Hydrocephalus and Treatment: Shunts and Endoscopic Third Ventriculostomy
Posted Aug 21 2012 10:07pm
Hydrocephalus is an abnormal build-up of cerebrospinal fluid (CSF) in the
ventricles inside the brain. The ventricles are fluid-filled spaces in the
brain. CSF is a clear, colourless fluid that looks like water and contains small
amounts of salt, sugar, and cells.
CSF is constantly produced in the ventricles. It moves around the brain and
spinal cord, is absorbed, and is then replaced by new CSF. Some of the functions
of CSF are:
to protect the brain and spinal cord from injury
to nourish brain cells, which helps with brain functioning
to carry waste products from brain cells away
CSF moves around the brain and spinal cord on a specific pathway. When too
much CSF gets trapped anywhere along this pathway, it can expand the ventricles
and put pressure on the brain. This condition is called hydrocephalus.
There are two types of hydrocephalus
Communicating hydrocephalus is the build-up of pressure from too much CSF
that is not being properly absorbed.
Non-communicating hydrocephalus is the build-up of pressure from CSF when a
blockage occurs within the brain. Some causes ofCommunicating hydrocephalus
may be a tumour, a blood clot, or a narrowing of part of the CSF pathway found
A person born with hydrocephalus is said to have congenital hydrocephalus.
Those who develop it later in life are said to have acquired hydrocephalus.
To find out if your child has hydrocephalus, the doctor will assess your
child and do some tests.
Your baby may have some or all of the following symptoms
vomiting (throwing up)
sleepy (hard to wake up) or not as awake or alert as usual
large head (your family doctor can measure this)
bulging soft spot (fontanelle) on the top of the head
seeming irritable (cries easily or without reason)
very noticeable scalp veins
slowness at reaching milestones (for example, slow to roll over, slow to
"sunset" eyes, when the eyes appear to be always looking down and are not
able to look up
Your child may have some or all of the following symptoms
nausea and vomiting
tired (sleeping more than usual, difficult to wake up, does not want to play
changes in personality, behaviour, or school performance
loss of coordination
changes in vision
Hydrocephalus is often diagnosed with imaging tests. These tests include CT
scan, MRI, and ultrasound. These technologies give doctors different views of
what is going on inside the brain. These imaging tests may reveal a blockage or
a build-up of CSF.
Using MRI and ultrasound, hydrocephalus is sometimes diagnosed before a child
Because CT scans and MRI require a person to be still while the pictures are
being taken, some children need to be given sedation medicine to help them keep
still during the tests.
There are no effective medicines for hydrocephalus. Most children require
surgery. The goal is to lessen the pressure in the brain by providing another
pathway for CSF to be drained and absorbed away from the brain.
There are two types of surgery for hydrocephalus
The most common treatment is the insertion of a shunt. The shunt works by
moving fluid from an area where there is too much CSF to an area where it can be
absorbed into the body.
Some children with non-communicating hydrocephalus can have surgery called
an endoscopic third ventriculostomy (ETV). This surgery creates an opening to
allow CSF to flow in and around the brain as it should.
Both these surgeries are described in detail below.
The most common treatment of hydrocephalus is the surgical placement of a
shunt. A shunt is a soft, flexible tube.
The top end of the shunt is placed in the ventricle fluid spaces inside the
brain. This tube is attached to a valve that controls the flow of CSF through
the shunt. The tube is then tunnelled below the skin to an area of the body
where the fluid can be absorbed. One area is the lining of the abdominal cavity
(the peritoneum). This is called a ventriculo-peritoneal shunt (VP shunt).
Less often, the shunt is connected from the brain to other parts of the
A shunt from the brain to the lining around the lung (pleural space) inside
the chest is called a ventriculo-pleural shunt.
A shunt from the brain to veins draining into the heart is called a
Your child's neurosurgeon will decide what type of shunt tube is best for
your child. All shunts will only allow CSF flow in one direction. Some shunts
may also have a small bubble or "reservoir" near the top that the doctor can use
to take samples of CSF for testing.
Sometimes a special type of shunt is needed where the pressure setting is
adjustable. This is called a programmable shunt valve. This allows the surgeon
to program the shunt to control how much CSF is draining. It is important to
remember that the pressure setting of this shunt can be changed by a magnet. MRI
scans use large magnets, so if your child needs an MRI you must make sure to
tell the doctor first about the shunt. An X-ray may need to be taken after the
MRI to make sure that the pressure setting has not been changed.
Your child is brought down to the operating room and goes to sleep under
general anesthesia. Your child will not feel any pain during the opreation.
The area from the head to the abdomen (belly) is scrubbed with a special
soap. The surgeon makes incisions (cuts) on the head and abdomen. The shunt
tubing is tunnelled just below the skin. The ventricular (top) end of the shunt
is passed through a small hole in the skull made by the surgeon and gently
passed into the ventricle. The abdominal (bottom) end is passed through a small
opening in the abdomen. The incisions are then closed using staples or stitches.
The operation takes between 1 and 2 hours.
An endoscopic third ventriculostomy (ETV) is the second type of surgery done
on some children who have hydrocephalus. Your surgeon will tell you if this
surgery is possible for your child.
During an ETV, the surgeon makes an opening in the floor of the ventricle at
the base of the brain. The CSF is then no longer blocked inside the ventricle.
Now it can flow in and around the brain as it should.
This means that the child will not need a shunt, but instead will rely on the
opening made by the surgeon during surgery. It is still very important to watch
your child for signs that the pressure is building up again, as it is possible
that the ETV could fail or become blocked. If any signs come back, it is very
important to call your surgeon right away so that your child can be checked.
Your child is brought down to the operating room and is put asleep under
general anesthesia. Your child will not feel any pain during the operation. An
incision is made on the head. A special scope with a camera on it is passed into
the ventricle. The surgeon uses the camera to see the part of the ventricle that
needs to be opened up. Once the opening is made, the surgeon will be able to see
if the CSF is now flowing outside of the ventricle.
If the surgeon is not able to safely do the ETV, a shunt will be inserted
instead. The incisions are then closed using staples or stitches.
The operation takes between 1 and 2 hours.
Your child is then taken to the Post Anesthetic Care Unit (PACU) recovery
room. Your child will wake up soon after the operation. You will be able to see
your child as soon as he wakes up. Your child will spend about 1 to 2 hours in
the PACU to recover from the anesthetic. Then your child will be returned to his
room in the Neurosurgical Unit.
Your child will have a bandage on the head. If your child received a
shunt, he will have another bandage on the abdomen or chest, depending on the
type of shunt.
The nurse will check your child often. She will also be checking to see how
easily your child wakes up, even at night.
Your child will have an intravenous (IV) line after surgery until he is
Your child may have a CT scan after surgery to make sure the ventricles have
decreased in size and, if your child needed a shunt, that the shunt is in a good
After the operation, your child may have pain at the operative sites. The
nurse will give your child medicine by mouth about every 4 hours. This should
control the pain. If it does not control the pain, speak to your child's nurse.
Your child may also learn other ways to control pain, such as blowing bubbles
or relaxation breathing. As your nurse or Child Life specialist to help you and
your child learn how to do this.
Your child's surgeon will tell you when your child can start normal activity,
such as sitting up and walking. After your child has recovered from the surgery,
he can go home.
The shunt may stop working properly after you go home. Sometimes the tube can
become blocked, come apart, or break. Or your child may grow taller so that the
tube moves out of the abdomen. Or it may become infected.
Similarly, an endoscopic third ventriculostomy (ETV) does not guarantee your
child's hydrocephalus will never come back. If you notice any signs of
hydrocephalus coming back, it is very important to call your surgeon right away.
Your child needs medical attention right away if you see any signs or
symptoms of a shunt problem or a failed ETV.
If your child's shunt or ETV is not working properly, the pressure will
return to the brain. Signs that the shunt or ETV is not working are the same as
the signs of hydrocephalus, listed above. Your child may have the same signs as
before their shunt was put in, or there may be new signs.
Signs of a shunt infection include the following:
puffiness or redness of the skin around the tube and at incision (cut) sites
a stiff neck
fluid coming out of the incision
loss of appetite or not eating well
generally feeling sick
abdominal (belly) pain
If your child has any of these symptoms, call 911 or your local emergency
services right away. Shunt malfunctions, infections, and failed ETVs that are
not treated promptly and appropriately can lead to coma and possibly death.
How your child's staples or stitches are taken out depends on the type of
staple or stitch that was used. Your surgeon or nurse will tell you what type of
stitches were used.
If your child has staples or stitches that need to be taken out, your family
doctor will need to do this. The stitches should be taken out about 7 to 10 days
after the operation. Staples should be removed about 10 days after the
operation. Your surgeon or nurse will tell you when they need to come out.
If staples were used, you will be given a special remover to take to your
If your child has the kind of stitches that dissolve on their own, you can
see your family doctor to have the incision line checked, but the stitches will
not need to be taken out.
Your surgeon will need to see your child for a follow-up clinic visit about 6
weeks after you go home. The appointment may be made for you when your child
leaves the hospital. If not, call the neurosurgery clinic to make an appointment
Any medical questions you may have can be answered by your surgeon. Be sure
to write down your questions before you meet the surgeon. Other questions can be
answered by your nurse or by a Nurse Practitioner.
Your child's neurosurgeon is
Your child's nurse practitioner is
Their telephone number is
A child with hydrocephalus needs to see a doctor often to make sure the shunt
or ETV is working properly and that the pressure does not begin to build up
again. Several members of a team will help and guide you as your child grows and
develops. You should encourage your child to become involved in this ongoing