• Zoltan Mencser, Zsolt Kopniczky, David Kis, and Pal Barzo.
• Department of Neurosurgery, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary. Electronic address: mencser67@gmail.com.
• World Neurosurg. 2019 Oct 1; 130: 493-498.

BackgroundSymptomatic slit ventricle is one of the most challenging complications of shunt surgery in children. Clinical signs and symptoms may appear with a wide range of intracranial pressure (ICP) values. We report the case of a 10-year-old girl, who did not present the classic clinical features of extremely elevated ICP, which was proven by multiple invasive ICP recordings, performed during shunt revisions.Case DescriptionAt the age of 6 months, the patient presented squeal for many hours, accompanied with sunset eyes, bulging anterior fontanel, and dilated ventricles of all 4 ventricles on computed tomography scan. Acute ventriculoperitoneal shunt insertion was performed with adjustable valve. During the following 9 years, she was regularly seen and medically treated for intermittent headache, with nausea and vomiting. From 9 years of age, she was hospitalized for severe (10/10 on the visual analog scale), unbearable headache, agitation, and screaming on multiple occasions. Altogether, we had to revise the shunt system 5 times throughout 1 year. Radiologic imaging always showed narrow ventricles. Ophthalmologic examination of the fundus never revealed signs of raised ICP. Perioperative monitoring of the ICP with intraparenchymal sensor showed unexpected high values of 40-45 mm Hg. However, repetitive shunt revisions were successful only temporarily because the symptoms always returned. Only bilateral shunting of the ventricular system was able to eliminate the symptoms permanently.ConclusionsImages of slit ventricle can be associated either with low or extremely high ICP needing urgent surgical consideration, including ICP monitoring. Bilateral shunt insertion can be effective treatment for slit ventricle syndrome.Copyright © 2019 Elsevier Inc. All rights reserved.

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