What is the management approach for communicating hydrocephalus?

Management of Communicating Hydrocephalus

The definitive management of communicating hydrocephalus requires cerebrospinal fluid (CSF) diversion through either temporary measures for acute cases or permanent shunting for chronic cases, based on the clinical presentation and underlying etiology. 1

Acute Management

• Acute symptomatic communicating hydrocephalus should be managed by CSF diversion using external ventricular drainage (EVD) or lumbar drainage, depending on the clinical scenario 1
• For patients with subarachnoid hemorrhage (SAH)-associated hydrocephalus, EVD placement is generally associated with neurological improvement 1
• The risk of aneurysm rebleeding with EVD placement in SAH patients is controversial, with conflicting evidence in retrospective studies 1
• Weaning EVD over >24 hours does not appear to be effective in reducing the need for ventricular shunting and should not be routinely performed 1
• Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus and should not be routinely performed 1

Chronic Management

• Chronic symptomatic communicating hydrocephalus should be treated with permanent CSF diversion (ventriculoperitoneal, ventriculoatrial, or lumboperitoneal shunts) 1
• Chronic shunt-dependent hydrocephalus occurs in 8.9% to 48% of patients with SAH 1
• Factors associated with the need for permanent CSF diversion include older age, early ventriculomegaly, intraventricular hemorrhage, poor clinical condition on presentation, and female sex 1

Special Considerations for Pediatric Patients

• For posthemorrhagic hydrocephalus (PHH) in premature infants, several temporary surgical options exist 1:
  • Ventricular access devices (VADs)
  • External ventricular drains (EVDs)
  • Ventriculosubgaleal (VSG) shunts
  • Lumbar punctures (LPs)
• VSG shunts reduce the need for daily CSF aspiration compared with VADs in premature infants 1
• The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants 1

Pharmacological Management

• Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended to reduce the need for shunt placement in premature infants with PHH 1
• Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH 1
• While a small historical study suggested acetazolamide and repeated lumbar punctures might be effective for communicating hydrocephalus in tuberculous meningitis 2, more recent evidence and guidelines do not support this approach as primary therapy

Endoscopic Third Ventriculostomy (ETV)

• There is insufficient evidence to recommend the routine use of ETV in premature infants with posthemorrhagic hydrocephalus 1
• ETV may be considered in select cases of communicating hydrocephalus, particularly when there is evidence of partial obstruction 3
• ETV with or without choroid plexus cauterization is being increasingly used as an alternative to shunting in selected cases 4, 5

Diagnostic Considerations

• Contrast-enhanced MRI is recommended to evaluate for hydrocephalus and distinguish between communicating and non-communicating types 6
• Ventriculomegaly (not from cerebral atrophy) and transependymal edema are hallmarks of acute hydrocephalus 6, 3
• Lumbar puncture with measurement of opening pressure can help diagnose communicating hydrocephalus 6, 3
• Changes in mental status, nausea, vomiting, cranial neuropathy, incontinence, or gait disturbance should prompt neuroimaging 6, 3

Pitfalls and Caveats

• Surgical interventions for hydrocephalus, though lifesaving, have a high incidence of failure and complications requiring re-intervention 7, 4
• There is no specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH; clinical judgment is required 1
• When hydrocephalus is secondary to another condition (infection, hemorrhage, tumor), the underlying cause should also be addressed 3
• Long-term outcomes for patients with hydrocephalus vary widely and depend on both intrinsic (genetic) and extrinsic factors 5