Non-invasive intracranial pressure monitoring in management of slit ventricle syndrome - Case report

Non-invasive intracranial pressure monitoring in management of slit ventricle syndrome - Case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Non-invasive intracranial pressure monitoring in management of slit ventricle syndrome - Case report Walter Fagundes, Paulo Vitor da Cruz, Wander Valentim, Gustavo Frigieri, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4953151/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Oct, 2025 Read the published version in Child's Nervous System → Version 1 posted 5 You are reading this latest preprint version Abstract Slit ventricle syndrome (SVS) is condition of severe headaches, usually intermittent, suffered by patients after ventricular shunting for hydrocephalus with normal or smaller ventricle size, although in some cases the correct diagnosis and management can be a significant challenge. This case report aims to highlight the application of non-invasive ICP monitoring (nICP) technology in the diagnose and management of SVS providing insights into its benefits and limitations. A 6-year-old boy with a known history of autism spectrum disorder had undergone a VPS for a communicating hydrocephalus. Post operative, patient was asymptomatic with magnetic resonance images (MRI) showing small ventricle size. However, the patient started to develop recurrent symptoms of headache, nausea, and vomiting, a fresh MRI was ordered which demonstrated findings consistent with the previous MRI. We therefore decided to evaluate ICP and compliance by non-invasive monitoring using brain4care technology. Noninvasive monitoring was suggestive of low ICP and hyperdrainage, leading to the adjustment of the shunt valve from a medium to high pressure device, which normalized ICP waves and ICP as well ventricles size and the patient became asymptomatic. Therefore, we propose that noninvasive ICP monitoring may be a helpful tool to better classify the SVS type and guide the appropriated management. Slit ventricle syndrome Hydrocephalus Ventriculoperitoneal shunt Headache Non-Intracranial pressure monitoring Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Slit ventricle syndrome (SVS) is condition of severe headaches, usually intermittent, suffered by patients after ventricular shunting for hydrocephalus, in the context of ventricles that are normal or smaller, although some cases the correct diagnosis can be a challenge [ 1 – 3 ] and it can complicate the long-term management of those patients [ 1 – 4 ]. The development of non-invasive intracranial pressure (ICP) monitoring technologies may contribute to diagnose of the SVS and allows to define the appropriated therapeutic strategies for SVS, especially when neuroimaging scans are not conclusive [5, 7–12]. This case report aims to highlight the application of non-invasive ICP monitoring (nICP) technology in the diagnose and management of SVS providing insights into its benefits and limitations. Case Report A 6-year-old boy presented to our emergency department with a recurrent history of severe headache and vomiting. The boy had a known history of ventriculoperitoneal shunt placement at 11 months of age following a diagnosis of communicating hydrocephalus after recurrent seizure episodes. The VP shunt so placed was a fixed medium pressure valve without an anti-siphon device. Follow-up MRI at the time of shunt placement demonstrated reduced-sized ventricles and the ventricular catheter positioned in the frontal horn. After 4 years of VP shunt placement, the patient started to experience recurrent episodes of headache, nausea and vomiting. Magnetic resonance imaging (MRI) of the brain performed at this stage showed small ventricles with focal meningeal enhancement, consistent with the findings of the last MRI study. Clinical measures including analgesic medication and intravenous hydration were given and the patient improved considerably, following which the patient was discharged. After six months, the patient was admitted again with severe headaches and vomiting. An MRI confirmed the previous findings without additional abnormalities (Fig. 2 ). Given the recurrence in his symptoms and imaging findings consistent with small ventricles we decided to perform non-invasive intracranial pressure monitoring (nICP) to decide for the appropriate management of the patient. Non-invasive intracranial pressure monitoring was performed using Brain4Care device in different patient positions (0°, 15°, 30°, 45°, sitting and standing), results showed low intracranial pressure favouring hyper drainage of cerebrospinal fluid (CSF) with P2/P1 of 0.54 and time to peak (TTP) of 0.03 [ 6 , 13 – 16 ] (Fig. 3 A). Based on these findings, we adjusted the shunt valve surgically from a medium to a fixed high-pressure without anti siphon setting. After adjustment, a new nICP monitoring was performed, suggesting normal ICP and compliance with P2/P1 of 0.91 and TTP of 0.12 [ 6 , 13 – 16 ] (Fig. 3 B). The patient remains asymptomatic. A postoperative MRI showed ventricles with normal size (Fig. 4 ) Discussion A severe and intermittent headache in VP shunt patient with ventricles that have normal or smaller size may indicate SVS. This diagnose may be not so evident in some cases, especially in those patients with normal size ventricles [ 2 , 3 ]. In this context, the use of nICP monitoring can provide valuable data to complement MRI and clinical features, aiding in decision-making regarding the appropriated surgical approach to the shunt system [ 17 , 18 ]. As observed in the case, this information was pivotal in deciding the management plan of this patient. Considering the subtypes classification of SVS, different management is required in each one. Intracranial hypotension typically manifests as intense headaches influenced by the patient's posture. These headaches intensify when the patient stands and alleviate quickly upon lying down. This suggests to over-shunting and patients tend to improve with a programmable valve adjusted to a higher setting and the use of an anti-siphon device In our case, although the best treatment option for intracranial hypotension typically involves a programmable valve and an anti-siphon device, these devices are not readily accessible within the Brazilian public health system. The main goal in SVS management is to normalize ICP by adjusting CSF drainage based on the evaluation of the function system [ 2 , 3 ]. The success observed following the adjustment of the shunt in our case supports the potential of non-invasive technologies, offering a new effective tool for diagnosis and management of shunt dysfunction. In this context, it seems worth considering a new nomenclature for this condition, which must be more inclusive, based on the broad spectrum of SVS. We propose “Shunt-Related Ventricular Syndrome” once it can include all the subtypes of SVS described by Rekate et al. [ 2 , 3 , 4 ] Based on the different SVS subtypes, a non-invasive device able to evaluate ICP seems to be helpful in detection of shunting malfunction earlier and its complications and the appropriate management of it. A nICP monitoring was also able to help increase the effectiveness in the use of more invasive and extensive interventions, thereby minimizing the potential risks and complications associated with advanced investigations. This contributes to improved patient safety and overall care outcomes, as well as for the reduction of costs of treatment. In conclusion, nICP monitoring may be a helpful tool to accurately determine the type of “Shunt-Related Ventricular Syndrome” and guide appropriate management, as was observed by us. However, further investigations are necessary to validate these findings. Declarations Ethics approval Ethics approval this project was approved by the ethics in research committee (id: 64685122.2.0000.5060). Consent to publish Written informed consent was given by the patient's legal guardian regarding the publication of images and clinical data included in this report. Competing interests WF has nothing to declare. PVC has nothing to declare. WV declares personal fees as an employee (Consultant) from Braincare Desenvolvimento e Inovação Tecnológica S.A. GF declares personal fees as an employee (Scientific Director) from Braincare Desenvolvimento e Inovação Tecnológica S.A. during this study. In addition, GF has a patent US9826934B2 issued and a patent US9993170B1 issued. Funding There was no research grants or research support from funding agencies. Authors contribution W.F. and P.V.C. wrote the main manuscript text. W.V. and G.F. helped with the monitoring technology and data interpretation. M.W. prepared figures 1-4. All authors reviewed the manuscript References Fried AH, Epstein MH Childhood Hydrocephalus: Clinical Features, Treatment, and the Slit-Ventricle Syndrome. Neurosurg Q 4(1):p 51–65, March 1994. Rekate HL (2008) Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst 24(4):423–430. https://doi.org/10.1007/s00381-008-0579-7 Rekate HL (2004) Nov-Dec;40(6):259 – 63 The slit ventricle syndrome: advances based on technology and understanding. Pediatr Neurosurg. https://doi.org/10.1159/000083737 Baskin JJ, Manwaring KH, Rekate HL (1998) Ventricular shunt removal: the ultimate treatment of the slit ventricle syndrome. J Neurosurg JNS 88(3):478–484. https://doi.org/10.3171/jns.1998.88.3.0478 Folchini CM, Karuta SCV, Ricieri MC, Motta FA, Manços GR, Frigieri G, Maeda AK (2022) From disease to noninvasive intracranial monitoring. Arq Neuropsiquiatr 80(5):539–542. https://doi.org/10.1590/0004-282X-ANP-2021-0298 Ballestero M, Dias C, Gomes ICN, Grisi LS, Cardoso RAM, Júnior ELZ, de Oliveira RS (2023) Can a new noninvasive method for assessment of intracranial pressure predict intracranial hypertension and prognosis? Acta Neurochir (Wien) 165(6):1495–1503. https://doi.org/10.1007/s00701-023-05580-z Rabelo NN, da Silva Brito J, da Silva JS, de Souza NB, Coelho G, Brasil S, Frigieri G (2021) The historic evolution of intracranial pressure and cerebrospinal fluid pulse pressure concepts: Two centuries of challenges. Surg Neurol Int 12:274. https://doi.org/10.25259/SNI_53_2021 Robba C, Frigieri G, Brasil S, Taccone FS (2022) Early prognostic value of non-invasive intracranial pressure methods in brain-injured patients. Intensive Care Med 48(12):1812–1814. https://doi.org/10.1007/s00134-022-06899-4 Frigieri G, Robba C, Machado FS, Gomes JA, Brasil S (2023) Application of non-invasive ICP waveform analysis in acute brain injury: Intracranial Compliance Scale. Intensive Care Med Exp 11(1):5. https://doi.org/10.1186/s40635-023-00492-9 Gomes I, Shibaki J, Padua B, Silva F, Gonçalves T, Spavieri-Junior DL, Frigieri G, Mascarenhas S, Dias C (2021) Comparison of Waveforms Between Noninvasive and Invasive Monitoring of Intracranial Pressure. Acta Neurochir Suppl 131:135–140. https://doi.org/10.1007/978-3-030-59436-7_28 Brasil S, Frigieri G, Taccone FS, Robba C, Solla DJF, de Carvalho Nogueira R, Yoshikawa MH, Teixeira MJ, Malbouisson LMS, Paiva WS (2023) Noninvasive intracranial pressure waveforms for estimation of intracranial hypertension and outcome prediction in acute brain-injured patients. J Clin Monit Comput 37(3):753–760. https://doi.org/10.1007/s10877-022-00941-y Zanon N, da Costa Benalia VH, Hoesker T, Hayashi CY, Frigieri G, Coelho G (2023) Noninvasive intracranial pressure monitoring throughout brain compliance guiding a ventriculoperitoneal shunt replacement in hydrocephalus-case report. Childs Nerv Syst 39(8):2215–2219. https://doi.org/10.1007/s00381-023-05922-3 Ballestero MFM, Frigieri G, Cabella BCT, de Oliveira SM, de Oliveira RS (2017) Prediction of intracranial hypertension through noninvasive intracranial pressure waveform analysis in pediatric hydrocephalus. Childs Nerv Syst 33(9):1517–1524. https://doi.org/10.1007/s00381-017-3475-1 Paraguassu G, Khilnani M, Rabelo NN, Cobos LD, Frigieri G (2021) Case Report: Untreatable Headache in a Child With Ventriculoperitoneal Shunt Managed by Use of New Non-invasive Intracranial Pressure Waveform. Front Neurosci 15:601945. https://doi.org/10.3389/fnins.2021.601945 de Moraes FM, Brasil S, Frigieri G, Robba C, Paiva W, Silva GS (2024) ICP wave morphology as a screening test to exclude intracranial hypertension in brain-injured patients: a non-invasive perspective. J Clin Monit Comput 38(4):773–782. https://doi.org/10.1007/s10877-023-01120-3 de Moraes FM, Adissy ENB, Rocha E, Barros FCD, Freitas FGR, Miranda M, Valiente RA, de Andrade JBC, Chaddad-Neto FEA, Silva GS (2023) Multimodal monitoring intracranial pressure by invasive and noninvasive means. Sci Rep 13(1):18404. https://doi.org/10.1038/s41598-023-45834-5 Additional Declarations Competing interest reported. Conflict of interest WF has nothing to declare. PVC has nothing to declare. WV declares personal fees as an employee (Consultant) from Braincare Desenvolvimento e Inovação Tecnológica S.A. GF declares personal fees as an employee (Scientific Director) from Braincare Desenvolvimento e Inovação Tecnológica S.A. during this study. In addition, GF has a patent US9826934B2 issued and a patent US9993170B1 issued. Cite Share Download PDF Status: Published Journal Publication published 21 Oct, 2025 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Revision requested 13 Jul, 2025 Reviewers invited by journal 05 Jul, 2025 Editor assigned by journal 23 Aug, 2024 Submission checks completed at journal 23 Aug, 2024 First submitted to journal 21 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4953151","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":353677244,"identity":"82f2552b-de4f-4fa7-9cc8-470ba86d38f8","order_by":0,"name":"Walter Fagundes","email":"data:image/png;base64,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","orcid":"","institution":"Universidade Federal do Espírito Santo","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Walter","middleName":"","lastName":"Fagundes","suffix":""},{"id":353677245,"identity":"94c8391e-c08b-47b1-9546-fe19c397f481","order_by":1,"name":"Paulo Vitor da Cruz","email":"","orcid":"","institution":"Universidade Federal do Espírito Santo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Paulo","middleName":"Vitor da","lastName":"Cruz","suffix":""},{"id":353677246,"identity":"72e9d817-361c-470d-8696-f074b09ba44f","order_by":2,"name":"Wander Valentim","email":"","orcid":"","institution":"Brain4care Desenvolvimento e Inovacao Tecnologia SA","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wander","middleName":"","lastName":"Valentim","suffix":""},{"id":353677247,"identity":"ba04e20b-d283-45ec-b6a1-0410f4f27716","order_by":3,"name":"Gustavo Frigieri","email":"","orcid":"","institution":"Brain4care Desenvolvimento e Inovacao Tecnologia SA","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gustavo","middleName":"","lastName":"Frigieri","suffix":""},{"id":353677248,"identity":"93ba3a0c-5077-4667-b383-badc2cc0bb86","order_by":4,"name":"Wajid Majeed Mir","email":"","orcid":"","institution":"Government medical college srinagar Kashmir India","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wajid","middleName":"Majeed","lastName":"Mir","suffix":""}],"badges":[],"createdAt":"2024-08-21 17:00:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4953151/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4953151/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-025-06990-3","type":"published","date":"2025-10-21T16:16:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66741655,"identity":"74950f62-da50-4d3a-8d5b-4c821936a19e","added_by":"auto","created_at":"2024-10-16 05:55:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":506118,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative control MRI showing small ventricules but with patient asymptomatic. Coronal T1, \u003cem\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003c/em\u003e. FLAIR axial image, \u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e. Sagittal T1 image, \u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4953151/v1/2fe3d805bf361e0fb2acc8f0.png"},{"id":66742244,"identity":"5e89c4a5-6edf-4e00-b161-21ed868b9b28","added_by":"auto","created_at":"2024-10-16 06:03:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":732404,"visible":true,"origin":"","legend":"\u003cp\u003eMRI showing the same pattern previously observed at the postoperative MRI with small ventricles but now with focal meningeal enhancement and the patient presenting symptomatic. FLAIR axial image, \u003cem\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003c/em\u003e. axial T2 image, \u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e. Sagittal T1image, \u003cem\u003e\u003cstrong\u003ec\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4953151/v1/85d81ac5b5a8cdb897eb067e.png"},{"id":66741654,"identity":"445141f2-c063-40c8-ad28-262ee26b4912","added_by":"auto","created_at":"2024-10-16 05:55:59","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":123037,"visible":true,"origin":"","legend":"\u003cp\u003eNon-invasive intracranial pressure and compliance exam. Monitoring performed with patient presenting headache and vomiting, after the MRI shown in figure 2. It is possible to see the low P2/P1 ratio and Time to Peak, suggesting low ICP and hyper drainage from the VPS, \u003cem\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003c/em\u003e. Monitoring performed after the surgically valve pressure adjustment, showing normalization of both the P2/P1 ratio and the Time to Peak. \u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4953151/v1/a4955af1a9d078dc54084934.jpeg"},{"id":66742243,"identity":"1fd170f1-b990-453d-a32f-1ca33dfd8c85","added_by":"auto","created_at":"2024-10-16 06:03:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":698294,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative MRI demonstrating normal ventricles size with the patient asymptomatic. FLAIR axial image, \u003cem\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003c/em\u003e. Axial T2 image, \u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e. Sagittal T2 image, \u003cem\u003e\u003cstrong\u003ec\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4953151/v1/fe419a48513ec0ed06d92d41.png"},{"id":94490208,"identity":"19b0e4fd-fde2-43a4-98a3-a9d7d09c7947","added_by":"auto","created_at":"2025-10-27 17:08:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3311559,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4953151/v1/2384c1ef-77bf-4738-a6cd-e6f4a9b28273.pdf"}],"financialInterests":"Competing interest reported. Conflict of interest\n\n WF has nothing to declare. PVC has nothing to declare. WV declares personal fees as an employee (Consultant) from Braincare Desenvolvimento e Inovação Tecnológica S.A. GF declares personal fees as an employee (Scientific Director) from Braincare Desenvolvimento e Inovação Tecnológica S.A. during this study. In addition, GF has a patent US9826934B2 issued and a patent US9993170B1 issued.","formattedTitle":"Non-invasive intracranial pressure monitoring in management of slit ventricle syndrome - Case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSlit ventricle syndrome (SVS) is condition of severe headaches, usually intermittent, suffered by patients after ventricular shunting for hydrocephalus, in the context of ventricles that are normal or smaller, although some cases the correct diagnosis can be a challenge [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and it can complicate the long-term management of those patients [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The development of non-invasive intracranial pressure (ICP) monitoring technologies may contribute to diagnose of the SVS and allows to define the appropriated therapeutic strategies for SVS, especially when neuroimaging scans are not conclusive [5, 7\u0026ndash;12]. This case report aims to highlight the application of non-invasive ICP monitoring (nICP) technology in the diagnose and management of SVS providing insights into its benefits and limitations.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 6-year-old boy presented to our emergency department with a recurrent history of severe headache and vomiting.\u003c/p\u003e \u003cp\u003eThe boy had a known history of ventriculoperitoneal shunt placement at 11 months of age following a diagnosis of communicating hydrocephalus after recurrent seizure episodes. The VP shunt so placed was a fixed medium pressure valve without an anti-siphon device. Follow-up MRI at the time of shunt placement demonstrated reduced-sized ventricles and the ventricular catheter positioned in the frontal horn.\u003c/p\u003e \u003cp\u003eAfter 4 years of VP shunt placement, the patient started to experience recurrent episodes of headache, nausea and vomiting. Magnetic resonance imaging (MRI) of the brain performed at this stage showed small ventricles with focal meningeal enhancement, consistent with the findings of the last MRI study. Clinical measures including analgesic medication and intravenous hydration were given and the patient improved considerably, following which the patient was discharged. After six months, the patient was admitted again with severe headaches and vomiting. An MRI confirmed the previous findings without additional abnormalities (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGiven the recurrence in his symptoms and imaging findings consistent with small ventricles we decided to perform non-invasive intracranial pressure monitoring (nICP) to decide for the appropriate management of the patient.\u003c/p\u003e \u003cp\u003eNon-invasive intracranial pressure monitoring was performed using Brain4Care device in different patient positions (0\u0026deg;, 15\u0026deg;, 30\u0026deg;, 45\u0026deg;, sitting and standing), results showed low intracranial pressure favouring hyper drainage of cerebrospinal fluid (CSF) with P2/P1 of 0.54 and time to peak (TTP) of 0.03 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR11\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e16\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Based on these findings, we adjusted the shunt valve surgically from a medium to a fixed high-pressure without anti siphon setting.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter adjustment, a new nICP monitoring was performed, suggesting normal ICP and compliance with P2/P1 of 0.91 and TTP of 0.12 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR11\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e16\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The patient remains asymptomatic. A postoperative MRI showed ventricles with normal size (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA severe and intermittent headache in VP shunt patient with ventricles that have normal or smaller size may indicate SVS. This diagnose may be not so evident in some cases, especially in those patients with normal size ventricles [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In this context, the use of nICP monitoring can provide valuable data to complement MRI and clinical features, aiding in decision-making regarding the appropriated surgical approach to the shunt system [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. As observed in the case, this information was pivotal in deciding the management plan of this patient.\u003c/p\u003e \u003cp\u003eConsidering the subtypes classification of SVS, different management is required in each one.\u003c/p\u003e \u003cp\u003eIntracranial hypotension typically manifests as intense headaches influenced by the patient's posture. These headaches intensify when the patient stands and alleviate quickly upon lying down. This suggests to over-shunting and patients tend to improve with a programmable valve adjusted to a higher setting and the use of an anti-siphon device\u003c/p\u003e \u003cp\u003eIn our case, although the best treatment option for intracranial hypotension typically involves a programmable valve and an anti-siphon device, these devices are not readily accessible within the Brazilian public health system.\u003c/p\u003e \u003cp\u003eThe main goal in SVS management is to normalize ICP by adjusting CSF drainage based on the evaluation of the function system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The success observed following the adjustment of the shunt in our case supports the potential of non-invasive technologies, offering a new effective tool for diagnosis and management of shunt dysfunction.\u003c/p\u003e \u003cp\u003eIn this context, it seems worth considering a new nomenclature for this condition, which must be more inclusive, based on the broad spectrum of SVS. We propose \u0026ldquo;Shunt-Related Ventricular Syndrome\u0026rdquo; once it can include all the subtypes of SVS described by Rekate et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBased on the different SVS subtypes, a non-invasive device able to evaluate ICP seems to be helpful in detection of shunting malfunction earlier and its complications and the appropriate management of it.\u003c/p\u003e \u003cp\u003eA nICP monitoring was also able to help increase the effectiveness in the use of more invasive and extensive interventions, thereby minimizing the potential risks and complications associated with advanced investigations. This contributes to improved patient safety and overall care outcomes, as well as for the reduction of costs of treatment.\u003c/p\u003e \u003cp\u003eIn conclusion, nICP monitoring may be a helpful tool to accurately determine the type of \u0026ldquo;Shunt-Related Ventricular Syndrome\u0026rdquo; and guide appropriate management, as was observed by us. However, further investigations are necessary to validate these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval this project was approved by the ethics in research committee (id: 64685122.2.0000.5060).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was given by the patient\u0026apos;s legal guardian regarding the publication of images and clinical data included in this report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;WF has nothing to declare. PVC has nothing to declare. WV declares personal fees as an employee (Consultant) from Braincare Desenvolvimento e Inova\u0026ccedil;\u0026atilde;o Tecnol\u0026oacute;gica S.A. \u0026nbsp; GF declares personal fees as an employee (Scientific Director) from Braincare Desenvolvimento e Inova\u0026ccedil;\u0026atilde;o Tecnol\u0026oacute;gica S.A. during this study. In addition, GF has a patent US9826934B2 issued and a patent US9993170B1 issued.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no research grants or research support from funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW.F. and P.V.C. wrote the main manuscript text. W.V. and G.F. helped with the monitoring technology and data interpretation. M.W. prepared figures 1-4. All authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFried AH, Epstein MH Childhood Hydrocephalus: Clinical Features, Treatment, and the Slit-Ventricle Syndrome. Neurosurg Q 4(1):p 51\u0026ndash;65, March 1994.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRekate HL (2008) Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst 24(4):423\u0026ndash;430. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00381-008-0579-7\u003c/span\u003e\u003cspan address=\"10.1007/s00381-008-0579-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRekate HL (2004) Nov-Dec;40(6):259\u0026thinsp;\u0026ndash;\u0026thinsp;63 The slit ventricle syndrome: advances based on technology and understanding. 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Sci Rep 13(1):18404. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41598-023-45834-5\u003c/span\u003e\u003cspan address=\"10.1038/s41598-023-45834-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Slit ventricle syndrome, Hydrocephalus, Ventriculoperitoneal shunt, Headache, Non-Intracranial pressure monitoring","lastPublishedDoi":"10.21203/rs.3.rs-4953151/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4953151/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSlit ventricle syndrome (SVS) is condition of severe headaches, usually intermittent, suffered by patients after ventricular shunting for hydrocephalus with normal or smaller ventricle size, although in some cases the correct diagnosis and management can be a significant challenge.\u003c/p\u003e \u003cp\u003eThis case report aims to highlight the application of non-invasive ICP monitoring (nICP) technology in the diagnose and management of SVS providing insights into its benefits and limitations.\u003c/p\u003e \u003cp\u003eA 6-year-old boy with a known history of autism spectrum disorder had undergone a VPS for a communicating hydrocephalus. Post operative, patient was asymptomatic with magnetic resonance images (MRI) showing small ventricle size. However, the patient started to develop recurrent symptoms of headache, nausea, and vomiting, a fresh MRI was ordered which demonstrated findings consistent with the previous MRI. We therefore decided to evaluate ICP and compliance by non-invasive monitoring using brain4care technology. Noninvasive monitoring was suggestive of low ICP and hyperdrainage, leading to the adjustment of the shunt valve from a medium to high pressure device, which normalized ICP waves and ICP as well ventricles size and the patient became asymptomatic.\u003c/p\u003e \u003cp\u003eTherefore, we propose that noninvasive ICP monitoring may be a helpful tool to better classify the SVS type and guide the appropriated management.\u003c/p\u003e","manuscriptTitle":"Non-invasive intracranial pressure monitoring in management of slit ventricle syndrome - Case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-16 05:55:54","doi":"10.21203/rs.3.rs-4953151/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-13T19:44:35+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-05T21:06:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-23T04:37:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-23T04:37:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-08-21T16:59:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6e5c2aa1-e2c5-4d7b-85a0-4e0dce454be7","owner":[],"postedDate":"October 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:24:33+00:00","versionOfRecord":{"articleIdentity":"rs-4953151","link":"https://doi.org/10.1007/s00381-025-06990-3","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2025-10-21 16:16:12","publishedOnDateReadable":"October 21st, 2025"},"versionCreatedAt":"2024-10-16 05:55:54","video":"","vorDoi":"10.1007/s00381-025-06990-3","vorDoiUrl":"https://doi.org/10.1007/s00381-025-06990-3","workflowStages":[]},"version":"v1","identity":"rs-4953151","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4953151","identity":"rs-4953151","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}