From the Guidelines
The initial treatment for bilateral subdural hematoma resulting from over-drainage of a ventriculoperitoneal (VP) shunt involves raising the valve setting of the programmable shunt to reduce CSF drainage, typically to the highest setting (180-200 mmH2O) 1. This approach is aimed at reducing the pressure gradient that drives overdrainage and subsequently causes traction on bridging veins, leading to bleeding into the subdural space. The provided evidence, although primarily focused on the management of coccidioidomycosis and shunt infections, does not directly address the treatment of bilateral subdural hematomas due to overdrainage of a VP shunt. However, the general principle of managing shunt malfunction and the importance of adjusting shunt settings to prevent overdrainage can be inferred from the discussions on shunt management in the context of infections 1. Key considerations in the management of these patients include:
- Adjusting the shunt valve setting to reduce drainage
- Temporary external ligation if the shunt lacks programmability
- Bed rest with the head flat to reduce pressure gradients
- Surgical evacuation for symptomatic patients with significant hematomas
- Maintaining hydration to promote CSF production
- Potential shunt revision with the addition of an anti-siphon device or conversion to a programmable valve system for persistent overdrainage
- Placement of a lumbar drain for controlled CSF drainage in some cases. Close neurological monitoring and serial imaging are crucial to assess the resolution of hematomas and guide management adjustments.
From the Research
Treatment Options for Bilateral Subdural Hematoma
- Increasing the shunt valve pressure to reduce flow through the shunt and mildly increase intracranial pressure can result in rapid resolution of the acute subdural hematoma, as seen in a case report where a 63-year-old man with normal-pressure hydrocephalus and an adjustable valve ventriculoperitoneal shunt developed an acute subdural hematoma after sustaining head trauma 2.
- Surgical treatment, including subdural hematoma evacuation and shunt ligation, may be necessary in some cases, particularly if the patient is not neurologically intact or if the hematoma is large 2.
- Installing a programmable valve with a virtual off-function can be a useful treatment method for chronic subdural hematoma after VP shunt surgery, as it allows for the shunt function to be stopped and restarted at will, and the pressure to be set to an optimal level after the subdural hematoma has improved 3.
- Burr hole drainage (BHD) and replacement of the adjustable pressure shunt valve may be necessary in cases where the shunt valve breakdown is caused by excessive external forces, as seen in a case report of a 68-year-old man with a V-P shunt for 8 years who developed bilateral CSDH after a brain injury 4.
- Subdural-peritoneal shunt can be used as a mode of treatment for recurrent chronic subdural hematoma, particularly in cases where repeated drainage or tapping is not effective, as seen in a case report of an adult with recurrent bilateral chronic subdural hematoma who was successfully managed by repeated burr-hole evacuation initially, followed by insertion of a subdural-peritoneal shunt 5.
Considerations for Treatment
- The treatment approach may depend on the underlying cause of the subdural hematoma, such as over-drainage of a VP shunt or shunt valve breakdown 6, 4.
- The use of a programmable valve with a virtual off-function can help to prevent further recurrence of the subdural hematoma by allowing for the shunt function to be stopped and restarted at will 3.
- Surgical treatment may be necessary in cases where the patient is not neurologically intact or if the hematoma is large, and may involve evacuation of the hematoma and replacement of the shunt valve 2, 6.