Critical shunt-induced subdural hematoma treated with combined pressure-programmable valve implantation and endoscopic third ventriculostomy

The authors present 2 patients with VP shunt-induced subdural hematomas (SD H) treated with pressure-programmable valve implantation and endoscopic thi rd ventriculostomies (TV). The first patient is an 11-year-old girl who dev eloped a shunt-induced SDH, Revision of the shunt valve with a higher-press ure valve resulted in a prolonged deterioration of her consciousness. Exter nal ventricular drainage at low pressure led to clinical improvement. A pre ssure-programmable valve set at 50 mm H2O was implanted, and the pressure g radually increased. At a pressure of 120 mm H2O symptoms recurred, even tho ugh the subdural collection was beginning to decrease in size. An endoscopi c TV was performed, and the valve pressure was then increased to 200 mm H2O without any neurological symptoms. The second patient, a 7-year-old boy wi th shunt-induced SDH, had recurrent SDH, even after shunt revision with pla cement of a higher-pressure valve, which resulted in prolonged lethargy. A pressure-programmable valve was implanted with concurrent endoscopic TV Gra dual valve pressure increases up to 200 mm H2O could be performed without r ecurrent symptoms, Eventually, the shunt system was ligated to resolve resi dual positional headache, and the Tl has been patent for more than 3 years. In both patients, the pressure-programmable valve was useful, since the op timal CSF drainage pressure changed during the period of recovery from symp tomatic subdural collections. Concurrent TV appeared to enable increasing t he valve pressure gradually without any neurological symptoms. The advantag es of this combined approach are discussed. Copyright (C) 2000 S.Karger AG, Basel.