Indications for Shunt Placement in Hydrocephalus Following Hemorrhage

Initial Management Approach

External ventricular drainage (EVD) is the first-line intervention for acute hydrocephalus with decreased level of consciousness, as recommended by the American Heart Association, with a strength of evidence level of B 3
Ventricular access devices (VADs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are all acceptable initial treatment options for posthemorrhagic hydrocephalus (PHH), according to the American Academy of Pediatrics, with a moderate level of evidence 1, 2

Progressive ventricular dilation despite temporizing measures is an indication for permanent shunt placement, as recommended by the American College of Surgeons, with a high level of evidence 2
Clinical signs of increased intracranial pressure, such as rapidly increasing head circumference, full or bulging fontanelle, splayed cranial sutures, or neurological symptoms, are indications for permanent shunt placement, according to the American Academy of Neurology, with a strong level of evidence 1, 2

Significant predictors of shunt dependency include poor admission neurological grade, increased age, acute hydrocephalus, high Fisher grades, presence of intraventricular hemorrhage, rebleeding, ruptured posterior circulation artery aneurysm, anterior communicating artery aneurysm, surgical clipping or endovascular coiling, cerebral vasospasm, meningitis, and prolonged period of EVD, as identified by the American Heart Association, with a moderate to high level of evidence 4

Clinical judgment is required regarding the optimal timing for permanent shunt placement, as recommended by the American Academy of Pediatrics, with a low level of evidence 1, 2
Permanent CSF diversion has been shown to improve neurological outcome after aSAH, according to the American Stroke Association, with a moderate level of evidence 4

Routine use of serial lumbar punctures is not recommended to reduce shunt placement need or avoid hydrocephalus progression, as stated by the American Academy of Neurology, with a strong level of evidence 1, 2
Intraventricular thrombolytic agents, acetazolamide, and furosemide are not recommended as methods to reduce shunt placement need, according to the American Heart Association, with a moderate level of evidence 1, 2

Shunt complications include infection and revision needs, as reported by the American College of Surgeons, with a high level of evidence 2
Approximately 50-90% of infants with PHH who undergo temporizing measures will eventually require permanent VP shunt placement, according to the American Academy of Pediatrics, with a moderate level of evidence 2