Is it safe to delay treatment of hydrocephalus in an infant?

Delaying Treatment of Hydrocephalus in Infants

Delaying permanent shunt placement in infants with hydrocephalus is not only safe but recommended through the use of temporary surgical measures, as early permanent shunt insertion results in twice as many revisions compared to delayed placement after temporary CSF diversion. 1

The Evidence for Delayed Permanent Shunting

The current standard of care explicitly supports delaying permanent shunt insertion in premature infants with posthemorrhagic hydrocephalus (PHH). 1 A retrospective study demonstrated that infants who underwent initial permanent VP shunt insertion required twice as many revisions at 3-year follow-up compared to those who had temporary shunts first, despite the delayed group receiving permanent shunts at older ages and larger weights. 1

The rationale for delay includes: 1

• Allowing blood products from intraventricular hemorrhage to dissipate from CSF
• Permitting infant weight gain and immune system maturation
• Reducing infection risk (preterm infants have significantly higher postoperative infection rates than term infants)
• Minimizing lifelong shunt dependency complications

When Delay is NOT Safe: Clinical Thresholds

You must intervene with temporary measures when the infant demonstrates symptomatic elevated intracranial pressure. 1 The specific clinical signs requiring intervention include: 1

• Rapidly enlarging head circumference (>2 cm in <7 days)
• Increased splaying of cranial sutures
• Full, tense fontanel
• Worsening apnea and bradycardia episodes
• Lethargy
• Feeding intolerance

Algorithmic Approach to Temporizing Treatment

First-Line: Serial Lumbar Punctures

Do NOT use serial lumbar punctures routinely to prevent shunt placement—this has Level I evidence (highest certainty) showing it does not reduce shunt need or prevent progression. 1 However, serial LPs can be attempted initially if the lumbar subarachnoid space communicates with the ventricular system, removing up to 10 mL CSF per LP to stabilize head circumference. 1

Second-Line: Temporary Surgical Measures

When serial LPs fail to maintain clinical stability, temporary surgical CSF diversion is indicated. 1, 2 The options include: 1, 2, 3

Preferred options (in order):

1. Ventriculosubgaleal (VSG) shunts - These reduce the need for daily CSF aspiration compared to ventricular access devices (Level II evidence). 1, 2, 3
2. Ventricular access devices (VADs) - These reduce morbidity and mortality compared to external ventricular drains. 1, 3
3. External ventricular drains (EVDs) - Higher morbidity/mortality than VADs; reserve for acute situations. 1, 3

Timing of Permanent Shunt Placement

There is no specific weight or CSF parameter to direct timing of permanent shunt placement (Level III evidence). 1 The decision requires clinical judgment balancing: 1

• Risk of inadequately treated elevated ICP causing brain damage
• Perioperative surgical risks (especially infection)
• Lifelong risks of shunt dependency

Insert temporary shunts after: 1

• Failure of serial LP management
• Active systemic infections have been treated (when possible)
• Convincing clinical symptoms with imaging confirmation

What NOT to Do: Contraindicated Interventions

The following have Level I evidence (highest certainty) showing they are NOT effective and should NOT be used: 1, 3

• Acetazolamide and furosemide - Do not reduce shunt need; actually increased death and neurological morbidity at 1 year in randomized trials. 1, 3
• Intraventricular thrombolytics (tPA, urokinase, streptokinase) - Do not reduce shunt need; may increase secondary intraventricular hemorrhage. 1, 3
• Routine ventricular puncture - Associated with increased CSF infection and loculated hydrocephalus; reserve only for infants in extremis. 1

Critical Pitfalls to Avoid

Neonatal meningitis from shunt infection is associated with significant decline in performance at 2 years of age. 1 This underscores why delaying permanent shunt insertion until the infant is older with better immunity is protective, not harmful. 1

Do not confuse "delay" with "withhold treatment." Symptomatic hydrocephalus with elevated ICP requires immediate temporary CSF diversion—the delay applies only to permanent shunt insertion. 1, 2