What are the consequences of delayed surgical intervention for hydrocephalus (fluid accumulation in the brain)?

From the Guidelines

Delay in surgery for hydrocephalus can lead to serious and potentially permanent neurological damage, and thus, prompt surgical intervention is crucial to prevent increased intracranial pressure and its associated complications. The primary consequences of delayed surgery include increased intracranial pressure causing progressive brain damage, cognitive impairment, developmental delays in children, vision problems including blindness, seizures, and in severe cases, death 1. Specific neurological deficits depend on which brain regions are most affected by the pressure and can include memory problems, gait disturbances, urinary incontinence, and personality changes. In infants, delays may result in enlarged head circumference, bulging fontanelles, irritability, poor feeding, and developmental regression.

The timeline for damage varies based on the cause and rate of cerebrospinal fluid accumulation, but irreversible damage can occur within days to weeks of symptom onset in acute cases. According to the 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline, pressures ≥250 mm H2O define the need for urgent or emergent intervention 1. Treatment should be initiated promptly with surgical interventions such as ventriculoperitoneal shunt placement or endoscopic third ventriculostomy. These procedures divert excess cerebrospinal fluid to relieve pressure on the brain.

Key considerations for surgical intervention include:

• Symptom severity: emergency surgery is needed for patients showing rapid neurological deterioration, decreased consciousness, or signs of brainstem compression
• Pressure management: the pressure should be lowered by removal of CSF in a volume sufficient to reduce the pressure to 50% of the opening pressure or 200 mm of H2O, whichever is greater 1
• Neuroimaging: a contrast-enhanced MRI should be undertaken in all patients with hydrocephalus at presentation or shortly thereafter to evaluate for the presence of hydrocephalus and to distinguish communicating from noncommunicating hydrocephalus 1. Prompt surgical management is essential because while some recovery is possible after pressure relief, many neurological deficits caused by prolonged pressure may be permanent.

From the Research

Consequences of Delay in Surgery for Hydrocephalus

• Delay in surgery for hydrocephalus can result in severe consequences, including death, as left untreated, hydrocephalus can lead to fatal outcomes 2.
• The current treatment for hydrocephalus uses ventriculoperitoneal (VP) shunts with valves to redirect CSF from the ventricles into the peritoneum, but shunt technology is limited by various complications, such as infection, obstruction, disconnection, and overdrainage or underdrainage of CSF 2.
• Studies have shown that shunt-related complications are common, with infection being the most frequent complication, occurring in 14.6% of patients, and overall mortality rates ranging from 4.59% to 32% 3, 4.
• Delay in surgery may also lead to increased morbidity, including neurocognitive and motor impairment, as hydrocephalus is a neurological pathology linked to high morbidity 5.
• The effectiveness of treatment varies widely, and there is a need for innovative and low-cost, accessible treatment strategies to improve outcomes, particularly in lower-income countries where surgical procedures are often poorly tolerated due to insufficient diagnostic resources and suboptimal outcomes 6.

Complications of Delayed Surgery

• Infection is a common complication of VP shunts, occurring in 14.6% of patients, and can be life-threatening if left untreated 3.
• Obstruction of the shunt due to clot formation or catheter obstruction by scar tissue or choroid plexus can also occur, leading to increased intracranial pressure and potentially fatal outcomes 2.
• Delay in surgery may also lead to disconnection and tubing migration, which can result in shunt failure and require re-intervention 2.
• Overdrainage or underdrainage of CSF due to valve malfunction can also occur, leading to increased morbidity and mortality rates 2.

Importance of Prompt Surgery

• Prompt surgery is essential to prevent severe consequences, including death, and to improve outcomes in patients with hydrocephalus 2, 3.
• Early intervention can also reduce the risk of complications, such as infection and shunt failure, and improve the overall quality of life for patients with hydrocephalus 6, 5.
• Studies have shown that comprehensive follow-up and properly designed prospective studies can provide a better understanding of the magnitude of the problem and improve current outcomes 3, 4.