Current Trends in the Treatment of Pediatric Hydrocephalus: Ventriculoperitoneal Shunt or Endoscopic Third Ventriculostomy? A Narrative Review of Relevant Meta-Analyses Centered on the Indications, Safety and Efficacy Characteristics Along with Long-term Outcomes of the Available Treatment Modalities
Authors: Panagopoulos Dimitrios , Stranjalis Georgios , Gavra Maro , Boviatsis Efstathios , Korfias Stefanos , Karydakis Ploutarchos 
Published: October 2024

The pathophysiologic substrate of pediatric hydrocephalus has not been thoroughly explained. Because of that, the available treatment options and protocols will be largely based on expert opinions or the results of single-center databases, until a more comprehensive knowledge of the various subcategories of hydrocephalus is undertaken. In retrospect, we mention that valve-based shunt systems have been constituting the mainstay of therapy since the late 1950s. The initially used shunt systems were concerning the ventricular system and the atrium. In the 1970s, VA shunts were not the main stay of treatment, as the primary location for the distal end was substituted by the peritoneum, due to the emergence of the ventriculoperitoneal shunts. Several types of one-way valve-based shunt systems have been developed. The ultimate goal was the drainage of the appropriate amount of CSF, in order to avoid either overdrainage or underdrainage, without interfering with normal brain development or cognition. Our review briefly analyzes these valve types and attempts a comparison, based on their functional characteristics. In addition to the peritoneum, other distal locations for shunt placement have been explored, including the pleural space and gallbladder. A separate subcategory includes the shunt systems which incorporate the lumbar subarachnoid space as the proximal location for the central catheter. Nowadays, the only available surgical alternative for the treatment of hydrocephalus is ETV. Since 2000, approximately 50% of children suffering hydrocephalus have been considered to be candidates for the execution of ETV. The potential benefits are that it closely resembles to the normal, physiological pathway of CSF absorption, thus circumventing the need for an artificial shunt system. Moreover, this technique is associated with lower infection rates, as well as on average, with a lower reoperation rate. Attempts of future progression are largely based on the development of improved shunt valve systems that could be affordable worldwide, as well as with the constant availability of ETV in developing countries.
Another term that deserves special mention is related with the outcome of ETV in children who had a medical history of previously incorporated shunts and who were subsequently experiencing shunt dysfunction. This subset of patients is discussed in terms of efficacy (success rate from 40% to 80%) and safety (0%–32.5% of complications). Based on literature reviews, well-recognized predictive factors associated with secondary ETV failure include age, early onset of hydrocephalus, and prematurity. Currently, there is no consensus when the optimum surgical strategy is concerned in the different subgroups of patients, who are suffering from shunt dysfunction. Therefore, another issue that this review attempts to elucidate is the identification of subgroups of patients in whom shunt treatment is associated with a favorable outcome, compared to ETV, and vice versa.
The objective of our study is to evaluate the comparative safety and efficacy, as well as the outcomes, of shunting and ETV in pediatric hydrocephalus cases. Anatomic and molecular substrate of hydrocephalus need to be better elucidated, so that medications or genetic modifications become more effective in order to offer a potential cure for hydrocephalus. Advancements in the treatment of hydrocephalus will depend on research into the shared molecular mechanism underlying various forms of the condition, paving the way for new therapeutic strategies.