Case reportOverdrainage after ventriculoperitoneal shunting in a patient with a wide depressed skull bone defect: The effect of atmospheric pressure gradient

•Postoperative hydrocephalus is a frequent complication requiring cerebrospinal fluid (CSF) diversion. It is so complicated in the patient who had a wide decompressive craniectomy.•We herein emphasize the efficacy of VP shunting, supine bed rest and cranioplasty in treating hydrocephalus patients who have undergone craniectomy.•The gravitational effect and the atmospheric pressure gradient effect are two factors associated in the treatment of hydrocephalus for the patient who had decompressive craniectomy. These effects can be eliminated by supine bed rest and cranioplasty.

IntroductionIn patients with traumatic brain injury, an effective approach for managing refractory intracranial hypertension is wide decompressive craniectomy. Postoperative hydrocephalus is a frequent complication requiring cerebrospinal fluid (CSF) diversion.Presentation of caseA 50-year-old male who underwent decompressive craniectomy after traumatic brain injury. He developed hydrocephalus postoperatively, and accordingly we placed a ventriculoperitoneal shunt. However, an imbalance between the intra- and extra-cranial atmospheric pressures led to overdrainage, and he suffered cognitive disorders and extremity weakness. He remained supine for 5 days to avoid the effect of gravity on CSF diversion. After 20 days, we performed a cranioplasty using a titanium plate. The postoperative course was uneventful, and the patient achieved satisfactory recovery.DisccusionThe gravitational effect and the atmospheric pressure gradient effect are two factors associated in the ventriculoperitoneal (VP) shunt treatment of hydrocephalus for the patient who had decompressive craniectomy. These effects can be eliminated by supine bed rest and cranioplasty.ConclusionWe herein emphasize the efficacy of VP shunt, supine bed rest and cranioplasty in treating hydrocephalus patients who have undergone craniectomy. A flexible application of these procedures to change the gravitational effect and the atmospheric pressure gradient effect should promote a favorable outcome.