From Shunt to Recovery: A Multidisciplinary Approach to Hydrocephalus Treatment in Severe Acquired Brain Injury Rehabilitation

Abstract

Background: Hydrocephalus among Severe Acquired Brain Injury (SABI) patients remains overlooked during rehabilitation. Methods: A retrospective cohort study was carried out of traumatic and non-traumatic SABI patients with hydrocephalus, consecutively admitted over 9 years in a tertiary referral specialized rehabilitation hospital. Patients were treated with ventriculoperitoneal shunt before or during inpatient rehabilitation and assessed using the Level of Cognitive Functioning Scale and Disability Rating Scale. Logistic regression models were used to identify predictors of post-surgical complications. Linear regression models were used to investigate predictors of hospital length of stay (LOS), disability, and cognitive function. Results: Of the 82 patients, 15 had post-surgical complications and 16 underwent cranioplasty. Shunt placement complication risk was higher when fixed vs. when programmable pressure valves were used. A total of 56.3% achieved functional improvement at discharge and 88.7% improved in cognitive function; of the 82 patients, 56% were discharged home. In multiple regression analyses, higher disability at discharge was related to cranioplasty and longer LOS, while poorer cognitive function was associated with cranioplasty. Increase in LOS was associated with increasing time to shunt and decreasing age. Conclusions: A significant improvement in cognitive and functional outcomes can be achieved. Cranioplasty increased LOS, and fixed pressure valves were related to poorer outcomes.

Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel

“…The EP rated the use of programmable valves as inappropriate for the fixed valve, reflecting the literature data available ( Ting et al, 2020 ; Gill et al, 2021 ; Zhang et al, 2022 ; Castellani et al, 2021 ). This indication is reasonably related to the possibility of hypershunting due to a modification of CSF dynamics that can occur during the postoperative follow-up or due to the presence of an overtreated ventriculomegaly.…”

“…Traditional valve has been reported as an additional option in fewer reports ( Zhang et al, 2022 ; Castellani et al, 2021 ) ( Table 2 ). A recent systematic review and meta-analysis conducted by Ahmed et al (2023) revealed that the summary of the proportions of the incidence rate of complications was less for Adjustable Differential Pressure Valves (ADPV) as compared to Fixed Differential Pressure Valves (FDVP), but the confidence intervals overlapped.…”

Measuring CSF shunt flow with MRI using flow enhancement of signal intensity (FENSI)

“…16 More quantitative approaches have used phase contrast MRI for differentiating the reportedly obstructed and functioning shunts. 17 Phase contrast is used in many quantitative techniques for flow measurements, 8,18 but there are challenging spatial resolution requirements that must be met to achieve quantitative accuracy with flow rate (velocity) measurements in the shunt. The diameters of shunt tubes are 1 ∼ 2 mm, and ideally three to four pixels must be included across the lumen of the shunt tube in both directions to achieve an accurate measurement.…”

The compensatory mechanism and clinical significance of hydrocephalus after cranioplasty

“…The main causes of hydrocephalus include the loss of bone flap support, the impact of atmospheric pressure outside the intracranial abnormal pressure, as well as local brain tissue in the bone window location and position shift, all of which result in varying degrees of cerebral perfusion disorders and cerebrospinal fluid circulation disorders, cerebrospinal fluid accumulation, and oppression subarachnoid and brain pool ( 7 ). Currently, cranioplasty (CP) and ventriculoperitoneal shunt are the two major treatments (VPS) ( 8 ) CP can effectively solve circulatory disorders and insufficient blood supply caused by skull defects and improve the appearance of patients, brain tissue safety and neurological function ( 9 ). VPS is the drainage of excess cerebrospinal fluid from the ventricles of the patient into the abdominal cavity and absorption, thereby improving the symptoms of hydrocephalus ( 10 ).…”