Surgery for post-traumatic hydrocephalus: lessons, challenges and future directions.

Introduction: Post-traumatic hydrocephalus (PTH) is characterized by ventriculomegaly, intracranial pressure (ICP) impairment and progressive neurological deterioration; it is a common yet often under-recognized and under-treated complication of traumatic brain injury (TBI). Early identification and intervention are critical for optimizing neurological recovery and functional outcomes. The proportion of patients requiring intervention for PTH is highly variable but is supposed to reach up to one-third of individuals sustaining a TBI. Shunt surgery represents gold standard treatment, but precise recommendations regarding therapeutic decision-making and operative techniques are still lacking. The aim of this narrative review is to synthetize current evidence on surgical management of PTH, highlighting available options with their respective strengths and limitations. Methods: A comprehensive literature search was conducted focusing on studies from the past decades that reported surgical management of PTH. Relevant retrospective and prospective series, comparative analyses, and recent narrative/systematic reviews were included. Discussion: Ventriculoperitoneal shunting (VPS), lumboperitoneal shunting (LPS), and ventriculoatrial shunts (VAS) are the most widely explored techniques in PTH management. VPS is the most performed treatment, but LPS and VAS are feasible alternatives showing similar rate of improvement although possibly higher risks of malfunction and systemic complications should be considered. Programmable valves represent the preferred choice for PTH shunt surgery, demonstrating less complications and need of surgical revisions compared to fixed-pressure systems. ETV-traditionally viewed as a relative contraindication in PTH-has shown satisfactory results, though long-term efficacy remains uncertain. Simultaneous cranioplasty and shunting is increasingly reported in clinical practice, however there is contradictory evidence supporting its safety and efficiency. Moreover, outcomes and complications rate vary widely, reflecting the heterogeneity of patient populations, injury patterns, and timing of intervention. There is also limited but growing evidence for conservative strategies, particularly in long-term management of PTH and TBI's clinical sequelae, even though their role is less clearly delineated. Conclusion: PTH management has deeply evolved during the last decades, enhancing the standard of care and achieving better long-term prognosis, but still lacks firm consensus on diagnostic and therapeutic indications, with scarce prospective comparative data. Refining surgical decision-making and prospective, multicenter trials are crucial to improve outcomes of this complex condition.