Preparation for Surgery for Slit Ventricle Syndrome in Children

Indications for Procedure

• Symptoms and signs of elevated ICP: Children with severe headache, vomiting, or bradycardia need admission for vital sign monitoring and neurological checks, as elevated ICP represents an urgent or emergent neurosurgical condition. It may be impossible to differentiate slit ventricle syndrome with a functional vs. non-functional (obstructed) shunt by imaging and history.
• Reprogram shunt: Hypotension symptoms can sometimes be managed in the outpatient setting with an adjustment of the programmable shunt to increase resistance.

Preoperative orders

• Steroids: Dexamethasone can temporize headache symptoms pending surgical intervention (optional).
• Antibiotic: Prophylactic cefazolin or vancomycin is advocated perioperatively for shunt surgery or ETV.
• Clamp time for CSF drain: Time varies by physician preference and the child’s condition. It is at least 1–2 hours before surgery with ICP monitoring while the clamp is in place.

Anesthetic Considerations

• See Hydrocephalus Chapter

Devices to Be Implanted

Possible equipment or devices needed:

• ICP monitor: A cranial access kit can be used to insert the monitor wire.
• Shunt material: Catheters and drainage bags for EVD(s) and the shunt valve of choice should be available.

Ancillary/Specialized Equipment

• Endoscope: An endoscope must be available for ETV or to remove a stuck ventricular catheter using low-power electrocautery. It is also needed for cyst or septal communication and if an endoscopic assisted proximal shunt revision is planned (see video of shunt revision with small ventricles).
• Neuronavigation: Intraoperative CT or MR navigation can be useful for entry into small ventricles or communication of complex cystic collections.
• Intraoperative ultrasound: Intraoperative ultrasound provides guidance for accessing small ventricles and assessing for intraoperative complications (i.e. hematoma).