Managing adults with hydrocephalus : pearls

This post assumes patients who received a shunt as a child has problems as an adult

1. Signs of shunt malfunction/ increased ICP. On PE look for VI n palsy, papilledema, +/- reliability of shunt pump test

2. On history consider HA worse in AM or with recumbency, associated vomiting with relief, and diplopia suggest raised intracranial pressure. If HA is worse when up, consider low pressure headache

3. On imaging, assess all 4 ventricles independently, look for periventricular edema, edema around proximal shunt tip, loss of cerebral sulcal pattern near vertex, or loss of CSF spaces in basal cistern and Sylvian fissure. ALWAYS compare to prior scan closely.

4. ETV or endoscopic third ventriculostomy is used in some patients especially with third ventricular obstructions. ETV has a risk of catastrophe, a higher risk of immediate failure, a lower risk of long term failure but still can obstruct years later (unlike most standard shunts). ETV has the compelling advantage of a lower infection risk.

5. Patients with myelomeningocoele should be evaluated in a top down manner: shunt obstruction, Chiari malformation, syringomyelia/syringobulbia, and tethered cord. Often neurosurgeons will want to surgically manage the shunt to make sure it is working before embarking on other issues in these cases. An example case in Continuum was a patient who had presented with hand weakness and syringomyelia, but who had massively dilated ventricles and whose primary problem was in fact the shunt dysfunction.