eMedicine Specialties > Physical Medicine and Rehabilitation > Traumatic Brain Injury

Posttraumatic Hydrocephalus: Treatment & Medication

Author: Percival H Pangilinan Jr, MD, Clinical Instructor and Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Michigan Health System.
Coauthor(s): Brian M Kelly, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Assistant Program Director, Residency Training Program, Consulting Staff, Service Chief 6A, Inpatient Rehabilitation Services, University of Michigan Health System; Joseph E Hornyak IV, MD, PhD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Consulting Staff, Medical Director of Human Performance Laboratory, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center; Scott Strum, MD, Director of Traumatic Brain Injury Service, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Feb 12, 2008

Treatment

Rehabilitation Program

Physical Therapy

The resumption of rehabilitation is usually prompt after the placement of a ventriculoperitoneal (VP) shunt.21 Patients are typically observed for 2-3 days postoperatively. They then return to rehabilitation services to complete their brain-injury rehabilitation program. Successful shunting is usually related to more obvious and rapid improvements during rehabilitation efforts.22

Occupational Therapy

See Physical Therapy.

Speech Therapy

See Physical Therapy.

Recreational Therapy

See Physical Therapy.

Surgical Intervention

  • Before treatment, conditions such as infection, anemia, hypoxia, seizure disorder, uremia, and encephalopathy must be ruled out or addressed. If PTH is suspected, prompt neurosurgical evaluation is highly recommended.
  • Shunting is the most common treatment for hydrocephalus. The outcome is usually favorable.
  • A shunt is usually placed from the right ventricle to the peritoneal space. The right side is normally used to avoid injury to the language centers on the left side of the brain. Shunts are usually equipped with reservoirs that are used for transiently increasing output and for testing the patency of flow.
  • Patients with acute presentations and clear signs of high-pressure hydrocephalus benefit from a shunting procedure. Patients with chronic presentations can be observed with frequent CT scanning of the brain to monitor for progression of hydrocephalus.5
  • In a study by Tribl and Oder, 52% of patients with PTH had significant improvement within 3 months of shunting.23
  • Patients with NPH also may benefit from a shunting procedure. In patients with a TBI and communicating hydrocephalus, Groswasser found that shunting promoted a recovery of consciousness and motor capacity but not a return of neurobehavioral function.6
  • Complications and shunt malfunctions are common.23,21 Complications of shunts include the following:
    • Infection - Wound infection or contamination during placement
    • Shunt failure - Displacement and leakage
    • Occlusion - Kinking and tube clotting
    • Overshunting - More fluid is shunted than necessary
    • Placement errors
  • Assessing the efficacy of surgical intervention can be problematic because of the heterogeneity of TBI severity, TBI location, nonuniform diagnostic criteria used across studies, variants of PTH, the severity of PTH, and the length of time between the occurrence of a TBI and the development of PTH. Further research is needed to control for confounding factors, elucidate criteria for surgical intervention, and assess the outcome of surgery.15

Consultations

When hydrocephalus is confirmed, consultation with a neurosurgeon should be expedited.

Medication

The management of hydrocephalus centers on the reduction of intracranial pressure and on the correction of factors that lead to increased ICP. Elevation of the head may help to reduce pressure, as well as to maintain normotensive blood pressure. Medications with osmotic effects (such as mannitol) or that reduce CSF production (such as acetazolamide) may have limited value. Hence, medications likely do not play a major role in the treatment of PTH. The condition is treated surgically. 

The discontinuation of medications that may contribute to the impairment of cognitive or physical functioning should be considered.

More on Posttraumatic Hydrocephalus

Overview: Posttraumatic Hydrocephalus
Differential Diagnoses & Workup: Posttraumatic Hydrocephalus
Treatment & Medication: Posttraumatic Hydrocephalus
Follow-up: Posttraumatic Hydrocephalus
References
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References

  1. Bontke CF. Medical complications related to traumatic brain injury. Phys Med Rehabil: State Art Rev. 1989;3:43-58.

  2. Narayan RJ, Gokaslan ZL, Bontke CF. Neurologic sequelae of head injury. In: Rosenthal M, ed. Rehabilitation of the Adult and Child With Traumatic Brain Injury. 2nd ed. Philadelphia, Pa: Davis; 1990:94-106.

  3. Stein S, Schrader P. Neurologic sequelae. Phys Med Rehabil: State Art Rev. 1990;4:543-57.

  4. Katz RT, Brander V, Sahgal V. Updates on the diagnosis and management of posttraumatic hydrocephalus. Am J Phys Med Rehabil. Apr 1989;68(2):91-6. [Medline].

  5. Guyot LL, Michael DB. Post-traumatic hydrocephalus. Neurol Res. Jan 2000;22(1):25-8. [Medline].

  6. Groswasser Z, Cohen M, Reider-Groswasser I, et al. Incidence, CT findings and rehabilitation outcome of patients with communicative hydrocephalus following severe head injury. Brain Inj. Oct-Dec 1988;2(4):267-72. [Medline].

  7. Mazzini L, Campini R, Angelino E, et al. Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil. Nov 2003;84(11):1637-41. [Medline].

  8. Dandy WE, Blackfan KD. Internal hydrocephalus: an experimental, clinical, and pathological study. Am J Dis Child. 1914;8:406.

  9. Adams RD, Victor M. Disturbances of cerebrospinal fluid and its circulation, including hydrocephalus and meningeal reactions. In: Principles of Neurology. 4th ed. New York, NY: McGraw-Hill Information Services Co; 1989:623-35.

  10. Portnoy HD, Chopp M, Branch C, et al. Cerebrospinal fluid pulse waveform as an indicator of cerebral autoregulation. J Neurosurg. May 1982;56(5):666-78. [Medline].

  11. Kaye AH, Laws ER, eds. Brain Tumors: An Encyclopedic Approach. 2nd ed. New York, NY: Churchill Livingstone; 2001:205.

  12. Mori K, Shimada J, Kurisaka M, et al. Classification of hydrocephalus and outcome of treatment. Brain Dev. Sep-Oct 1995;17(5):338-48. [Medline].

  13. Kim SW, Lee SM, Shin H. Clinical Analysis of Post-Traumatic Hydrocephalus. J Korean Neursurg Soc. 2005;38:211-214.

  14. Long DF. Diagnosis and management of intracranial complications in traumatic brain injury rehabilitation. In: Horn LJ, Zasler ND, eds. Medical Rehabilitation of Traumatic Brain Injury. Philadelphia, Pa: Hanley & Belfus; 1996:333-62.

  15. Paoletti P, Pezzotta S, Spanu G. Diagnosis and treatment of post-traumatic hydrocephalus. J Neurosurg Sci. Jul-Sep 1983;27(3):171-5. [Medline].

  16. Wostyn P, Audenaert K, De Deyn PP. Alzheimer's disease-related changes in diseases characterized by elevation of intracranial or intraocular pressure. Clin Neurol Neurosurg. Feb 2008;110(2):101-9. [Medline].

  17. Factora R, Luciano M. Normal pressure hydrocephalus: diagnosis and new approaches to treatment. Clin Geriatr Med. Aug 2006;22(3):645-57. [Medline].

  18. Tian HL, Xu T, Hu J, et al. Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage. Surg Neurol. Aug 16 2007;[Medline].

  19. Nasel C, Gentzsch S, Heimberger K. Diffusion-weighted magnetic resonance imaging of cerebrospinal fluid in patients with and without communicating hydrocephalus. Acta Radiol. Sep 2007;48(7):768-73. [Medline].

  20. Graff-Radford NR. Normal pressure hydrocephalus. Neurol Clin. Aug 2007;25(3):809-32, vii-viii. [Medline].

  21. Wu Y, Green NL, Wrensch MR, et al. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery. Sep 2007;61(3):557-62; discussion 562-3. [Medline].

  22. Bontke CF, Zasler ND, Boake C. Rehabilitation of the head-injured patient. In: Narayan RK, Wilberger JE, Povlishock JT, eds. Neurotrauma. New York, NY: McGraw-Hill; 1996:841-58.

  23. Tribl G, Oder W. Outcome after shunt implantation in severe head injury with post-traumatic hydrocephalus. Brain Inj. Apr 2000;14(4):345-54. [Medline].

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Further Reading

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Keywords

posttraumatic hydrocephalus, PTH, hydrocephalus, traumatic brain injury, TBI, head injury, noncommunicating hydrocephalus, obstructive hydrocephalus, communicating hydrocephalus, nonobstructive hydrocephalus, normal pressure hydrocephalus, NPH

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Contributor Information and Disclosures

Author

Percival H Pangilinan Jr, MD, Clinical Instructor and Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Michigan Health System.
Percival H Pangilinan Jr, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Brian M Kelly, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Assistant Program Director, Residency Training Program, Consulting Staff, Service Chief 6A, Inpatient Rehabilitation Services, University of Michigan Health System
Brian M Kelly, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Joseph E Hornyak IV, MD, PhD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Consulting Staff, Medical Director of Human Performance Laboratory, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center
Joseph E Hornyak IV, MD, PhD is a member of the following medical societies: American Academy of Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Scott Strum, MD, Director of Traumatic Brain Injury Service, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Scott Strum, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Medical Editor

Elizabeth A Moberg-Wolff, MD, Associate Professor and Pediatric PM&R Fellowship Director, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin; Program Director, Tone Management and Mobility, Department of Physical Medicine and Rehabilitation, Children's Hospital of Wisconsin
Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy of Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Medtronic Neurological Grant/research funds Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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