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Review Article *Corresponding author Iraj Lotfinia, Department of , Tabriz University of Medical Science Tabriz, Fax: A Review in Pediatric 009841133340830, Email: Submitted: 25 January 2017 : Physiology, Accepted: 20 February 2017 Published: 22 February 2017 Copyright Classification, Clinical © 2017 Lotfinia Presentation, Imaging and OPEN ACCESS Treatment Iraj Lotfinia* Department of Neurosurgery, Tabriz University of Medical Science Tabriz, Iran

Abstract Hydrocephalus, increased (CSF) within the , is a common disease, and it may develop due to various causes, such as congenital anomalies, tumors, infections, , trauma and idiopathic disorders. The disease can occur in all ages, even prior to birth through late old age, and is associated with various clinical symptoms. Lack of treatment or delays in treatment can lead to permanent brain damage. Appropriate therapy can prevent the occurrence of this complication in most cases, and a ventriculoperitoneal (VP) is often used to treat this disease. However, this method is accompanied with numerous complications and problems, and, as a result, the patient may require repeated surgeries. Careful selection of patients for surgical intervention and surgery using proper techniques can reduce these side effects.

INTRODUCTION Physiology The term hydrocephalus is derived from two Greek words: Parts of the brain tissue that constitute the cerebral ventricles hydro, meaning water, and cephalus, meaning head. The disease and the space surrounding the brain and that include has been known since ancient times because of the strange person who described decompression and trepanation in these the subarachnoid space contain CSF. This liquid has several appearance of these patients; Hippo-crates were the first andfunctions a reduction of which in thethe mostlikelihood important of damage are a significant followed by reduction sudden motionin the weight and impact of the onbrain the andinner spinal surface cord of floating the skull. in theThe liquid, other patients [1]. Hydrocephalus is defined as an increased volume accumulatesof intracranial outside cerebrospinal the ventricles fluid and CSF.in the Although subarachnoid this space fluid aroundaccumulates the brain, in the and ventricles such cases in ismost called cases, external the CSF hydrocephalus sometimes forfunction excess of neurotransmitters CSF is its nutritional and role some for metabolic the brain andwaste spinal products cord [1]. surface areas. In addition, CSF is probably the disposal pathway produced by the choroid plexus in the lateral, third, and fourth Prevalence from the (CNS). The majority of CSF is Hydrocephalus is the most frequent neurosurgical problem through the choroidal capillary endothelium wall. This secretion seen in pediatric medicine also, there is no preponderance ventricles. The CSF is synthesized naturally by the ultrafiltration this lesion is unknown, more than half of the surgeries performed is dependent on the sodium-potassium-ATPase pump in the bybetween pediatric males neurosurgeons and females [1]. involve Although embedding the exact prevalence or revision of choroid plexus apex and is an energy-dependent process. No change is found at the level of CSF secreted from the choroid plexus following a sharp rise in (ICP), but surgerythe shunt for [2]. hydrocephalus Surgery for ishydrocephalus 3.4 per 100,000 is in much adults less undergoing frequent a decrease in the secretion of CSF will occur in chronic increased surgeryin adults. [1]. According Moreover, to so investigations,me cases of hydrocephalus the annual incidenceare believed of ventriclesICP due to and atrophy the subarachnoid created in the space. choroid The plexus historical [4]. treatmentA smaller to be caused by genetic factors [3]. amount of CSF is created by ependymal secretion within the

of plexectomy for hydrocephalus has failed because of this fluid Cite this article: Lotfinia I (2017) A Review in Pediatric Hydrocephalus: Physiology, Classification, Clinical Presentation, Imaging and Treatment. JSM JSM Pediatr Neurol 1(1): 1002. Lotfinia (2017) Email:

Central Bringing Excellence in Open Access enlargement of the ventricles requires time, which depends on the severity and velocity of hydrocephalus formation. In newborn secretion from areas other than the choroid plexus. According to infants with open sutures that are not surrounded by rigid skull, withrecent the studies, maintenance secretion ofof CSF electrolytes and interstitial and therefore fluid is the osmotic result pressureof water in filtration the vessels, through which the causes vessel reuptake walls. This of isliquid associated to the bulging fontanelle and diastasis of sutures, and so ventricular capillary venous [5]. This theory posits that the formation and dilatationincreased may ICP innot the be observed early stages [11]. may In other be compensated groups of patients, for by a new balance may be established between production and lowabsorption cross-sectional of fluid areatake [5].place Water in different constitutes areas more of the than CNS, 99% and of sagittal sinus granulations play little role in fluid uptake due to absorption of CSF following enlargement of the ventricles. In this case, the ICP is normal, and the infants probably will not benefit vessels.CSF; all theThe waterdistribution does not of otherpass throughsubstances the in entire the subarachnoid CSF route in from the insertion of a shunt [11]. Da Silva et al. [12], showed that spacethe subarachnoid occurs to a greater space, butextent rather when is thereabsorbed reuptake in of the them adjacent to the dominantlycerebral blood around flow inthe acute ventricles. hydrocephalus This hypoperfusion was reduced can globally lead microvessels is slower [5]. toand brain the damage decrease due in to blood the reduction flow in chronicof oxygen hydrocephalus and glucose in was the The liquid enters from the lateral ventricles through the oxidative changes and may lead to gliosis in all of the brain [13]. foramina of Monro into the third ventricle, and then into the brain [11]. The increased fluid pressure also can cause significant hydrocephalus, such as ependymal rupture, periventricular edema,Some white and matter collapse abnormalities of periventricular seen in patients capillaries, with untreated will be afourth central ventricle foramen through of Magendie the aqueduct and twoof Sylvius. lateral The foramina CSF from of the fourth ventricle flows into the subarachnoid space through reversible with early treatment, but axonal degeneration and gliosis are signs of permanent damage in the white matter [11] Luschka. According to the traditional hypothesis, this flow is and remain following the treatment of hydrocephalus. arachnoidunidirectional villi around[5] and theafter superior flowing sagittal around sinus the intobrain the and systemic spinal Classification subarachnoid space, the fluid can be reabsorbed through the its absorption is passive [6]. This absorption is dependent on the circulation. The CSF formation requires energy consumption, but Various types of hydrocephalus have been described. As cranial pressure. On the other hand, when pressure in the sagittal main forms based on the site of blockage: obstructive and non- CSF pressure and can be increased significantly with higher intra obstructive.mentioned earlier, Instead hydrocephalus of these two words,can be non-communicating classified into two [7]. In patients with and trauma, sinus increases, the ICP must increase too for CSF to be absorbed hydrocephalus into the obstructive and non-obstructive types is notand enough communicating if it is possible can alsoto identify be used. the actual Simple site classification of obstruction of fibrosis along the route of CSF flow can induce hydrocephaly [8]. ICP has been defined as the hydrostatic pressure within CSF aqueduct is unable to produce a change in intraventricular [7]. Studies have shown that acute obstruction of the Sylvius duraland is sinuses.dependent Due on to certain the above factors, factors, such ashydrocephalus active CSF secretion, may be resistance to exit routes, and passive CSF absorption into the caused by three mechanisms: increased production, obstruction pressure. This finding suggests a balance between production in the route, and elevated venous pressure in the dural sinuses, besides obstruction, therefore, are likely involved in the developmentand absorption of ofhydrocephalus. CSF within the Hence, ventricles it is better [5]; several to modify factors the be balance and coordination among the production, storage, which reduce CSF absorption [1]. For normal ICP, there must classification of obstructive and non-obstructive hydrocephalus and absorption of CSF, and the occurrence of any imbalance in systemto reflect and patient cause age, communicating the presence of hydrocephalus, lesions and rapidity including and this area can lead to clinical symptoms. According to the site of tumorchronicity surgery, of lesions brain trauma, [7]. Various infections factors and can subarachnoid affect the andCSF obstruction and disruption in the CSF flow, hydrocephalus can be divided into two groups: the obstructive (non-communicating) according to the clinical experience of Xu [14], a large percentage ventricles, and which may occur in any part of the ventricular intraparenchymal hemorrhage within the brain. Nevertheless, systemtype where such as there the lateral, is blockage third, inand the fourth CSF ventricles; flow through and the of these patients do not suffer from hydrocephalus because of the

compensatory CSF absorption capacity within a certain range. thenon-obstructive arachnoid villi (communicating) and, thus, non-normal type where absorption there [9]. is aThe normal non- based on time of onset of the lesion, which is divided into two obstructiveventricular CSFtype flow is uncommon path and impairedand develops CSF absorptiondue to factors through such types:Another congenital form and of acquired. classification In congenital used in hydrocephalus, hydrocephalus the is as recurrent subarachnoid hemorrhage or , which lesion is present in the infant prior to birth, such as a narrowing of the cerebral aqueduct and hydrocephaly associated with the choroid plexus papilloma has been described as a cause of neural tube defects. In some cases, congenital hydrocephalus has communicatingdisrupt the function hydrocephalus, of absorption. but The this CSF concept overproduction is controversial from idiopathic etiology. The incidence of congenital hydrocephalus enlargement of the ventricles and increased pressure inside involves [16]. It should be considered the[10]. skull. The Increased increase in intracranial CSF volume pressure inside can the lead skull to results neuronal in thatis about hydrocephalus 0.5−0.8 per in 1,000 all cases live birthsof the [15]congenital and most form commonly may not loss and brain damage. The ventricles may not be dilated after exist at birth, but may appear later in life. Other terms used hydrocephalus and CSF blockage in the early stages [11]. The in the classification of hydrocephalus are normal pressure JSM Pediatr Neurol 1(1): 1002 (2017) 2/8 Lotfinia (2017) Email:

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The term normal pressure is not appropriate, and attacks of hydrocephalus (NPH) and high-pressure hydrocephalus (HPH). increased ICP can be observed in these patients [17,18]. Another classification is applied in this case: internal hydrocephalus in which the ventricles are dilated and the CSF accumulates in the ventricles (Figure 1), and external hydrocephalus in which the dividedCSF accumulates into two types: in the active subarachnoid hydrocephalus space in which surrounding the patient the showsventricles clinical (Figure features, 2). Hydrocephalus and occult due hydrocephalus to clinical symptoms in which is inthe the patient growth has of the an increaselesions and in no intracranial increase in CSF ventricular in imaging, volume but overwithout time. clinical The hydrocephalusfeatures. Arrested based hydrocephalus on the appearance implies rate a halt of clinical symptoms is divided into three types: acute (within days), subacuteClinical (withinfeatures weeks), and chronic (within months). Symptoms: The clinical symptoms will vary depending on the primary cause of lesions leading to hydrocephalus, age, and acute or chronic condition of the lesion. Prior to closure of the

Figure 1c

Sagittal T2 weighted MRI of a patient with hydrocephaly.

Figure 1a

CT scan of a patient with very severe internal hydrocephalus, nearly almost all of the skull filled with CSF.

Figure 2 Three-month-old patient with birth trauma history and severe

see a bridging vein under sever tension. external hydrocephaly in which CSF accumulated outside the brain you can also

cranial sutures and the fontanels at an early age, the dominant manifestations of the disease are a progressive increase in head

symptoms may be observed at an early age, including poor circumference and bulging of the fontanels (Figure 3). Different impaired eye movements, bradycardia, hypertension, and feeding, vomiting, general irritability, drowsiness, seizures, sutures, the dominant clinical symptoms are related to increase prominence of scalp veins. After the closure of the cranial nausea, vomiting, irritability, drowsiness, blurred vision, and doubleICP, and vision, the patientloss of bladder presents control predominantly and changes with in personality , and memory. Headache, nausea, and vomiting are usually worse Figure 1b

Cronal T1 weighted MRI of another patient with hydrocephaly. in the morning, and there are two reasons for this. The ICP will JSM Pediatr Neurol 1(1): 1002 (2017) 3/8 Lotfinia (2017) Email:

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sutures can be seen in infants. The increase in skull size will neonatallead to a infectiondisproportion (toxoplasmosis, between the rubella, sizes cytomegalovirus,of the skull and face. and The pathologic calcification, such as that due to brain tumor or

beatenherpes appearance simplex) may in the be skull, detectable may be by seen this in method. plain radiography. Also, signs of increased ICP, such as destruction of dorsum sellae and silver Ultrasound: This is a noninvasive method that does not have

hydrocephalus, the etiology is not usually diagnosed by this method.any proven It can side be effects.used in Although infants with it is open able fontanelle, to detect prenataland can

in the brain and the presence of lesions, such as cerebral hemorrhagedetermine the and size spaceof the occupyingventricles very lesions well. can Fluid be accumulation detected by ultrasound. Computerized tomographic scan (CT-Scan):

CT-Scan is able to show the size of the ventricles and lesions, such as bleeding, pathologic calcification, vascular lesions and tumors, subarachnoidas well as some space. of the signs of increased ICP, such as edema Figure 3 surrounding the ventricles, flattened cerebral gyri, and reduced A hydrocephalic patient before suture closing. You can see the large Magnetic resonance imaging (MRI): sunset sign. head circumference, inappropriate size of head to face, dilated scalp veins, and hydrocephalus and pathologic factors, without the complications MRI can diagnose increase further at night because of the lying position, resulting application can be used in patients with suspected hydrocephalus in some venous stasis. Moreover, carbon dioxide retention occurs associated with radiation. In addition, phase-contrast cine MRI causes dilation of cerebral blood vessels and, thus, the increase patientto assess during how CSFthe examination,flows and to sedationlocate possible may be obstruction needed in young sites. briefly during sleep due to mild respiratory depression, which childrenDue to the and time infants. required and the need for immobilization of the ultrasonography (TCD): extremitiesin blood volume which withinpass along the skull,the lateral and, ventricle consequently, may be ICP more will increase further. Because the corticospinal fibers of the lower ultrasonography can be used as a noninvasive method at the prone to stretching and tension, their dysfunction will lead to TCD weakness in the lower limbs, impaired gait, and frequent falls. status can be assessed with regard to systolic and diastolic blood The patient may complain of neck pain that can be caused bedside, which indirectly measures ICP [11]. In this way, the ICP by the herniation of the cerebellar tonsils. The patient may also complain of transient attacks of blurred vision, indicating oftenflow in uncertain the brain [11]. and its changes. This method is useful, especially in young babies, whose signs and symptoms of increased ICP are cases, prompt medical and surgical measures should be taken. Treatment impaired blood flow and ischemic optic neuropathy. In these In rare cases, endocrinological symptoms, such as delayed growth, obesity, and early puberty, may occur due to the to determine the underlying causes of the hydrocephalus. In The treatment process is specified after the necessary studies enlargement of the third ventricle and the pressure on the cases where other lesions, such as tumors, vascular lesions, or hypothalamus. infection are present, relevant therapeutic measures should be done. In the following section, we will primarily discuss the Signs: In the lower ages and prior to closure of the cranial treatment of hydrocephalus. sutures, the most important sign is excessive abnormal head circumference. Usually, there is no papilledema in these ages, Non-surgical treatment: Drug therapy: There are no compelling non-surgical weakness may be seen in the lower limbs due to the stretching of therapies for hydrocephalus [19], but, in cases like cerebral but often it is seen after the closure of the cranial sutures. Spastic hemorrhage leading to hydrocephalus, since hydrocephalus may be transient, drug treatment can be considered for a short time. recesscorticospinal of the dilatedfibers. Theventricle. patient This may condition have the can failure lead of to upward sunset gaze due to pressure on the tectal plate through the suprapineal For this purpose, acetazolamide (50-100 mg/kg/day) can be eye sign in infants (Figure 3). Unilateral or bilateral sixth nerve used alone or in combination with furosemide (1 mg/kg/day). Diagnostic techniques [20]. palsy also can be seen, which is often the result of high ICP. The effect of these drugs on CSF secretion is rapid and reversible Plain radiography: This technique is less frequently used The mechanism of action of acetazolamide is the inhibition to diagnose hydrocephalus. Increased skull size and open of carbonic anhydrase enzyme, which thereby reduces CSF JSM Pediatr Neurol 1(1): 1002 (2017) 4/8 Lotfinia (2017) Email:

Central Bringing Excellence in Open Access secretion. The mechanism of action of furosemide that reduces treatment of high pressure and normal pressure hydrocephaly [25,26].its large artifacts In MRI [24] it is efficient and safe tool in the ICP is unclear, but its impact is likely due to a decrease in interstitialLumbar fluid puncture: in the brain. In this way, the ventricular catheter is inserted into the where the cause of hydrocephalus is temporary, lateral ventricle through surgery and is connected to the pump can be attempted repeatedlySimilar and to for medical a limited treatment, time to in reduce cases that is placed under the skull skin. The peritoneal catheter is also connected to other side of the pump and is inserted in the performed only in communicating hydrocephalus. This method peritoneal cavity via subcutaneous tunneling. The ventricular canICP. lead It should to death be noted if used that for lumbar the obstructive puncture is type allowed due to to the be part is embedded by frontal entry point (10 cm above the nasion occurrence of and its complications. Surgical treatment: isand conducted 2.5 cm on toward the right) the orlateral occipital ventricle entry frontal point (6horn. cm Maximumabove the CSF diversion with shunt placement catheterinion and entry 3 cm is off 6 cmthe frommidline the on frontal the right region side). and The 11 cmcatheter from ventriculoperitoneal shunt is commonly used [21]. In cases where there is no possibility of using this method: For because this purpose, of factors a quadrant of the abdomen is used. The catheter is placed about 20- such as abdominal infection or previous surgical adhesions, a 30the cm occipital [27] into region. the peritoneum. For the peritoneal In these region, cases, use the of right antibiotic upper ventriculoatrial or ventriculopleural shunt can be used. With the ventriculoatrial shunt, the distal portion of the shunt is inserted reduction in infection rate [22]. impregnated catheters will be associated with a significant One of the shunt complications is over drainage in the standing or sitting positions as a result of gravity. To deal with shuntthrough tip the should jugular be vein controlled and its tip by must intraoperative be parallel to radiography; the junction this problem, an anti-siphon device is added to the shunt system. theof the perfect superior position vena of cava shunt and tip right placement atrial. For is between this purpose, the sixth the and seventh thoracic vertebrae. In the case of communicating Endoscopic third (ETV): insertion of a ventriculoperitoneal shunt is one of the most lumboperitoneal shunt can be used. The ventriculoperitoneal common neurosurgery procedures in our daily practiceAlthough [28] and the shunthydrocephalus, is preferred and due when to several the ventricular factors, the size most is important small, a often children with hydrocephalus are treated with it [9], other of which is related to the unique ability of the peritoneum to treatments should also be considered due to the high prevalence of the complications of this method. In the last two decades, the easiest method of shunt surgery [21]. Moreover, with this there have been shifts in the therapeutic pattern from the method,easily localize a substantial infection length and prevent of the peritoneal its spreading. catheter This can is also be ventriculoperitoneal shunt toward the ETV [29]. In cases where placed inside the abdomen to avoid disruption of shunt function by child development and shunt peritoneal catheter stretching fourth , the ETV may be a useful approach [30]. upwards, which avoids the need for repeated surgery. In these Thethere use is aof certain this method obstruction is effective in the inCSF both pathway children in the and third adults or cases, use of antibiotic-impregnated catheters will be associated of the cerebral aqueduct due to its low rate of complications [21,31].[29]. Also, ETV seems to be the first-line therapy in the narrowing withThese a significant shunts reduction basically in consist infection of rate three [22]. parts: ventricular catheter, pump, and peritoneal, lumbar, or arterial catheter ETV is a routine and safe method for treating obstructive hydrocephalus [32]. The use of this technique has been on of shunts which have fundamental differences in the pump. The shunt(depending pump on acts the assite a of one-way shunt insertion). valve, and, There depending are many on types the choice for treatment of obstructive hydrocephalus [32]. In this approach,the rise in age the is past a determining two decades factor [33], andfor prognosis today it is [34]. the first The success rate with this method is higher in children over one-year- discardedpressure set from for the it, thesystem CSF atcomes lower out pressure. of the brain The cerebral when the shunt CSF old and patients who have no history of surgery [35]. Because pressure is higher than the set pressure, and no fluid will be there is no need for an implant in ETV, the incidence of long-term and its settings can be changed after surgery depending on the complications is reduced [36]. pump is manufactured in two forms. The first type is adjustable, ETV can be used in the patients with non-communicating intracranial pressure will be reduced or increased. The changes hydrocephalus. This method is therefore appropriate for inCSF the volume pump takerequired place to through drain from the skin, the brain.using aWith special the magneticchanges, treatment of hydrocephalus secondary to obstruction due to tumor, aqueductal stenosis, myelomeningocele, postinfectious hydrocephalus and intraventricular hemorrhage [35]. In this way, pumpsfield. The are second made typein low, of pumpmedium, has and a constant high pressure pressure settings. and allows The an endoscope is inserted through a small burr hole in the skull pumpdraining valve CSF opensfrom the at brain the pressures at a constant of 5, pressure 10, and setting. 15 cm water,These into the lateral ventricle and then the third ventricle through the respectively. The type used is selected depending on the medical condition, the lesion causing hydrocephalus, and the volume ventricleforamina intoof Monro the subarachnoid and creates spaceforamina and incan the continue floor of its the normal third ventricle. As a result, the CSF will be able to exit from the third mostrequired of the to time drain the the medium CSF. Thepressure pressure setting required is used. forDespite these a pumps to drain CSF from the brain is not changeable. However, few complications reported with programmable valve [23], and flow. In the patients who are appropriately selected and where the CSF absorption in the subarachnoid space is appropriate, the JSM Pediatr Neurol 1(1): 1002 (2017) 5/8 Lotfinia (2017) Email:

Central Bringing Excellence in Open Access acceptable result will be obtained. However, the basilar artery status in these patients should be evaluated prior to surgery. In with a history of meningomyelocele repair, swelling and pain maydrowsiness, be seen abdominal in the surgical pain, irritability,site. In infants, and seizures.whose sutures In children and of intraoperative damage increases, and this method should not fontanelle are still not closed, the bulging fontanelle and increased becases used where in the an surgeryartery is [37]. lower ETV than is the a preferred ventricular method floor, thefor riskthe treatment of the narrowing of an aqueduct in most neurosurgical size of head circumference may be observed. To examine the dysfunctionshunt function, and observationalso to locate of the the disorder. emptying In andnormal filling mode of theby surgery.centers [31]. According to Warf [38], the result will be better pressingshunt pump on theafter pump, finger the pressing pump can will be be easily very helpful emptied to anddetermine slowly using bilateral ventricle choroid plexus cauterization during this It should be considered that only the presence of is emptied by high pressure, this means that the blockage has occurredfilled afterward. in the If distal the pump or abdominal is not emptied parts by of hand the shunt. pressure If the or considered as an indication for surgery [11]. In cases with normal ventriculomegaly in ultrasound, CT-Scan, or MRI cannot be shunt pump is emptied easily and is filled with delay or is not or slightly elevated ICP, even if the size of the ventricles is large, intracranial parts of the shunt. In such cases, all aspects of the shuntfilled, thisneed means to be checkedthat the blockagein terms mayof kinking occur andin the disconnection proximal or andthe CSF on the drainage other hand,will be the contraindicated shunt complications [11]. In will this be case, added. on the one hand, the surgery is not associated with a beneficial result, of the shunt components. Given that the shunt tubes are visible Complications on plain radiography; plain radiography can be employed for this several complications have been reported, including shunt purpose. Also, a brain CT scan can confirm shunt dysfunction by Following the insertion of a ventriculoperitoneal shunt, showing changes in ventricular size and their enlargement, as to different organs or shunt kinking, and disconnection of the well as increased ICP symptoms, such as periventricular edema malfunction, infection, , seizures, migration shunt components [21]. and the narrowing of subarachnoid cisterns. Further, MRI can andhelp possible to diagnose obstruction. increased ICP symptoms, intracranial bleeding within the ventricles, brain parenchyma, and catheter passing or infection. The cine MRI application can determine CSF flow Following surgery, a small amount of blood is often seen function. Technetium is used for this purpose. However, the Radioisotope methods can be recruited to evaluate shunt hemorrhagestract, but the often occurrence occur ofshortly clinically after significant surgery [39]. symptoms Different is riskuncommon factors in havethese beenlesions described [28]. Also, forsymptomatic the occurrence intracerebral of an ofinjection the shunt should because be done of the in theone-way proximal valve tube in theof the pump shunt, [9]. and the intracerebral hemorrhage following a cerebral shunt insertion, injection in the pump cannot evaluate the proximal obstruction The ventriculoatrial shunt and lumboperitoneal shunt are by the shunt, vascular damage caused by the shunt passing rarely used. Ventriculoatrial shunt infection can lead to life- throughincluding brain disseminated tissue, bleeding intravascular from the coagulationtumor or hidden (DIC) vascular caused threatening complications, such as septic endocarditis, septic lesion, coagulation disorders, and brain trauma shortly after pulmonary emboli, and immune complex glomerulonephritis [9]. shunt insertion [40]. The lumboperitoneal shunt is associated with a high incidence of herniation of the cerebellar tonsils, brain stem compression, and In the delayed hemorrhages, most probably the mechanism syringomyelia, as well as the possibility of leading to scoliosis and pulsation transmitted by the shunt tube [28]. of bleeding is vascular injury and its wall erosion due to the To reduce the complications associated with the use of Other possible complications of using a shunt are over nerve-root deficit [9]. shunts, the surgery should only be performed on patients with drainage, which may lead to a slit ventricle, and, in tumor cases, metastasis of tumor cells through the shunt tube may occur. moderate dilation of ventricles and mild ventricular enlargement Over 50% of patients within two years after followinghydrocephalus surgical who repair also have of meningomyelocele symptoms of increased can be ICP. controlled Mild or ventriculoperitoneal shunt placement experience shunt without shunt placement [42]. failure [17,41]. Most of these cases are caused by obstruction Prognosis that occurs most frequently in the proximal part of the shunt the lateral ventricle through the burr hole created in the right condition causing hydrocephalus and duration of symptoms and parietal(proximal bone. to theThe pump) shunt tip [9]. is The best shunt placed is in usually the lateral inserted ventricle into treatment-relatedFundamentally, complications. prognosis depends on the underlying anterior to the foramen of Monro that lacks the choroid plexus. Increased intracranial pressure can lead to neuronal loss and This consequently reduces the likelihood of growth and sticking of the choroid plexus to the holes in the shunt tube and, thus, natural course of hydrocephalus is not treated, the disease will prevents its obstruction; however, these adhesions lead to the leadbrain to damage death within [43], according 10 years in to 54% Laurence of the andcases. Coates They [44],also noted if the occurrence of intraventricular hemorrhage during the removal that 62% of children who did survive had cognitive impairments. and replacement of the shunt. The shunt tip placed anterior to the foramen of Monro reduces these problems. et al. [45], showed that the 10-year survival rate of these children wasIn child-ren 90% and who only were 30% treated, of them the had results cognitive are far impairments. better. Shurtleff

Shunt dysfunction can lead to headache, nausea and vomiting, JSM Pediatr Neurol 1(1): 1002 (2017) 6/8 Lotfinia (2017) Email:

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Cite this article Lotfinia I (2017) A Review in Pediatric Hydrocephalus: Physiology, Classification, Clinical Presentation, Imaging and Treatment. JSM JSM Pediatr Neurol 1(1): 1002.

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