Pediatric Surgery
Hydrocephalus is treated by giving the fluid around the brain a new way out, with a shunt or with an endoscopic opening inside the brain. Choosing the right one for each child spares many children a lifelong shunt.
In hydrocephalus, cerebrospinal fluid builds up inside the brain because its flow or absorption is blocked, and the pressure can harm the developing brain. For decades the standard treatment has been a shunt, a thin tube that drains fluid to the abdomen. Shunts save lives and fail frequently, with 40 percent of first shunts in children needing revision within a year in a large international trial. Endoscopic third ventriculostomy, which makes a small opening inside the brain through a camera, avoids an implant altogether and works well in selected children. A validated score helps predict which children it will help. Send us your child's scans and reports, and a pediatric neurosurgeon will tell you which treatment fits and how long to plan.
61%
First shunts still working at one year, 344 children
6% vs 2%
Shunt infection with standard against antibiotic-impregnated shunts
7 to 10 days
In Istanbul for most children
Free
Pediatric neurosurgeon's review of your child's scans
Free consultation
Cerebrospinal fluid shunt failure, predominantly from shunt obstruction and infection, remains a persistent problem in pediatric hydrocephalus.
Randomized valve design trial of 344 children, Neurosurgery, 1998
Shunt or endoscopic third ventriculostomy?
Two very different operations.
Children most likely to succeed with ETV can now be accurately identified and spared the long-term complications of CSF shunting.
International analysis of 618 ventriculostomies, Journal of Pediatrics, 2009
The shunt
A shunt has three parts, a tube in the fluid space of the brain, a valve that controls the flow, and a tube running under the skin to the abdomen, where the fluid is absorbed.
Strengths and weaknesses
A shunt works for every type of hydrocephalus and at every age. Its weakness is that it is a mechanical device inside a growing child. It can block, become infected, break or drain too much, and most children with a shunt need at least one revision during childhood.
Endoscopic third ventriculostomy
Through a small hole in the skull, a thin camera passes into the fluid spaces, and the surgeon makes an opening in the floor of the third ventricle, so fluid can bypass the blockage and flow around the brain to be absorbed naturally. No device stays in the body.
Who it suits
It works best in older children with a blockage of the channel between the fluid spaces, a cause known as aqueductal stenosis, or a tumor in the back of the brain. Young babies and children whose hydrocephalus followed infection or bleeding have lower success. In some centers, burning part of the tissue that makes the fluid, the choroid plexus, is added in infants.
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Shunt against endoscopic third ventriculostomy
| Feature |
Shunt |
Endoscopic third ventriculostomy |
| Implant |
Yes, for life |
No |
| Suitable for |
All types and ages |
Selected children, mainly obstructive hydrocephalus |
| Early failure |
Lower |
Higher, mostly in the first months |
| Late failure |
Continues for years |
Uncommon once it has worked for months |
| Infection risk |
Present with every operation |
Low |
The operations
1
Ventriculostomy
Under general anesthesia, through a small cut behind the hairline, about an hour. Most children go home after two to three days.
2
Shunt insertion
Tubes are passed under the skin from head to abdomen through two small cuts, about an hour. Home after two to four days.
3
Checks
A scan before discharge confirms the position of the shunt or the size of the fluid spaces, and a wound check follows a week later.
Shunt surgery in practice
The surgeon chooses a valve to suit the child, in many centers a programmable valve whose setting can be adjusted with a magnet from outside the head. Antibiotic-impregnated tubing and strict operating-room routines reduce infection. The abdominal end is placed with spare length, so that the tube can stretch as the child grows.
- Age, with the highest success in children over one year.
- The cause of hydrocephalus, with aqueductal stenosis and tumors doing best.
- Whether the child has had a shunt before, which lowers the chance that a ventriculostomy will work, though it remains worth trying in selected children who want to be free of a device.
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Why first shunts failed, valve design trial of 344 children
| Cause |
Children |
| Obstruction |
108, 31.4 percent |
| Infection |
28, 8.1 percent |
| Overdrainage |
12, 3.5 percent |
| Shunt-free at one and two years |
61 and 47 percent |
The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN.
Hydrocephalus Clinical Research Network, Journal of Neurosurgery Pediatrics, 2011
Preventing infection
Two ways infection was cut
The American Hydrocephalus Clinical Research Network introduced the same checklist at four centers, covering hand scrubbing, antibiotics, handling of the shunt and the number of people in the room, and infection after shunt surgery fell from 8.8 to 5.7 percent across 1,571 operations.
In the BASICS trial in the United Kingdom and Ireland, 1,605 patients of all ages received a standard, an antibiotic-impregnated or a silver-impregnated shunt. Infection needing revision occurred in 6 percent with standard shunts, 2 percent with antibiotic shunts and 6 percent with silver shunts, and the authors recommended antibiotic shunts for first insertions.
What are the signs that a shunt or ventriculostomy is failing?
Parents learn them by heart.
- Headache, especially on waking, and vomiting.
- Sleepiness.
- Irritability, or a change in behavior or school performance that parents and teachers notice over days or weeks, sometimes the only sign in an older child.
- In babies, a bulging soft spot, a fast-growing head or eyes turned downward.
- Swelling or fluid along the shunt track, redness or fever.
What families should do
Any of these signs needs urgent assessment by a neurosurgical team, the same day, even years after the operation. Families receive a written summary of the child's shunt or ventriculostomy, the valve type and setting and the latest scan, to show any emergency department.
What do the results and follow-up look like?
Success depends above all on choosing the right child for each treatment.
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Endoscopic third ventriculostomy in 300 Ugandan children
| Group |
Success |
| Over one year, after infection |
81 percent |
| Over one year, other causes |
90 percent |
| Under one year, after infection |
59 percent |
| Under one year, other causes |
40 percent |
What the studies show
An international analysis of 618 ventriculostomies at 12 centers found success at six months in two thirds of children, and developed the ETV Success Score from age, cause and previous shunt to predict each child's chance. A series of 300 children in Uganda, most of them under one year, found success in 59 percent overall, much higher in older children, and showed that in infants the cause and the anatomy on ultrasound predicted the result.
This practice will benefit patients of all ages by reducing the risk and harm of shunt infection.
BASICS randomized trial of 1,605 patients, The Lancet, 2019
Programmable valves, MRI and travel
Strong magnets in MRI scanners can change the setting of some programmable valves, so the setting is checked after every MRI. Airport scanners and phones pose no problem. Children with a shunt travel, swim and play most sports, and the neurosurgeon advises on heavy contact sports such as boxing.
Days, cost and the trip
- MRI or CT scans, ideally the images themselves.
- Reports of previous operations, and the valve type and setting if a shunt is present.
- Head circumference measurements for babies.
Plan seven to ten days in Istanbul for a first shunt or ventriculostomy, including the scans after surgery and a wound check. Children can fly once the wound has healed and the surgeon is satisfied, a week after the operation for most children.
Cost depends on the operation, the valve, the scans and the hospital stay. Your own figure follows the free review of your child's file.
One coordinator plans the visit with the family, from the visa invitation letter sent ten days ahead to the transfer and a family hotel near the hospital. A parent stays with the child throughout, and the team works in seven languages with halal meals and a prayer room available. Back home, the neurosurgeon reviews scans sent by your local team and stays reachable on the same WhatsApp number, and the family leaves with a written summary in their own language listing the operation, the valve and its setting, the most recent scan and the signs of failure, so that any doctor who sees the child in an emergency, at home or on holiday, understands at once what was done and what to check first.
When to go to emergency
Severe headache with vomiting, drowsiness that is hard to rouse, a seizure, or in a baby a tense bulging soft spot need the nearest emergency department at once, with the shunt summary in hand.
Hydrocephalus surgery in children FAQ
Is a shunt or an endoscopic ventriculostomy better?
It depends on the child. Ventriculostomy avoids a lifelong implant and works best in older children with a blockage, while a shunt works for all types and ages.
How often do shunts fail?
In a trial of 344 children, 39 percent of first shunts failed within a year and 53 percent within two, mostly from blockage or infection.
Can shunt infection be prevented?
Strict operating protocols and antibiotic-impregnated shunts both cut infection, to 2 percent with antibiotic shunts in the BASICS trial.
What are the signs of shunt failure?
Headache, vomiting, sleepiness, irritability, and in babies a bulging soft spot or fast-growing head. These need same-day assessment.
How long will we stay in Istanbul?
Seven to ten days for most children, including scans and a wound check.
Can a parent stay with the child?
Yes, throughout.
References
- Drake JM, Kestle JR, Milner R, et al. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery. 1998;43(2):294-303.
- Kulkarni AV, Drake JM, Mallucci CL, et al. Endoscopic third ventriculostomy in the treatment of childhood hydrocephalus. Journal of Pediatrics. 2009;155(2):254-259.
- Warf BC. Hydrocephalus in Uganda: the predominance of infectious origin and primary management with endoscopic third ventriculostomy. Journal of Neurosurgery. 2005;102(1 Suppl):1-15.
- Kestle JR, Riva-Cambrin J, Wellons JC, et al. A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. Journal of Neurosurgery Pediatrics. 2011;8(1):22-29.
- Mallucci CL, Jenkinson MD, Conroy EJ, et al. Antibiotic or silver versus standard ventriculoperitoneal shunts (BASICS): a multicentre, single-blinded, randomised trial and economic evaluation. Lancet. 2019;394(10208):1530-1539.
