Cerebrospinal shunts: Selection of components, techniques for insertion and for revision

The treatment of hydrocephalus in the era since the nineteenth century and the early twentieth centuries can be summarized succinctly as a series of creative yet ultimately ineffective attempts at diminishing the buildup of fluid within the brain through various medicines, natural remedies, and physical maneuvers. Afterwards, the neurosurgeons were experimenting with various anatomical sites and cavities and attempting to locate offered the ideal space for cerebrospinal fluid (CSF) to collect and be absorbed. They were also reacting to problems of the shunt apparatus itself and responding in kind with innovative designs and approaches. At its most basic, a CSF shunt contains a proximal catheter, a valve and a distal catheter. Of all components of the CSF ventricular shunt, no aspect has undergone more modification or has been the subject of more technological nuance and attention, than the valve. To date, no valve design has proven superior to any other, regardless of the clinical situation of the patient. Despite the countless technological advances in shunt technology, mechanical, infectious, and functional complications remain an ever-present reality in the lives of nearly all shunted patients. Because of this the last few years has witnessed a switching of the pendulum, away from shunting, and back towards third ventriculostomy (albeit nowadays performed endoscopically) and choroid plexus cauterization. Despite recent success with ETV there is still a large sub-population of hydrocephalic infants and children that ultimately require shunts. To that end, the search for a “smart” shunt continues. Maybe, the ultimate solution to the quest for a perfect shunt rests in challenging some of our original suppositions. Looking back on advances in the treatment of pediatric hydrocephalus, we have surely traveled a long and winding road. And we trek on.