NEUROLOGY + NEUROSURGERY
CSF SHUNT
Known shunt, headache, confused
PromptList differentials for confused shunt patient
ResponseBrain
Fractured shunt >> hydrocephalus
Shunt blockage >> hydrocephalus
Shunt infection
SAH/ICH
Non brain (AEIOUTIPS)
Hypoglycaemia/DKA
hypo/hypernatraemia
encephalitis/meningitis
Toxidrome
Fractured shunt >> hydrocephalus
Shunt blockage >> hydrocephalus
Shunt infection
SAH/ICH
Non brain (AEIOUTIPS)
Hypoglycaemia/DKA
hypo/hypernatraemia
encephalitis/meningitis
Toxidrome
PromptInvestigations for Shunt patient with confusion
ResponseBSL
Sodium, urea/creatanine
VBG + lactate
LP/shunt reservoir aspiration (Apparently LP has no role as can be negative with shunt infection… might do if suspect meningitis?)
XR shunt series ? fractured shunt
CT brain ? hydrocephalus
Sodium, urea/creatanine
VBG + lactate
LP/shunt reservoir aspiration (Apparently LP has no role as can be negative with shunt infection… might do if suspect meningitis?)
XR shunt series ? fractured shunt
CT brain ? hydrocephalus
PromptWhere do shunts drain
ResponsePeritoneal (VP shunt)
Pleural cavity
Right atrium
Ureter
Gall bladder
Pleural cavity
Right atrium
Ureter
Gall bladder
PromptCauses of shunt obstruction
ResponseInfection anywhere
Proximal: tissue debris, choroid plexus, clot, infection, catheter tip migration, localised immune response to tubing
Distal: Kinking/disconnection of tube, pseudocyst formation
Proximal: tissue debris, choroid plexus, clot, infection, catheter tip migration, localised immune response to tubing
Distal: Kinking/disconnection of tube, pseudocyst formation
PromptBacteria causing shunt infection
ResponseStaph epidermidis
PromptManagement of hydrocephalus in shunt causing seizure
ResponseSeizure:
Oxygen
IV benzo
IV phenytoin/keppra
IV osmotic agent - hypertonic saline vs Mannitol
IV antibiotics/antivirals
Seek and treat electrolyte/sugar abnormalities
Oxygen
IV benzo
IV phenytoin/keppra
IV osmotic agent - hypertonic saline vs Mannitol
IV antibiotics/antivirals
Seek and treat electrolyte/sugar abnormalities
PromptManagement of hydrocephalus in shunt causing status epilepticus
ResponseIntubation + CO2 control
IV phenobarbitone
IV osmotic agent
Shunt aspiration
Neurosurgeons (+/- retrieval to neurosurgical centre if not on site)
Ie: same as any other seizure other than shunt aspiration and neurosx referral
IV phenobarbitone
IV osmotic agent
Shunt aspiration
Neurosurgeons (+/- retrieval to neurosurgical centre if not on site)
Ie: same as any other seizure other than shunt aspiration and neurosx referral
PromptShunt problem - spot diagnosis on CT
ResponseSlit ventricle syndrome. Overdraining causes loss of ventricles then blockage by tissue. ICP increases and eventually disengages then drains CSF. Cyclical presentation with waxing and waning of symptoms.
PromptShunt problem - Spot diagnosis on CT
ResponsePresentation headache, confusion, abdo pain (didn’t get told shunt in stem)
Hydrocephalus (Dilated ventricles)
Compresson of sulci (evidence of raised ICP
Tip of ventricular shunt in position (can also see shunt artifact at R occipital region)
DDx
Meningitis secondary to peritonitis
SHunt malfunction
Ix
CTAP, CT chest to assess for shunt malposition, broken shunt and septic focus
Hydrocephalus (Dilated ventricles)
Compresson of sulci (evidence of raised ICP
Tip of ventricular shunt in position (can also see shunt artifact at R occipital region)
DDx
Meningitis secondary to peritonitis
SHunt malfunction
Ix
CTAP, CT chest to assess for shunt malposition, broken shunt and septic focus