Treatment of traumatic acute subdural hematoma in adult hydrocephalus patients with cerebrospinal fluid shunt
Introduction
Patients treated with cerebrospinal fluid (CSF) shunt for hydrocephalus often present with non-traumatic subdural hematoma and hygroma. A number of reports have noted that mild head injuries can give rise to severe intracranial hemorrhage among individuals with CSF shunt [1], [2], [3], [4], [5], [6], [7]. This indicates that CSF shunt is a predisposing factor for the onset and development of traumatic intracranial hemorrhage [8]. We have encountered 12 cases of adult traumatic acute subdural hematoma (SDH) in patients with hydrocephalus that had been treated using a CSF shunt. We conducted precise follow-up of SDH and hydrocephalus in these cases using serial examinations with computed tomography (CT), and studied how post-traumatic shunt management affected radiological and neurological manifestations. We also report cases in which development of SDH was delayed once the hematomas were reduced while the shunt was ligated.
Section snippets
Patients and methods
We reviewed hospital records between April 1999 and January 2009 from the Department of Neurosurgery at Dokkyo Medical University Koshigaya Hospital for adult traumatic patients with placement of a CSF shunt for hydrocephalus. Twelve patients with acute SDH were identified.
The following data were retrospectively reviewed:
- 1.
Patient background, including age, sex, underlying pathology that had caused hydrocephalus, type of shunt, and pressure level of the shunt valve at the time of head trauma.
- 2.
Patient backgrounds
Subjects comprised six women and six men, with a mean age of 64.4 years (range, 39–88 years). All cases in the present study had communicating hydrocephalus. Hydrocephalus in nine patients was secondary to subarachnoid hemorrhage or hypertensive intracerebral hemorrhage. Three patients had suffered idiopathic normal pressure hydrocephalus (iNPH). Shunt type was ventriculo-peritoneal (V-P) in 10 patients and lumbo-peritoneal (L-P) in two patients. Devices used and pressure levels of shunt valves
Case 6
An 84-year-old woman with V-P shunt fell down and sustained a mild head injury. Consciousness deteriorated the following day, and she was transferred to our hospital. CT showed right acute SDH with a mild midline shift (Fig. 3a). After the shunt was ligated, SDH thickness reduced by ventricular dilatation (Fig. 3b). Level of consciousness gradually improved, then suddenly deteriorated 13 days after admission, and left hemiparesis became evident. CT disclosed that right SDH mimicking chronic
Discussion
Overdrainage by the CSF shunt system reduces ventricular size and causes fluid collection in the subdural spaces [9]. In such conditions, bridging veins are excessively stretched between the brain and dura. Mild head injury can easily tear these vessels and trigger intracranial bleeding [1], [2], [3], [5], [6], [7], [10]. The shunt system allows hematoma to develop after intracranial bleeding starts [2], [4], [10]. As this works to avoid elevations in intracranial pressure (ICP), sufficient
Conclusions
Acute SDH is prone to develop and some patients may experience critical deteriorations due to massive hematomas if the shunt is left functioning at low pressure levels. Hematoma removal without shunt management may result in hematoma recurrence and the need for a second treatment. Readjustment of the programmable valve to raise the pressure level or shunt ligation is effective to prevent hematoma recurrence after surgical removal. Shunt management can reduce hematoma volume as an initial
References (12)
- et al.
Acute subdural hematoma due to minor head trauma in patients with a lumboperitoneal shunt
Surg Neurol
(1988) Subdural hematoma in a shunted patient
J Emerg Med
(2005)- et al.
Management with a programmable pressure valve of subdural hematomas caused by a ventriculoperitoneal shunt: case report
Surg Neurol
(1991) Acute subdural hematoma of arterial origin in a patient with a lumboperitoneal shunt
Neurol Med Chir (Tokyo)
(1987)Lumboperitoneal shunt: clinical applications, complications, and comparison with ventriculoperitoneal shunt
Neurosurgery
(1990)- et al.
Traumatic acute giant epidural hematoma in a hydrocephalic shunted child
Pediatr Neurosurg
(2000)
Cited by (12)
Preexisting Ventricular Shunts Are Associated with Failed Evacuation of Acute Subdural Hematomas: Single-Institution Case Series of Complications and Management Strategies
2022, World NeurosurgeryCitation Excerpt :Several other reports have documented evacuation for traumatic aSDHs, although they lacked details regarding the type of surgery, shunt management, and clinical outcomes.13-15 Several reports have documented the use of increasing the resistance of programmable shunts and ligating no-programmable shunts after traumatic aSDH.2,3,12 Burr hole evacuation can be performed successfully with shunt adjustment if a substantial component of the collection is chronic.16
Intraoperative ventricular volume restoration by intraventricular Ringer solution injection in a normal-pressure hydrocephalus patient with traumatic bilateral acute subdural hematoma and ventricular system collapse caused by cerebrospinal fluid shunt overdrainage: illustrative case
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