Morning Report

Morning Report: Pediatric Headache with a VP Shunt

HPI:

9 yo female with a PMH of a brain tumor (GBM) diagnosed 2 years ago with seizures. Pt has had several rounds of radiation (stopped a few months ago) and chemo (last dose in May) and craniotomy about 1 month ago with a VP shunt placed 3 weeks ago. Today, pts father states she has had a severe headache all night and wasn’t able to sleep. Father gave tylenol at 6am which pt stated has helped. Currently denies any pain and states she feels fine now. No major recent illness. Denies nausea or vomiting, photophobia, head or neck pain. Denies fever. No seizures.

Vital signs stable.

ED Course:

DDx includes: Headache vs VP shunt obstruction vs tumor recurrence. Shunt is newly-placed and had a CT scan evaluation which showed patency two weeks ago but because it is relatively new requested Neuro-Surgery to come evaluate the shunt. Slightly hypertensive. Pt now pain free after one dose of tylenol at home at 6am which makes headache more likely. Pt complained of headache upon standing up for discharge. Tylenol was ordered which treated the pts headache and pt cleared for discharge by Neuro-Surgery. Pts father instructed to bring patient back if symptoms worsen or new symptoms develop.

Discussion/Learning points:

1. Symptoms of shunt malfunction usually develop over several days. Clinical features include mental status changes, headache, nausea, vomiting, abdominal pain, lethargy, decreased intellectual performance, ataxia, coma, and autonomic instability. Often, the presenting complaint is vague.

2. To exclude CSF shunt infection, a shunt tap is required. A traditional lumbar puncture often misses CSF shunt infection and has no meaningful role in the evaluation when shunt infection is suspected.

3. Comparison with previous CT scans is needed, because many patients with shunts have an abnormal baseline ventricular size.

4. Surgical intervention is generally required in cases of shunt obstruction. As a temporizing measure, intracranial pressure can be lowered by standard methods of hyperventilation and osmotic diuresis (mannitol). If these measures fail and surgical intervention is not immediately available, intracranial pressure can be lowered by removing CSF via the reservoir if the malfunction is distal.

 

References:

Tintinalli’s Emergency Medicine: Chapter 169, Central Nervous System Procedures and Devices.

Browd SR, Ragel BT: Failure of cerebrospinal fluid shunts. Part I: obstruction and mechanical failure. Pediatr Neurol 34: 2, 2006.

 

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