I recognize that the two sentences mentioned up in my question were put by top researchers in this topic and should be highly respected. As a simple man I trust of course their scientific work, but what they say is bad news for me and my colleague patients. At the same time I think that we have to be very careful and not to use their results in all the situations of worsening of symptoms in some of shunted patients. Shunts are having bad reputation of frequent problems and malfunction. They are very undependable putting neurosurgeons in very bad situations many times. On the other hand they are also the only current way to treat hydrocephalus. Also the same experts wrote in other articles that the perfect valve did not come yet. It is also known that fine adjustment is very sensitive and difficult in many cases even with best neurosurgeons worldwide. So some patients worsening should not be regarded as neurodegeneration in every case. As a patient I prefer that more should be directed on correctable factors. This gives me much better hope than assuming that irreversible damage has done as part of a natural course of disease. What is attractive and hopeful in hydrocephalus is its remarkable reversibility. Their conclusion makes me remember what I am telling to some of my patients. This happens when after intensive investigations and treatment, result is unfavorable. As a treating doctor I cannot keep silent in front of my patient and I have to say something logical to explain my failure.

From my own personal experience, I dare to suggest a better clinical wisdom related to this context:

Any symptom or deterioration in a shunted patient should be considered hydrodynamic until proved otherwise

Also if neurodegeneration should inevitably happen in some patients, the following question should arise: Were these degenerations preventable? In case we normalized the insulting high CSF pressure why we got degeneration? I thought of one possible factor that the wider adjustment steps might be harmful to brain tissue. If this hypothesis is correct, then smaller steps should stop CSF pressure wide excursions bad effects. But we have to confirm that they are harmful.

At the end I have to stress that I am not of course the person suitable to agree or disagree on these kind of researches. I am telling only my reflections from my own personal adjustment experiences which included 15 adjustments

Christopher,

Thank you for sharing. Neurosurgeons found reversibility in most chronic hydrocephalus patients after shunting. Some patients in the research mentioned above are deteriorating after intial improvement. As you said this may be due to stretching of nerve fibres. Brain should adapt to lower CSF pressures slowly. I am suggesting smaller adjustment steps trying to avoid this incidence.