What is the immediate management for a patient presenting with generalized tonic-clonic seizures (GTCS) and computed tomography (CT) brain findings suggestive of hydrocephalus?

Immediate Management of GTCS with CT Evidence of Hydrocephalus

A patient presenting with generalized tonic-clonic seizures and CT brain findings suggestive of hydrocephalus requires urgent neurosurgical consultation for consideration of cerebrospinal fluid diversion, alongside immediate seizure control and investigation of the underlying etiology of hydrocephalus. 1

Acute Seizure Management

• Terminate the seizure immediately using standard protocols with benzodiazepines followed by appropriate antiepileptic drugs (AEDs) if seizures persist or recur 2
• Secure airway, breathing, and circulation as GTCS carries the greatest risk of harm among common epileptic seizures 2
• Obtain intravenous access and check bedside glucose, as metabolic derangements may contribute to seizures

Urgent Neurosurgical Evaluation

The presence of acute hydrocephalus on CT mandates urgent neurosurgical consultation for potential external ventricular drain (EVD) placement. 1

• Patients with new onset acute hydrocephalus should be referred for urgent neurosurgical consultation, particularly if there is altered level of consciousness 1
• Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario) 1
• The decision for EVD placement depends on the degree of hydrocephalus, clinical symptoms, and whether the patient is clinically deteriorating 1

Determine Etiology of Hydrocephalus

The underlying cause of hydrocephalus must be identified urgently as it directs definitive management:

Hemorrhagic Causes

• Subarachnoid hemorrhage (SAH): Look for sudden severe headache ("thunderclap"), nuchal rigidity, or focal neurological deficits 1

  • If SAH is confirmed, patients require vascular imaging (CTA or catheter angiography) to identify aneurysm 1
  • Aneurysm should be secured urgently within 24-48 hours by endovascular coiling or microsurgical clipping 1

• Intraparenchymal hemorrhage (ICH): Assess for history of hypertension, anticoagulation, or trauma 1

  • Check coagulation studies (INR/PTT) immediately if patient is on anticoagulation 1
  • Reverse coagulopathy promptly with prothrombin complex concentrate (PCC) and vitamin K for warfarin use 1

Infectious Causes

• Tuberculous meningitis (TBM): Hydrocephalus occurs in approximately 29% of TBM cases at presentation and is associated with longer symptom duration, ataxia, and poor outcome 3

  • Consider in patients with subacute presentation, fever, constitutional symptoms, or risk factors for TB
  • Lumbar puncture (if safe) for CSF analysis showing lymphocytic pleocytosis, elevated protein, low glucose

• Coccidioidal meningitis: Hydrocephalus is the most common complication, occurring in approximately 40% of cases 1

  • Consider in endemic areas (southwestern United States)
  • Requires lifelong azole antifungal therapy 1

Obstructive Causes

• Cerebellar hemorrhage or mass: Requires urgent neurosurgical consultation for possible posterior fossa decompression 1
• Tumor or other mass lesions: May require urgent surgical intervention depending on location and degree of obstruction

Intracranial Pressure Management

• Monitor for signs of elevated ICP: Altered mental status, headache, nausea/vomiting, papilledema, Cushing's triad 1
• If increased ICP is documented (opening pressure ≥250 mm H₂O on lumbar puncture when safe to perform), CSF should be removed to reduce pressure to 50% of opening pressure or 200 mm H₂O, whichever is greater 1
• This should be repeated at least daily for 4 days until pressure stabilizes to <250 mm H₂O 1
• If medical therapy and repeated lumbar punctures fail to stabilize pressure, permanent shunting procedures should be explored with neurosurgery 1

Antiepileptic Drug Selection

For ongoing seizure prophylaxis after initial control:

• Levetiracetam, lamotrigine, perampanel, or topiramate have the strongest regulatory evidence for GTCS control 2
• Levetiracetam is often preferred in acute settings due to:
  • Minimal drug interactions 2
  • IV formulation available
  • No need for therapeutic drug monitoring
  • Rapid titration possible

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation if hydrocephalus is present on CT, as acute decompensation can occur rapidly 1
• Do not perform lumbar puncture without first reviewing CT if there is concern for mass effect or obstructive hydrocephalus, though communicating hydrocephalus from SAH or meningitis may be safely tapped 1
• Do not assume hydrocephalus is chronic based on imaging alone—clinical correlation is essential as acute hydrocephalus may have minimal radiographic changes initially 1
• Do not stop anticoagulation without reversing it in patients with ICH and elevated INR 1

Disposition and Monitoring

• Admit to neuro-intensive care unit or stroke unit for close neurological monitoring 1
• Patients require serial neurological examinations to detect deterioration 1
• Repeat neuroimaging should be obtained if clinical status changes 1