CSF drainage strategy and complication management of hydrocephalus

Abstract

Conventional CSF drainage strategies—using external ventricular drainage (EVD) for acute hydrocephalus and permanent shunts (ventriculoperitoneal [VP], ventriculoatrial [VA], lumboperitoneal [LP]) for chronic hydrocephalus-are often inadequate in complex clinical scenarios (e.g., patients with intracranial hemorrhage, active infection, or unstable conditions who cannot undergo permanent shunt surgery). This creates an urgent need to comprehensively review drainage modalities to address the core challenge of reducing surgical frequency while effectively controlling intracranial pressure (ICP) and avoiding complications. This review systematically examines seven major CSF drainage methods: EVD, lumbar drainage (LD), Ommaya reservoir EVD, long-tunneled EVD (LTEVD), VP shunt, VA shunt, and LP shunt. It details each method’s indications, contraindications, advantages, disadvantages, and typical application duration based on clinical evidence and literature. Additionally, the review covers key aspects of external drainage management and targeted strategies for handling common complications. This review aims to provide neurosurgeons with a practical, evidence-based reference for selecting optimal CSF drainage strategies. It also proposes a stepwise clinical protocol to guide decision-making—from initial intervention for acute hydrocephalus to transition to long-term or permanent drainage solutions—with the goal of balancing reduced surgery numbers, effective ICP control, and complication prevention to improve patient prognosis. A practically feasible protocol with preliminary clinical evidence is proposed: initiate EVD for acute hydrocephalus; for shunt-dependent patients, use LD for communicating hydrocephalus or Ommaya reservoir EVD for obstructive hydrocephalus; if permanent shunts remain unfeasible after re-evaluation, switch to LTEVD; and finally transition to appropriate permanent shunts when conditions permit. This protocol optimizes drainage strategies, addresses gaps in traditional approaches, and supports neurosurgeons in personalized treatment selection.