Abstract
Most patients with hydrocephalus are still managed with the implantation of a cerebrospinal fluid (CSF) shunt in which the CSF flow is regulated by a differential-pressure valve (DPV). Our aim in this review is to discuss some basic concepts in fluid mechanics that are frequently ignored but that should be understood by neurosurgeons to enable them to choose the most adequate shunt for each patient. We will present data, some of which is not provided by manufacturers, which may help neurosurgeons in selecting the most appropriate shunt. To do so, we focused on the management of patients with idiopathic “normal-pressure hydrocephalus” (iNPH), as one of the most challenging scenarios, in which the combination of optimal technology, patient characteristics, and knowledge of fluid mechanics can significantly modify the surgical results. For a better understanding of the available hardware and its evolution over time, we will have a second look at the design of the first DPV and the reasons why additional devices were incorporated to control for shunt overdrainage and its related complications. We try to persuade the reader that a clear understanding of the physical concepts of the CSF and shunt dynamics is key to understand the pathophysiology of iNPH and to improve its treatment.
Highlights
Hydrocephalus is the most frequent cause of acute and chronic intracranial hypertension both in children and adults and is the condition that pediatric neurosurgeons treat most frequently
We focused on the management of patients with idiopathic “normal-pressure hydrocephalus”, as one of the most challenging scenarios, in which the combination of optimal technology, patient characteristics, and knowledge of fluid mechanics can significantly modify the surgical results
Despite the popularity of endoscopic third ventriculostomy in the neurosurgical armamentarium, most patients with hydrocephalus are still managed with the implantation of a cerebrospinal fluid (CSF) shunt in which the CSF flow is regulated by a differential-pressure valve (DPV)
Summary
Hydrocephalus is the most frequent cause of acute and chronic intracranial hypertension both in children and adults and is the condition that pediatric neurosurgeons treat most frequently. The wide range of designs and functional complexity of shunt assemblies currently available allow reduction of the complications of shunt over- or under-drainage and to improve the long-term outcome of patients with hydrocephalus. In acute posthemorrhagic or tumoral hydrocephalus, any simple DPV available on the market will work but, in complex clinical scenarios, such as in patients with pseudotumor cerebri, arachnoid cysts, negative-pressure hydrocephalus, slit-ventricle syndrome, hydrocephalus in the pediatric population, and in patients with idiopathic “normal-pressure hydrocephalus” (iNPH) syndrome, the appropriate selection of shunt hardware is crucial for obtaining the best possible outcome and reducing shunt-associated complications. Current shunt technology allows for selection among a wide variety of hardware and adapts it to patients’ age, height, weight, clinical, and neuroradiological characteristics This selection is especially relevant in patients with iNPH in which the shunt selection is essential to reduce both the rate of nonresponders and shunt-related complications. Our statement seems to be contradictory with the lack of evidence that any valve or shunt assembly is superior in managing hydrocephalus [4], we hope to persuade the reader of the need to reconsider the old concepts regarding DPV
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