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“Not a lot” may be the general impression, but then it is easy to forget that, until the advent of shunts (almost 50 years ago), hydrocephalus was usually fatal. It is probably true to say that further fundamental advances have been slow in coming, but this has not been through lack of endeavour. What has occurred over the years is an understanding of how shunts malfunction (and technical attempts to combat this, including the development of endoscopic treatment for certain types of hydrocephalus) and a greater awareness of the metabolic and hydrodynamic changes that occur in the brain as a result of hydrocephalus (fig 1). Although perhaps overdue, reasonable studies on long term follow up of patients with hydrocephalus are now becoming available.
The prevalence of congenital and infantile hydrocephalus is between 0.48 and 0.81 per 1000 births (live and still),1 ,2 and a significant percentage of these patients will be left with persistent neurological deficits.2 ,3 In the United Kingdom and Ireland, the number of shunt operations is estimated to be 3500–4000 a year by the Cambridge based UK Shunt Registry. In the United States, about 125 000 shunt procedures are carried out annually at an estimated cost of $100 million.4 In relatively recent times in the United Kingdom, the number of paediatric neurosurgeons has increased, and in many regions the care of children with hydrocephalus has been inherited from the general paediatric surgeons.
Cerebrospinal fluid (CSF) circulation
The generally accepted view is that the CSF circulation is one of bulk flow, from the choroid plexus (production) to the pacchionian granulations (absorption). The evidence for this came in the 1960s when Welch and Friedman5 found that the pacchionian granulations …