22 Ventriculoatrial Shunt
22.1 Symptoms and Signs
Gait disturbance
Difficulty maintaining balance and walking
Mild dementia
Impaired bladder control
Headache
Fatigue
Nausea
Irritability
Confusion
Large head size
Seizures
Impaired vision
Abnormal sleeping behavior
Memory loss
22.2 Surgical Pathology
Cranial benign/malignant trauma
Cranial benign/malignant infection
Cranial benign/malignant tumor
Cranial benign/malignant surgical complication
22.3 Diagnostic Modalities
Patient history
Physical examination
Neurological examination
CT of brain (detect enlarged ventricles)
MRI of brain (detect enlarged ventricles)
Ultrasound of brain
Cerebrospinal fluid (CSF) testing (predict shunt responsiveness, determine shunt pressure)
Lumbar or spinal tap
External lumbar drainage
Measure CSF outflow resistance
22.4 Differential Diagnosis
Communicating hydrocephalus: CSF can still flow between ventricles, but gets blocked after exiting
Resulting from subarachnoid hemorrhage, head trauma, infection, tumor, or surgical complication
Normal pressure hydrocephalus (NPH)
Noncommunicating hydrocephalus (obstructive hydrocephalus): CSF flow blocked along passage(s) connecting ventricles
Congenital hydrocephalus vs. acquired hydrocephalus
Hydrocephalus ex-vacuo: Occurs when stroke, degenerative diseases, or head trauma damages brain (brain tissue shrinkage may occur)
22.5 Treatment Options
22.5.1 Surgery if Deemed Suitable Candidate
Determine overall prognosis and Karnofsky performance score
If poor surgical candidate with poor life expectancy, medical management recommended
Endoscopic third ventriculostomy (neuroendoscope visualizes ventricular surface and a hole is created in floor of third ventricle, allowing CSF to bypass obstruction and flow toward sites of resorption)
Shunting (relieving fluid buildup responsible for hydrocephalus)
Types:
Ventriculoperitoneal (VP): Ventricular inflow, peritoneal cavity (abdomen) outflow
Lumboperitoneal (LP): Lumbar spine inflow, peritoneal cavity (abdomen) outflow
Ventriculopleural (VPL): Ventricular inflow, pleural cavity (lung) outflow
Ventriculoatrial (VA): Ventricular inflow, right atrium of heart outflow
Components:
Inflow/proximal catheter (drains CSF from ventricles or subarachnoid space)
Valve mechanism (regulates differential pressure or controls flow through shunt tubing, connected to proximal catheter)
Outflow/distal catheter (directs CSF from valve to abdominal or peritoneal cavity, heart, or other drainage site)
22.6 Indications for Surgical Intervention
Gait disturbance
Known cause for hydrocephalus (i.e., trauma or hemorrhage)
Ventricle size disproportionately larger than CSF in subarachnoid space
Removal of spinal fluid through lumbar puncture or catheter results in temporary relief
Intracranial pressure (ICP) or spinal fluid pressure monitoring demonstrates abnormal range or pattern of spinal fluid pressure or sufficiently elevated CSF outflow resistance
Multiple failures of ventriculoperitoneal (VP) shunts
Peritoneum not acceptable site for distal catheter placement
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