What is the treatment for obstructed hydrocephalus?

Treatment of Obstructed Hydrocephalus

Ventriculostomy is the first-line treatment for symptomatic obstructive hydrocephalus, with decompressive suboccipital craniectomy indicated when brainstem compression is present or if cerebrospinal fluid diversion fails to improve neurological function. 1

Initial Management

• Patients with obstructive hydrocephalus should be rapidly transferred to a center with neurosurgical expertise if their condition is deemed survivable 1
• Serial physical examinations and appropriate neuroimaging should be performed to identify worsening brain swelling 1
• Patients should be immediately intubated if they develop neurological deterioration with respiratory insufficiency 1

Surgical Management Algorithm

First-Line Treatment:

• Emergency ventriculostomy (external ventricular drain placement) is the initial surgical intervention for acute obstructive hydrocephalus 1
• Ventriculostomy is effective in isolation in relieving symptoms in many cases, even among patients with acute ischemic cerebellar stroke 1
• The procedure involves placement of a catheter into the ventricular system to drain cerebrospinal fluid (CSF) and reduce intracranial pressure 1

Second-Line Treatment:

• If cerebrospinal fluid diversion by ventriculostomy fails to improve neurological function, decompressive suboccipital craniectomy should be performed 1
• Decompressive suboccipital craniectomy with dural expansion is indicated when:
  • Cerebellar infarction causes neurological deterioration from brainstem compression despite maximal medical therapy 1
  • Evidence of mass effect and hydrocephalus is present, as 85% of patients progressing to coma die without intervention 1

Combined Approach:

• When deemed safe and indicated, obstructive hydrocephalus should be treated concurrently with ventriculostomy during decompressive surgery 1
• Suboccipital craniectomy, durotomy, and duraplasty to reduce mass effect on the brainstem and restore CSF drainage should be considered early 1

Special Considerations

• Risk of upward herniation exists with ventriculostomy alone but can be minimized with conservative cerebrospinal fluid drainage 1
• Conservative measures such as elevating the head of bed, osmotic diuretics, and hyperventilation provide only transient benefit 1
• Half of patients progressing to coma who are treated with suboccipital decompression have good outcomes 1
• When considering decompressive suboccipital craniectomy, it is reasonable to inform family members that the outcome after cerebellar infarct can be good after the procedure 1

Endoscopic Approaches

• In centers with neuro-endoscopic expertise, endoscopic third ventriculostomy (ETV) is the preferred procedure for certain cases of obstructive hydrocephalus 1
• ETV can be performed through a right frontal burr hole, creating a perforation in the third ventricular floor that is enlarged using appropriate instruments 2
• This approach can be effective even in children under 1 year of age, potentially avoiding the need for permanent CSF shunting 2

Pharmacological Management

• Acetazolamide may be used as an adjunctive treatment in certain cases of hydrocephalus, though it is not a replacement for definitive surgical management 3

Monitoring and Follow-up

• Patients require regular neurological checks, monitoring for signs of increased intracranial pressure, management of the drainage system, and monitoring for potential complications 4
• Patients with hydrocephalus typically require at least 48 hours of close neurological monitoring to stabilize intracranial pressure and assess the need for continued CSF drainage 4
• Long-term follow-up is essential as delayed failure of treatment may occur 2