Seizures in pediatric patients with hydrocephalus: a predictive symptom of ventricular shunt malfunction?

Hydrocephalus in pediatric patients is commonly managed with ventricular shunt systems, which are associated with a high rate of malfunction. Seizures are a frequent symptom in this population, but their predictive value for shunt dysfunction remains controversial. This study aims to determine whether seizures are a predictive symptom of ventricular shunt malfunction and to identify other factors associated with shunt dysfunction in this group of patients.

We conducted an observational, retrospective cohort study of pediatric patients with hydrocephalus and ventricular shunt who presented to the emergency department for suspected shunt malfunction between January 2020 and February 2023. The association between seizures and shunt malfunction was assessed. Diagnostic test performance metrics, including sensitivity, specificity, and predictive values, were calculated. Demographic data, etiology, seizure history, and previous malfunction surgeries were also analyzed.

Shunt malfunction was diagnosed in 14.58% of patients presenting with seizures. Seizures alone were associated with a significantly lower probability of shunt malfunction (OR 0.25; CI95% 0.13-0.47; p < 0.0001). However, seizures accompanied by symptoms of increased intracranial pressure, such as headache and altered mental status, were the only factor significantly associated with shunt dysfunction (OR 19.22; CI95% 4.51-81.96; p = 0.001). First-time seizures were also associated with an increased likelihood of shunt dysfunction in the bivariate analysis (OR 3.59; CI95% 1.01-12.78; p = 0.049), though this association was not sustained in the multivariate model. Sensitivity and specificity of seizures for the diagnosis of shunt malfunction were 14.6% (CI95% 8.2-23.3%) and 59.9% (CI95% 54.4-65.3%), respectively, with a positive predictive value of 9.8% (CI95% 5.5-15.9%) and a negative predictive value of 70.2% (CI95% 64.4-75.5%).

Our study demonstrates that while seizures may be a common symptom in patients with hydrocephalus, their ability to predict shunt malfunction is limited in the absence of concomitant classic symptoms of intracranial hypertension. The presence of a first-time seizure, however, may warrant careful evaluation as it represents an important clinical finding that could help identify patients at higher risk of shunt dysfunction. This finding underscores the necessity of considering the patient's entire clinical presentation, including a thorough physical examination, when making diagnostic and therapeutic decisions.