Shunt Exposure Research Articles

Aqueous shunt exposure repair: outcomes and risk factors for recurrence.

To investigate the outcomes of aqueous shunt exposure repair and to identify risk factors for recurrent exposure after surgical repair. This is a retrospective interventional case series of consecutive patients who underwent repair of an exposed aqueous shunt. Demographic and clinical data were extracted from the patients' records and survival analysis was employed to determine the probability of survival of the repair without further exposure. Cox proportional regression analysis was utilised to identify potential risk factors for failure of the repair surgery. Seventy-six eyes of 76 patients were included in the study. The probability of survival without further exposure was 76.2% (CI 66.9-86.8%), 72.7% (CI 62.8-84.1%) and 54.7% (40.5-73.7%) at 1,2 and 4 years, respectively. No eye in which the tube was repositioned in the anterior chamber or in the sulcus (n = 9; 11.8%) developed a recurrence of the exposure. A shorter interval from the time of tube insertion to the repair surgery (HR 2.87 [CI 1.11-7.39]; p = 0.03; reference longer interval), a history of previous surgical revision (HR 3.06 [1.15-8.12]; p = 0.02; reference no prior revision) and the use of a human pericardial donor patch at the time of revision (HR 3.43 [1.16-10.13]; p = 0.03; reference other than pericardium) was associated with an increased risk of exposure recurrence. Aqueous shunt exposure revision is associated with reasonable mid and long term success. A shorter interval from tube insertion to exposure revision, previous revisions and the use of a human pericardium patch were associated with increased risk of failure.

Patent ductus arteriosus management in very-low-birth-weight prematurity: a place for an early operation?

The goal was to evaluate neonatal outcomes based on treatment strategies and time points for haemodynamically significant patent ductus arteriosus (hsPDA) in very-low-birth-weight preterm infants, with a particular focus on surgical closure. This retrospective study included very-low-birth-weight infants born between 2014 and 2021 who received active treatment for hsPDA. Neonatal outcomes were compared between (i) primary surgical closure versus primary ibuprofen; (ii) early (<14th post-natal day) versus late primary surgical closure (≥14th post-natal day); and (iii) primary versus secondary surgical closure after ibuprofen failure. Further analysis using 1:1 propensity score matching was performed. Logistic regression was conducted to analyse the risk factors for post-ligation cardiac syndrome (PLCS) and/or acute kidney injury (AKI). A total of 145 infants with hsPDA underwent active treatment for closure. The in-hospital death rate and the incidence of severe bronchopulmonary dysplasia (BPD) were similar between the primary surgical closure group and the primary ibuprofen group in a 1:1 matched analysis. Severe BPD was significantly higher in the late surgical closure group than in the early primary surgical closure group with 1:1 propensity score matching (72.7% vs 40.9%, P=0.033). The secondary surgical closure group showed the mildest clinical condition; however, the probability of PLCS/AKI was highest (38.6%) compared to the early (15.2%) or the late primary surgical group (28.1%, P<0.001), especially in extremely premature infants (gestational age < 28 weeks). Surgical patent ductus arteriosus closure is not inferior to pharmacologic treatment. Considering the harmful effect of a prolonged patent ductus arteriosus shunt exposure, a timely decision and timely efforts should be made to minimize the risk of severe BPD and PLCS/AKI after surgical closure.

Exposure to persistent hemodynamically significant patent ductus arteriosus is associated with retinopathy of prematurity

BackgroundHemodynamically significant patent ductus arteriosus (hsPDA) shunt may predispose infants to retinopathy of prematurity (ROP) because of its higher preductal cardiac output and blood oxygen content, which may augment ocular oxygen delivery. MethodsA retrospective cohort study of preterm infants, born at <27 weeks’ gestation and admitted at <24h postnatal age to a large quaternary referral was conducted. The primary composite outcome was death at <32 weeks or moderate-to-severe ROP (≥stage 2 or requiring treatment) in either eye. Secondary outcomes included ROP requiring treatment, and any ROP. Univariate analysis of patient characteristics and outcomes was performed as well as logistic regression. A receiver operating characteristics curve was generated for the outcome of ROP ≥stage 2 or requiring treatment. ResultsA total of 91 patients were screened, of whom 86 (54 hsPDA, 32 controls) were eligible for inclusion. hsPDA patients were younger and lighter at birth and had a higher burden of hyperglycemia and respiratory illness. The rates of the composite outcome (death <32 weeks or moderate-to-severe ROP) and of any ROP were more frequent in the hsPDA group. hsPDA shunt exposure was independently associated with development of any ROP among survivors to assessment (P = 0.006). PDA cumulative exposure score of 78 (clinical equivalent = 7 days high-volume shunt exposure) predicts moderate-to-severe ROP with 80% sensitivity and 78% specificity. ConclusionsAmong infants <27 weeks, hsPDA shunt is associated with increased risks of a composite outcome of death or moderate-to-severe ROP, as well as ROP of any stage. Shunt modulation as a strategy to reduce ROP represents a biologically plausible avenue for investigation.

Approaches to ventriculoperitoneal shunt scalp erosion: countersinking into the calvarium. Illustrative case.

Ventriculoperitoneal shunting (VPS) is a standard procedure for the treatment of hydrocephalus, and the management of its complications is common in the practice of pediatric neurosurgery. Shunt exposure, though a rare complication, can occur because of thin, fragile skin, a young patient age, protuberant hardware, poor scalp perfusion, and a multitude of other patient factors. The authors report a complex case of VPS erosion through the scalp in a young female with Pfeiffer syndrome treated with external ventricular drainage, empirical antibiotics, and reinternalization with countersinking of replaced shunt hardware into the calvarium to prevent internal skin pressure points, reduce wound tension, and allow wound healing. Recessing the shunt hardware, or countersinking the implant, into the calvarium is a simple technique often used in functional neurosurgical implantation surgeries, providing a safe surgical strategy to optimize wound healing in select cases in which the skin flap is unfavorable.

Managing Ventriculoperitoneal Shunt Exposure in Adult Patients: Surgical Options and Implant Removal Prevention

Ventriculoperitoneal (VP) shunt exposure is rare. Small series reporting on managing this complication mainly focus on the pediatric population, where wound breaks over cerebrospinal fluid (CSF) chambers are observed most frequently. However, case series on adult patients are missing. Between June 2004 and December 2019, 18 patients underwent VP shunt revision due to implant exposure. Pertinent data were retrospectively collected from the hospital database. Their full clinical history, laboratory values, neuroradiological imaging, pretreatment CSF characteristics, photographic and video material, and surgery types were reviewed. The ventricular catheter was exposed in 8 patients (the frontal region in 6 and the occipital region in 2), the valve chamber at the retroauricular region in 6, the shunt tube in 7 (at the neck in 4, the supraclavicular region in 2, and the abdominal incision in 1). Multiple exposure sites were found in 2 cases. Two patients with CSF infections benefitted from system removal and temporary external ventricular drainage until infection control was achieved. The remaining 16 patients underwent on-ward revision (wound curettage, skin mobilisation, and resuture over the exposed part of the shunt), which was effective in 14 patients, but further revision was required in 2 patients. While rare, VP shunt exposure is a serious complication. In our experience, a prompt and accurate on-ward revision could save the implant in most patients without CSF infections.

Ventriculoperitoneal shunt surgery in a Nigerian city

Introduction. Improvements in surgical techniques and advancements in antibiotic management have significantly reduced the complications associated with Ventriculoperitoneal Shunting which is still the most common procedure for the treatment of hydrocephalus. These complications are believed to be highest in Low and middle-income countries due to delayed presentation to care facilities. The authors report our experience of managing paediatric hydrocephalus in an institution with evolving Neurosurgical practice in North Central Nigeria. Material and methods. We retrospectively reviewed all cases of VP shunting from 2011 to 2018 taking into consideration the demographics, aetiologies of hydrocephalus, length of hospital stay, postoperative morbidity and mortality, and overall outcome. Complications sought included, Surgical Site infections, shunt exposure, obstruction or any other cause of shunt malfunction. The minimum follow-up period was 24 months Results. There were 27 VPS procedures done in 25 patients of whom 15 were males and 10 females (M:F ratio of 1.5:1). The age range was 8 days to 9 years with a median age of 5 months. Of the 25 cases, 24 (96%) were non-tumoral in origin comprising 17 congenital and 7 acquired hydrocephalus. At 2 years post shunt insertion, 21 (84%) of the 25 initial cases were still functional. The total complication rate was 28%, comprising Surgical Site infection, shunt exposure, shunt obstruction, seizure, and one death, There were 3 (12%) shunt failures from shunt obstruction (2) and shunt exposure (1). Conclusion With meticulous control of the surgical environment and improved experience in ventriculoperitoneal shunting, the complication rate can be significantly reduced. There is a need to increase the awareness of the population to the availability of care for seemingly hopeless conditions. The burden of the cost of care on individuals should be lightened through better health insurance coverage.

Ventriculosubgaleal shunt as a proposed technique for post-infectious hydrocephalus

BackgroundThe management of post-infectious hydrocephalus (PIH) remains challenging for neurosurgeons. It requires a temporary diversion procedure till the normalization of CSF parameters prior to the permanent one. Ventriculosubgaleal shunt (VSGS) was widely used in pediatric cases with post-hemorrhagic hydrocephalus (PHH). However, its role in PIH is still lacking. This study was done to elucidate the safety and efficacy of VSGS as a temporary CSF diversion procedure before the permanent one in patients with PIH.Patients and methodsThis retrospective investigation analyzed the data of 50 consecutive cases who underwent VSGS for PIH.ResultsThe age of the included patients ranged between 1 and 10 months. Twenty-six cases had meningitis and or ventriculitis (52%), while the remaining had shunt infection. At follow-up, arresting of hydrocephalus was noted in ten patients (20%), while another 36 cases required the permanent diversion procedure within 35 days. Regarding the shunt complications, scalp infection, tissue breakdown, and shunt exposure were encountered in ten cases (20%), while CSF leakage was noted in 12 cases (24%). Shunt migration was noted in only two patients (4%). Shunt revision was needed in 16 cases (32%). Mortality was encountered in four cases (8%) because of sepsis. Risk factors for morbimortality included younger age, lower weight, male gender, and meningitis and or ventriculitis.ConclusionVSGS is a safe and effective procedure in infants awaiting definitive VPS for postinfectious hydrocephalus. It was proven that VSGS has shortened the hospital stay and the economic burden on the country.

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.

Patent ductus arteriosus shunt elimination results in a reduction in adverse outcomes: a post hoc analysis of the PDA RCT cohort.

A post hoc appraisal of the PDA RCT to assess the relationship between early patent ductus arteriosus (PDA) shunt elimination and chronic lung disease or death (CLD/Death). Infants <29 weeks were divided into four groups: intervention arm in whom PDA closure was achieved (n = 17); intervention arm in whom PDA closure was not achieved (n = 13); placebo arm (n = 30); low risk infants (n = 13). The main outcome measure was CLD/Death. The rates of CLD/Death were lower in the Intervention Success Group (29%) when compared to the Intervention Failure Group (85%) or the Placebo Group (60%, all p < 0.05). There was no difference in CLD/Death between the Intervention Success and Low Risk Groups (8%, p > 0.05). A persistent PDA beyond Day 8 was associated with CLD/Death (aOR 6.5 [1.7-25.5]). Early shunt elimination in preterm infants with a PDA may reduce respiratory morbidity when compared to infants with prolonged shunt exposure.

Shunt exposure as a ventriculoperitoneal shunt complication: A case series

IntroductionShunting is a technique in neurosurgery for treating hydrocephalus. Shunting is an effective choice for both cases of obstructive or communicative hydrocephalus. However, in some rare cases, complications, such as exposed shunt, can occur. In this case series, the author discusses 6 cases of hydrocephalus patients with exposed shunts. The risk factors, diagnosis, and management of exposed VP shunt will be discussed further in this case series report. MethodsThis study was an analysis of all cases treated in a period of 1 year from January to December 2018 with an inclusion criterion of history of exposed shunt of any age group. This study is a single-centre retrospective report of the clinical presentation and radiology examination before and after treatment. Clinical and radiology evaluation were performed in immediate post procedural period. A detailed clinical examination was performed to look for exposed shunt complication. ResultsIn this series of studies 6 patients with hydrocephalus who had shunts were reported. All patients were pediatric patients. Six patients had exposed shunt on the scalp or abdomen. Radiological examinations including CT scan, chest X-ray or babygram were performed to evaluate the location of the shunt. The data reported was from January to December 2018 and there were 301 VP shunt installment cases. Management included surgical revisions and treatments to prevent further complications. ConclusionShunting is still a routine therapy in the field of neurosurgery, although other modalities such as endoscopic third ventriculostomy (ETV) have started to be performed more frequently. Complications such as exposed shunt are rare in the treatment of pediatrics with hydrocephalus. We presented that exposed shunt is a rare complication (2.3% incidence rate) which might be caused by certain risk factors, such as age of patient when the shunting was performed, and nutritional status. Early diagnosis and treatment are important to prevent further complications, especially infections. Subpericranial technique for shunt tunneling might be useful in preventing exposure of shunts with associated morbidity factors.

Cerebrospinal fluid contents and risk of shunt exposure in hydrocephalus

Background: Exposure of the shunt is a rare but severe complication after ventriculoperitoneal (VP) shunt placement. It is unclear whether particular levels of cerebrospinal fluids (CSF) protein, glucose, or polymorphonuclears (PMNs) may influence the shunt exposure in high-risk individuals.This study aims to find the relation between CSF parameters and shunt exposure.Methods: Examined preoperative CSF characteristics included CSF colour, protein, glucose, and PMNs content in 513 patients with hydrocephalus. Mann-Whitney test was used to determine the correlation between CSF parameters and shunt exposure.Results: Shunt exposure was detected in 25 cases (4.87%). There was a significant relationship between distal tip exposure with preoperative glucose (p=0.000), protein level (p=0.007), or PMNs count (p=0.043).Conclusion: Preoperative CSF contents had a significant correlation with shunt exposure in hydrocephalus patients.

Outcome Analysis of Patients of Congenital Hydrocephalus with Ventriculoperitoneal Shunt at a Tertiary Care Hospital in North India

Introduction: Ventriculoperitoneal (VP) shunt is a commonly performed neurosurgical procedure in pediatric surgical practice. This study is aimed at determining the outcome of congenital hydrocephalus patients who underwent shunt surgery at our center. Materials and Methods: A total of 278 operated cases of congenital hydrocephalus with a minimum follow-up of 6 months were analyzed in terms of complications. Hydrocephalus associated with intracranial hemorrhage, neural tube defects, and ventriculitis were excluded from the study. Results: Complications were observed in 32.0% (89/278) of cases. Shunt block and chamber migration were the most common complications (29.21%). Abdominal wound complications were seen in 4.49% of cases. Shunt exposure due to erosion of overlying skin was noted in 6 patients. Shunt infection was diagnosed in only 9 patients (4.4%). New-onset seizures were seen in 4 cases. Overall, 21% of patients required redo shunt and there were 2 mortalities. Conclusion: VP shunt continues to have high complication rates. Shunt migration and new-onset seizure disorders are important late complications. In spite of inherent problems, shunt surgery is the procedure of choice until a safer effective alternative is available.

Management of exposed ventriculoperitoneal shunt on the scalp in pediatric patients.

The exposure of a ventriculoperitoneal shunt on the scalp is a serious complication. There are limited studies evaluating this complication's management in the literature. The aim of this study is to define the management of shunt salvage and the reconstruction of the scalp. This retrospective study included seven pediatric patients with ventriculoperitoneal shunts that were exposed on the scalp for various reasons. The demographic characteristics of the patients and the medical and surgical treatments used were recorded. The patient follow-up durations and complications associated with these methods were determined. Four female and three male patients with an average age of 5.7 were followed for an average of 9.4months. All but one of these patients were treated without removing the shunt. While one skin flap was used in one patient, successful repairs were made with double skin flaps in five patients. There were no complications during follow-up for the patients treated with these methods. In this study, the appropriate management of shunt exposure, which is common in pediatric cases, has been revealed. Given appropriate infection prevention, the reconstruction of the scalp is possible without the removal of the shunt.

"Reverse J Shaped " Skin Flap and Cranial Bone Groove for Shunt Hardware: A New Technique for Patients with Fragile Skin.

Shunt systems are not perfect devices and can cause severe complications. Complications may originate from problems related to the valve, the patient, or the surgery and are more common in neonates, infants, especially preterm, by reason of the special characteristics of these patients. We, therefore, have successfully developed a useful and viable surgical technique in order to provide helpful aspects to the surgical issues mentioned above. This technique includes a "reverse J shaped" skin incision nonintersecting the shunt's hardware and distal catheter to reduce wound problems to a minimum by opening a "bone groove". We believe that the above technique described by us will both reduce issues such as scalp ulceration, wound dehiscence, and shunt exposure in premature and pediatric hydrocephalus cases with a friable scalp, and eliminate a cosmetic problem in hydrocephalic patients of all ages.

Does Shunt Selection Affect the Rate of Early Shunt Complications in Neonatal Myelomeningocele-Associated Hydrocephalus? A Multi-Center Study.

To evaluate the effect of shunt selection on the rate of shunt revision due to early shunt complications in neonatal myelomeningocele-associated hydrocephalus. The data of 157 neonatal myelomeningocele cases in three pediatric neurosurgery centers (Ankara University, Kocaeli University, Selcuk University) who underwent shunt surgery at the time of myelomeningocele repair between 2000 and 2014 were retrospectively analyzed. Clinical features of the patients, shunt types, and early shunt complications within the first three months were recorded. The patients were classified according to several features of the shunt systems, such as the valve type, valve size/contour and catheter type. Of all patients, 71 (45.2%) underwent early shunt revision surgery due to various complications. Mechanical complications were the most frequent cause of shunt failure, followed by infection. There was no significant difference among the valve types. Also, no significant difference was observed among the catheter types. Only valve contour/size (contoured regular/ultra-small/burr-hole/ cylindrical/neonatal) seemed to significantly affect the rate of early complications. The patients with neonatal-design valves or ultrasmall valves had significantly less complications, such as poor wound-healing, wound-dehiscence, cerebrospinal fluid leak or shunt exposure. The infection rate secondary to these complications was found to be lower. Myelomeningocele patients with prominent hydrocephalus frequently have a friable skin, due to reduced macrocrania-related subcutaneous tissues. Small-sized (neonatal-design or ultra-small) valves may significantly reduce the early shunt complication rate among this population.

Chronic overcirculation-induced pulmonary arterial hypertension in aorto-caval shunt

Pulmonary arterial hypertension is a common complication of congenital heart defects with left-to-right shunts. Current preclinical models do not reproduce clinical characteristics of shunt-related pulmonary hypertension. Aorto-caval shunt was firstly described as a model of right ventricle volume overload. The pathophysiology and the possible determination of pulmonary arterial hypertension of different periods of shunt exposure are still undefined.A method to create standardized, reproducible aorto-caval shunt was developed in growing rats (260±40g). Three groups of animals were considered: shunt exposure for 10weeks, shunt exposure for 20weeks and control (sham laparotomy).Echocardiography and magnetic resonance revealed increased right ventricular end diastolic area in shunt at 10weeks compared to control. Hemodynamic analysis demonstrated increased right ventricular afterload and increased effective pulmonary arterial elastance (Ea) in shunt at 20weeks compared to control (1.29±0.20 vs. 0.14±0.06mmHg/μl, p=0.004). At the same time point, the maximal slope of end-systolic pressure–volume relationship (Ees) decreased (0.5±0.2mmHg/ml vs. 1.2±0.3, p<0.001). Consequently, right ventricular–arterial coupling was markedly deteriorated with a ≈50% decrease in the ratio of end-systolic to pulmonary artery elastance (Ees/Ea). Finally, left ventricular preload diminished (≈30% decrease in left ventricular end-diastolic volume). Histology demonstrated medial hypertrophy and small artery luminal narrowing.Chronic exposure to aorto-caval shunt is a reliable model to produce right ventricular volume overload and secondary pulmonary arterial hypertension. This model could be an alternative with low mortality and high reproducibility for investigators on the underlying mechanisms of shunt-related pulmonary hypertension.

Aqueous Shunt Exposure

To describe the patient outcomes and factors affecting those outcomes after aqueous shunt exposure repair. Forty-three eyes from Robert Cizik Eye Clinic and Bascom Palmer Eye Institute from 1995 to 2007 suffered from aqueous shunt exposure and were repaired by participating surgeons. Thirty-three were tube exposures and 7 were plate exposures. The remaining 3 exposure classified complications included a patch graft exposure, an elbow exposure, and 1 unknown complication. Forty eyes were followed for evidence of additional aqueous shunt exposures or additional surgical interventions for 46.6 weeks (40.2 wk) (range: 3 to 168 wk). Seventeen of 40 eyes required additional surgical intervention: 15 (45%) from the tube exposure group and 2 (29%) from the plate exposure group. Five (13%) eyes needed eventual removal of the shunt. Black race, diabetes mellitus, a high number of glaucoma medications before shunt implantation, a history of multiple glaucoma laser procedures, and combination of an initial aqueous shunt implantation with another surgery were found to be associated with a worse outcome after exposure repair. Intraocular pressure, number of medications, and visual acuity remained stable during follow-up after revision. Diabetes mellitus was associated with a shorter average time between initial repair and reintervention, and 4 other variables were associated with a higher likelihood of reintervention.

Risk Factors for Tube Shunt Exposure: A Matched Case-Control Study

Risk Factors for Tube Shunt Exposure: A Matched Case-Control Study

Risk Factors for Tube Shunt Exposure: A Matched Case-Control Study

Purpose. To evaluate potential risk factors for developing tube shunt exposure in glaucoma patients. Patients and Methods. Forty-one cases from 41 patients that had tube shunt exposure from 1996 to 2005 were identified from the Robert Cizik Eye Clinic and Bascom Palmer Eye Institute. Each case was matched with 2 controls of the same gender and with tube shunts implanted within 6 months of the index case. Conditional logistic regression was used to determine risk factors. Results. The study cohort includes a total of 121 eyes from 121 patients. The mean age was 63.6 ± 19.7 years, ranging from 1 to 96 years. The average time to exposure was 19.29 ± 23.75 months (range 0.36–85.74 months). Risk factors associated with tube exposure were Hispanic ethnicity (P = 0.0115; OR = 3.6; 95% CI, 1.3–9.7), neovascular glaucoma (P = 0.0064; OR = 28.5; 95% CI, 2.6–316.9), previous trabeculectomy (P = 0.0070; OR = 5.3; 95% CI, 1.6–17.7), and combined surgery (P = 0.0381; OR = 3.7; 95% CI, 1.1–12.7). Conclusions. Hispanic ethnicity, neovascular glaucoma, previous trabeculectomy, and combined surgery were identified as potential risk factors for tube shunt exposure. These potential risk factors should be considered when determining the indication for performing tube shunt implantation and the frequency of long-term followup.

Threatened ventriculostomy shunt exposure: augmenting native soft tissue coverage with acellular dermal matrix graft

Avoiding threatened ventriculostomy shunt exposure in the pediatric population remains a difficult problem for the neurosurgeon and reconstructive surgeon. In this case series, the authors present a novel method of augmenting scalp soft tissue with acellular dermal matrix (ADM) in patients with a history of ventricular shunt revisions. Soft tissue augmentation with ADM successfully prevented shunt exposure in 3 patients with a history of shunt revision due to impending exposure following conventional techniques.