Management of Ventricle Enlargement with Altered Mental Status

Initial Assessment and Stabilization

The American College of Radiology recommends obtaining urgent non-contrast CT or MRI of the head to differentiate between acute obstructive hydrocephalus, idiopathic normal pressure hydrocephalus (NPH), infectious causes, or underlying neurodegenerative disease, while simultaneously stabilizing the patient and investigating reversible causes of altered mental status 1
The American Heart Association, as published in Circulation, suggests assessing for signs of increased intracranial pressure, including bradycardia, hypertension, and irregular respirations (Cushing's triad) 3
Transfer the patient immediately to a monitored setting to prevent aspiration and falls, and assess airway protection, considering intubation if necessary, as recommended by medical guidelines 2

Obtain non-contrast CT head immediately as the first-line imaging test to evaluate ventriculomegaly, exclude obstructive hydrocephalus, mass lesions, hemorrhage, and assess for transependymal CSF flow, according to the American College of Radiology 1
If CT is non-diagnostic or shows findings requiring further characterization, proceed to MRI head without contrast to better evaluate for NPH features, ventriculitis, or underlying neurodegenerative disease, as recommended by the American College of Radiology 1

Confirm diagnosis with imaging criteria, including Evans index >0.3, enlarged temporal horns, callosal angle <90°, evidence of altered brain water content, and aqueductal flow void on MRI, as recommended by the American College of Radiology 1
Do not perform lumbar puncture if signs of increased ICP or mass effect, as recommended by the American College of Radiology 1
Perform high-volume lumbar puncture (30-50 mL CSF removal) and assess for clinical improvement in gait/cognition over 24-48 hours, if safe, as recommended by medical guidelines 1

Avoid benzodiazepines if any concern for hepatic dysfunction, as they precipitate hepatic encephalopathy, as recommended by medical guidelines 2
Use propofol for intubated patients, as it has a short half-life and is easily titratable, as recommended by medical guidelines 2
Use dexmedetomidine, an alpha-2 agonist, as it reduces ventilation duration and preserves cognitive function, as recommended by medical guidelines 2

Do not assume ventriculomegaly alone requires shunting, as 50% of patients with enlarged ventricles and suspected NPH do not meet criteria for shunt surgery after comprehensive evaluation, as recommended by medical guidelines 1
Do not perform lumbar puncture without imaging first if any signs of increased ICP or focal neurological deficits, as recommended by the American College of Radiology 1
Insufficient data exists to conclude ventricular size impacts neurocognitive development, so avoid aggressive interventions based solely on ventricular size, as reported in Neurosurgery 5, 6, 7