Headache with shunts

In individuals with hydrocephalus, CSF shunts are used remove CSF from the ventricular system to prevent the build up of excessive pressure. A number of different CSF diversion procedures exist.

• External ventricular drain
• Ventriculoperitoneal shunts
• Ventricular access devices

Individuals who have had CSF diversion procedures who develop headaches can pose a diagnostic challenge and shunt malfunction or a complication such as infection need to be considered in addition to the usual differential diagnosis for a headache. Both neurosurgeons and neurologists need to be aware of the approach required to prevent patients falling into the cracks between specialities. While shunt malfunction or complications are potentially life-threatening and should not be missed, in many cases the headache will be directly related to the shunt.

Approach to headache with shunts

Evaluating shunt function

If the patient presents with a headache consistent with raised intracranial pressure it is important to determine if the shunt has malfunctioned. This is not always straightforward to determine and information from several different sources can be useful:

• Neuroimaging can be used to assess ventricular size. In acute shunt failure ventriculomegaly may occur. It should be remembered that in some cases ventriculomegaly will have been present historically in this patient population so drawing comparisons between old scans with knowledge of the patient's clinical condition at the time of each scan may be required.
• Direct measurement of intracranial pressure is possible but invasive and carries a risk of complication. It is not often required.
• The structure of the shunt can be examined using plain radiographs. Examination of a ventriculoperitoneal shunt requires radiographs of the skull, chest and abdomen. This series of radiographs is often referred to as a 'shunt series'. The wiring of the shunt can be inspected to look for cinks of breaks. Note that in some patients with severed tubing there is no evidence of shunt malfunction. This might be because a tract forms around the tubing allowing the diversion of CSF even in cases where tubing is severed.

Considering infection

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