Pediatric emergency medicine trisk 4014 4014

TABLE 122.1
CLINICAL MANIFESTATIONS OF SHUNT MALFUNCTION
Acute

Subacute or chronic

Nausea
Vomiting
Irritability
Seizures
Headache
Lethargy
Coma
Stupor

Change in behavior
Neuropsychological signs
Change in feeding patterns
Developmental delay
Change in school performance
Change in attention span
Daily headaches
Increase in head size

Diagnostic Imaging. CT of the brain and a shunt series x-rays are
routinely used to aid in the diagnosis of shunt malfunction. More recently,
brain MRI has emerged as a reasonable alternative to CT of the brain for the
evaluation of ventricular morphology. MRI to evaluate CSF flow and
morphology of choroid plexus in patients who have undergone ETV with or
without choroid plexus cauterization (CPC) should also be considered. The
size of the ventricles may be small, normal, or enlarged in the presence of

shunt malfunction. Comparing ventricular morphology on presentation to
the morphology of the ventricular system at the time of the first or
subsequent shunt obstructions is imperative and may be predictive in
determining the present status of the shunt system.
Management. The urgency of referral to a neurosurgeon is based on the
patient’s clinical presentation and radiographic signs. In general, patients
should be referred for asymptomatic radiographic changes, such as mildly
enlarging ventricles, in a semiurgent manner or as an outpatient.
Asymptomatic patients with changes in physical examination findings, such
as increasing head circumference, tense anterior fontanelle, upgaze or CN
VI palsies or papilledema, require urgent neurosurgical consultation.
Immediate neurosurgical consultation is mandated for symptomatic patients
or the presence of radiographic changes.