US Pharm. 2013;38(3):HS8-HS11.
ABSTRACT: In hydrocephalus, a disease or anatomical defect causes
an increase in the amount of cerebrospinal fluid (CSF) present in the
cranium, which most commonly results in increased pressure against the
brain tissue. Hydrocephalus is difficult to diagnose because of its
varied signs and symptoms, which commonly overlap with those of other
medical conditions. There are generally two approaches to the treatment
of hydrocephalus: 1) shunt placement and 2) endoscopic third
ventriculostomy (surgical creation of an opening in the floor of the
third ventricle to enable the passage of CSF). The treatment of
hydrocephalus often requires long-term care and lifelong follow-up,
especially in children and neonates in whom there is a congenital cause.
Hydrocephalus is a condition in which a disease state or defect
causes an increase in the amount of cerebrospinal fluid (CSF) present in
the cranium, most commonly resulting in increased pressure against the
brain tissue.1 The word hydrocephalus translates to
“water on the brain,” but the condition is caused by a variety of
disorders and disease states, thus making it complex to define and
diagnose.1 Most CSF is produced by the choroid plexus in the third and fourth ventricles in the brain.2 It fills the subarachnoid spaces, protecting and cushioning the brain.2
As more CSF is produced, it runs from the brain to the spinal cord and
is removed from circulation via the arachnoid villi and the vertebral
venous plexus.2 When hydrocephalus occurs, part of this
process is blocked, although different parts are blocked depending upon
the type of hydrocephalus. Causes range from obstructions to congenital
diseases (TABLE 1).1,3-5
Because hydrocephalus has many different causes, it is difficult to
classify specific varieties. As a result, many different classification
systems have been developed. The most common way to classify
hydrocephalus is to determine whether a case is 1) congenital or
acquired or 2) obstructive or communicating. Congenital hydrocephalus is
caused by a birth defect or genetic disorder; acquired hydrocephalus
has other causes, such as a hemorrhage, infection, or tumor.1 Obstructive hydrocephalus is caused by an obstruction of CSF drainage by a tumor, congenital defect, or infection.6
Most cases of hydrocephalus are obstructive. Communicating
hydrocephalus is caused by an overproduction of CSF that allows
insufficient drainage time, or occurs when CSF is not absorbed at a
normal rate. Examples include cranial hemorrhage and meningitis.6
Other classifications have been developed that specify the type of
hydrocephalus, such as normal pressure hydrocephalus (NPH). A relatively
new classification system is the multicategorical hydrocephalus
classification (McHC), which is complicated and involves eight different
categorical sections, including cause, pathophysiology, and occurrence
of shunt placement.7 McHC is little known and seldom used,
but it does provide a more accurate description of each patient’s case
as it progresses. Regardless of the cause and subsequent classification,
hydrocephalus patients present with similar symptoms (although these
differ with age) and have the same limited number of treatment options.
Detection and Diagnosis
It is difficult to detect hydrocephalus because of its varied signs
and symptoms, which commonly overlap with those of other diseases.
Infants are likely to have a different disease progression from that of
children and adults. Nausea and vomiting are common in infants and
adults. In infants, fussiness and poor appetite are common indicators of
hydrocephalus; however, the most prominent sign is a distended skull.1,3
The sutures in infant skulls are soft and not fully developed, which
allows them to expand upon increased pressure from CSF accumulation.1,3
The increased intracranial pressure commonly causes headaches in adults
and children, as their skull bones are not flexible. Difficulty with
concentration and memory, a lack of balance, decreased bladder control,
and a downward gaze are the most obvious signs in adults and children.1
Since there are many conditions that could potentially cause symptoms
suggestive of hydrocephalus, the most effective process for
identification is to determine the symptoms, complete a differential
diagnosis to rule out other causes (TABLE 2), and perform a CT scan or MRI of the brain to detect any ventriculomegaly.8
Although many causes of hydrocephalus exist, the number of treatments
is limited. All successful, long-term treatments are surgical. There is
little use for medication in hydrocephalus. In some acquired cases, as
with tumors and infections, resolving the underlying condition will
resolve the hydrocephalus, but most patients still require surgical
There are generally two approaches to treating hydrocephalus. The most common treatment is the placement of a shunt.3
In use since the 1950s, this approach is considered the best treatment
option in most cases. The other procedure, endoscopic third
ventriculostomy (ETV), involves the surgical creation of an opening in
the floor of the third ventricle to enable the passage of CSF.6,9
Shunt Placement: As noted above, the standard
treatment for hydrocephalus is shunt placement. Shunts are usually
placed in the lateral ventricle and can have one of three different
drainage points. The most common drainage site is the peritoneum, which
is connected to the shunt with subcutaneous tubing.3,8 This is known as a ventriculoperitoneal shunt. Two other types of shunts, ventriculopleural and ventriculoatrial, terminate in the pleural space and the internal jugular vein, respectively.3 The last type, the lumboperitoneal shunt, is placed in the lumbar intradural space.3
Shunt systems include a valve that controls the rate of drainage. The
valve may have to be accessed surgically, or it may be placed so that
adjustments can be made without further surgery (FIGURE 1).
With current standards and infection control, the postoperative mortality rate for shunt placement is less than 5%.10
Although shunt placement is considered the best treatment for
hydrocephalus, it has several drawbacks. Shunt failure occurs at a rate
of approximately 20% and can be caused by overdrainage, obstruction, or
shunt collapse.8,11 Infection, which eventually can lead to sepsis, occurs at a rate of 5% to 15%.4 Antibiotic-infused shunt catheters appear to greatly reduce the rate of infection.4
ETV: As mentioned previously, ETV is an
alternative treatment for hydrocephalus. It is indicated in patients
with an obstruction that prevents CSF from draining between the third
ventricle and the cortical subarachnoid spaces.9 In this procedure, the floor of the third ventricle is punctured, allowing CSF to flow into the cortical subarachnoid space.6,9
ETV is currently approved in the treatment of obstructive hydrocephalus
and in patients who have had multiple shunt failures and replacements.6,9 ETV also has been shown to be effective for treating NPH.9
The procedure is difficult and requires that the third ventricle floor
and the surrounding structures have dimensions appropriate for
successful completion of the procedure.6 Imaging must be performed before surgery to determine that the anatomy of these structures is appropriate.6
One risk of ETV is piercing an unseen artery on the opposite side of
the third ventricle floor, and infection can occur, although the rate is
lower than that for shunts. There is also a risk of the drain becoming
occluded, which would necessitate additional surgery. ETV may not be
effective in neonates. The survival rate is extremely low for infants
younger than 3 months, but reaches 64% around age 6 months. ETV
generally is not performed in neonates if other options are available.10
Lumbar Puncture: A short-term option for the
treatment of hydrocephalus is to perform periodic lumbar punctures. This
is a temporary approach to reduce the amount of CSF until a long-term
treatment can be performed.12 Lumbar puncture may be used to
treat communicating hydrocephalus, although it is sufficient only for
patients who are still able to absorb some CSF.12 In some
cases, a drain may be placed so that continuous lumbar tapping is not
necessary; however, there is a relatively high rate of infection with
this approach compared with serial lumbar punctures.12 Lumbar puncture may be used in neonates, who have an extremely low surgical success rate with ETV.13
Noninvasive Treatments: At present, there are no
significant noninvasive treatment alternatives. Some studies have shown
that acetazolamide or furosemide may be acceptable for CSF fluid
reduction, but these medications currently are used only on a temporary
basis.14 Both drugs act to reduce the production of CSF by the choroid plexus.14
As with lumbar puncture, these agents are typically used in
low-birthweight infants who will have a low success rate with shunt
placement or ETV.13 There is no evidence that either of these
medications increases survival rates, and a Cochrane review concluded
that therapy with acetazolamide or furosemide is neither effective nor
safe for treating posthemorrhagic ventricular dilatation in infants.14
TABLE 3 gives a brief summary of the different treatment options available for the treatment of hydrocephalus.3,4,6,8,10-14
The treatment of hydrocephalus requires long-term care and lifelong
follow-up. This is especially true for children and neonates whose
hydrocephalus has a congenital cause. Even after appropriate placement
of a shunt, annual neurologic visits are required.11
Complications, including shunt collapse, infection, and occlusions, can
cause a rise in CSF pressure that may lead to symptom recurrence and the
need for additional surgeries.3 Recognizing these signs is
challenging because a number of other diseases have symptoms similar to
those of hydrocephalus. Delaying medical treatment can be deadly, and
all patients with a history of hydrocephalus need to be aware of
pertinent symptoms and seek help immediately if they arise.
Children with hydrocephalus face developmental disorders as they age.
Hydrocephalus patients have reduced motor function, a
lower-than-average adult IQ, and decreased visual function; they also
are at risk for developing epilepsy.11 The extent of the
complications observed is dependent upon the type of hydrocephalus, but
patients with epileptic seizures (approximately 30%) have the worst
clinical outcomes and, compared with patients who did not develop
seizures, are more likely to have an IQ lower than 90.15
About 60% of children with hydrocephalus are able to attend school
(although many have difficulties), and approximately 40% of children
will lead relatively normal lives.1,10,11
Hydrocephalus is a complicated condition to diagnose, and treatment
options are limited. Current long-term treatment options are restricted
to surgical interventions, including shunt placement and ETV. Even if
the underlying disease state, such as an infection or tumor, is
resolved, most patients will require surgical intervention and long-term
1. National Institute of Neurological Disorders and Stroke.
Hydrocephalus fact sheet.
Accessed January 30, 2013.
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14. Whitelaw A, Kennedy CR, Brion LP. Diuretic therapy for newborn infants with posthemorrhagic ventricular dilatation. Cochrane Database Syst Rev. 2001(2):CD002270.
15. Bourgeois M, Sainte-Rose C, Cinalli G, et al. Epilepsy in children with shunted hydrocephalus. J Neurosurg. 1999;90:274-281.
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