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[Critical intracranial pressure crises in drained hydrocephalus with minimally enlarged or normal ventricles]
W Kölfen1, R Korinthenberg, H Schmidt
1Universitäts-Kinderklinik, Universität Münster.
Insights
Pediatric hydrocephalus shunt malfunction can be subtle. Even with normal CT scans, minimally dilated ventricles on comparison scans indicate obstruction, requiring surgical revision.
Area of Science:
- Pediatric Neurosurgery
- Neuroradiology
- Neurology
Context:
- Hydrocephalus is a common condition in children requiring cerebrospinal fluid (CSF) shunting.
- Shunt obstruction is a frequent complication, leading to significant morbidity.
- Diagnosing shunt malfunction can be challenging, especially when imaging is equivocal.
Purpose:
- To evaluate the diagnostic utility of serial CT scans in identifying subtle shunt obstruction in pediatric patients.
- To highlight the limitations of standard CT interpretation in cases of suspected shunt malfunction.
- To emphasize the importance of comparing serial imaging for detecting minimal ventricular changes.
Summary:
- Ten pediatric patients (3-18 years) with shunts for hydrocephalus presented with symptoms suggestive of obstruction (headache, vomiting, lethargy).
- Initial CT scans were interpreted as normal, but serial comparisons revealed minimally dilated ventricles in 6 children.
- EEG abnormalities, papilledema, and splayed sutures were observed in some patients.
- Conservative management failed in all cases; symptoms resolved only after surgical shunt revision.
Impact:
- This study underscores that a normal CT scan during symptomatic periods does not exclude shunt obstruction in children.
- Serial CT scan comparisons are crucial for detecting subtle ventricular dilation, indicative of raised intracranial pressure.
- Clinical suspicion of shunt malfunction in pediatric patients warrants thorough investigation, including serial imaging review, to guide timely surgical intervention.
Abstract:
We report on 10 patients between 3 and 18 years of age who had been treated in the neonatal and postneonatal period for hydrocephalus of various causes with a ventriculo-atrial or ventriculo-peritoneal shunt. Between the age of 2 and 17 years these children suffered from recurrent attacks of headache, vomiting bradycardia and lethargy suggesting shunt-obstruction. 8 children showed slowing of electrical activity in their EEG, 4 had papilledema on fundoscopy. Splayed sutures were found in one child by skull x-ray. In all the above cases the CT-headscans assessed by radiologists showed no evidence of shunt-obstruction. Only on direct comparison with previous CT-scans we were able to detect minimally dilated ventricles in 6 children. In all cases conservative treatment failed. Symptoms only ceased after surgical shunt-revision. In all children treated with shunts headache, vomiting and vegetative symptoms must be considered as signs of shunt-obstruction until proved otherwise. A negative CT-scan done while symptoms are present cannot rule out raised intracranial pressure. Only by direct comparison with previous CT-scans carried out during an asymptomatic period a minor dilatation of the ventricles can often be detected. This should be taken as a sign of shunt-obstruction.