Hydrocephalus — a condition in which an abnormal amount of fluid accumulates in the brain — is a common problem in pediatric surgery. It has been a challenge for as long as physicians such as Dr. Sanjiv Bhatia have treated children with neurological diseases.

“If we have a child where the cerebrospinal fluid either doesn’t circulate properly or is not absorbed normally, it puts a lot of pressure on the developing brain,” Dr. Bhatia says. “If the condition occurs soon after they’re born, the children develop an increasingly larger head circumference.”

That is one of the first clues. There is a well-defined, accepted growth curve for the development of a child’s head from the age of birth to five years of age. But if the child’s head size increases rapidly, doctors always suspect that there’s an underlying cause: be it hydrocephalus, bleeding, or a tumor.

Dr. Bhatia, a pediatric neurosurgeon at the Nicklaus Children’s Brain Institute® in Miami, says his facility has made breakthrough strides in offering less invasive — and more successful — treatments for hydrocephalus than ever before.

“Parents often come to us saying, ‘I noticed my child’s fontanelle is bulging, even when he is sleeping quietly. Is that normal?’ And that certainly is not normal. Sometimes the scalp veins are bulgy, which is another sign of hydrocephalus,” according to Dr. Bhatia. “Lastly, we might see children experience difficulty in looking upwards. In the early newborn phase, if parents notice that the head is growing rapidly or the child has bulging of the fontanelle and veins, and then they start having difficulty in looking upwards, that is what is called a ‘sunset’ sign. If the child is unable to look upwards due to the pressure on the brain, parents should seek medical attention.”

More extreme symptoms of advanced hydrocephalus can include a failure to thrive, vomiting and/or lethargy. If the symptoms are ignored, the result can be deadly.

“As this is happening,” Dr. Bhatia says, “there is progressive compression on the brain, and that becomes a source of neurological injury. About 70- to 80-percent of brain growth occurs in the first two years of life. If we don’t correct this problem early, the child may be left with permanent neurological impairment.”

The treatment of hydrocephalus, for the last 50 years, has been to place a shunt tubing from the cavity of the brain into the abdominal cavity. But the shunt has a high risk of breaking down, getting blocked, and risks infections.
Over the last decade, pediatric neurosurgeons such as Dr. Bhatia at Nicklaus Children’s Hospital — Florida’s undisputed leader in providing care for children with brain anomalies — have worked on an alternative, endoscopic method of treatment.

“And if you place the shunt in a two- or three-month-old, the chances of revising it in the first year is about 60 percent,” Dr. Bhatia says. “The burden to the child and to the family from having a shunt is enormous. The shunt is a lifelong method of diverting fluid, and the kids have to be under constant supervision. And even if the shunt is working, there can be other complications related to it, just because the shunt tends to drain more fluid than it needs to. But there was never an alternative … until now.

“We use a camera to look through a small hole into the cavity of the brain,” he explains, “and divert the fluid around a blockage. If the child’s brain has the ability to absorb the brain fluid, and we bypass that blockage, the child can take care of his hydrocephalus. We alter the plumbing and the child uses his own native system to do the job.”

A second procedure during the operation, a choroid plexus cauterization — focused on the part of the brain that creates the excess fluid — increases the chances of success.

“That has substantially improved our results and allowed young children to manage hydrocephalus without a shunt,” according to Dr. Bhatia. “Now we don’t place shunts on those children unless it really is necessary and unless they have really failed the first line of treatment.”