What are the treatment options for hydrocephalus?

Treatment of Hydrocephalus

Primary Treatment Decision

Both cerebrospinal fluid (CSF) shunts and endoscopic third ventriculostomy (ETV) are equally effective treatment options for hydrocephalus, with selection based on hydrocephalus type, patient age, and anatomical suitability. 1, 2

Treatment Selection Algorithm

Step 1: Classify Hydrocephalus Type

For obstructive (non-communicating) hydrocephalus:

• If aqueductal stenosis is present with suitable anatomy (normal ventricular configuration, adequate third ventricle floor), ETV should be considered first due to lower long-term failure rates after the initial 3-month period 2, 3
• ETV demonstrates higher early failure rates (within 3 months) compared to shunts, but superior outcomes beyond 3 months 1, 3

For communicating hydrocephalus:

• VP shunt placement is the recommended treatment as ETV is not anatomically feasible for this type 2, 4

Step 2: Evaluate Anatomical Suitability for ETV

VP shunt is indicated when:

• Complex ventricular anatomy exists that precludes safe ETV 2, 4
• Previous ETV has failed 2, 4
• Slit ventricles make catheter placement technically challenging (though this requires careful surgical planning rather than absolute contraindication) 4

Step 3: Screen for Contraindications

Absolute contraindications to VP shunt placement:

• Active untreated CNS infection—ensure appropriate antimicrobial therapy is established first 2, 4
• Scalp or abdominal skin infection at proposed surgical sites 4

Relative contraindications requiring delay:

• Active systemic infection without CNS involvement (shunt infection occurs in approximately 11% of initial placements within 24 months) 2, 4
• Recent abdominal surgery with peritoneal inflammation 4

Infection Prevention Protocol

Mandatory infection reduction measures:

• Administer gram-positive antibiotic coverage before skin incision, which reduces infection risk from 10.7% to 5.9% 2, 4

High-risk patients requiring antibiotic-impregnated shunt tubing:

• Previous shunt infection history 2, 4
• Recent shunt revision 2, 4
• Premature infants 2, 4
• In pediatric patients specifically, antibiotic-impregnated catheters reduce infection with an odds ratio of 0.21 (95% CI 0.08-0.55) 2, 4

Special Population Considerations

Normal Pressure Hydrocephalus

VP shunt insertion is indicated when all three classic symptoms are present:

• Documented gait disturbance 2, 4
• Cognitive decline 2, 4
• Urinary incontinence 2, 4
• This demonstrates 91.2% overall improvement at 12 months 2, 4

Pediatric Patients Under 1 Year

• Expect 45% shunt revision rate within 9 months, requiring close follow-up 2, 4
• For premature infants, delay permanent shunt placement until infant reaches approximately 2.5 kg to decrease infection risk 2, 4
• Consider temporary management with ventricular access devices or external drains in posthemorrhagic hydrocephalus of prematurity 4

Cryptococcal Meningitis with Refractory Elevated ICP

VP shunt insertion is indicated for:

• Persistent elevated intracranial pressure (≥25 cm CSF) despite conservative measures including repeated lumbar drainage for more than 2 days 2, 4
• VP shunt placement can proceed during active cryptococcal CNS infection without complete CSF sterilization if appropriate antifungal therapy is being administered 4

Critical Pitfalls to Avoid

Do not overlook ETV in appropriate candidates with obstructive hydrocephalus and suitable anatomy, as it has superior long-term outcomes after the initial 3-month period compared to shunts 2, 4

Do not place permanent shunts in premature infants under 2.5 kg when temporary measures such as ventricular access devices can be used 2, 4

Do not proceed with shunt placement during active untreated infection—this is an absolute contraindication that requires antimicrobial therapy establishment first 2, 4

Do not skip antibiotic prophylaxis—gram-positive coverage before skin incision nearly halves infection rates 2, 4

Timing Considerations

Emergency placement required for:

• Acute visual deterioration with papilledema requiring urgent decompression 4
• Acute shunt malfunction with neurological deterioration 4

Elective outpatient placement appropriate for:

• Stable normal pressure hydrocephalus patients without acute complications 4