Primary Treatment Options for Hydrocephalus
The primary treatments for hydrocephalus are cerebrospinal fluid (CSF) shunts and endoscopic third ventriculostomy (ETV), both of which demonstrate equivalent outcomes in clinical studies. 1
Surgical Management Options
CSF Shunts
- Ventriculoperitoneal (VP) shunts are the most common type of CSF shunt used for hydrocephalus treatment 1
- CSF shunts work by diverting excess cerebrospinal fluid from the ventricles to another body cavity (typically the peritoneum) where it can be absorbed 1
- Antibiotic-impregnated shunt tubing should be used to reduce the risk of shunt infection, particularly in children (Level I recommendation, high degree of clinical certainty) 1
Endoscopic Third Ventriculostomy (ETV)
- ETV creates an alternative pathway for CSF flow by making an opening in the floor of the third ventricle 1
- Advantages include lower failure rates and potential to avoid shunt placement and its inherent risks 1
- May be combined with choroid plexus coagulation (CPC) in the treatment of infant hydrocephalus 1
Evidence-Based Recommendation
According to the Congress of Neurological Surgeons systematic review and evidence-based guidelines:
- Both CSF shunts and ETV are options in the treatment of pediatric hydrocephalus (Level II recommendation, moderate clinical certainty) 1
- The selection between these two procedures should be based on the etiology of hydrocephalus and patient-specific factors 1
Special Considerations
For Posthemorrhagic Hydrocephalus in Premature Infants
- Temporary measures may be needed before definitive treatment:
- Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures are treatment options (Level II recommendation) 1
- VSG shunts reduce the need for daily CSF aspiration compared with VADs (Level II recommendation) 1
- Routine use of serial lumbar puncture is not recommended to reduce shunt placement or avoid progression of hydrocephalus (Level I recommendation) 1
Technical Advancements
- Neuronavigation for proximal catheter placement and laparoscopy for distal catheter placement can reduce shunt failure rates by up to 44% 2
- Laparoscopic techniques facilitate rapid, safe, and direct placement of the peritoneal component of VP shunts 3
Complications and Pitfalls
- Shunt failure rates can be alarmingly high, with up to 50% of patients requiring revision surgery within 2 years 2
- Common complications include:
Follow-up Considerations
- Regular follow-up is essential to monitor shunt function
- Symptom recurrence may occur even after successful initial treatment (approximately 45.5% of patients may experience worsening symptoms at 1-year follow-up) 4
- Standardized assessment of gait, balance, and cognition before and after temporary CSF diversion can help identify patients likely to benefit from VP shunt placement 4
Despite ongoing research into non-surgical approaches, surgical intervention remains the mainstay of hydrocephalus treatment, with the choice between CSF shunts and ETV being determined by patient-specific factors and the underlying etiology of hydrocephalus 5.