Diagnosis and management of shunt complications in the treatment of childhood hydrocephalus

The history of the treatment of hydrocephalus by using cerebrospinal fluid (CSF) shunt devices is characterized by two main features. The first of them is the great success rate as far as the percentages and, in most cases, the quality of survival are concerned, for a condition which in the past invariably led to the patient's death or severe clinical deterioration. The second characteristic is the number of the complications associated with this type of therapy, which has tempered the initial enthusiasm and, subsequently, the hope arisen by the introduction of any newly designed CSF shunt apparatus. Actually, the overall analysis of the results after treatment clearly indicates that the impact of CSF shunt device improvements on the failure rates seems to be very limited. To better identify the involved mechanisms further basic research into the pathophysiology of some specific shunt complications (e.g. the Slit Ventricle Syndrome) is clearly necessary. Unfortunately, mathematic models as well as animal models have proved to be not sufficient in such a regard. From a practical point of view, prevention and early identification and management of CSF shunt failures remain the main possibilities to assure the quality of the patient's long term outcome. In fact, fifty years of history teach us that the efficacy of new treatments should be scrutinized scientifically, by considering uncontrolled series and testimonial asserptions with great skepticism. With these assumptions in mind we can agree with Drake's suggestion that shunt failure rates of about or little less than 5% per year and infection rates of less than 1% per year should be considered the reasonable goals for the next decade in this new millennium (1).