Safety of Transcranial Direct Current Stimulation With a Programmable Ventriculoperitoneal Shunt: A Case Report

Disorders of consciousness (DoC) following severe brain injury have limited therapeutic options. Noninvasive brain stimulation (NIBS), particularly transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), has shown promise in improving consciousness. However, the use of NIBS in patients with programmable ventriculoperitoneal (VP) shunt valves poses unique challenges, as these devices are susceptible to electromagnetic interference. While TMS may alter valve settings or induce heating, the safety of tDCS in such patients remains largely unexplored. We report the feasibility and safety of high-definition tDCS (HD-tDCS) in a 9-year-old girl with a minimally conscious state following severe traumatic brain injury and an implanted programmable VP shunt. Stimulation targeting the left dorsolateral prefrontal cortex was delivered using a neuronavigation-guided montage optimized through computational modeling. Sessions were conducted with continuous clinical monitoring and serial imaging to assess valve pressure. The patient completed 15 sessions with gradual titration of current intensity up to 1 mA. No major adverse events were observed. Serial imaging confirmed stable VP shunt position and pressure settings throughout the intervention. Although no significant change was noted in Coma Recovery Scale-Revised scores, subtle clinical improvements were observed, including increased spontaneous movements, improved muscle tone, enhanced eye movements, and intermittent responsiveness to environmental stimuli. This case highlights the potential safety and feasibility of HD-tDCS in patients with programmable VP shunts. tDCS may represent a viable neuromodulatory alternative when TMS is contraindicated, warranting further systematic investigation.