Cranial expansion as primary surgical treatment in pediatric idiopathic intracranial hypertension

OBJECTIVE: Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure with normal imaging tests and absence of secondary causes. Shunt techniques (ventricular and lumbar) and optic nerve sheath fenestration are surgical options for the treatment of IIH. Cranial expansion techniques have been described in the literature for refractory cases. The aim of this study was to evaluate the chess-table cranial expansion technique as a first-line surgical treatment in pediatric IIH. METHODS: The authors retrospectively analyzed patients diagnosed with IIH who were treated at a single institution between 2019 and 2024. All patients were treated using the dynamic chess-table cranial expansion technique as the first surgical approach. Patients with prior shunt placement, suture synostosis, secondary causes of IIH, evidence of venous sinus stenosis, or incomplete follow-up imaging were excluded. Data collection included demographic characteristics, clinical variables, and intracranial volume measurements. Volumetric analysis on CT images was performed using ITK-Snap software. RESULTS: Thirteen patients (9 female, median age 9 years) were analyzed, with a mean follow-up duration of 30 months. Eleven patients (85%) were successfully managed with the chess-table technique, showing significant clinical improvement without the need for a shunt during follow-up. The median 1-year postoperative intracranial volume was 1389 cm3, corresponding to a median volumetric increase of 76 cm3. CONCLUSIONS: Cranial expansion techniques, previously used as rescue procedures in refractory cases, can also be considered a therapeutic alternative as a first-line surgical therapy in pediatric IIH, with the potential to improve symptoms of intracranial hypertension and reduce the need for shunt implantation, especially for patients with extremely small ventricles.