Surgical management of raised ICP in craniosynostosis: experience-based selection of posterior vault expansion techniques

Abstract

Objective: To evaluate outcomes of three posterior vault expansion (PVE) techniques in children with craniosynostosis and confirmed raised intracranial pressure (ICP) and propose a practical framework to guide surgical technique selection based on patient-specific characteristics. Methods: We retrospectively analyzed 116 pediatric patients who underwent their first PVE for confirmed raised ICP between January 2018 and January 2024 at a tertiary craniofacial center. Patients underwent one of three surgical techniques: static remodeling (PVE-S), spring-assisted posterior vault expansion-classic (SAPVE-C), or spring-assisted posterior vault expansion-vertical vector (SAPVE-VV). Outcomes included functional improvement (fundoscopy, VEPs, symptoms, Chiari I), volumetric change in intracranial volume (ICV), operative time, transfusion rates, complications, and reoperation-free survival. Analyses were stratified by age and syndromic diagnosis. Results: All techniques significantly improved functional markers, with complete resolution of papilledema and normalized VEPs in over 80% of patients. SAPVE-C and SAPVE-VV achieved greater increases in ICV compared to PVE-S (18.9% and 17.2% vs. 12.7%, respectively). SAPVE-C was fastest (mean 138 min), followed by SAPVE-VV (174.7 min) and PVE-S (214.5 min). Transfusion rates were highest in SAPVE-C (64.1%) and SAPVE-VV (60.5%). Reoperation occurred in 11.2% of patients, with significantly higher risk in those operated before age 1 (p = 0.04). Age-stratified outcomes revealed SAPVE-C achieved the highest volumetric gain in < 2 years, while SAPVE-VV was most effective in older patients. Conclusions: Each PVE technique offers distinct advantages. SAPVE-C is optimal for syndromic infants, SAPVE-VV provides volumetric control in complex cases across ages, and PVE-S remains effective for older, non-syndromic patients. A tailored, age- and diagnosis-based selection strategy is essential for optimizing outcomes in craniosynostosis-related raised ICP.