Intracranial pressure monitoring in pediatric and adult patients with hydrocephalus and tentative shunt failure: a single-center experience over 10 years in 146 patients

Abstract

OBJECT In patients with hydrocephalus and shunts, lasting symptoms such as headache and dizziness may be indicative of shunt failure, which may necessitate shunt revision. In cases of doubt, the authors monitor intracranial pressure (ICP) to determine the presence of over- or underdrainage of CSF to tailor management. In this study, the authors reviewed their experience of ICP monitoring in shunt failure. The aims of the study were to identify the complications and impact of ICP monitoring, as well as to determine the mean ICP and characteristics of the cardiac-induced ICP waves in pediatric versus adult over- and underdrainage. METHODS The study population included all pediatric and adult patients with hydrocephalus and shunts undergoing diagnostic ICP monitoring for tentative shunt failure during the 10-year period from 2002 to 2011. The patients were allocated into 3 groups depending on how they were managed following ICP monitoring: no drainage failure, overdrainage, or underdrainage. While patients with no drainage failure were managed conservatively without further actions, over- or underdrainage cases were managed with shunt revision or shunt valve adjustment. The ICP and ICP wave scores were determined from the continuous ICP waveforms. RESULTS The study population included 71 pediatric and 75 adult patients. There were no major complications related to ICP monitoring, but 1 patient was treated for a postoperative superficial wound infection and another experienced a minor bleed at the tip of the ICP sensor. Following ICP monitoring, shunt revision was performed in 74 (51%) of 146 patients, while valve adjustment was conducted in 17 (12%) and conservative measures without any actions in 55 (38%). Overdrainage was characterized by a higher percentage of episodes with negative mean ICP less than −5 to −10 mm Hg. The ICP wave scores, in particular the mean ICP wave amplitude (MWA), best differentiated underdrainage. Neither mean ICP nor MWA levels showed any significant association with age. CONCLUSIONS In this cohort of pediatric and adult patients with hydrocephalus and tentative shunt failure, the risk of ICP monitoring was very low, and helped the authors avoid shunt revision in 49% of the patients. Mean ICP best differentiated overdrainage, which was characterized by a higher percentage of episodes with negative mean ICP less than −5 to −10 mm Hg. Underdrainage was best characterized by elevated MWA values, indicative of impaired intracranial compliance.