1508 - Improving Function in a Patient with Disorder of Consciousness: A Case Study of Non-Siphon Ventriculoperitoneal Shunt Implementation

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

SH

Sara Herzberg, MD

Resident Physician
Kessler Institute for Rehabilitation/ Rutgers NJMS
Fair Lawn, New Jersey, United States

Co-Author(s)

Neil Jasey, MD

Attending Physiatrist
Kessler Institute for Rehabilitation
West Orange, New Jersey, United States

Case Diagnosis: hydrocephalus

Case Description: Following a car accident, a 24-year-old male required a left-sided craniectomy and a programmable anti-siphon ventriculoperitoneal (VP) shunt for elevated intracranial pressure. In rehabilitation, he consistently scored six on the coma recovery scale, signifying a state of unresponsive wakefulness. Despite medication optimization, multiple shunt adjustments, and cranioplasty, his progress remained limited. Throughout his course, CT head scans consistently showed ventriculomegaly. One year post-injury, neurosurgery replaced his shunt valve to one without anti-siphon capabilities to attempt to improve his cognition. After the shunt revision, he again underwent acute inpatient rehabilitation, where he emerged, and began engaging in conversation and actively participating in therapy.

Discussions: Hydrocephalus is a common complication after traumatic brain injury and usually managed with a VP shunt. By connecting the intracranial and intra-abdominal compartments, VP shunts may potentially cause excessive drainage from the high-pressure cranial system to the lower-pressure peritoneal system when a patient is upright. To counteract this, valves are often equipped with anti-siphon devices to prevent overdrainage while sitting or standing.

However, brain injury patients with disorder of consciousness (DoC) are non ambulatory and have limited ability to assume upright positions for prolonged periods of time. In this patient population, anti-siphon devices may impede adequate drainage. Consequently, patients with DoC may benefit from valves without anti-siphon devices to ensure appropriate CSF drainage.

Conclusions: This patient’s ventriculomegaly and cognitive function improved drastically once the anti-siphon device was removed. Physiatrists should be aware of the various types of valves and may discuss the potential for a valve exchange with neurosurgery if a patient is non-ambulatory and making little or slow functional gain.