Child's Nerv Syst (1989) 5:361-363 © Springer-Verlag 1989 Therapeutic criteria in hydrocephalic children Manuel Castro-Gago 1, In6s Novo Rodriguez ~, Antonio Rodriguez-Nfifiez ~, Jos6 Pefia Guiti/m 1, Santiago Lojo Rocamonde 2, and Santiago Rodriguez-Segade 2 1 Department of Pediatrics, Neuropediatrics Service, and z Central Laboratory Service, Hospital General de Galicia, School of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain Abstract. The xanthine, hypoxanthine, and total oxypurine levels were determined in the CSF of 28 hydrocephalic pa- tients (age from newborn to 2 years) and 8 healthy controls using HPLC. The Evans' index, the mean weekly increase in cranial circumference, and the intracranial pressure were also measured. Of the hydrocephalic patients 13 were self- compensated and the other 15 had a shunt implanted during the course of the study. The mean xanthine, hypoxanthine, and total oxypurine levels in the normal children were 5.20, 5.94, and 11.29 gmol/1, respectively. In the self-compensated hydrocephalics these levels were 5.17, 5.71, and 10.79 gmol/1, respectively. In the noncompensated hydrocephalics, they were 9.90, 9.91, and 19.82 gmol/1. The differences between the latter group and the first two are statistically significant (P<0.001). The mean Evans' index and the mean weakly increase in cranial circumference in the self-compensated hy- drocephalics were 0.35 and 0.25 cm, respectively. In the non- compensated hydrocephalics, they were 0.55 and 0.95 cm. The differences between the two groups are statistically sig- nificant (P < 0.001). Two weeks after implantation of shunts in the noncompensated cases, the mean xanthine, hypoxan- thine, and total oxypurine levels fell to 4.22, 4.57, and 8.80 gmol/1, respectively. These changes are statistically sig- nificant (P<0.001). We think that the two criteria (clinical and biochemical) are equally useful for the prediction of self-compensation in hydrocephalic children and that the oxypurine values after shunt implantation can be used to monitor progress in noncompensated cases. Key words: Hydrocephalus - Hypoxanthine - Xanthine - Oxypurines 7 Cerebrospinal fluid. In treating infantile hydrocephalus it is frequently necessary to decide whether it is better to implant a shunt or to wait for spontaneous improvement. There are presently no uni- versally accepted criteria on which to base this decision [4, 5, 8, 181. Offprint requests to: M. Castro-Gago Saugstad and other investigators have pointed out the importance of the breakdown product of ATP, hypoxan- thine, as a biochemical indicator of tissue and cellular hy- poxia [1, 14, 15]. There are few references to the measure- ment of this metabolite in the cerebrospinal fluid (CSF) [1, 9, 11, 12]; they have shown high hypoxanthine concentra- tions in perinatal hypoxia, after convulsions [12], in bacterial meningitis [11, 12] and in hydrocephalus [1, 6, 10]. Recently, we proposed that the xanthine, hypoxanthine, and total oxypurine levels in CSF can be used in cases of hydrocephalus as guides for therapeutic action and to mon- itor its progress [6]. In the present study we compare the CSF oxypurine levels in hydrocephalic children with the Evans' index, the mean weekly increase in cranial circumference, and the in- tracranial pressure, to evaluate their usefulness as criteria to therapeutic action in these patients. Materials and methods Twenty-eight hydrocephalic infants, ranging from newborn to 2 years of age (mean age, 6.2 months) were monitored from August 1987 to January 1989. The hydrocephalus was communicating in 17 cases and obstructive in the other 11. Shunts were necessary in all the obstructive cases and in 4 of the communicating hydrocephalics. No therapeutic action was required in the 13 communicating hydro- cephalics whose psychomotor development beyond 17 months was considered to be normal, with no increase in ventricular size, as measured by means of real time ultrasound and computerized to- mography (CT). The hydrocephalus was, accordingly, deemed to have self-compensated. The xanthine, hypoxanthine, and total oxypurine levels in the CSF of all hydrocephalic patients were quantitatively measured by high performance liquid chromatography (HPLC) [16] at the time of diagnosis, after lumbar or ventricular puncture. The HPLC method used can separate hypoxanthine and xanthine, and it is specific and sensitive [10]. To determine the normal range the same measurements were made for 8 "reference" children (nonhydro- cephalic patients in the same age range for whom a lumbar puncture was performed as a part of a study on febrile disease and the results of conventional analysis were considered to be normal). All samples showing any evidence of blood contamination were excluded from the study. Samples for oxypurine analysis were immediately stored at -20 °C for later analysis. The Evans' index (as a measure of ventriculomegaly) and the presure through the anterior fontanel or the intracranial pressure