are a predisposed category for this com-plication, possessing friable and delicate skin, larger head size with added skin stresses on pressure points, occasionally malnourished or premature, all of which can lead to or accel-erate the process. Objective: The aim of this study is to address the technique of the pericranial flap and the sub-pericranial shunt valve placement in the pediatric hydrocephalic patients predisposed to shunt exposure due to friable skin in an attempt to overcome this serious complication. Methods: This study was done prospectively in the Cairo University hospitals, on pediatric patients suffering from hydrocephalus including 40 patients treated between January 2018 and January 2020, having predisposing factors for shunt exposure,operated upon by the technique of elevating a pericra-nial flap and the sub-pericranial shunt valve placement. Results: Out of the 40 patient included in the study, none of the cases developed any breakdown of skin or liability for exposure, with viable and healthy skin flaps, all cases had good wound healing, most of the cases requiring shunt insertion do so in the 1st 6 monhts of age, congenital hydrocephalus (60%) was the main etiology for shunt insertion followed by post infection & post-hemorrhagic etiology, most of the cases (80%) were below weight for age, 3 cases (7.5%) of cases developed shunt malfunctioning requiring revision (2 proximal, 1 distal), 2 cases (5%) had mild superficial wound infection resolved afterward, none of the cases developed Cerebrospinal Fluid (CSF) leak. Conclusion: Sub-periosteal shunt reservoir placement is simple, easy, non-time consuming, yet was very effective in reducing the nightmare of shunt exposure & CSF leak in predisposed malnourished or premature pediatric patient, abolishing the costly and exhausting need for reoperation and shunt transfer or skin grafting and risks of CSF infection.