Treatment of Hydrocephalus
The recommended first-line treatment for hydrocephalus is cerebrospinal fluid (CSF) diversion through either ventriculoperitoneal shunting (VPS) or endoscopic third ventriculostomy (ETV), with the choice between these surgical interventions depending on the specific etiology and patient characteristics. 1, 2
Treatment Algorithm Based on Hydrocephalus Type
Acute Symptomatic Hydrocephalus
- Urgent CSF diversion via external ventricular drainage (EVD) and/or lumbar drainage should be performed to improve neurological outcomes 2
- Implementation of EVD bundled protocols addressing insertion, management, education, and monitoring is essential to reduce complications and infection rates 2
Chronic Symptomatic Hydrocephalus
- Permanent CSF diversion is recommended 2
- Options include:
- Ventriculoperitoneal shunt (VPS)
- Endoscopic third ventriculostomy (ETV)
Choosing Between ETV and VPS
ETV is preferred when:
- Obstructive hydrocephalus is present
- Patient has favorable anatomy for the procedure
- Avoiding long-term shunt dependence is a priority
- Patient is not an infant (better success rates in older children and adults) 1
VPS is preferred when:
- ETV is technically challenging due to anatomical variations
- Previous ETV has failed
- Patient has communicating hydrocephalus
- Narrow prepontine space or basilar artery anomalies are present 1
Special Considerations by Etiology
Subarachnoid Hemorrhage-Associated Hydrocephalus
- Acute management: External ventricular drainage (EVD) or lumbar drainage 2
- Chronic management: Permanent CSF diversion 2
- Note: Routine fenestration of the lamina terminalis is not recommended for reducing shunt dependency 2
Intraventricular Neurocysticercosis
- Removal of cysticerci by minimally invasive neuroendoscopy is recommended for cysts in lateral and third ventricles 2
- Antiparasitic drugs with corticosteroid therapy following shunt insertion may decrease subsequent shunt failure when surgical removal is not possible 2
Posthemorrhagic Hydrocephalus in Premature Infants
- Neuro-endoscopic lavage is a feasible option for removing intraventricular clots and may lower the rate of shunt placement 2
Shunt Hardware Considerations
- Antibiotic-impregnated shunt tubing reduces the risk of shunt infection compared to conventional silicone hardware and should be used for children requiring shunt placement (Level I recommendation) 2
- There is insufficient evidence to demonstrate an advantage for one specific shunt hardware design over another 2
- Both programmable and nonprogrammable valves are options for treatment (Level II recommendation) 2
Complications and Monitoring
Common Complications
- Shunt infection (5-10%)
- Shunt malfunction (10-20%)
- Overdrainage (5-10%) 1
Monitoring Requirements
- Regular neurological assessment
- Follow-up imaging to evaluate ventricular size
- Regular assessment of symptom improvement
- Shunt programming adjustments as needed 1
Limitations of Medical Management
While surgical interventions remain the mainstay of treatment, limited pharmacological options exist:
- Acetazolamide (alone or with furosemide) may be considered in specific circumstances 3
- Fibrinolytic therapy administered directly into the ventricular system may help manage hydrocephalus by preventing catheter obstruction and accelerating clot resolution 3
- However, these medical treatments generally do not replace the need for surgical intervention 4, 5
Future Directions
Research is increasingly focused on understanding the cellular and molecular mechanisms of hydrocephalus to develop nonsurgical interventions, as current surgical treatments have high failure rates and complications requiring re-intervention 4, 5, 6.