Shunt Complications in Children

• See also Adult hydrocephalus and shunt complications Adult Hydrocephalus and Shunt Complications.

Essentials

• The symptoms and signs of shunt malfunction are similar to those of hydrocephalus.
  • The symptoms and signs of shunt blockage and disconnection are the same as in hydrocephalus
  • If an infection is present, the patient always has fever and often abdominal pain.
• Symptoms related to overdrainage (headache, tiredness, vomiting) are usually worsened by an upright position and therefore become prominent towards the evening.
• A suspicion of hydrocephalus or shunt malfunction in a child is an indication for an emergency referral to a paediatric hospital. The referral letter should include x-ray images of the head/brain and data relating to the growth of the child (height, weight and head circumference).
  • If the conscious level is affected or the child is unconscious, ensure adequate circulation and breathing by intubation and assisted ventilation as necessary, after which transfer the patient to the hospital and call the hospital in advance.
• Lumbar puncture is dangerous and contraindicated. The absence of papilloedema does not rule out increased intracranial pressure.

Hydrocephalus in a child

• In 90% of all cases, excluding tumours, hydrocephalus is diagnosed within the first year of life.
• In about 50% of cases, the cause is prenatal (malformation, sequelae to cerebral haemorrhage/ischaemia/inflammation).
• Postnatal causes of hydrocephalus are cerebral haemorrhage (perinatal bleeds in small premature infants), infections (meningitis, encephalitis) and tumours.
• Patients with hydrocephalus are usually treated with a ventriculoperitoneal shunt, but some patients can be treated by an internal bypass operation, i.e. by endoscopic perforation of the bottom of the third ventricle.

Symptoms and signs of disturbed circulation of cerebrospinal fluid (in hydrocephalus)

• Accelerated growth of head circumference in an infant or young child (head growth charts!) see Head Growth in Children.
• Tiredness, crying, difficulty feeding
• Headache (at night, first thing in the morning)
• Vomiting
• Blurred vision/impaired vision

Clinical findings in disturbed circulation of cerebrospinal fluid (in hydrocephalus)

• Infant: taut and bulging anterior fontanelle, widely open cranial sutures
• Impaired upgaze (”sunsetting”), strabismus (abducens nerve palsy), papilloedema
• Brisk tendon reflexes, ankle clonus
• Ataxia
• Dislike of being handled
• Decreased level of consciousness

Symptoms and signs of shunt complications: an emergency referral

• Swelling, redness or skin infection around the shunt site
• Vomiting, headache or irritability
• Abdominal pain
• Nuchal rigidity, opisthotonus
• Painful head or eye movements
• Abnormal eye movements on examination
• New-onset strabismus
• New-onset convulsive attacks
• Headache or feeling unwell in the afternoons
• Decreased level of consciousness
• Unexplained fever
• Also a perforation made at the bottom of the third ventricle may become obstructed, leading to similar symptoms and findings as seen in shunt obstruction.