Hydrocephalus and Management of VP shunts
Causes of hydrocephalus
- Congenital malformation (especially aqueduct stenosis), may be associated
with spina bifida (Arnold Chiari malformation); vascular malformations.
- Neoplasm or tumour
- Infection: Secondary to meningitis, intrauterine infection.
- Post haemorrhagic: Premature infants with intraventricular haemorrhage, post
- Dural venous sinus thrombosis
Signs and Symptoms
- Rapidly increasing head circumference. Measure at least weekly. Paediatric Surgical
Ward provides "hydrocephalus passports" with percentiles for the measurements.
- Bulging fontanelle
- Widening suture lines (if not closed yet)
- Distended scalp veins
- Setting sun eye sign
- Signs of raised intracranial pressure (headache, vomiting, blurred vision, high BP, low
PR, reduced conscious level)
- Developmental delay, ataxia
- Cranial USS
- Consider lumbar puncture and/or ventricular tap if signs of infection/ raised intracranial pressure (ICP)
- Treat infection if any (ventriculitis may require longer term parenteral treatment than
- Therapeutic ventricular tap if signs acute raised ICP
- Surgical referral for ventriculo-peritoneal (VP) shunt or endoscopic third ventriculostomy
Complications of VP shunts
Shunts can become infected or blocked and need to be treated urgently.
Suspect in a child with VP shunt if any of the following:
- Reduced level of consciousness
- Cranial nerve palsy
- Visual disturbance
Investigations of possibly blocked shunts:
- Blood culture if febrile
- Xray shunt series.
- USS brain/ CT if possible
- Avoid LP as can result in coning if shunt blocked. Consider ventricular tap.
Treatment of blocked shunts:
- Start iv antibiotics as for meningitis
- Refer to surgeons for possible urgent shunt removal if blocked or infected and subsequent
revision/replacement at a later date