Objective: The current study aimed at evaluating experience with pediatric hydrocephalus and reviewing time trends and age-related differences in etiology, management, and outcomes of pediatric hydrocephalus at a tertiary care center in a south Asian country. Methods: We conducted a retrospective cohort study based on case note review of pediatric Patients (age, 1 month to 15 years) with hydrocephalus managed at Aga Khan University Hospital Karachi, over an 18-year period (1988-2005). For analysis, the study period was divided into two epochs (period A, 1988-1996, period B, 1997-2005) and study population was divided into two age groups (0-12 months and 1-15 years). Results: A total of 338 cases of pediatric hydrocephalus were identified. Most common etiology of pediatric hydrocephalus was meningitis (38.1%), followed by congenital hydrocephalus (20.4%) and brain tumors (8.3%). Shunt infection and blockage were seen in 38 (11.2%) and 54 (16.0%) children, respectively, 67 (19.8%) required shunt revision. Highest rates of shunt failure were seen in bacterial meningitis (35.3%) and aqueductal stenosis (29.2%). Neurological and/or cognitive deficits were observed more frequently in children under 1 year of age (P=0.029). Duration of hospital stay in period A was significantly higher than in period B (PConclusion: Despite recent advancements, hydrocephalus is still associated with high rate of shunt failure and mortality. Factors associated with poor outcome include younger age group and etiology of hydrocephalus.