General
- Is a complication of TBI
- It is important to recognize and treat PTH, since it could both impact morbidity and mortality if left untreated
Numbers
- Incidence of PTH
- 0.7% - 51.4%
- However, it is often difficult to determine whether ventriculomegaly observed post- TBI is related to atrophy or hydrocephalus;
Risk factors
Decompressive craniectomy
- Studies have supported and refuted this (0% and 88.2% (Ding et al., 2014))
- It is thought that CSF malabsorption or obstructed flow are the cause of post- DC hydrocephalus.
- However, the current case series are limited by their design and heterogeneity of criteria used to diagnose hydrocephalus.
Predisposing factors for post-DC hydrocephalus
- Interhemispheric hygroma development
- Subdural hygroma development
- Low GCS score upon admission*
- Increased ICP before DC
- Elderly patients
- Proximity of the DC (< 2.5 cm) to the anatomical midline
- Delayed (> 3 months) CP
Clinical features
- Worsening neurological status or lack of improvement associated with pressure related headaches or the normal pressure hydrocephalus syndrome.
- Late CSF leak is also suspicious for PTH.
Investigation
- Repeated cranial imaging (e.g. CT, MRI) can provide information regarding any changes in the patient’s ventricular system.
- Computerized CSF infusion studies have been reported to be useful in distinguishing between the two different processes
- CSF infusion studies may be helpful in patients with VM to determine the presence of HC, after a cranioplasty has been performed.
Management
- Selection of patient benefiting from permanent CSF diversion is important, since shunting is also associated with significant complications.
- No clear guidelines exist for PTH treatment, however adjustable or flow-regulated ventriculo-peritoneal shunts are most commonly described as the preferred choice of shunting to reduce the risk of overdrainage.
- ETV
- PTH has been reported as a relative contraindication to endoscopic third ventriculostomy
- This notion has been challenged by others
- It is difficult to predict the response of CSF diversion in PTH, since these patients often have comorbidities and significant underlying brain injury.
- For patient with craniectomy
- The optimal management of decompressed patients with ventriculomegaly remains uncertain but the performance of a cranioplasty prior to definitive CSF diversion should be considered as it can help restore an intact intracranial system.
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