eMedicine Specialties > Neurology > Behavioral Neurology and Dementia

Hydrocephalus: Follow-up

Author: Alberto J Espay, MD, MSc, Assistant Professor, Department of Neurology, University of Cincinnati
Contributor Information and Disclosures

Updated: Aug 20, 2009

Follow-up

Further Inpatient Care

  • Patients with shunt-dependent hydrocephalus should be admitted for consideration of shunt revision if shunt malfunction or infection is suspected.
  • In children, shunt revisions are scheduled according to growth rate.

Further Outpatient Care

  • Patients on acetazolamide (ACZ) or furosemide (FUR) should be followed for possible electrolyte imbalance and metabolic acidosis. Clinical signs that should prompt attention are lethargy, tachypnea, or diarrhea.
  • Patients with shunts should be reevaluated periodically, including assessment of distal shunt length in growing children. The first follow-up examination usually is scheduled 3 months after surgery, and CT scan or MRI of the head should be done at that time. Follow-up is performed every 6-12 months in the first 2 years of life. In children aged 2 years and older, follow-up is performed every 2 years.

Inpatient & Outpatient Medications

  • Medications include acetazolamide and furosemide. These are helpful for temporizing the hydrocephalus until compensation occurs. If compensation does not occur, then shunting is indicated.
  • Medications should not be used in patients with functional shunts.
  • Medication is not effective in long-term treatment of chronic hydrocephalus, and it may induce metabolic consequences.
  • If seizures occur, antiepileptic drugs are recommended.

Transfer

  • In cases of acute hydrocephalus or shunt complications, immediately transfer the patient to a center with a neurosurgery service.

Deterrence/Prevention

  • Avoid trauma: The valve and tubing system are located superficially under the skin and can be damaged easily by trauma.

Complications

  • Related to progression of hydrocephalus
    • Visual changes
      • Occlusion of posterior cerebral arteries secondary to downward transtentorial herniation
      • Chronic papilledema injuring the optic disc
      • Dilatation of the third ventricle with compression of optic chiasm
    • Cognitive dysfunction
    • Incontinence
    • Gait changes
  • Related to medical treatment
  • Related to surgical treatment
    • Signs and symptoms of increased intracranial pressure (ICP) can be a consequence of undershunting or shunt obstruction or disconnection.
    • Subdural hematoma or hygroma is secondary to overshunting. Headache and focal neurological signs are common.
    • Treat seizures with antiepileptic drugs.
    • Shunt infection occasionally can be asymptomatic. In neonates, it manifests as alteration of feeding, irritability, vomiting, fever, lethargy, somnolence, and a bulging fontanelle. Older children and adults present with headache, fever, vomiting, and meningismus. With ventriculoperitoneal (VP) shunts, abdominal pain may occur.
    • Shunts can act as a conduit for extraneural metastases of certain tumors (eg, medulloblastoma).
    • Hardware erosion through the skin occurs in premature infants with enlarged heads and thin skin who lie on 1 side of the head.
    • VP shunt complications include peritonitis, inguinal hernia, perforation of abdominal organs, intestinal obstruction, volvulus, and CSF ascites.
    • Ventriculoatrial (VA) shunt complications include septicemia, shunt embolus, endocarditis, and pulmonary hypertension.
    • Lumboperitoneal shunt complications include radiculopathy and arachnoiditis.

Prognosis

  • Long-term outcome is related directly to the cause of hydrocephalus.
  • Up to 50% of patients with large intraventricular hemorrhage develop permanent hydrocephalus requiring shunt.
  • Following removal of a posterior fossa tumor in children, 20% develop permanent hydrocephalus requiring a shunt. The overall prognosis is related to type, location, and extent of surgical resection of the tumor.
  • Satisfactory control was reported for medical treatment in 50% of hydrocephalic patients younger than 1 year who had stable vital signs, normal renal function, and no symptoms of elevated ICP.
  • Criteria exist for predicting improvement with shunting in NPH, but they are controversial.
    • If gait disturbance precedes mental deterioration, the chance of improvement is 77%. Patients with dementia and no gait disturbance rarely respond to shunting.
    • Focal impingement of corpus callosum on MRI indicates unstable ICP and is associated with a good response to shunting.
    • Initial OP of CSF greater than 100 mm H2 O predicts better response.
    • Response to a single LP or to controlled CSF drainage via lumbar subarachnoid catheter (ELD) has some value in predicting outcome.
    • Cerebral blood flow of 32 mL/100 g per minute or greater predicts clinical improvement after shunt.
    • CSF pressure of 180 mm H2 O with frequent Lundberg B waves on continuous CSF pressure monitoring is associated with good prognosis after shunting. Lundberg B waves represent an accentuation of physiological phenomena, reflecting arterial waves. They represent fluctuating ICP waves of 4-8 per minute frequency and 20-30 mm Hg (260-400 mm H2 O) amplitude. Occasionally they can occur in normal sleep.
    • Large ventricles with flattened or invaginated sulci (entrapped sulci) suggest that hydrocephalus is not due to atrophy alone. These patients have good prognosis with shunting.
    • If isotopic cisternography shows persistent ventricular activity on a late scan (42-72 h), the probability of improving with shunting is 75%.

Patient Education

  • Knowledge of the signs and symptoms of shunt malfunction or infection and the necessity for emergent medical evaluation in these instances is mandatory in patients, family members, and caregivers.
  • The patient, family, and caregivers should know that periodic re-evaluation is necessary.
  • Pumping the shunt is contraindicated in most cases.
  • Patients with vascular shunts, and some patients with other types of shunts, should receive prophylactic antibiotics before dental procedures or instrumentation of the bladder.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize signs and symptoms of new onset hydrocephalus
  • Failure to recognize signs and symptoms of shunt malfunction or shunt infection, and failure to refer to a neurosurgeon immediately when these are suspected
  • Failure to inform patients with shunts and family members concerning the lifelong possibility of shunt complications.

Special Concerns

  • Patients with arrested hydrocephalus need close follow-up. They can decompensate at any time, often after minor head injuries or an infectious process. The patient and family should know the signs of acute and chronic progressive hydrocephalus.
  • Occasionally in hydrocephalus due to a Chiari malformation, further herniation of cerebellar tonsils can occur after shunt placement. This can lead to quadriparesis or death.
  • True normal pressure hydrocephalus (NPH) should be heralded by gait and not cognitive impairments; this hydrocephalus is disproportionate to the degree of atrophy (if any). Shunting ex-vacuo hydrocephalus (due to Alzheimer disease, for instance) can only be harmful.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Eugenia-Daniela Hord, MD, to the original writing and development of this article.



More on Hydrocephalus

Overview: Hydrocephalus
Differential Diagnoses & Workup: Hydrocephalus
Treatment & Medication: Hydrocephalus
Follow-up: Hydrocephalus
Multimedia: Hydrocephalus
References
Further Reading
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Further Reading

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Keywords

normal pressure hydrocephalus, communicating hydrocephalus, noncommunicating hydrocephalus, obstructive hydrocephalus, arrested hydrocephalus, acute hydrocephalus, gait apraxia, incontinence, dementia, Arnold-Chiari malformation, papilledema, precocious puberty, Dandy–Walker malformation, obesity, delayed onset of puberty, urinary incontinence, Parkinsonism, seizures, toxoplasmosis, Bickers-Adams syndrome, mental retardation, medulloblastoma, astrocytoma, prematurity, achondroplasia, cysticercosis, treatment, diagnosis

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Contributor Information and Disclosures

Author

Alberto J Espay, MD, MSc, Assistant Professor, Department of Neurology, University of Cincinnati
Alberto J Espay, MD, MSc is a member of the following medical societies: American Academy of Neurology and Movement Disorders Society
Disclosure: Boehringer-Ingelheim Consulting fee Consulting; Codman Grant/research funds Other; Medtronic Honoraria Speaking and teaching; Medtronic Grant/research funds Other; Allergan Grant/research funds Other; UCB-Schwarz Pharm Honoraria Speaking and teaching; Novartis  Speaking and teaching

Medical Editor

Anthony M Murro, MD, Laboratory Director, Professor, Department of Neurology, Medical College of Georgia
Anthony M Murro, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard J Caselli, MD, Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair, Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Neurological Association, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Howard A Crystal, MD, Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center
Howard A Crystal, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association
Disclosure: Medivations Honoraria Consulting

 
 
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