(Kiosk 4) Low-pressure Hydrocephalus (LPH) After Severe Traumatic Brain Injury and Subarachnoid Hemorrhage

Case Diagnosis: A 21-year-old male with low-pressure hydrocephalus after severe TBI and Subarachnoid hemorrhage (SH)

Case Description or Program Description: 21 yo M, admitted after an unhelmeted motorcycle crash sustaining a severe TBI and diffuse subarachnoid hemorrhage (GCS 3). External Ventricular Drain (EVD) was placed from post-injury day (PID) 1-9 with normal pressures. He was initially in a vegetative state but by PID 30 he emerged to a Post-Traumatic Confusional State. On PID 50, repeat head CT showed worsening ventriculomegaly requiring EVD placement for a second time. Persistent ventriculomegaly and very low pressures on EVD led to a programmable shunt placement on PID 59. The patient remained neurologically stable and was admitted to an Inpatient rehabilitation facility (IRF) on PID 64, however, follow-up CT still showed persistent ventriculomegaly despite repeat pumping and setting the shunt at the lowest pressure possible. After revision, a fixed pressure valve at the lowest pressure setting was placed on PID 79 with reduction in ventricular size seen in the following days.

Setting: SICU/IRF

Assessment/Results: On discharge from IRF on PID 114 patient had normal strength, independent gait, ability to express needs and ideas, mild anomia, intermittent confabulation and perseveration. He had improved alertness and attention, focusing for up to 10-15 minutes on tasks. Memory profoundly impaired. Follow-up MRI on PID 133 demonstrated no evidence of hydrocephalus.

Discussion (relevance): Low Pressure Hydrocephalus (LPH) is a rare entity that can occur after hemorrhage, neoplasm, trauma as well as CSF-related surgery; may present with decreased levels of consciousness, headaches and cranial nerve deficits. Patients undergo multiple unsuccessful shunt or EVD revisions for presumed device failure before the diagnosis is made.

Conclusions: We should suspect LPH in patients with TBI and hemorrhage who develop ventriculomegaly and do not improve after placement of EVD or VP shunt. These patients should be tracked by multiple specialists to achieve resolution.