Introduction Hydrocephalusisoneofthesurgicallytreatablepaediatric problem. 1 Cerebrospinal fluid (CSF) shunting is the most commonwayofmanaginghydrocephalusandventriculo- peritoneal shunt (VPS) is the mainstay of CSF shunting though having high rate of complications ranging from 1% to 40% with the mean shunt survival being about 5 years. 2 The rate of complication is very high in neglected cases of hydrocephalus. Despite the significant advances in shunt technology, most of the complications are relatedtoshunthardwareandinfections. 3,4 Neglected hydrocephalus can be defined as marked enlargement of head with thinned out scalp, pressure sores on bony prominences, with established neurological deficit as visual loss, marked ventricular dilatation with less than 2cm cortical mantle associated withabsence/agenesisofthecerebellarvermis. The idea of surgical intervention in neglected cases was related to availability of on-demand provision of free medicaltreatment,moralreasonstoeasetheproblemsof family with handling of the disabled and actively ill child. Various factors contributing to delay in neurosurgical advice were religious taboos, local quackery and lack of education. The current study was planned to review the outcome of surgical intervention in neglected hydrocephalus and to assess the various risk factors having adverse effect on outcome. Patients and Methods The quasi-experimental study was conducted at the Neurosurgery Department of the Combined Military Hospital (CMH), Rawalpindi, from January 2012 to June 2014, and comprised infants of either gender who presented late with congenital hydrocephalus, fronto- occipitalcircumference(FOC)significantlyhigherthan98 percentileofmatchedagegroup,havingsignsofmarked hydrocephalus such as tense fontanelle, irritability, perinaud'sphenomenonandfailuretothrive. After getting written informed consent from respective parents, comorbid conditions of spina bifida, systemic anomalies and chest infections were recorded. Infants of normal or small FOC with hydrocephalus, secondary craniosynostosis, hydrocephalus ex-vacuo, post- JPakMedAssoc 430 ORIGINAL ARTICLE Experience of ventriculo-peritoneal shunt insertion in late presenting congenital hydrocephalus ZahidHussain,AbdulGhaffar,ShahzadAhmedQasmi,JunaidMushtaq Abstract Objective: To evaluate the outcomes of insertion of ventriculo-peritoneal shunts in paediatric neglected hydrocephalus. Methods: The quasi-experimental study was conducted at the Combined Military Hospital, Rawalpindi, from January 2012 to June 2014, and comprised infants of both genders who presented late with congenital hydrocephalus,havingfronto-occipitalcircumferencemorethan98percentileofmatchedagegroup.Pre-operative assessment was based upon detailed history, clinical examination, laboratory investigations and computed tomography scan of head. After insertion of ventriculo-peritoneal shunt, patients were followed up for outcomes. DatawasanalysedusingSPSS17. Results: Of the 30 infants, 12(40%) were girls and 18(60%) were boys. Overall mean age was 7.73±1.41 months (range: 5-10 months). Mean fronto-occipital circumference was 54.30±3.08. Cerebrospinal fluid infection was documentedin12(40%).Abdominalwoundcomplicationswereobservedin7(23.3%)infants.Ventriculo-peritoneal shunt was removed in 18(60%) and eventually replaced in 18(60%). In-hospital mortality on account of complications was encountered in 13(43.3%). Correlation of fronto-occipital circumference to mortality was significant (p=0.001). Conclusion: To shunt or not to shunt remains a dilemma for poor-risk infants, but timely reporting of infants with hydrocephalus,propercaseselectionmayimprovetheoutcomeofsurgicalintervention. Keywords: Ventriculo-peritoneal shunt, VPS, Hydrocephalus, Neglected, Fronto-occipital circumference, FOC. (JPMA66:430;2016) Combined Military Hospital, Rawalpindi Cantonment, Pakistan. Correspondence: Zahid Hussain. Email: zahidsurgeon@gmail.com