History of Management of Hydrocephalus in Children

Authors

Andrew Jea, M.D.

Abhaya V. Kulkarni, M.D.

Kemel Ahmed Ghotme, M.D.

James M. Drake, M.D.

Rick Abbott, M.D.

Section Editor

Shlomi Constantini, M.D.

Editor in Chief

Rick Abbott, M.D.

Understanding of Disease

• Ancient time – CSF: Ancient descriptions of “water on the brain” appear in the writings of Hippocrates, Galen, Vesalius, and others (75).
• 1664 – choroid plexus: In 1664, Thomas Willis suggested that choroid plexus produces CSF (75).
• 1701 – pacchionian granulations: In 1701 Pacchioni described the arachnoid granulations (75).
• 1875 – CSF circulatory pathway: In 1875, Key and Retzius described in detail virtually the entire CSF circulation system (75).

Technological Development

Shunts

• Ancient Greeks: The ancient Greeks reportedly practiced ventricular punctures (19).
• 19th century – first attempts at CSF diversion to treat hydrocephalus: The fluid was usually diverted to the subcutaneous or subdural spaces. Glass wool, gold tubes, and glass tubes were used, as well as strands of catgut and linen. Indwelling setons or collared cannulas were also used for continuous drainage with poor results, and death from meningitis was common. The first lumboperitoneal shunt described was employed by Dandy, using a silver wire (19).
• 1917 – linen threads: Sharpe reported 41 cases treated with linen threads, from the ventricle in non-communicating cases and the subarachnoid spaces in communicating hydrocephalus (63).
• Early 20th century – rubber tubes: Rubber tubes were introduced to divert CSF in the first half of the 20th century.
• 1949 – lumbo-urethral shunt: Matson introduced the lumbar-urethral shunt using a polyethylene plastic tube in 1949 (68).
• 1952 – ventriculo-jugular shunt: Nulsen and Spitz reported the successful use of a ventriculo-jugular shunt using a spring and stainless steel ball valve (69).
• 1955 – valved shunt: The Holter valve was the first shunt to use silicone; almost at the same time, Pudenz confirmed that silicone was the best material for shunts (19).
• 1966 – unidirectional valved shunt: Hakim improved and developed a unidirectional valve with the capacity to regulate the CSF pressure by adding a spring pressure control in a stainless steel cone and synthetic sapphire ball (70).
• 1973 – antisiphon valve: Portnoy et al. reported on the development of an antisiphon device in 1972 (72).
• 1987 – variable flow valve: Sainte Rose et al. in 1987 reported the development of a valve that varied flow in response to the outflow pressure in the shunt (the Orbis Sigma valve) (73).

Third Ventriculostomy

• 1879 – Nitze’s lens endoscope: Nitze introduced the first endoscope with lens magnification in 1879 (44).
• 1882 – Newman’s modification with light bulb: A major draw back of Nitze’s scope was the heat produced by the illumination element at its distal tip. In 1883 Newman replaced the element with a light bulb, thereby lessening the problem of heat at the tip of the endoscope (45).
• 1950s – Hopkins’s rigid endoscope: Work done by Harold Hopkins in the 1950s led to a significant improvement in image quality and illumination. First he replaced the design of a series of lenses in an air-filled tube with the design of a series of glass rods gapped in such a way that the intervening air served as the scope’s lens. This design resulted in a dramatic increase in the endoscope’s refractory index and field of view. He then used Lamm’s findings that light could be conducted down glass fibers for relatively long distances with little loss in intensity. The result was the rigid rod endoscope design still in use today (46).
• 1954 – Kapany and Hopkins’s flexible endoscope: Work on the use of glass fibers for the conduction of light led to the discovery that fiber bundles could be used to conduct not only light but also an image. When the fiber orientation was maintained from one end of the bundle to the other (so-called coherent fiber bundles), the image being “seen” by one end of the fiber bundle was conducted undistorted to the other, where it could be projected for visualization. This finding led to the development of flexible endoscopes (47).

Surgical Technique

Shunts

• 19th century – Dandy: Dandy developed the first lumboperitoneal shunt.
• 1939 – Torkildsen: Torkildsen described the lateral ventricle to cisterna magna shunt (64).
• 1949 – Matson: Matson introduced the lumbar-urethral shunt (68).
• 1957 – Pudenz et al.: Pudenz and colleagues presented ventriculo-atrial shunts (74).
• 1967 – Ames: On the basis of work by Ames, the peritoneum was settled on as the best resorptive site (71).

Third ventriculostomy

• 1923 – Mixter performs first ETV: In 1923 a Boston neurosurgeon, W. J. Mixter, reported on the first ETV used to treat a 9-month-old child with hydrocephalus. Others followed, but the technique never gained wide acceptance (48).
• 1990 – Jones reintroduces ETV to pediatric neurosurgery: Starting in the late 1980s, R.F.C. Jones began to speak of successfully managing a series of hydrocephalic children with ETVs. This started a wave of trials in pediatric neurosurgical centers in Europe and North America, resulting in the wide acceptance of ETV for the management of hydrocephalus in children (23).