How is it treated and managed?
Treatment depends upon the underlying cause of the hydrocephalus and in infancy, the weight of the child.
Treatment of the hydrocephalus is the first priority. However, very often, treatment of the underlying cause must be carried out at the same time or very soon afterwards.
Most children with hydrocephalus are treated by surgical insertion of a shunt to divert cerebrospinal fluid (CSF) from the lateral ventricle to another part of the body, where it can be absorbed thereby reducing pressure in the brain. This procedure is performed in the operating room by a neurosurgeon. A flap is cut in the scalp and a small hole is drilled in the skull. A small silastic catheter is passed into a ventricle of the brain. A one way valve which controls flow of CSF is attached to the catheter. Another catheter is attached to the valve and tunnelled under the skin, behind the ear, down the neck and chest and usually into the peritoneal (abdominal) cavity (ventriculoperitoneal shunt). Less often used alternative sites to the peritoneal cavity include the right atrium of the heart via neck veins or the pleural space surrounding the lungs.
Some children can be treated by an alternative procedure called endoscopic third ventriculostomy (ETV) in which a neuroendoscope is used to make a small hole in the floor of the third ventricle so that CSF can drain towards the re-absorption sites of the brain.
Another procedure that can be performed is External Ventricular Drainage (EVD), which is the temporary drainage of CSF from the lateral ventricles to a closed collection system outside the body.
For children less than 2kg in weight, shunting tends to be deferred because of the high rate of shunt failure, usually secondary to infection. Temporary procedures, such as serial lumbar punctures, serial ventricular taps, EVD or an Ommaya reservoir can be used until the child is old enough for a permanent procedure to be carried out.
Shunt care
Parents and older children need to be taught about the signs and symptoms of shunt failure. They will be provided with printed information about the shunt and a management plan about who to contact and when to go to hospital. Children with shunts should be encouraged to live as normal a life as possible. However, there are some special precautions that apply. These include avoiding some contact sports like boxing that may cause injury to the shunt valve or head injury and avoiding wearing bags on the side of the body where the shunt tubing passes down the side of the neck.
If a child has a programmable shunt, the shunt can be adversely affected by magnetic fields. Parents and children are advised not to place or play with magnets near the shunt and the shunt may require reprogramming before the child undergoes certain procedures, for example MRI scanning.
Shunt related problems
These include -:
- Mechanical, either obstruction or fracture/destruction of the shunt tube
- Infection which usually occurs within six months of insertion
- Acute over drainage which can result in sub-dural haematomas (blood clots under the skull overlying the brain due to tearing of blood vessels) or chronic over drainage which can result in collapse of the ventricles (slit ventricles) resulting in obstruction
- “Shuntalgia” which is discomfort at the shunt valve or along the route of the catheter in the neck.
- Accumulation of CSF at the site of deposition, for example abdominal swelling or hydroceles (fluid surrounding the testicles) in ventriculoperitoneal shunts
Shunt revision
About 6 of every 10 children require shunt revision or replacement at some time in their lives because of shunt failure. Shunt failure is most likely in the first year after insertion. Causes of shunt failure include obstruction, infection and disconnection, breakage or displacement of components.
Aids and adaptations
There are no aids or adaptations specific to the management of hydrocephalus. However, various aids and adaptations may be used for the associated disabling conditions.
