How to keep shunts functioning, or "the impossible dream".

Hydrocephalus is a benign condition, and as our expertise in surgical treatment has increased, many of the "inevitable complications" are disappearing, and a normal life associated with satisfactory shunt function is no longer "the impossible dream." While this chapter has identified a few of the problems that may complicate long-term management, it is important to reemphasize that the most important single factor which determines success or failure is the attitude and experience of the neurosurgeon. While there is a great deal of surgical pride associated with removing a meningioma or clipping an aneurysm, we do not receive accolades from our colleagues when we have inserted or replaced a shunt. Whereas the surgical technique that is employed to remove an acoustic tumor or a meningioma at the base of the brain is a testimony to the skill of the neurosurgeon, it is not a technical feat to revise a shunt in an acutely ill child. When the surgical outcome is a satisfactory one, it is taken for granted, and when recurrent problems evolve they are assumed to reflect problems intrinsic to caring for hydrocephalus, and little consideration is given to the technical and conceptual skills required to retrieve the situation. Neurosurgeons often lose sight of the fact that hydrocephalus is the most benign intracranial disorder which is treated in large numbers. I believe that the most serious problem in the treatment of hydrocephalus has been the reluctance of experienced neurosurgeons to devote their time and energies to understanding the underlying pathophysiology and the potential complications and to instituting appropriate treatment. A neurosurgeon who is devoted to both the patient and the family and is committed to understanding and treating complications associated with shunts and shunt dependency will be the best insurance of the future of the patient, and ultimately as normal adults these patients will be a permanent testimony to the skills of the primary neurosurgeon.