Hydrocephalus pp 259-280 | Cite as

Complex Hydrocephalus: Management by “Smart Shunt”

  • Nobuhito MorotaEmail author


Complex hydrocephalus implies the hydrocephalus, which requires multiple surgeries for the treatment. However, its exact definition of what is “complex” is not clear. Treatment of hydrocephalus in general is regarded straightforward and managed by a VP shunt or endoscopic procedures. Anatomical, pathological, mechanical, and human factors can attribute to form complex hydrocephalus. The author defines “complex hydrocephalus” as those which may require multiple surgeries for the treatment of hydrocephalus when treated standard procedures. Basic concept of handling hydrocephalus in the author’s hands is “the simpler, the better.” Whatever the anatomy or background pathogenesis is complex, a simple surgical procedure often brings better surgical outcome. It should be reminded that simple hydrocephalus does have potential to turn into complex one if anything unfavorable develops or being handled poorly in the clinical course. On the other hand, potentially complex hydrocephalus can be controlled by single or staged procedures if treated appropriately. Most of complex hydrocephalus is the product of maltreated hydrocephalus. The best way to prevent complex hydrocephalus is to avoid complications during the initial treatment of hydrocephalus. The initial surgery is the key for preventing complex hydrocephalus, especially among the pediatric population.

Once the case resulted in complex hydrocephalus, every possible effort should be paid to avoid further complication. If any of the endoscopic procedure is indicated, it should be applied first. Avoiding a VP/VA shunt placement is the best choice. An internal shunt with or without endoscopic procedure will help to install a shunt system simple, thus enables avoiding future complications related to the shunt system.

In this chapter, the author described nine cases of complex hydrocephalus and how they were treated. It is strongly recommended to implant a single shunt system with the use of the internal shunt or/and endoscopic procedures, which the author calls “smart shunt.” If a VP shunt is unavoidable, the idea of “smart shunt” should be reminded. The simpler the shunt system, the better the clinical outcome.


Complex hydrocephalus ETV VP shunt Shunt complications 

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  1. 1.
    Hassan SHA, Holekamp TF, Murphy TM, Mercer D, Leonard JR, Smyth MD, Park TS, Limbrick DD Jr. Surgical management of complex multiloculated hydrocephalus in infants and children. Childs Nerv Syst. 2015;31:243–9.CrossRefGoogle Scholar
  2. 2.
    Simon T, Hall M, Riva-Cambrin J, Albert JE, Jeffries HE, LaFleur B, Dean JM, Kestle JRW, Hydrocephalus Clinical Research Network. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. J Neurosurg Pediatr. 2009;4:156–65.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Spennato P, Cinalli G, Carannante G, Ruggiero C, DeCaro MLDB. Multiloculated hydrocephalus. In: Cinalli G, Maixner WJ, Sainte-Rose C, editors. Pediatric hydrocephalus. Milano: Springer; 2004. p. 219–44.Google Scholar
  4. 4.
    Cheok S, Chen J, Lazareff J. The truth and coherence behind the concept of overdrainage of cerebrospinal fluid in hydrocephalus patients. Childs Nerv Syst. 2014;30:599–606.CrossRefPubMedGoogle Scholar
  5. 5.
    Hoppe-Hirsch E, Sainte-Rose C, REnier D, Hirsch JF. Pericerebral collections after shunting. Childs Nerv Syst. 1987;3:97–102.CrossRefPubMedGoogle Scholar
  6. 6.
    Drake JM, Kestle JR, Milner R, Cinalli G, Boop F, Piatt J Jr, Haines S, Schiff SJ, Cochrane DD, Steinbok P, MacNeil N. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery. 1998;43:294–303.CrossRefPubMedGoogle Scholar
  7. 7.
    Gelabert-Gonzalez M, Aran-Echabe E, Serramito-Garcia R. Subdural collections: hygroma and haematoma. In: Di Rocco C, Turgut M, Jallo G, Martinez-Lage JF, editors. Complications of CSF shunting in hydrocephalus: Prevention, identification, and management. Heidelberg: Springer; 2015. p. 285–99.Google Scholar
  8. 8.
    Martínez-Lage JF, Pérez-Espejo MA, Almagro MJ, Ros de San Pedro J, López F, Piqueras C, Tortosa J. Syndromes of overdrainage of ventricular shunting in childhood hydrocephalus. Neurochirugia (Astur). 2005;16:124–33. (Spanish)Google Scholar
  9. 9.
    Pudentz RH, Foltz EL. Hydrocephalus: overdrainage by ventricular shunts. A review and recommendations. Surg Neurol. 1991;35:200–12.CrossRefGoogle Scholar
  10. 10.
    Morota N, Sakamoto K, Kobayashi N, Kitazawa K, Kobayashi S. Infantile subdural fluid accumulation. Diagnosis and postoperative course. Childs Nerv Syst. 1995;11:459–66.CrossRefPubMedGoogle Scholar
  11. 11.
    Gruber RW, Roehrig B. Prevention of ventricular catheter obstruction and slit ventricle syndrome by the prophylactic use of the Integra antisiphon device in shunt therapy for pediatric hypertensive hydrocephalus: a 25-year follow-up study. J Neurosurg Pediatr. 2010;5:4–16.CrossRefPubMedGoogle Scholar
  12. 12.
    Hatlen TJ, Shurtleff DB, Loeser JD, Ojemann JG, Avellino AM, Ellenbogen RG. Nonprogrammable and programmable cerebrospinal fluid shunt valve: a 5-year study. J Neurosurg Pediatr. 2012;9:462–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Lewis AI, Keiper GL, Crone KR. Endoscopic treatment of multiloculated hydrocephalus. J Neurosurg. 1995;82:780–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Oka K, Ohta T, Kibe M, Tomonaga M. A new neurosurgical ventriculoscopy–technical note. Neuro Med Chir (Tokyo). 1990;30:77–9.CrossRefGoogle Scholar
  15. 15.
    Ang BT, Steinbok P, Cochrane DD. Etiological differences between the isolated lateral ventricle and the isolated fourth ventricle. Childs Nerv Syst. 2006;22:1080–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Ogiwara H, Morota N. Endoscopic transaqueductal or intraventricular stent placement for the treatment of isolated fourth ventricle and pre-isolated fourth ventricle. Childs Nerv Syst. 2013;29:1563–7.CrossRefPubMedGoogle Scholar
  17. 17.
    James HE. Spectrum of the syndrome of the isolated fourth ventricle in posthemorrhagic hydrocephalus of the premature infant. Pediatr Neurosurg. 1990–1991;16:305–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Fritsch MJ, Kienke S, Manwaring KH, Mehdom HM. Endoscopic aqueductoplasty and intraventriculostomy for the treatment of isolated fourth ventricle in children. Neurosurgery. 2004;55:372–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Schroeder C, Fleck S, Gaab MR, Schweim KH, Schroeder HWS. Why does endoscopic aqueductoplasty fail so frequently? Analysis of cerebrospinal fluid flow after endoscopic third ventriculostomy and aqueductoplasty using cine phase-contrast magnetic resonance imaging. J Neurosurg. 2012;117:141–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Ogiwara H, Uematsu K, Morota N. Obliteration of the choroid plexus after endoscopic coagulation. J Neurosurg Pediatr. 2014;14:230–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Kulkarni AV, Riva-Cambrin J, Browd SR, Drake JM, Holubkov R, Kestle JRW, Limbrick DD, Rozzelle CJ, Simon TD, Tamber MS, Wellons JC III, Whitehead WE. Endoscopic third ventriculostomy and choroid plexus cauterization in infants with hydrocephalus: a retrospective hydrocephalus clinical research network study. J Neurosurg Pediatr. 2014;14:224–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Warf BC. Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg. 2005;103(6 Suppl):475–81.PubMedGoogle Scholar
  23. 23.
    Morota N, Fujiyama Y. Endoscopic coagulation of choroids plexus as treatment for hydrocephalus: indication and surgical outcome. Childs Nerv Syst. 2004;20:816–20.CrossRefPubMedGoogle Scholar
  24. 24.
    Alp MS. What is a Torkildsen shunt? Surg Neurol. 1995;43:405–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Morota N, Ihara S, Araki T. Torkildsen shunt: re-evaluation of the historical procedure. Childs Nerv Syst. 2010;26:1705–10.CrossRefPubMedGoogle Scholar
  26. 26.
    Keucher RT, Mealey J. Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg. 1979;50:179–86.CrossRefPubMedGoogle Scholar
  27. 27.
    Massimi L, Di Rocco C. Complications specific to the type of CSF shunt: atrial shunt. In: Di Rocco C, Turgut M, Jallo G, Martinez-Lage JF, editors. Complications of CSF shunting in hydrocephalus: Prevention, identification, and management. Heidelberg: Springer; 2015. p. 177–85.Google Scholar
  28. 28.
    Richardson MD, Handler MH. Minimally invasive technique for insertion of ventriculopleural shunt catheters. J Neurosurg Pediatr. 2013;12:501–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Aldana PR, James HE, Postlethwatt RA. Ventriculogallbladder shunts in pediatric patients. J Neurosurg Pediatr. 2008;1:284–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Samadani U, Mattielo JA, Sutton LN. Ventriculo sinus shunt placement: technical case report. Neurosurgery. 2003;53:778–80.CrossRefPubMedGoogle Scholar
  31. 31.
    Tubbs RS, Tubbs I, Loukas M, Cohen-Gadol AA. Ventriculoiliac shunt: a cadaveric feasibility study. J Neurosurg Pediatr. 2015;15:310–2.CrossRefPubMedGoogle Scholar
  32. 32.
    Khanna RK, Rosenblum ML, Rock JP, Malik GM. Prolonged external ventricular drainage with percutaneous long-tunnel ventriculostomies. J Neurosurg. 1995;83:791–4.CrossRefPubMedGoogle Scholar
  33. 33.
    Fichtner J, Güresir E, Seifert V, Raabe A. Efficacy of sliver-bearing external ventricular drainage catheter: a retrospective analysis. J Neurosurg. 2010;112:840–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Raffa G, Marseglia L, Gitto E, Germano A. Antibiotic-impregnated catheters reduce ventriculoperitoneal shunt infection rate in high-risk newborns and infants. Childs Nerv Syst. 2015;31:1129–38.CrossRefPubMedGoogle Scholar
  35. 35.
    Yamaguchi S, Hida K, Takeda M, Mitsuhara T, Morishige M, Yamada N, Kurisu K. Visualization of regional cerebrospinal fluid flow with a dye injection technique in focal arachnoid pathologies. J Neurosurg Spine. 2015;22:554–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Division of NeurosurgeryTokyo Metropolitan Children’s Medical CenterFuchuJapan

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