Hydrocephalus is the most common condition treated by pediatric neurosurgeons. It arises when there is a disturbance in the normal production, circulation and/or reabsorption of cerebrospinal fluid (CSF) in the brain. When this occurs there is a characteristic buildup of CSF within the ventricles (normal hollow cavities within the brain) that may cause progressive pressure, leading to brain damage or death.
A shunt is essentially a hollow tube with a small valve that prevents over drainage. The top end of the tube is in the ventricle and has access to the CSF and the bottom end goes to a body cavity where the fluid may be reabsorbed. The most common cavity utilized is the peritoneum/abdomen (VP shunt) or atrium of the heart (VA shunt). Shunts were developed in the 1960s and have proven an effective way through a challenging way of controlling hydrocephalus; however, they are prone to obstruction and infection. In virtually all pediatric neurosurgery centers only about half of shunts inserted to control hydrocephalus are still functioning 2 years later.
Our group has extensive experience with ventricular shunts. We perform over 300 shunt operations per year and are involved in multiple multi-center research initiatives (see Hydrocephalus Research below).
Endoscopic Third Ventriculostomy (ETV)
An ETV can be thought of as a CSF “bypass” procedure and is performed by making a small hole through the floor of the third ventricle of the brain. This allows the CSF to leave the ventricles, entering the space around the outside of the brain where it is normally absorbed. ETV is most effective if the primary problem is an obstruction to flow elsewhere in the brain. Perhaps the best part is that an effective ETV eliminates the need for a shunt in children with hydrocephalus. Only some children are good candidates for ETV and there are real though small risks associated with the procedure. All of our neurosurgeons perform ETV so it is readily available.
The historical success rate of ETV is low in infants less than 2 years of age. The addition of choroid plexus cauterization (CPC) to ETV by Ben Warf, MD, while practicing in Uganda, dramatically increased the treatment success rate in infants when compared to ETV alone. Along with our Hydrocephalus Clinical Research Network partner programs, we are performing increasing numbers of ETV/CPC procedures, hoping to reduce the overall number of shunts placed and the morbidity associated with them. Most of our neurosurgeons learned the technique for ETV/CPC directly from its inventor, Dr. Warf. Our ever-growing experience with ETV/CPC, together with that of our HCRN colleagues, will help us learn how to provide more effective and safer care for infants with hydrocephalus in the future
The most important research being performed in pediatric hydrocephalus is occurring within a 9 institution network called the Hydrocephalus Clinical Research Network. COA/UAB is proud to be a founding member of the HCRN and the leading contributor of patients /procedures to its many studies. The HCRN is a diverse group of researchers and neurosurgeons supported by research grants, philanthropists, and parents who devise and conduct rigorous multi-institutional trials about the diagnosis, treatment, and outcomes of hydrocephalus in children.
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