Management of Hydrocephalus in TBI, ICH, and SAH

Assessment and Indications for Intervention

Hydrocephalus is a common complication occurring in approximately 45% of patients with ICH and is associated with worse outcomes and increased mortality 1, 2
In SAH, hydrocephalus occurs in 8.9% to 48% of patients and is a significant predictor of poor outcomes 4
Patients with a GCS score of 8 or less may require ICP monitoring and potential CSF drainage 1, 5
Clinical evidence of transtentorial herniation may require ICP monitoring and potential CSF drainage 2, 5
Significant intraventricular hemorrhage or hydrocephalus may require ICP monitoring and potential CSF drainage 1, 3

Ventricular catheters are preferred over parenchymal monitors when safe and feasible as they allow for both ICP monitoring and CSF drainage 1, 5
Before insertion of any monitoring device, evaluate the patient's coagulation status 1, 3
Consider platelet transfusion for patients on prior antiplatelet therapy before inserting a monitoring device 2, 5
Reverse coagulopathy in patients on warfarin before inserting a monitoring device 3, 5

Place ventricular drainage catheter for hydrocephalus, especially in patients with decreased level of consciousness 1, 2
Target cerebral perfusion pressure of 50-70 mmHg, depending on cerebral autoregulation status 2, 3, 5
Avoid corticosteroids as they are not recommended for treatment of elevated ICP in ICH 1, 5
For refractory elevated ICP, consider osmotic therapy with hypertonic saline (3%) as an alternative 6

In SAH patients, consider risk factors for shunt dependency, including poor admission neurological grade, increased age, and high Fisher grades 4
Permanent CSF diversion (shunting) improves neurological outcome after SAH in appropriate candidates 4
Differential pressure gradients may exist in ICH, with ICP elevated near the hematoma but not distant from it 1, 5
Hydrocephalus is present in approximately 55% of ICH patients with IVH 1, 2

Risk of infection with ventricular catheters is approximately 4% 2, 3
Risk of intracranial hemorrhage with catheter placement is approximately 3% (higher in patients with coagulopathies at 15.3%) 1, 3