Hydrocephalus and Shunt Failure
Failure is a common complication of ventricular shunt placement for hydrocephalus, with myriad presentations that are essential for emergency providers to identify. Patients in failure may present with acute or chronic symptoms ranging from headache to acute mental status changes to seemingly unrelated complaints like shortness of breath. The most predictive are a bulging fontanel, palpable fluid collection along the shunt, depressed consciousness, irritability, abdominal pain, nausea/vomiting, and accelerated head growth. Risk factors for shunt failure—including prior revisions, young age, intracranial pathology, proximity to surgery and clinical suspicion—are a key to drive further evaluation. Appropriate workup of a suspected shunt failure includes shunt series radiographs, fast-sequence MRI (preferred) or CT, and standard labs to exclude pathophysiologic changes in other locations that might explain concerning symptoms. New, noninvasive tools, including optic nerve sheath diameter measurement and thermosensors, continue to be evaluated as adjunct diagnostics, with the goal of obviating the need for advanced imaging or potentially unsterile shunt taps. Surgery is almost always indicated in diagnosed shunt failure. The timing and extent of intervention are determined by suspicion for raised ICP, localization of the point of failure, and presence of infection. Judicious medical management may bridge patients to definitive surgery if emergent intervention is not indicated. Endoscopic third ventriculostomy may provide an alternative index treatment or function as a bridge or supplement for repeatedly failed shunts.
