Treatment Strategies and Challenges to Avoid Cerebrospinal Fluid Shunting for Pediatric Hydrocephalus

Abstract

Treatment for pediatric hydrocephalus aims not only to shrink the enlarged ventricle morphologically but also to create an intracranial environment that provides the best neurocognitive development and to deal with various treatment-related problems over a long period of time. Although the primary diseases that cause hydrocephalus are diverse, the ventricular peritoneal shunt has been introduced as the standard treatment for several decades. Nevertheless, complications such as shunt infection and shunt malfunction are unavoidable; the prognosis of neurological function is severely affected by such factors, especially in newborns and infants. In recent years, treatment concepts have been attempted to avoid shunting, mainly in the context of pediatric cases. In this review, the current role of neuroendoscopic third ventriculostomy for noncommunicating hydrocephalus is discussed and a new therapeutic concept for post intraventricular hemorrhagic hydrocephalus in preterm infants is documented. To avoid shunt placement and achieve good neurodevelopmental outcomes for pediatric hydrocephalus, treatment modalities must be developed.

Fibrinolytic (Thrombolytic) Therapy for Post Intraventricular Hemorrhagic Hydrocephalus in Preterm Infants

“…The next approach was to safely perform ventriculoperitoneal (VP) shunt surgery to treat the hydrocephalus and the subsequent challenge was to reduce the need for permanent VP shunt placement. The mission of current pediatric neurosurgeons is to reduce the risk of white matter damage and improve neurological outcomes [ 5 , 7 , 21 , 26 , 40 ].…”

“…The following therapeutic concepts should be considered to improve neurodevelopmental outcomes : 1) continuous intracranial pressure control from the early PIVHH stage; 2) morphological recovery of the brain mantle volume as soon as possible; 3) rapid hematoma dissolution and wash out; 4) reduction of free radicals and inflammatory cytokines; 5) restoration of physiological cerebrospinal fluid (CSF) dynamics; and 6) avoidance of permanent VP shunt placement. These therapeutic approaches contribute to the minimization of periventricular white matter damage [ 5 , 26 , 40 ].…”

“…Thirteen clinical studies have been conducted since 2000 [ 3 , 8 , 9 , 11 , 16 , 27 , 29 , 32 , 36 , 41 , 42 , 45 , 49 ]. Clinical outcomes, including VP shunt requirement rates, complication rates such as infection and secondary bleeding, and cognitive outcomes, were similar between the two treatment groups [ 19 , 26 ] ( Table 1 ). However, advanced surgical techniques are essential for performing NEL, and its application to extremely small heads and slightly enlarged ventricles is limited.…”

“…Considering various factors, the ideal treatment strategies for PIVHH in extremely low birth weight infants are now considered to be the following [ 5 , 25 , 26 ] ( Fig. 8 ) : step 1, EVD management combined with fibrinolytic therapy using UK (not tPA); step 2, NEL, if possible; and step 3, Either intermittent CSF evacuation using a ventricular reservoir, or a ventriculosubgaleal shunt, which has long been considered the standard treatment.…”

Perspectives : Understanding the Pathophysiology of Intraventricular Hemorrhage in Preterm Infants and Considering of the Future Direction for Treatment

“…Specifically, the goal has been to successfully place a permanent ventriculoperitoneal (VP) shunt after temporary cerebrospinal fluid (CSF) management (ventricular access device [VAD] or ventriculosubgaleal shunt [VSg] shunt), and the main concerns have been infection and shunt failure. From now on, however, pediatric neurosurgeons should focus their attention and efforts on reducing the incidence of WMI and improving long-term neurodevelopmental functional outcomes in ELBW infants [ 14 , 21 , 42 , 66 ]. In this paper, the recently clarified mechanism of brain damage caused by IVH and PHVD and new treatment approaches for PHH are briefly summarized.…”