According to a study published in the New England Journal of Medicine, implanting a shunt or endoscopically reducing intracranial pressure and reducing fluid production are equally effective in treating infants with hydrocephalus caused by brain infections, but endoscopy may have fewer down-the-line complications.

Steven Schiff, a researcher, said, "This clinical trial asked if we could do a version of shuntless surgery, without the need to implant a plastic tube. Hardware fails at a terrible rate in young children and needs to be repaired. The body becomes dependent on the shunt and patients need to be hospitalized quickly when the shunt fails."

While shunts can fail throughout a patient's lifetime, typically, the endoscopic approach tends to fail during the first six months after surgery, and failure is less dangerous. In hydrocephalus, cerebrospinal fluid builds up inside the skull and increases pressure on the brain.

In infants, whose head bones are not yet fused, hydrocephalus can enlarge and deform the shape of the skull. The increased pressure can prevent the brain from developing, leading to cognitive impairment or death. The standard procedure to treat hydrocephalus has been surgical implantation of a shunt.

With a shunt the fluid overdrains, but without a shunt, there is more fluid. It is needed to find out if the children do as well if there is more fluid within the brain. A total of 100 infants were enrolled in the trial with 51 randomly assigned to endoscopic surgery and 49 randomly assigned to receive a shunt.

The researchers used the Bayley Scale of Infant Development cognitive scale to score the infants at 12 months. They also tested the babies' motor and language skills. They found no significant difference between the babies with shunts and those receiving endoscopic surgery for cognition, motor skills or language skills.

The team saw that one-third of the children had died, which is twice the typical 16% mortality rate in Uganda. They also found that one-third of the children were quite disadvantaged, but one-third fell in the normal range. The current trial found that children in the normal range had more normal brain development.

To determine normal development, the researchers used CT scans. However, in order to categorize the infant's brains, the researchers needed growth curves of normal infant brain development. The researchers found that the mechanical pressure on the brain acted as a sort of growth dampener.

Higher pressures caused the brain to slow its growth, but when the pressure was lowered, brain growth sped up and in some cases reached normal growth ranges. The researchers would now like to automate the analysis of CT and MRI imaging to make it easier to monitor the growth of the brain of such children.

"Ultimately the answer for hydrocephalus will be in prevention. Until we can get rid of these infections – we think there are about 400,000 cases per year worldwide and up to half may be caused by infection – surgical approaches are the only answer," the researchers concluded.