What is the management of hydrocephalus in patients with Traumatic Brain Injury (TBI), Intracranial Hemorrhage (ICH), or Subarachnoid Hemorrhage (SAH)?

Management of Hydrocephalus in TBI, ICH, and SAH

Ventricular drainage is the primary recommended treatment for hydrocephalus in patients with TBI, ICH, or SAH, especially in those with decreased level of consciousness. 1

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
• In SAH, hydrocephalus occurs in 8.9% to 48% of patients and is a significant predictor of poor outcomes 1
• Patients requiring ICP monitoring and potential CSF drainage include:
  • GCS score of 8 or less 1, 2
  • Clinical evidence of transtentorial herniation 1, 2
  • Significant intraventricular hemorrhage or hydrocephalus 1
  • Supratentorial ICH, particularly in younger patients 2

Device Selection and Placement

• Ventricular catheters (VC) are preferred over parenchymal monitors when safe and feasible as they allow for both ICP monitoring and CSF drainage 1, 2
• Parenchymal catheters (PC) should be used when only ICP monitoring is needed without CSF drainage 2
• Before insertion of any monitoring device:
  • Evaluate the patient's coagulation status 1
  • Consider platelet transfusion for patients on prior antiplatelet therapy 1, 2
  • Reverse coagulopathy in patients on warfarin 1, 2

Management Protocol

First-line Management

• Place ventricular drainage catheter for hydrocephalus, especially in patients with decreased level of consciousness 1
• Target cerebral perfusion pressure (CPP) of 50-70 mmHg, depending on cerebral autoregulation status 1, 2
• Implement head of bed elevation to 30° with head midline to optimize venous drainage 2, 3

Pharmacological Management

• Avoid corticosteroids as they are not recommended for treatment of elevated ICP in ICH 1, 2
• For refractory elevated ICP, consider osmotic therapy:
  • Mannitol: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30-60 minutes 4
  • Hypertonic saline (3%) may be considered as an alternative, though evidence is limited 1, 3

Monitoring and Weaning

• Continuously assess ICP, including waveform quality 2
• Evidence of reduced CSF pressure should be observed within 15 minutes after starting mannitol infusion 4
• Implement standardized EVD weaning protocols to assess the need for permanent CSF diversion 2, 5

Special Considerations

SAH-Specific Management

• In SAH patients, consider risk factors for shunt dependency:
  • Poor admission neurological grade, increased age, high Fisher grades 1
  • Presence of intraventricular hemorrhage, ruptured posterior circulation aneurysm 1
• Acute low-pressure hydrocephalus (aLPH) may develop in some SAH patients (3.7%) and requires negative pressure drainage 5
• Permanent CSF diversion (shunting) improves neurological outcome after SAH in appropriate candidates 1

ICH-Specific Management

• Differential pressure gradients may exist in ICH, with ICP elevated near the hematoma but not distant from it 1, 2
• Patients with small hematomas and limited IVH usually will not require treatment to lower ICP 1, 2
• Hydrocephalus is present in approximately 55% of ICH patients with IVH 1

TBI-Specific Management

• Post-hemorrhagic hydrocephalus following TBI requires similar management principles as ICH 6
• Consider lumbar drainage as an alternative in communicating hydrocephalus when ventricular access is difficult 7

Complications and Pitfalls

• Risk of infection with ventricular catheters is approximately 4% 1
• Risk of intracranial hemorrhage with catheter placement is approximately 3% (higher in patients with coagulopathies at 15.3%) 1
• Delayed recognition and treatment of hydrocephalus can lead to irreversible neurological damage 8
• Overdrainage can lead to development of cranio-spinal pressure gradients and potential herniation 7