Treatment of Communicating Hydrocephalus
For communicating hydrocephalus, permanent CSF diversion through ventriculoperitoneal, ventriculoatrial, or lumboperitoneal shunting is the definitive treatment for chronic symptomatic cases, while acute presentations require temporary external ventricular drainage or lumbar drainage. 1
Acute Management Approach
For acute symptomatic communicating hydrocephalus, initiate CSF diversion immediately using external ventricular drainage (EVD) or lumbar drainage. 1 The choice between these modalities depends on clinical presentation:
- EVD is preferred when: patients have decreased level of consciousness (GCS ≤8), clinical evidence of transtentorial herniation, or significant intraventricular hemorrhage 2
- Lumbar drainage is an alternative when: there is confirmed communicating hydrocephalus without obstruction, particularly after intracerebral hemorrhage with ventricular extension where intraventricular blood has cleared 3
Critical Technical Points for Acute Management
- Target cerebral perfusion pressure of 50-70 mm Hg when using ICP monitoring 2
- For lumbar drainage, reduce pressure to 50% of opening pressure or 200 mm H₂O (whichever is greater) 4
- Continue daily lumbar punctures for at least 4 days until pressure stabilizes below 250 mm H₂O 4
- Do not routinely wean EVD over >24 hours, as this does not reduce the need for permanent shunting 1
Chronic/Definitive Management
Permanent CSF diversion is required for chronic symptomatic communicating hydrocephalus. 1 Options include:
- Ventriculoperitoneal (VP) shunt - most common approach 1
- Ventriculoatrial shunt - alternative when peritoneal cavity unavailable 1
- Lumboperitoneal shunt - option for communicating hydrocephalus without obstruction 1
Predictors of Need for Permanent Shunting
Factors associated with shunt-dependent hydrocephalus (occurring in 8.9-48% of cases after subarachnoid hemorrhage) include: 1
- Older age
- Early ventriculomegaly on imaging
- Intraventricular hemorrhage
- Poor clinical condition at presentation
- Female sex
Special Population: Premature Infants with Posthemorrhagic Hydrocephalus
For premature infants, use temporizing measures before definitive shunting. 2 The hierarchy of interventions:
Temporizing Surgical Options (in order of preference):
- Ventriculosubgaleal (VSG) shunts - reduce need for daily CSF aspiration compared to VADs 2, 1
- Ventricular access devices (VADs) - preferred over EVDs due to lower morbidity and mortality 2, 4
- External ventricular drains (EVDs) - higher morbidity/mortality than VADs 4
- Lumbar punctures - may be used but clinical judgment required 2
What NOT to Do in Premature Infants:
- Do not use serial lumbar punctures routinely - Level I evidence shows no reduction in shunt placement need 2, 1
- Do not use acetazolamide or furosemide - not effective for reducing shunt placement 1, 4
- Do not use intraventricular thrombolytics (tPA, urokinase, streptokinase) - not recommended for reducing shunt need 1, 4
Medications to Avoid
Corticosteroids should NOT be administered for treatment of elevated ICP in communicating hydrocephalus. 2 This is a Class III (No Benefit) recommendation with Level B evidence from the American Heart Association.
Diagnostic Confirmation Before Treatment
- Obtain contrast-enhanced MRI to confirm communicating hydrocephalus and distinguish from non-communicating type 1, 5
- Look for hallmark findings: ventriculomegaly (not from atrophy) and transependymal edema 1, 5
- Perform lumbar puncture with opening pressure measurement to confirm communicating nature 1
Common Pitfalls to Avoid
- Do not delay neurosurgical consultation - most patients with increased ICP will require permanent shunt placement 4
- Avoid repeated lumbar punctures - may contribute to subsequent shunt infection 4
- Do not use early prophylactic hyperosmolar therapy - not established for improving outcomes in hydrocephalus 2
- Address underlying etiology - when hydrocephalus is secondary to infection, hemorrhage, or tumor, treat the primary condition concurrently 1, 5