Permanent ventricular shunt and risk of meningitis: Challenges in weaning from external ventricular drain.

Rapid brain MRI (rMRI) provides a radiation-free neuroimaging tool to screen children without sedation. Our objective was to retrospectively analyze clinical rMRI utilization by describing demographics, operational metrics, clinical indications, and temporal trends associated with rMRI utilization in the emergency department (ED). We conducted a single-center, retrospective, cross-sectional study of children who underwent rMRI in the ED at an urban children's hospital between May 2014 and March 2024. We used descriptive statistics to examine operational metrics and trends in rMRI utilization over the study period. We performed a subgroup analysis of operational metrics by age and clinical indication. We included 2401 patients who underwent rMRI during their ED encounter. rMRI was frequently performed in infants and toddlers younger than 3 years old (n = 604, 25.1%), with a median patient age of 8.0 [interquartile range (IQR): 3.0 to 14.5] years. The median (IQR) time to scan was 3.5 (2.4 to 5.1) hours, and the median (IQR) ED length of stay was 7.5 (5.8 to 9.6) hours. Of the total, 1917 (79.8%) patients were initially triaged as "emergent," and 990 (41.2%) were discharged home from the ED. rMRI was predominantly used to evaluate ventricular shunt function (n = 2069, 86.1%) and traumatic brain injury (n = 214, 9.0%). Annual rMRI utilization increased by 80.8% between 2015 and 2023, with an average utilization rate increase of 46.1 scans annually between the years 2015 and 2019, and relatively static utilization rate from 2020 to 2023. This work supports the feasibility of widespread rMRI in the high-volume ED care setting, including for young children. rMRI utilization increased over time, with the technique most frequently used to evaluate ventricular shunt function and traumatic brain injury.

Predicting Failure of Ventricular Shunts in the Emergency Department: The SMaRT (Shunt Malfunction and Revision Triage) Score.

This article presents a clinical case of surgical intervention with cardiopulmonary bypass (CPB) in a patient with von Willebrand disease (VWD). VWD is the most common inherited bleeding disorder, significantly complicating surgical procedures due to impaired hemostasis. Surgical treatment of patients with VWD, particularly in the context of cardiovascular surgery involving CPB, requires an individualized approach. This includes the optimization of von Willebrand factor (vWF) and factor VIII (FVIII) levels, which are critical to preventing perioperative bleeding. The article describes the perioperative anesthetic management of the patient, emphasizing the importance of hemostasis monitoring, an individualized approach, and personalized dosing of replacement therapy to ensure effective treatment and minimize the risk of bleeding and thromboembolic complications. A 36-year-old male (181cm, 92kg) with type 2 von Willebrand disease and a history of childhood cardiac surgery (atrial septal defect repair, right ventricular outflow tract reconstruction) was admitted for elective aortic valve replacement with a bioprosthesis due to severe aortic regurgitation. Echocardiography revealed residual ventricular septal defect shunting, aortic root dilation, moderate mitral regurgitation, and cusp prolapse. The patient had a significant bleeding history and laboratory evidence of low vWF antigen/activity and FVIII deficiency. Perioperative management included ultrasound-guided vascular access, balanced general anesthesia, moderate hypothermic cardiopulmonary bypass, antifibrinolytic therapy, and tailored hemostatic replacement with vWF concentrate, FVIII, cryoprecipitate, platelets, and plasma. The patient was extubated 6h after surgery, required minimal transfusion support, and recovered without hemorrhagic or thromboembolic complications. He was discharged on postoperative day 10 in good condition. Proper management of the perioperative period is identified as a complex challenge for anesthesiologists, requiring a clear understanding of therapeutic mechanisms and their impact on coagulation.

Hydrocephalus due to intraventricular hemorrhage (IVH) during prematurity represents a challenging form of CSF circulation disturbance. It remains unresolved as to which temporary measures are best for intracranial pressure relief before sufficient body weight is reached to perform shunt implantation. The international Treatment of Posthemorrhagic Hydrocephalus in neonates (TROPHY) registry was designed to compare the safety and efficacy of 4 different methods of temporary treatment. The aim of this study was to investigate 6-month follow-up data from the TROPHY registry to characterize and compare perioperative measures, reoperations, complications, and shunt dependency among the different treatment methods. An online registry designed for multicenter international prospective data collection was reviewed for patients with complete datasets that included 6-month follow-up data. Eligible patients were neonates with IVH and progressive ventricular enlargement necessitating surgical pressure relief. Four possible methods of intervention were assessed: ventricular access device (VAD) placement, external ventricular drainage (EVD), ventricular subgaleal shunt (VSGS) placement, and neuroendoscopic lavage (NEL). Preoperative data, perioperative aspects of surgery, and 6-month follow-up data were collected in a standardized manner. Of 238 patients with posthemorrhagic hydrocephalus (PHH) included in this analysis, 47 received a VAD, 34 received EVD, 75 received a VSGS, and 82 received NEL. After 6 months of follow-up, differences were seen in the rate of unilateral frontal tissue defect at the entry point (p < 0.001, highest in the NEL group and lowest in the VAD group), multiloculated hydrocephalus (p < 0.05, highest in the EVD group and lowest in the NEL group), parenchymal defect (p < 0.05, highest in the VAD and lowest in the EVD group), and the proportion of patients needing a permanent shunt (p < 0.001, highest in the VSGS group and lowest in the NEL group). No significant differences were seen in rates of complications or revisions among the groups. Analysis of 6-month follow-up TROPHY registry data provided further insights into treatment options for PHH after neonatal IVH. NEL had the lowest probability of needing a shunt at 6 months. Further research will be performed to draw clearer conclusions.

Hydrocephalus is a frequently encountered neurological disorder of cerebrospinal fluid (CSF) physiology or dynamics, resulting in the abnormal enlargement of CSF spaces and often presenting with signs and symptoms of raised intracranial pressure. The etiology of hydrocephalus is numerous, regardless of the model used to understand its pathophysiology. Differentiating ventricular enlargement due to hydrocephalus or parenchymal atrophy can be difficult in pediatric patients, but certain imaging signs could help differentiate the two entities. The management of hydrocephalus aims to restore normal CSF dynamics, alleviate symptoms, and prevent long-term neurological complications with the help of ventricular drains and shunts. In this review, we will cover the updated pathophysiology, key etiologies, characteristic imaging findings of acute hydrocephalus and its complications, thus providing practical guidance for pediatric radiology fellows and radiologists in emergency settings.

Abstract INTRODUCTION Cerebral ventriculitis is a life-threatening infection of the ventricular system, frequently arising after external ventricular drain (EVD) placement or shunt surgery, and carries high morbidity and mortality despite systemic and intraventricular antibiotics. Ventricular lavage (VL) has been proposed to actively clear infected CSF and debris, but its comparative benefit over conventional EVD ± antibiotics remains unclear. We aim to systematically compare clinical and biochemical outcomes of ventricular lavage versus conservative treatment (EVD ± antibiotics) in patients with cerebral ventriculitis. METHODS A PRISMA-guided search of PubMed, Cochrane Library, and ClinicalTrials.gov was conduction from inception till January 19, 2025, which identified randomized controlled trials and cohort studies comparing VL with conservative therapy in ventriculitis patients. Key outcomes included mortality, length of hospital stay, neurological status (GCS/mRS), CSF parameter normalization, need for CSF diversion (EVD/shunt), cerebral abscess, hydrocephalus, and shunt infections. Three reviewers screened and extracted data; quality was appraised using Cochrane ROB tools. Owing to study heterogeneity, a narrative synthesis was performed. RESULTS Fourteen studies (total n = 322) met inclusion criteria. VL was associated with lower mortality (0–25% vs. 23.5–52.9%), a mean reduction in hospital stays of 20–22 days, and higher rates of favorable functional outcome (mRS ≤ 3 in 66.7–68.8% vs. 23.5–25%) compared to controls. CSF leukocyte counts normalized in 4 days versus 12 days in control group, and protein levels in 12.9 days versus 27.2 days. Shunt dependency ranged 56–91% with VL versus 100% conservatively, and VL groups experienced fewer shunt infections (2 vs. 7 cases). CONCLUSION Ventricular lavage yields superior survival, faster infection clearance, shorter hospitalization, and improved neurological outcomes compared to conservative management of cerebral ventriculitis. These findings support VL as an adjunct to antibiotics in appropriate patients, though further trials are needed to refine its role.

BackgroundIntraventricular haemorrhage (IVH) is a common and severe complication of preterm birth, affecting nearly 500 neonates annually in the UK. Over 50% of infants with IVH develop post-haemorrhagic ventricular dilatation (PHVD), which is associated with significant long-term neurodevelopmental impairment. Current treatment strategies involve the use of temporary CSF diversion, through options such as ventricular access devices (VADs) or ventricular subgaleal shunts (VSGS).Neuroendoscopic lavage (NEL) is an emerging technique that aims to directly reduce the load of intraventricular blood and its breakdown products, potentially reducing the risk of secondary brain injury. The ENLIVEN-UK trial aims to assess whether the addition of NEL to standard temporising device placement improves neurodevelopmental outcomes at 2 years of corrected age compared to temporising device placement alone.MethodsENLIVEN-UK is a national, multicentre, parallel-group, assessor-blinded, superiority randomised controlled trial (RCT) that aims to enrol 100 preterm infants with severe IVH and PHVD across UK paediatric neurosurgical centres. Infants will be randomised in a 1:1 ratio to receive either standard temporising device placement or NEL in addition to temporising device placement. Randomisation will be performed using a secure online system (Sealed Envelope), with outcome assessors and statisticians blinded to treatment allocation.The primary outcome measure will be cognitive quotient (CQ) at 2 years of corrected age, assessed using the Bayley Scales of Infant and Toddler Development (4th edition, Bayley-IV). Secondary outcomes will include motor and language development, the requirement for permanent CSF diversion with a ventriculoperitoneal (VP) shunt, surgical complications, health-related quality of life (EQ-5D-5L, TAPQOL), and healthcare costs.DiscussionThis study aims to provide level 1 evidence regarding the efficacy and safety of NEL in preterm infants with IVH and PHVD. If successful, this trial has the potential to change the standard of care and improve long-term neurodevelopmental outcomes in this cohort of patients.Trial registrationISRCTN Trial Registration: ISRCTN14018410.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13063-025-08952-1.

Abstract Background Hydrocephalus is one of the most common paediatric neurological diseases. The mainstay of the treatment of hydrocephalus has long been a shunt placement for CSF diversion, but recent years have seen the rise of alternative procedures such as endoscopic third Ventriculostomy (ETV), which provides similar efficacy in selected patients. However, there is a controversy regarding the outcome, efficacy and safety of these two surgical methods. Aim and Objectives The aim of this study is to evaluate the outcome and the safety of both endoscopic third ventriculostomy and ventricular shunt in treatment of congenital obstructive hydrocephalus in paediatric population. Subjects and Methods A systematic review and Meta-Analysis were conducted including database (PubMed and Cochrane Central Register of Controlled Trials databases). Literature search between 2000 and 2021 was performed in accordance with PRISMA guidelines. Eligible studies were included if they including paediatric patients (&amp;lt;18 years old) with congenital obstructive hydrocephalus treated with either ETV or ventriculoperitoneal shunt. Results Both procedures (ETV and VP shunt) proved to be effective clinically and radiographically with mean success rate. The pooled analysis indicated no statistically significant difference between the two interventions in terms of success (OR = 1.02, 95% CI [0.80, 1.29], Test for overall effect: Z = 0.14, (P = 0.89). The I2 value was 85%, indicating substantial heterogeneity. ETV tends to have lower complication rates but the difference did not reach statistical significance (OR = 0.66, 95% CI [0.42, 1.03], test for overall effect: Z = 1.83(P = 0.07) with no evidence of heterogeneity among the included studies (I² = 0%). Conclusion Both ETV and VPS are effective in treating congenital obstructive hydrocephalus, but their success and complication rates vary based on patient characteristics, age and the type of hydrocephalus. ETV tends to have lower complication rates compared to VPS however, both procedures require long-term follow up.

Headaches in chronic subdural hematoma: Does size matter?

Surgical versus endovascular treatment for idiopathic intracranial hypertension.

Hydrocephalus in pediatric patients is commonly managed with ventricular shunt systems, which are associated with a high rate of malfunction. Seizures are a frequent symptom in this population, but their predictive value for shunt dysfunction remains controversial. This study aims to determine whether seizures are a predictive symptom of ventricular shunt malfunction and to identify other factors associated with shunt dysfunction in this group of patients. We conducted an observational, retrospective cohort study of pediatric patients with hydrocephalus and ventricular shunt who presented to the emergency department for suspected shunt malfunction between January 2020 and February 2023. The association between seizures and shunt malfunction was assessed. Diagnostic test performance metrics, including sensitivity, specificity, and predictive values, were calculated. Demographic data, etiology, seizure history, and previous malfunction surgeries were also analyzed. Shunt malfunction was diagnosed in 14.58% of patients presenting with seizures. Seizures alone were associated with a significantly lower probability of shunt malfunction (OR 0.25; CI95% 0.13-0.47; p < 0.0001). However, seizures accompanied by symptoms of increased intracranial pressure, such as headache and altered mental status, were the only factor significantly associated with shunt dysfunction (OR 19.22; CI95% 4.51-81.96; p = 0.001). First-time seizures were also associated with an increased likelihood of shunt dysfunction in the bivariate analysis (OR 3.59; CI95% 1.01-12.78; p = 0.049), though this association was not sustained in the multivariate model. Sensitivity and specificity of seizures for the diagnosis of shunt malfunction were 14.6% (CI95% 8.2-23.3%) and 59.9% (CI95% 54.4-65.3%), respectively, with a positive predictive value of 9.8% (CI95% 5.5-15.9%) and a negative predictive value of 70.2% (CI95% 64.4-75.5%). Our study demonstrates that while seizures may be a common symptom in patients with hydrocephalus, their ability to predict shunt malfunction is limited in the absence of concomitant classic symptoms of intracranial hypertension. The presence of a first-time seizure, however, may warrant careful evaluation as it represents an important clinical finding that could help identify patients at higher risk of shunt dysfunction. This finding underscores the necessity of considering the patient's entire clinical presentation, including a thorough physical examination, when making diagnostic and therapeutic decisions.

To identify clinical variables associated with ventricular shunt infection and shunt failure in pediatric hydrocephalus. Patients ≤ 18years treated with ventricular shunts between 2013 and 2024 were identified from one institution's electronic medical record. Children with a confirmed diagnosis of hydrocephalus and ≥ 6months of postoperative follow-up were included. Primary and revision shunt surgeries were included. Records were manually reviewed for clinical variables. Statistical analyses were performed using R (version 4.2.3). The dataset included 474 surgeries, 146 primary and 328 revisions, undergone by 226 patients. Infection necessitating removal of a previously placed shunt occurred following 3.59% (17/474) of cases. Discharge in ≤ 4days had a 75% lower relative risk for infection compared to stays > 4days (1.5% vs. 6% 100-day infection risk; p = 0.011). Patients who underwent revision surgeries for shunt infections were more likely to experience subsequent infections in the first 100days postoperatively than those revised for other causes (2.42% vs. 21.05%; p < 0.0001). Patient characteristics associated with shunt failure during the 10-year study included younger age (median age: 2.23years in those with failure vs. 6.62years in those without; p < 0.0002) and lower weight (median weight: 11.8kg vs. 20.3kg; p < 0.0002) at the time of admission. Congenital hydrocephalus (OR = 1.86; p = 0.0045) and aqueductal stenosis (OR = 1.75; p = 0.025) were also associated with shunt failure. Length of stay > 4days and previous shunt infection are associated with an increased risk of infection after shunt surgery. These findings are important to consider when counseling pediatric patients and during postoperative monitoring.

Slit ventricle syndrome (SVS) is a condition of severe headaches, usually intermittent, suffered by patients after ventricular shunting for hydrocephalus with normal or smaller ventricle size; although in some cases, the correct diagnosis and management can be a significant challenge. This case report aims to highlight the application of non-invasive ICP monitoring (nICP) technology in the diagnosis and management of SVS, providing insights into its benefits and limitations. A 6-year-old boy with a history of ventriculoperitoneal (VP) shunt placement at 11months of age for communicating hydrocephalus presented with recurrent headaches, nausea, and vomiting. Imaging revealed small ventricles without signs of obstruction. Six months later, he was readmitted with worsening symptoms and again demonstrated small ventricles on MRI. To clarify the diagnosis and guide management, nICP monitoring using the Brain4Care device was performed. The waveform analysis suggested cerebrospinal fluid (CSF) overdrainage, with a P2/P1 ratio of 0.54 and time-to-peak (TTP) of 0.03 in the 45° position. Based on these findings, the shunt valve was revised to a fixed high-pressure setting. Postoperative nICP monitoring demonstrated normalized parameters (P2/P1 = 0.86 supine, 1.13 standing), and the patient remained asymptomatic. MRI confirmed normalization of ventricular size. This case highlights the utility of nICP monitoring in detecting overdrainage and guiding appropriate surgical management. The nICP monitoring may be a helpful tool for diagnosing and evaluating the type-specific SVS and guiding appropriate management. However, further investigations involving a larger number of patients are necessary to validate these findings.

Background: Ventricular reservoir infections and cerebrospinal fluid (CSF) shunt infections are diagnosed when bacteria are recovered from microbiological cultures of CSF samples from these devices. We applied high throughput sequencing (HTS) to understand the course of changes in ventricular reservoir and shunt infection microbiota. Objectives: Evaluate the utility of monitoring microbiota in CSF (1) from ventricular reservoirs to detect development of an infection and (2) during treatment of CSF shunt infections to assess treatment response. Methods: Study populations included (1) neonates with temporizing ventricular reservoirs who developed reservoir infection and (2) children undergoing treatment for conventional culture-confirmed CSF shunt infection. The V4 region of the 16S ribosomal RNA gene was amplified and sequenced. Comparison of taxonomic results of HTS with standard microbiological culture results (when available) was described for each CSF sample. A robust HTS signal was defined by a microbial load of ≥1e5 microbial genome equivalents/mL. Results: In none of the five ventricular reservoir infection cases was there a robust HTS signal for the responsible bacteria immediately prior to infection. In six of the seven CSF shunt infection cases, there was a robust HTS signal for the genus of the responsible bacteria in the sample at the time of positive CSF culture. The proportion of sequences from the genus associated with the responsible bacteria decreased during infection treatment. Conclusions: These pilot data suggest limited utility in using HTS for surveillance for ventricular reservoir infections, as they emerge abruptly. In CSF shunt infection, HTS demonstrates a return to heterogeneous microbiota when bacterial cultures become negative.

BACKGROUND AND OBJECTIVE:Ventricular shunt surgery, with either ventriculoperitoneal (VP) or ventriculoatrial (VA) shunts, is a primary treatment of idiopathic normal pressure hydrocephalus. However, postoperative seizures can complicate recovery. In this study, we investigated risk factors of postoperative seizures and assessed the risk of shunt-related hemorrhage.METHODS:Patients who underwent VP or VA shunt surgery for idiopathic normal pressure hydrocephalus between April 2020 and March 2023 were retrospectively reviewed. Exclusion criteria included a history of epilepsy or shunt revision surgery. Collected data included patient demographics, incidence of shunt-related intracranial hemorrhage, antithrombotic use, preoperative international normalized ratio, platelet count (within 2 weeks preoperatively), postoperative CRP levels (on day 1), time to seizure onset, and previous intracranial hemorrhage, cerebral infarction, or neurosurgery. Follow-up duration was recorded.RESULTS:This study enrolled 185 patients (102 men) with a mean age of 79.2 years (range: 53-94). Of these, 153 and 32 patients underwent VP and VA shunt surgery, respectively. Intracranial hemorrhage history was present in 9 patients (4.8%), cerebral infarction in 43 (23.2%), and previous intracranial surgery in 9 (4.8%). Hypertension was noted in 91 patients (49.1%). The mean CRP level on postoperative day 1 was 2.01 mg/dL (range: 0.05–14.99), whereas the mean preoperative international normalized ratio was 1.03 (range: 0.11-1.68). Shunt-related intracranial hemorrhage occurred in 14 patients (7.5%) and seizures in 8 (4%). Antithrombotic agents were used in 32 patients (17.2%). Patients with seizures had a higher incidence of shunt-related hemorrhage. Older age, previous intracranial surgery, and antithrombotic use were significantly associated with shunt-related hemorrhage. Logistic analysis identified shunt-related hemorrhage as a risk factor of seizures up to 2 years postoperatively.CONCLUSION:Our findings underscore the significance of shunt-related intracranial hemorrhage as a contributing factor to seizures after ventricular shunt surgery. This risk should be clearly communicated to patients during the informed consent process.

A novel strategy for left ventricular interventions in patients with double mechanical valves: Stylet-driven lead-guided transventricular access.

Abstract In healthy individuals, pulmonary veins drain oxygenated blood from the lungs into the left atrium. Total anomalous pulmonary venous connection (TAPVC) disrupts this process, causing severe clinical issues. TAPVC is classified into four types based on drainage site: supracardiac, cardiac, infracardiac, and mixed. Untreated, TAPVC is life-threatening with high neonatal mortality, though surgical advances have lowered mortality rates to below 10%. Early diagnosis and intervention are critical for better outcomes, especially in obstructed cases. Transthoracic echocardiography (TTE) is the primary diagnostic tool for TAPVC, identifying the absence of pulmonary venous connection to the left atrium and the presence of a common pulmonary venous trunk. However, TTE’s limitations, such as poor acoustic windows and inadequate spatial resolution, often necessitate advanced imaging like computed tomography angiography (CTA) and magnetic resonance imaging (MRI). CTA offers high spatial and temporal resolution, providing detailed anatomical information crucial for preoperative planning. Although it involves radiation exposure, it outperforms TTE in visualizing extracardiac vascular structures. MRI provides comprehensive anatomical and functional assessments without radiation, making it ideal for younger patients. It evaluates ventricular function, shunt ratios, and vascular anomalies but requires longer acquisition times. Cardiac catheterization remains the reference standard for diagnosing complex TAPVC, offering direct hemodynamic assessment despite being invasive. TTE is the first-line diagnostic tool for neonates, while CTA and MRI are preferred for detailed anatomical and functional assessments in adults. The manuscript reviews and compares these imaging techniques for optimal TAPVC diagnosis and management.

Background: From October 2023-June 2024 increased surgical site infection (SSI) rates were identified in our large pediatric hospital, 38% were caused by Staphylococcus aureus. Nasal S. aureus colonization is associated with increased SSI risk and preoperative nasal decolonization decreases S. aureus SSI risk. Historically, our institution recommended a five-day course of nasal mupirocin decolonization prior to selected high-risk procedure types, though this process it not possible for urgent cases and outpatient compliance is low. Nasal povidone iodine (PI) is a topical antiseptic used commonly in adults as an alternative to nasal mupirocin for S. aureus decolonization and SSI prevention. This practice is less commonly described in pediatric patients. Methods: In addition to standard SSI prevention measures, universal nasal PI application was implemented preoperatively (as a single topical application following induction of anesthesia) in July 2024 for patients ≥34 weeks corrected gestational age (CGA) undergoing the following high-risk surgical procedures: ventricular shunts, spinal fusions, and all cardiothoracic (CT) procedures. Compliance with nasal PI application was monitored based on documentation in the electronic medical record. Mean monthly total SSI rates (per 100 procedures) and mean monthly S. aureus SSI rates for these procedure types were followed pre- and post-implementation of universal nasal PI and compared via unpaired t-test. Results: Documented compliance with nasal PI application was 51% overall, ranging from 22% for ventricular shunts to 75% for CT procedures. Implementation of universal nasal PI preoperatively was associated with a non-statistically significant decrease in composite mean SSI rates (Figure 1A): 3.5 per 100 procedures pre-implementation, 2.3 post-implementation (p=0.52). A statistically significant decrease in composite mean S. aureus SSI rates was observed (Figure 1B): 1.3 per 100 procedures pre-implementation, 0.0 post-implementation (p=0.02). Conclusion: Despite modest documented compliance, implementation of a universal preoperative nasal PI program, in conjunction with standard SSI prevention measures, was associated with decreased S. aureus SSI rates in pediatric patients undergoing high-risk surgical procedures.Figure 1. Total (1A) and Staphylococcus aureus (1B) surgical site infection (SSI) rate per 100 ventricular shunt, spinal fusion, and cardiothoracic procedures (combined) by month from January 2023 through November 2024. The solid vertical line indicates the beginning of the period with increased S. aureus SSI rates (pre-implementation period). The dashed vertical line indicates the start of the implementation period. Mean SSI rates for the pre- and post-implementation periods are indicated by the horizontal lines and compared via t-test.

Rationale:This report details 2 complex cases of recurrent ventriculoperitoneal (VP) shunt failure due to peritoneal pathology and infection, highlighting the clinical rationale for utilizing ventriculatrial (VA) shunting as a salvage procedure and the potential for subsequent VP shunt reimplantation after peritoneal recovery.Patient concerns:Case 1: A 57-year-old male presented with recurrent episodes of progressive gait instability, somnolence, cognitive decline, and vomiting over 9 months following initial VP shunt placement, despite multiple surgical revisions. Case 2: A 46-year-old male with a long history of shunt complications presented with worsening gait instability, impaired concentration, episodic dizziness, and intermittent confusion approximately 16 months after a VA shunt was placed as a secondary measure.Diagnoses:Both cases were diagnosed with recurrent hydrocephalus secondary to shunt failure. Case 1 was diagnosed with distal VP shunt obstruction caused by peritoneal adhesions, followed by a subsequent shunt infection confirmed by cerebrospinal fluid analysis. Case 2 was diagnosed with VA shunt valve failure despite correct catheter position, as indicated by shunt pressure monitoring and persistent symptoms.Interventions:Case 1: After multiple unsuccessful peritoneal catheter revisions and externalization for infection control, the patient was converted to a VA shunt. Case 2: Following the failure of VA shunt valve adjustments, abdominal ultrasound confirmed peritoneal recovery. The VA shunt was subsequently replaced with a contralateral VP shunt featuring a more granular adjustable valve.Outcomes:Case 1: Conversion to a VA shunt resulted in full neurological recovery, resolution of hydrocephalus symptoms, and no further complications at follow-up. Case 2: Contralateral VP shunt reimplantation led to the resolution of all neurological symptoms, significant functional recovery, and a return to independent daily activities, with no recurrence at the 6-month follow-up.Lessons:VA shunting is a safe and effective salvage procedure for patients with VP shunt failure attributable to peritoneal complications. Furthermore, these cases demonstrate that the peritoneal cavity can recover over time, allowing for successful VP shunt reimplantation if distal catheter failure recurs. A dynamic and individualized management strategy is essential for complex hydrocephalus cases.