A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients

Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children's Hospital

BACKGROUND

At Red Cross War Memorial Children's Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures.

METHOD

A single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion.

RESULTS

Twenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3-14.9) and 5.3 years (0.5-13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2-28) versus 4.5 (2-17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0-67) and 5 months (0-118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group.

CONCLUSION

Our findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.

Ventriculo-atrial shunt with occlusion of the internal jugular vein: operative experience and surgical technique

BACKGROUND

Ventricular shunts are one of the most frequent techniques used for the management of hydrocephalus. The ventriculoperitoneal shunt (VPS) is the most commonly performed procedure, and the ventriculoatrial shunt (VAS) is the second option in most medical centers. The main objective of this study is to introduce and describe a surgical approach for VAS outlining our experience and comparing it with traditional shunting techniques.

METHODS

In this retrospective cohort comparison study, we included patients with hydrocephalus treated with a surgical procedure between January 2010 and February 2021 at a single academic institution. We categorized the procedures into two groups: patients with VPS and conventional VAS grouped together into the conventional technique (CT) group, and the second group was patients with whom we performed VAS with complete internal jugular vein occlusion (IJVOT). We compared the surgical time, postoperative complications, and occurrence of shunt failure among the groups by performing univariate analysis using the Fisher exact test.

RESULTS

Out of the 106 patients included in the analysis, IJVOT was performed in 66 patients, and CT in 40 patients. The median surgical time was 60 min (IQR 60-90) for IJVOT versus 100 min (IQR 60-120) for CT (p < 0.01). In the follow-up a month after the procedure, 83.3% of patients with IJVOT and 62.5% of patients with CT did not require shunt removal or shunt revision (p < 0.01). Shunt revision rates were 12.5% and 1.5% for CT while 1.5% and 2.5% for IJVOT at 1 and 6 months after the procedure.

CONCLUSION

Our findings demonstrate that VAS with IJVOT is a safe method that exhibited shorter surgical times and outcomes comparable to CT. However, since the present study represents the first cohort evaluating IJVOT, it is imperative to conduct larger prospective studies, along with clinical trials, to fully explore and establish efficacy, long-term outcomes, and an in-depth comparison among shunting techniques.

Ventriculoatrial Shunt Versus Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Ventriculoperitoneal shunt (VPS) is usually the primary choice for cerebrospinal fluid shunting for most neurosurgeons, while ventriculoatrial shunt (VAS) is a second-line procedure because of historical complications. Remarkably, there is no robust evidence claiming the superiority of VPS over VAS. Thus, we aimed to compare both procedures through a meta-analysis.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, the authors systematically searched the literature for articles comparing VAS with VPS. The included articles had to detail one of the following outcomes: revisions, infections, shunt-related mortality, or complications. In addition, the cohort for each shunt model had to encompass more than 4 patients.

RESULTS

Of 1872 articles, 16 met our criteria, involving 4304 patients, with 1619 undergoing VAS and 2685 receiving VPS placement. Analysis of revision surgeries showed no significant difference between VAS and VPS (risk ratio [RR] = 1.10, 95% CI: 0.9-1.34; I2 = 84%, random effects). Regarding infections, the analysis also found no significant difference between the groups (RR = 0.67, 95% CI: 0.36-1.25; I2 = 74%, random effects). There was no statistically significant disparity between both methods concerning shunt-related deaths (RR = 2.11, 95% CI: 0.68-6.60; I2 = 56%, random effects). Included studies after 2000 showed no VAS led to cardiopulmonary complications, and only 1 shunt-related death could be identified.

CONCLUSION

Both methods show no significant differences in procedure revisions, infections, and shunt-related mortality. The literature is outdated, research in adults is lacking, and future randomized studies are crucial to understand the profile of VAS when comparing it with VPS. The final decision on which distal site for cerebrospinal shunting to use should be based on the patient's characteristics and the surgeon's expertise.

Post-traumatic hydrocephalus: An overview of classification, diagnosis, treatment, and post-treatment imaging evaluation

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy's report in 1914. The pathogenesis of PTH has not been fully clarified. At present, it is believed that the obstacles of cerebrospinal fluid (CSF) secretion, absorption and circulation pathways are the reasons for the development of PTH. However, recent studies have also suggested that the osmotic pressure load of CSF and the pathological changes of CSF dynamics are caused by the development of hydrocephalus. Therefore, a better understanding of the definition, classification, diagnostic criteria, treatment, and evaluation of post-treatment effects of PTH is critical for the effective prevention and treatment of PTH. In this paper, we reviewed the classification and diagnosis of PTH and focused on the treatment and the imaging evaluation of post-treatment effects of PTH. This review might provide a judgment criterion for diagnosis of PTH and a basis for the effective prevention and treatment of PTH in the future.

Incidence and nature of complications associated with ventriculoatrial shunt placement: A systematic review and single-arm meta-analysis

BACKGROUND

Ventriculoatrial shunt (VAS) is considered the second option for treating hydrocephalus, but there remains a lack of robust evidence regarding its complications profile.

PURPOSE

Evaluate the complications associated with VAS.

METHODS

Adhering to PRISMA guidelines, the authors searched Embase, PubMed, and Web of Science databases to identify articles reporting on the complications of VAS. Eligible articles were required to report whether complications occurred in a cohort of at least four patients. The extraction process focused on various outcome measures, including overall complications, pulmonary complications, cardiac complications, mortality, shunt revisions, glomerulonephritis, intracranial hemorrhage, and hygroma. Complications were defined as any adverse events related to the procedure, including revisions.

RESULTS

After retrieving a total of 2828 articles, 53 studies met the predefined criteria, involving 2862 patients. The overall complication rate was estimated at 33 % (95 % CI: 25-42 %), while the long-term complications rate was found to be 49 % (95 % CI: 32-67 %). Among the pediatric population, the complication rate was calculated to be 53 % (95 % CI: 39-68 %). The overall revision rate was estimated at 32 % (95 % CI: 23-41 %), with an infection rate of 5 % (95 % CI: 3-7 %). Notably, in the pediatric group, the infection rate was 10 % (95 % CI: 6-13 %). The random analysis indicated an estimated risk of 0 % for glomerulonephritis, intracranial hemorrhage, hygroma, cardiac complications, pulmonary complications, and shunt-related mortality.

CONCLUSION

VAS is a safe alternative when ventriculoperitoneal shunting is not feasible. Risk of classic severe complications is minimal. Nevertheless, caution is required when shunting critical patients. Further randomized studies are warranted to establish the ideal shunt for different patients.

Distal shunt placement in pediatric ventriculoperitoneal shunt surgery: an international survey of practice

OBJECTIVE

Ventriculoperitoneal shunt (VPS) surgery is a common treatment for hydrocephalus in children and adults, making it one of the most common procedures in neurosurgery. Children being treated with a VPS often require several revisions during their lifetime with a lifetime revision rate of up to 80%. Several different techniques exist for inserting the distal catheter, while mini-laparotomy, trocar, or laparoscopy is traditionally used. As opposed to adults, only few studies exist, comparing the outcome of the different distal catheter placement techniques in children. This international survey aims to investigate the current daily practice concerning distal shunt placement techniques in children.

MATERIAL AND METHODS

An online questionnaire investigating the different techniques used to place the distal catheter in pediatric VPS surgery was distributed internationally. All results were analyzed using descriptive and comparative statistics.

RESULTS

A total of 139 responses were obtained. Mini-laparotomy was reported to be the most frequently used technique (n = 104, 74.8%) for distal shunt placement in children, while laparoscopic or trocar-assisted placements were only used by 3.6% (n = 5) and 21.6% (n = 30) of all respondents, respectively. Over half (n = 75, 54.0%) of all respondents do not believe that laparoscopic placement improves the outcome.

CONCLUSION

This international survey shows that mini-laparotomy is the most frequently used technique for distal VPS placement in children all over the world. Further randomized trials are needed to elucidate this matter.

Shunt Nephritis: A Case of Mistaken Identity

BACKGROUND

Membranoproliferative glomerulonephritis is a histological pattern of glomerular injury due to the deposition of immune complexes and complement factors. It is associated with bacterial and viral infections, auto-immune diseases such as systemic lupus erythematosus and Sjögren's syndrome, monoclonal gammopathy, and complement disorders (dense deposit disease and C3 glomerulopathy).  Case presentation: This is the report of a 25-year-old male with membranoproliferative glomerulonephritis who was initially treated for systemic lupus erythematosus, but who was later diagnosed with nephritis due to a chronic infection of a central nervous system shunt, last revised at the age of 3 years old.

DISCUSSION

We highlight the challenges in making an early diagnosis of shunt nephritis, and succinctly discuss the clinical, biochemical, histopathological findings, and differential diagnosis of this type of infection-related glomerulonephritis.

The Sheep as a Comprehensive Animal Model to Investigate Interdependent Physiological Pressure Propagation and Multiparameter Influence on Cerebrospinal Fluid Dynamics

The present study aims to develop a suitable animal model for evaluating the physiological interactions between cerebrospinal fluid (CSF) dynamics, hemodynamics, and abdominal compartment pressures. We seek to contribute to the enhanced recognition of the pathophysiology of CSF-dependent neurological disorders like hydrocephalus and the improvement of available treatment options. To date, no comprehensive animal model of CSF dynamics exists, and establishing an accurate model will advance our understanding of complex CSF physiology. Persisting knowledge gaps surrounding the communication and pressure propagation between the cerebrospinal space and adjacent anatomical compartments exacerbate the development of novel therapies for neurological diseases. Hence, the need for further investigation of the interactions of vascular, craniospinal, and abdominal pressures remains beyond dispute. Moreover, the results of this animal study support the optimization of in vitro test benches for medical device development, e.g., ventriculoperitoneal shunts. Six female white alpine sheep were surgically equipped with pressure sensors to investigate the physiological values of intracranial, intrathecal, arterial, central venous, jugular venous, vesical pressure, and four differently located abdominal pressures. These values were measured simultaneously during the acute animal trial with sheep under general anesthesia. Both carotid and femoral arterial blood pressure indicate a reliable and comparable representation of the systematic blood pressure. However, the jugular venous pressure and the central venous pressure in sheep in dorsal recumbency do not correlate well under general anesthesia. Furthermore, there is a trend for possible comparability of lateral intraventricular and lumbar intrathecal pressure. Nevertheless, animal body position during measurements must be considered since different body constitutions can alter the horizontal line between the cerebral ventricles and the lumbar subarachnoid space. While intra-abdominal pressure measurement in the four different abdominal quadrants yielded greater inter-individual variability, intra-vesical pressure measurements in our setting delivered comparable values for all sheep. We established a novel and comprehensive ovine animal model to investigate interdependent physiologic pressure propagation and multiparameter influences on CSF dynamics. The results of this study will contribute to further in vitro bench testing, the derivation of novel quantitative models, and the development of a pathologic ovine hydrocephalus model.

Endovascular retrieval of a broken distal ventriculoatrial shunt catheter within the heart: illustrative case

BACKGROUND

Displacement of a distal catheter of a ventriculoatrial (VA) shunt is a rare complication and can lead to a challenging extraction requiring endovascular retrieval of the distal catheter.

OBSERVATIONS

The authors describe a patient in whom the distal catheter of the VA shunt had become displaced and traveled through the tricuspid valve into the right ventricular outflow tract.

LESSONS

In this case report, the authors present a multidisciplinary approach to retrieving a displaced distal catheter from a VA shunt.

Ventriculoatrial Shunts: Review of Technical Aspects and Complications

Diversion of cerebrospinal fluid is required in many neurosurgical conditions. When a standard ventriculoperitoneal shunt and endoscopic third ventriculostomy are not appropriate options, placement of a ventriculoatrial shunt is a safe, relatively familiar second-line shunting procedure. Herein we reviewed the technical aspects of ventriculoatrial shunt placement using an illustrative case. We focused on the different modalities for inserting and confirming the location of the distal catheter tip. We discussed how to overcome typical difficulties and significant concerns, such as cardiac arrhythmias and venous thrombosis. In addition, we reviewed the current literature for the different complications associated with ventriculoatrial shunt placement.

Thrombosis associated with ventriculoatrial shunts

Ventriculoatrial shunts are the most common second-line procedure for cases in which ventriculoperitoneal shunts are unsuitable. Shunting-associated thrombosis is a potentially life-threatening complication after ventriculoatrial shunt insertion. The overall prevalence of this complication is still controversial because of substantial differences in the numbers found in studies using clinical data and in those analyzing postmortem findings. The etiology of thrombosis may be multifactorial, including shunt catheter itself, contents of cerebrospinal fluid, shunt infection, and genetic disorder. The clinical presentation can vary widely, ranging from asymptomatic to a life-threatening condition. Timely recognition of thromboembolic lesions is critical for treatment. However, early diagnosis and management is still challenging because of a relatively long asymptomatic latency and lack of clear guideline recommendations. The purpose of this review is to provide an overview of ventriculoatrial shunt thrombosis, especially to focus on its etiopathogenesis, diagnosis, treatment, and prevention.

Advances in CSF shunt devices and their assessment for the treatment of hydrocephalus

INTRODUCTION

Hydrocephalus is a neurological disorder caused by excessive accumulation of the cerebrospinal fluid (CSF) in the ventricles of the brain. It can be treated by diverting the extra fluid to different parts of the body using a device called a shunt. This paper reviews different shunt devices that are used for this purpose.

AREAS COVERED

Shunts have high failure rates either due to infection or mechanical failure, therefore there is still ongoing work to address these two main handicaps. They require additional devices for performance assessment. Here, the paper also reviews different approaches for assessing shunt limitations. Moreover, future prospects are also discussed.

EXPERT OPINION

This study shows that shunt devices still remain an important treatment option for hydrocephalus. However, further efforts are required to design more advanced shunts, to eliminate high failure rates in clinical use. Sophisticated sensor systems that can accurately detect and regulate changes in CSF drainage to optimize drainage for individual needs. Moreover, shunt infection problem is still present despite recent improvements such as antibiotic impregnated catheters.

Simple Removal of Ventriculoatrial Shunt and Simultaneous Ventriculoperitoneal Shunt Revision: Short Communication

Background  Ventriculoatrial shunt (VAS) is a common alternative treatment option for hydrocephalus in patients with ventriculoperitoneal shunt (VPS) failure. Most previous reports on VAS discuss the atrial-related complications and none focus on simple removal (i.e., without specialized equipment). We report a case of simple VAS removal and simultaneous VPS revision, with no obvious shunt-related cardiac complications.

Case presentation  The patient was an 87-year-old female who had received a VAS for idiopathic normal pressure hydrocephalus 6 years prior. She developed a right thalamic hemorrhage with intraventricular hemorrhage and was admitted to our hospital. She had a recurrence of the hydrocephalus and was diagnosed with shunt malfunction, due to simple obstruction without obvious shunt-related cardiac complications. The VAS was simply and safely removed, and a VPS was simultaneously placed, as per the usual procedure in our institution. She remains well with no evidence of complications on postoperative day 10.

Discussion  Since VAS is mostly used in pediatric cases that are difficult to treat with VPS, the duration of time elapsed allows VAS catheters to form strong adhesions with the surrounding cardiac tissue. Therefore, the simple removal of VAS is usually not straightforward.

Conclusion  If the follow-up period is short and there are no specific cardiac complications at the time of replacement, VAS can be safely removed and VPS can be spontaneously placed, without any specialized surgical techniques or equipment.

Reconversion to ventriculoperitoneal shunt following ventriculoatrial shunt malfunction in children

PURPOSE

To analyze the long-term efficacy of the ventriculoatrial shunt (VAS) in pediatric patients with hydrocephalus, focusing on the atrial catheter and suitable revision procedures of the distal catheter following VAS malformation performed at our institution.

METHODS

The authors retrospectively analyzed data of 28 pediatric patients under the age of 10 years who were treated with VAS for hydrocephalus and who had a follow-up period of at least 5 years.

RESULTS

A total of 42 atrial tube revision procedures were performed in 28 patients during the study period. The median atrial tube survival time due to atrial tube obstruction was 2.32 years (n = 31, range: 0.4-8.08 years). Atrial tube survival time was shorter in younger children (p < 0.0001) and in children who were shorter in height (p = 0.0001). As a revision procedure following atrial tube malfunction, 22 (78.6%) out of the 28 patients who had an inserted VAS had the VAS reconversion into a VPS at the last follow-up.

CONCLUSIONS

VAS can be a useful alternative to VPS, but it requires frequent atrial tube revisions, especially in younger children. Reconversion to VPS after VAS malfunction is a reasonable option and is associated with longer shunt survival time despite its previously observed difficulties.

Should not we be using aspirin in patients with a ventriculoatrial shunt? Borrowing a leaf from other specialities: a case for surrogate evidence

INTRODUCTION

Ventriculoatrial (VA) shunts are life-saving in circumstances where ventriculoperitoneal shunts (VP) have failed. They are at risk for different complications, and more specific of them are cardiopulmonary complications. Currently, there are no standard recommendations concerning screening for risk factors, prophylaxis, or anticoagulation treatment in patients after VA shunt placement. Our study aims to prospectively study the possible role and efficacy of the use of aspirin to increase the survival of shunts in children with VA shunt and avoid secondary morbidity. In this article, the authors describe the interim results of an ongoing prospective study which supports the use of aspirin for VA shunt.

MATERIALS AND METHODS

The study design is prospective. The duration of the study is 2011 onwards and is ongoing. Hospital ethics board clearance and consent from the family were taken before inclusion in the study. All patients who had VA shunt were given a once-a-day low-antiplatelet dose of aspirin 5 mg/kg, from the first postoperative day onwards. Primary endpoints of the study are as follows: (1) major distal end malfunction documented on echocardiography or (2) any cardiac complications associated with the VA shunt catheter.

RESULTS

We have 6 patient since march 2011, who are being followed up. None of the shunts had malfunctioned until the reporting. None of the patients had any cardiac issues reported. The patients are to be followed continually. The present follow-up ranges from 2.5 to 10 years. The patient follow-up is being continued.

CONCLUSIONS

Aspirin is a drug with well-accepted safety profile, and its use and our preliminary observation and outcome of the use of aspirin in VA shunt are promising.

The survival of reimplanted shunts following externalization: a single-institution cohort study

OBJECTIVE

The failure-free survival of ventriculoperitoneal shunts (VPSs) following externalization for distal catheter infection or malfunction has not been adequately explored. Conversion to a ventriculoatrial shunt (VAS) may allow earlier reinternalization in lieu of waiting for the peritoneum to be suitable for reimplantation. This option is tempered by historical concerns regarding high rates of VAS failure, and the risks of rare complications are rampant.

METHODS

In this retrospective cohort study, all patients undergoing externalization of a VPS at a single institution between 2005 and 2020 were grouped according to the new distal catheter terminus location at the time of reinternalization (VPS vs VAS). The primary outcomes were failure-free shunt survival and duration of shunt externalization. Secondary outcomes included early (< 6 months) shunt failure.

RESULTS

Among 36 patients, 43 shunt externalization procedures were performed. Shunts were reinternalized as VPSs in 25 cases and VASs in 18 cases. The median failure-free survival was 1002 (interquartile range [IQR] 161-3449) days for VPSs and 1163 (IQR 360-2927) days for VASs. There was no significant difference in shunt survival according to the new distal catheter terminus (log-rank, p = 0.73). Conversion to a VAS was not associated with shorter duration of shunt externalization (Wilcoxon rank-sum, p = 0.64); the median duration was 7 (IQR 5-11) days for VPSs and 8 (IQR 6-15) days for VASs. No rare complications occurred in the VAS group.

CONCLUSIONS

Shunt failure-free survival rates following externalization are similar to published survival rates for nonexternalized shunts. There was no significant difference in survival between reinternalized VPSs and VASs. Although the VAS was not associated with a shortened duration of externalization, this finding is confounded by strong institutional preference for the VPS over the VAS. Early conversion to the VAS may be a viable treatment option in light of reassuring modern VAS survival data.

Ultrasound-guided percutaneous brachiocephalic vein cannulation for ventriculoatrial shunt placement in a child

OBJECTIVE

As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approach to the internal jugular vein under ultrasonographic control has been hitherto strongly recommended. Unfortunately, children still represent a challenge, having them peculiar characteristics for which the internal jugular vein cannulation shows some disadvantages.

METHODS

In this manuscript, we describe a percutaneous placement of ventriculoatrial shunt via right brachiocephalic vein under intraoperative ultrasonographic control.

CONCLUSIONS

Brachiocephalic vein cannulation in surgery provides notable advantages in paediatric population and it may be considered as the first choice in younger children.

Case Series of Ventriculoatrial Shunt placement in Hybrid Room: Reassessment of Ventriculoatrial Shunt

Objective

Ventriculoatrial shunt (VAS) remains an alternate option for treatment of hydrocephalus in patients with ventriculoperitoneal shunt (VPS) failure. Unfamiliar anatomy for a neurosurgeon has resulted in the VAS falling out of favor as a treatment option. However, there are unsatisfactory reports on the long-term result of VPS, and VAS has been recently re-evaluated. We are to report the simple way to do the VAS using a peel-away sheath in a hybrid operation room.

Methods

A jugular vein path was drawn by ultrasound, a small incision was made above the clavicle, and a shunt catheter was tunneled into it. The jugular vein was punctured beside the tunneled catheter with a Seldinger needle under ultrasound guidance. A flexible guide wire was introduced into the vein and 6-Fr peel-away sheath was advanced into the vein along the wire. Under fluoroscopic guidance, the catheter was cut to position approximately mid-level in the atrium. After the guide wire was removed, the distal shunt catheter was passed down. After confirming proper position of the distal catheter under the fluoroscope, the catheter-guiding sheath was pulled out as a peeling-away manner. We performed this surgical procedures in 5 cases.

Results

All the procedures of the VAS using a peel-away sheath were performed in a hybrid operation room Of 5 patients, 3 patients had the distal catheter failures in the peritoneal cavity and 2 patients had shunt A distal catheter was successfully indwelling in all the cases without any difficulties. After the surgery, neither shunt infection nor thromboembolic event happened.

Conclusion

VAS using fluoroscopy and a peel-away sheath is a good alternative option for hydrocephalus patients with shunt failure related to peritoneal cavity complications.

Complex Management of Hydrocephalus Secondary To Choroid Plexus Hyperplasia

BACKGROUND

Hyperplasia of the choroid plexus represents a rare cause of communicating hydrocephalus in children. Recent work has associated such disease with genetic abnormalities (such as perturbations in chromosome 9). Given such extensive cerebrospinal fluid (CSF) overproduction, patients with choroid plexus hyperplasia often fail CSF diversion and therefore require adjuvant interventions.

CASE DESCRIPTION

We present the case of a male infant with a ventriculoperitoneal shunt and radiographic choroid hyperplasia who presented to our institution with a massive abdominal hydrocele caused by an inability to absorb the significant amount of CSF drainage into the abdomen.

CONCLUSION

The child was treated with an endoscopic third ventriculostomy and choroid plexus coagulation; however, he still required CSF diversion via a ventriculoatrial shunt. A genetic workup showed tetraploidy of chromosome 9. We discuss criteria for selection of treatment strategies, including endoscopic third ventriculostomy with choroid plexus coagulation and/or CSF diversion, that may prevent the need for re-operation in select patients with hydrocephalus due to choroid plexus hyperplasia.