Pediatric and adult patients with ventricular shunts frequently
seek medical attention in acute care settings with complaints that
may or may not be caused by a malfunction and/or infection
of these indwelling devices. The challenge for the clinician is
to determine if the shunt system is functioning properly and if
it is a direct cause of the patient’s acute problem. This
chapter will discuss the complications of ventricular shunt malfunction
Complications in children with ventricular shunts are common
whereas those in adults occur less frequently. Approximately 30
percent of infants will experience shunt complications during their first
year following shunt placement.1 Children who had shunts
placed as infants will require two shunt revisions secondary to
obstruction within their first 10 years.1 The overall shunt
infection rate is 10 to 20 percent.1–3 Approximately
90 percent of these infections will present within 3 months
of the shunt placement.1 These statistics apply to the
population with conventionally treated hydrocephalus using indwelling
ventricular shunt devices. It is significant to note that with the
wide application and development of neuroendoscopic techniques,
many of the complications discussed in this chapter will be eliminated
or significantly reduced.
Complications resulting from ventricular shunts take many forms.
These include proximal obstruction (most common), distal obstruction,
disconnection, wound and cerebrospinal fluid (CSF) infections, seizures,
epidural hygromas, subdural hematomas, low (overdrainage) and high pressure
(slit ventricle) syndromes, and cranial deformities. There are other
unique complications experienced by the smaller number of patients
who have ventriculoatrial (V-A) and ventriculopleural shunt systems
and these will be discussed separately. Unless stated otherwise,
the reader should assume that reference is being made to the more
common ventriculoperitoneal (V-P) shunt device.
Patients with shunts may present with clinical entities as benign
as a viral upper respiratory infection or with a life threat like
hydrocephalus; the wide range of possibilities is a challenge to
the practitioner’s diligence and clinical acumen. Common
presenting symptoms include headache, fever, vomiting, decreased
alertness, neck stiffness, visual changes, malaise, abdominal pain, abdominal
distension, and surgical site problems.
Hydrocephalus, a condition defined by an excessive quantity of
CSF, is the condition most frequently associated with the initial
need for a ventricular shunt or a shunt revision if it malfunctions.
Most abnormal accumulations of CSF are identified in the ventricles,
although it may also occur in the subarachnoid or subdural spaces.
Several types of hydrocephalus are cited in the literature.
Communicating hydrocephalus occurs when there is unobstructed
flow of CSF between the ventricular system of the brain and the
spinal cord. It frequently occurs in patients who have had a hemorrhage
or infectious process whereby particulate matter interferes with
the normal circulation and absorption of CSF. A congenital problem
such as aqueductal stenosis or a mass lesion in the posterior fossa
may obstruct the flow of CSF between the brain and spinal cord causing obstructive
hydrocephalus or noncommunicating hydrocephalus. Normal ...