Early Temporization Linked to Better Early Development in Premature Infants With Posthemorrhagic Hydrocephalus

• April 07, 2026
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  Nationwide Children's

A new HCRN study led by Nationwide Children’s links early temporary cerebral spinal fluid diversion and timely shunt conversion to better early development in preterm infants with posthemorrhagic hydrocephalus.

A new Hydrocephalus Clinical Research Network (HCRN) study, published in Journal of Neurosurgery: Pediatrics, suggests that starting with temporary cerebrospinal fluid (CSF) diversion and converting to a permanent shunt without delay when criteria are met is associated with better early development than immediate shunt placement for many preterm infants with posthemorrhagic hydrocephalus (PHH).

Led by Albert M. Isaacs, MD, PhD, a pediatric neurosurgeon and principal investigator in the Steve and Cindy Rasmussen Institute for Genomic Medicine at Nationwide Children’s Hospital, the multicenter, prospective cohort followed preterm infants with PHH treated between 2012 and 2021 across HCRN sites.

Researchers compared infants who underwent initial permanent CSF diversion with those who were first temporized using commonly employed methods. Developmental outcomes were measured with the Bayley Scales of Infant and Toddler Development, Third Edition (BSID‑III), at 15 to 30 months and, when possible, at 36 to 42 months of corrected age. The cohort included 106 infants; 15 received permanent diversion at the outset and 91 were temporized.

On adjusted analyses, infants who received permanent diversion initially had lower early cognitive scores than those who began with temporary diversion. Within the temporized group, children who ultimately required conversion to a permanent shunt scored lower on composite and language measures than those successfully weaned.

“These results underscore the burden of PHH and the value of avoiding permanent hardware when it can be done safely,” says Dr. Isaacs, who is also an assistant professor of Neurological Surgery at The Ohio State University College of Medicine.

Additionally, the team found that outcomes were similar whether centers used a ventriculosubgaleal shunt or a ventricular access reservoir during the temporizing phase, allowing logistics and clinician preference to guide the choice. The ventricular size at the time of conversion was more influential on outcomes. Larger ventricles, when a permanent shunt was placed after initial temporization, were associated with poorer motor performance, while ventricular size at the very first diversion procedure was not linked to later scores.

“How and when we intervene matters,” says Dr. Isaacs, who is also the director of the Hydrocephalus Program at Nationwide Children’s. “Early temporization can stabilize fragile preterm infants while we keep a close eye on ventricular size — and our findings reinforce the importance of not waiting too long once a shunt is truly needed.”

Most premature infants with PHH benefit from an initial temporizing strategy paired with rigorous surveillance and timely conversion when criteria are met, Dr. Isaacs adds. Individual considerations such as intraventricular hemorrhage severity, comorbidities and response to temporization still drive decision‑making, but the data point to actionable levers that teams can use to support early cognitive and motor development.

At Nationwide Children’s, Dr. Isaacs says those levers are embedded in routine practice. The Hydrocephalus Program provides coordinated care from fetal diagnosis through adolescence, with neonatal neurosurgery, neonatology, neurology and developmental pediatrics working in concert. As a member of the Hydrocephalus Clinical Research Network, the program applies evidence‑based protocols and contributes multicenter data that continue to refine when to temporize, when to convert and how to minimize risk.

Reference:

Isaacs AM, Shannon CN, Browd SR, Hauptman JS, Holubkov R, Jensen H, Kulkarni AV, McDonald PJ, McDowell MM, Naftel RP, Nunn N, Pindrik J, Pollack IF, Reeder R, Riva-Cambrin J, Rozzelle CJ, Rocque BG, Strahle JM, Tamber MS, Whitehead WE, Kestle JRW, Limbrick DD, Wellons JC. Neurodevelopmental outcomes of permanent and temporary CSF diversion in posthemorrhagic hydrocephalus: A Hydrocephalus Clinical Research Network study. Journal of Neurosurgery: Pediatrics. 2025;35(4):315-326.

Image credit: Nationwide Children’s