Rethinking Definitive Treatment for Hydrocephalus in Infancy: A Review of Outcomes and Evolving Surgical Strategies

The current standard of treatment for hydrocephalus is attempted definitive management with ventriculoperitoneal (VP) shunt or endoscopic third ventriculostomy (ETV), often combined with choroid plexus cauterization (CPC). However, VP shunts, ETVs, and ETV/CPCs have high failure rates in young patients, raising the question if definitive management is the best treatment paradigm in this population. Accordingly, this review aims to compile treatment outcomes for pediatric hydrocephalus patients <6 months of age, with the aim of highlighting the need for alternative treatments or treatment strategies in this population. This review finds that definitive management with VP shunts in patients <6 months of age at time of surgery in pooled etiology cohorts have documented failure rates ranging from 38-59%. Definitive management with ETV or ETV/CPC in patients <6 months of age at time of surgery in pooled etiology cohorts have failure rates from 47 to 80%. Failure rates this high raise the question if early definitive management is effectively unpredictable temporized treatment. Temporizing procedures including ventriculosubgaleal shunts and ventricular access devices can allow patients additional time to develop prior to definitive management, typically last for 1-2 months, and have been safely used in patients with a variety of hydrocephalus etiologies. Given the known, longstanding, high failure rates of definitive intervention with VP shunts and ETV/CPC in patients <6 months of age, alternative treatments or treatment strategies are needed. Temporizing procedures may represent one avenue to improve treatment strategy in young hydrocephalus patients.