Hydrocephalus: An Owner’s Manual Part 4 of 6
Signs & Symptoms of Hydrocephalus or Shunt Failure
The benefits of shunting include treating the hydrocephalus and its attendant signs and symptoms. Symptoms are what a patient complains of (headache, nausea, vomiting, double vision, blurred or decreased vision, clumsiness, etc.) and signs are what a physician discovers on examination (decreased consciousness, abnormal eye movements including sunsetting and crossed eyes, enlarging head circumference in infants, etc.).
The most important sign of hydrocephalus is the patient’s level of consciousness. The more advanced the hydrocephalus—that is, the greater the pressure in the head—the sleepier the patient becomes. In advanced cases, the patient can lapse into a coma, even death.
Headache is an important but too general symptom of hydrocephalus. In this context, it is rarely important in isolation, but gains more significance in the company of other symptoms, such as nausea and vomiting, double vision, and abnormal eye movements.
In a shunted patient, the combination of headache and one or more of these symptoms should not be ignored.
The eyes are very telling in shunt patients. Obviously abnormal eye movements—where such abnormal movements did not exist previously—must be investigated emergently.
In more subtle cases of shunt malfunction, the eyes may have a glassy appearance. Often the parents will notice this when others don’t. Such a child should be watched carefully.
Nausea & Vomiting
Much like headache, nausea and vomiting is too general to be of much use in isolation. It is more useful in the presence of other signs and symptoms, such as headache and/or double vision, which would suggest the need for emergent evaluation.
Nausea and vomiting associated with diarrhea, or without any other associations, are not likely related to the shunt, though if the symptoms persist beyond a few days evaluation by your doctor is advisable.
While some shunt infections can cause belly pain, a non shunt problem (including a simple viral infection) is much more likely. This is not a cause for concern unless persistent, severe, and/or associated with vomiting or diarrhea, in which case see your physician. It is unlikely to be a shunt problem in any event.
Fever is too nonspecific to be of use when in isolation. Again, fever in the company of other findings (such as discussed under headache) may be more significant.
Irritability & Poor Feeding
These symptoms are seen in infants and perhaps others who lack the ability to communicate readily.
The patient becomes something other than himself, being more cranky, irritable, and not wanting to play. By poor feeding is meant a tendency not to take the bottle well or not wanting to eat. Some babies in this situation will spit up whatever they are fed, even small volumes. This can lead to dehydration and thus should be attended to with some urgency.
Seizures & Opisthotonus
Rarely is a seizure a sign of a shunt problem. This is true even in patients with an underlying seizure disorder. Many patients with shunts have underlying seizure disorders and the two are not necessarily related. The exception is in a patient with a sudden flurry of seizure activity and no discernable cause. In such a case, the shunt should be evaluated by a neurosurgeon.
There is one important notice that must be taken in regard to shunts and seizures. Opsithotonus is a condition loosely defined as extreme arching of the back and especially the neck. In opisthotonus, the patient’s head is thrown back forcibly and the appearance is one of extreme discomfort with the neck in extension. Attempts to straighten out the patient meet with great resistance and may be impossible. The patient may have a distant look in the eyes, or may be unconscious altogether. Opisthotonus may be intermittent or sustained.
Opsithotonus is not a seizure, though at times it is referred to confusingly as a ‘brainstem seizure’ or brainstem spell. It is an ominous discovery, indicating one of the herniations (brain shifts) alluded to above. Its importance cannot be overstated. Patients with opisthotonus are at a life-threatening moment and must be evaluated and perhaps operated on immediately. I once ran down three flights of stairs with a young child in my arms, his neck arched in opisthotonus all the way. The elevator had failed.
Opsithotonus is not a seizure, but to the uninitiated it can look like a seizure. In a patient with shunted hydrocephalus and no history of seizures, the report of a seizure should never be taken at face value. Given even the slightest bit of arching, one should assume a life-threatening shunt malfunction and act accordingly.
Disclaimer: The information contained in this blog is simply that, information. I am not doling out specific medical advice. Nothing contained herein is meant to replace a complete evaluation by a qualified member of the medical establishment. This page is nonfiction.