Clinical outcome after ventriculoperitoneal shunt removal in an infant with hydrocephalus: The decisive role of rural primary care

Dear Sir,

Progressive macrocephaly in infancy is a clinically relevant finding in primary care and may represent the earliest visible sign of evolving hydrocephalus. In resource-limited and rural settings, head circumference measurement is often inconsistently performed, contributing to delayed diagnosis and referral. Routine use of growth charts and systematic follow-up are therefore essential for early identification and timely escalation of care.^[1,2]

Hydrocephalus in infants may present with ventricular enlargement, a bulging fontanelle, irritability, vomiting, or accelerated head growth, reflecting altered cerebrospinal fluid (CSF) dynamics and intracranial pulsatility.^[3,4] Ventriculoperitoneal (VP) shunting remains the most widely used treatment worldwide; however, this intervention requires close monitoring because complications such as overdrainage, subdural collections, and shunt malfunction are common during follow-up, particularly in young children.^[4,5]

We describe the clinical course of a 14-month-old male infant born after insufficient prenatal care and without TORCH screening. During his 1^st year of life, the child showed progressive macrocephaly without overt neurological symptoms. Cranial computed tomography (CT) revealed communicating hydrocephalus with an Evans index of 0.55 and no signs of intracranial hypertension, consistent with a compensated state [Figure 1]. Acetazolamide was initiated, and a medium-pressure VP shunt was subsequently placed. Early post-operative imaging demonstrated recovery of cortical reserve spaces, allowing hospital discharge.

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Figure 1:

Axial cranial computed tomography scan at presentation showing communicating hydrocephalus with marked ventricular enlargement, underscoring the importance of early detection and follow-up in primary care settings. The sulcal effacement (Orange arrow).

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Two months later, the patient was readmitted with irritability, vomiting, language regression, and intermittent fever. CT imaging showed a chronic subdural hematoma with acute rebleeding, attributed to shunt overdrainage. A minicraniotomy was performed, with evacuation of approximately 100 cc, resulting in initial clinical improvement. Follow-up imaging demonstrated resolution of the hematoma but persistent ventriculomegaly, suggesting valve-related overshunting.

In the following weeks, the child developed fluctuating neurological symptoms and variable CSF profiles, including periods of elevated protein and xanthochromia. Serial cultures yielded different skin commensals at separate time points, raising concern for contamination rather than a true shunt-related infection. Given the unstable clinical course, the VP shunt was completely removed. Intraoperative CSF appeared clear and under high pressure.

Subsequent etiologic evaluation confirmed congenital cytomegalovirus infection and elevated Toxoplasma antibody titers, both of which are considered plausible contributors to the hydrocephalus. After shunt removal, the patient exhibited transient gait instability and intermittent strabismus, with signs of partially compensated intracranial hypertension. Although reinsertion of a high-pressure valve was considered, the child evolved favorably under close observation, without recurrence of overt intracranial hypertension.

At final discharge, the patient was clinically stable, with resolution of irritability and febrile episodes and no evidence of language regression or persistent gait disturbance. Follow- up imaging showed stable ventriculomegaly without new complications. The family received detailed instructions regarding continued neurological follow-up, early rehabilitation, and warning signs requiring prompt evaluation.

This clinical course illustrates several key points relevant to rural practice. First, longitudinal primary care surveillance, particularly systematic head circumference monitoring, is fundamental for early detection of hydrocephalus and postoperative complications. Second, shunt-related complications such as overdrainage and subdural hematoma remain frequent, especially in settings with limited access to specialized follow-up.^[5-9] Third, underlying etiologies such as congenital infection may influence intracranial dynamics and clinical evolution, underscoring the need for individualized management strategies.^[10]

Although long-term CSF diversion is required in most cases of congenital hydrocephalus, a subset of infants may achieve compensated ventriculomegaly following shunt removal, particularly when brain compliance improves or the underlying condition stabilizes. Careful reassessment and close follow-up are therefore essential before committing to repeated shunt revisions.

In conclusion, this experience highlights the decisive role of rural primary care in the early detection, monitoring, and coordination of care for infants with complex hydrocephalus. Structured follow-up, caregiver education, and effective communication between primary and specialized services are critical to optimizing neurological outcomes in resource-limited settings.