Emergency Evaluation of

Hydrocephalus Shunt
Patients

The Society of Neurological Surgeons

Bootcamp
 Communicating vs. Obstructive
Hydrocephalus
• Communicating Hydrocephalus
– All 4 ventricles are enlarged
– Causes: IVH of prematurity (grade III/IV), adult IVH, aneurysmal SAH,
meningitis
– May do lumbar puncture

• Obstructive Hydrocephalus
– Dilatation of lateral and third ventricles with small, compressed or
normal size 4th ventricle
– Asymmetry or enlargement of lateral ventricle when obstruction is at
Foramen of Monro ( e.g. colloid cyst)
– Posterior fossa mass lesions (tumor, ICH, cyst), intraventricular mass
lesions (tumor, IVH, cyst), aqueductal stenosis
– Do NOT do lumbar puncture
 Communicating Hydrocephalus
• Enlargement of lateral, 3rd, and 4th ventricles
– Note sulcal effacement, temp horns, rounded 3rd,
and enlarged 4th
 Obstructive Hydrocephalus
• Aqueductal stenosis
– Note enlarged frontal horns, temporal tip dilation,
rounded 3rd but small or normal 4th ventricle
 Shunt Technology
• Pressure differential valves
• Antisiphon valves
• Flow regulated valves
• Programmable valves

OSV
 CSF Shunt Malfunction:
Infants

• Progressive macrocephaly
• Tense anterior fontanelle
• Sutural splaying
• Downgaze, lid retraction
• Esotropia (VIth nerve palsy)
 CSF Shunt Malfunction:
Children

• Developmental delay
• Decline in school
performance (esp.
verbal IQ)
• Visual loss
 Radiology

• Compare ventricular
size to “well” baseline
– Infants: Trans-
fontanelle ultrasound
– CT
– MRI
• Shunt x-ray series
– Disconnection or
fracture of tubing
 Invasive Studies
• CSF shunt tap
– Assess flow and pressure (although proximal
obstruction may commonly interfere with accuracy)
– Send CSF for GS/Cx, Glu/Pro, cell counts if infection
suspected
– Relieve pressure if obstructed distally
• Radionuclide shuntogram
– Assess proximal and distal flow
– Ventricular reflux and outflow each correlate with
appropriate function (but test is imperfect)
• Intracranial pressure monitoring
 CSF Shunt Infection

• Organisms • Therapy
• Staph. Epi (40%) • Externalize shunt
• Staph. Aureus • Change hardware
(20%) • Antibiotics
• Gram Negatives • Consider LP
• Diptheroids
• Yeast
 Differential Diagnosis of Shunt
Infection
• Gastroenteritis
– Often associated with sick contacts, diarrhea

• Otitis
– May often be detected on physical examination

• Urinary tract infection

– Important to differentiate from colonization in
spina bifida patients
 CSF Shunt Complications:
Mechanical Failure

• Blockage
• Choroid plexus
• Ependyma
• Fracture
• Disconnection
• Valve failure
 CSF Shunt Complications:
Mechanical Failure

• Distal failure
• Kinked tubing
• Malabsorption
• Pleural effusion
• Cor pulmonale
• Shunt nephritis
 CSF Shunt Complications:
Abdominal failure

• Umbilical hernia
• Extra-peritoneal
catheter
• Bowel perforation
 CSF Shunt Complications:
Overdrainage

• Postural (Low
pressure) headache
• Subdural hygroma
• Craniostenosis
 CSF Shunt Complications:
Hemorrhage

• Parenchymal damage
• Raised ICP
• IVH: Valve obstruction
• Ependymal adhesions and
multicompartmental
hydrocephalus
 Shunt Evaluation Protocol:
History

• History • Current Symptoms

– Hydrocephalus – Headache
etiology • Severity/location
– Exact date of last tap • Positional
or revision • Morning
– Symptoms of last – Mental status changes
failure – Fever
– Seizure disorder? – Shuntalgia
– Latex allergy? – Nausea/vomiting
– Intercurrent illness
 Shunt Evaluation Protocol:
Diagnostic Studies
• Non-contrast head CT scan (shunt protocol)
or ‘quick brain’ MRI
• Shunt x-ray series
• Abdominal ultrasound, if indicated
• Shunt tap, if indicated
– Formal skin preparation
– 25g butterfly needle: test OP and valsalva
(OP may be obscured by proximal obstruction)
– CSF sample for GS/Cx, Cell count, Glu/Prot
 Shunt Evaluation Protocol:
Admission
• Immediate intervention for:
– Definite, acute malfunction
– Pain
– Infection
– Bradycardia
– Decreased mental and/or vision
• Cardiorespiratory monitoring
• Frequent neurological checks
• NPO except meds
• Anti-microbial shampoo
• Consider steroid prep for latex allergy
 Conclusions
• Involve experienced team members in significant
care decisions
• When in doubt, keep the patient for observation
• Listen to parents
• Myelomeningocele patients may have protean
forms of presentation and increased risk for
sudden deterioration
• Remember that, above all, shunt malfunction is a
clinical diagnosis, supported by imaging studies
and other data
 Case 1

• History
– 6 y.o. with post-hemorrhagic hydrocephalus
– 3 days progressive fever and malaise
– Intermittent right sided headaches
– Last revision 3 years ago for obtundation
 Case 1
• Physical Examination • Imaging
– Irritable – Axial imaging: ventricles
– Neurological exam unchanged from last
non-focal well scan
– Temperature 102.5 F. – Shunt x-rays without
– Inflamed right disconnection
tympanic membrane
with effusion
• Diagnosis
– Otitis media
– No surgical intervention
 Case 2
• History • Physical Examination
– 10 y.o. with – Alert
myelomeningocele and – Baseline
hydrocephalus – No papilledema
– One week of
progressive frontal
headaches and neck • Radiology
pain – Axial imaging
– One day of vomiting unchanged from well
– Mother states these baseline (small
are typical malfunction ventricles)
symptoms – Shunt x-rays without
– Last revision distant disconnection
 Case 2

• Diagnosis
– VP shunt malfunction
– Total proximal shunt obstruction was observed at
surgery
 Case 3

• History • Physical Examination

– 10 y.o. brought to E.R. – Unresponsive
by ambulance, – RR 15, labored
obtunded – HR 70
– EMT: “Has a shunt for – Pupils 4 mm, sluggish
hydrocephalus; had
headaches at home for – Frontal valve-reservoir
palpable
last few days”
 Case 3
• Diagnosis • Treatment
– Severe ventricular – Neurosurgeon
shunt malfunction attempts to drain CSF;
shunt tap is dry
– 1 gram/kg mannitol is
given

• E.R. Course
– Intubated
– During CT, heart rate
drops to 40