Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

suitable for surgery

1st line – ventriculoperitoneal shunting

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ONGOING
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suitable for surgery
1st line – 

ventriculoperitoneal shunting

Surgery should be considered in patients with a good response to any of the diagnostic cerebrospinal fluid (CSF) procedures, after an assessment of risks and benefits.

A catheter is placed into the lateral ventricle under general anaesthesia, usually via the non-dominant cerebral hemisphere, and the distal end placed in the peritoneal cavity via a line tunnelled under the skin. The valve is usually positioned behind the ear. A programmable shunt is used.

Common shunt complications include subdural haematoma, mechanical obstruction, and infection, and occur in about 22% of patients.[31] Shunt obstruction may cause a sudden change in walking function, but this may also be due to stroke or subdural haematoma. Obstruction more commonly causes a gradual return of symptoms present before surgery.

The adjustment of shunt valve pressure is contentious. In one double-blind randomised controlled trial, gradual lowering of the valve setting to pressures below 12 cm water was associated with significantly better outcomes (but increased risk of over-drainage) compared with fixed valve setting at a mean of 13 cm water.[31] However, another double-blind RCT failed to find a significant difference in clinical improvement between gradual reduction of the valve setting compared with a fixed valve setting of 12 cm water.[32]

Under-drainage of CSF may produce recurrence of symptoms and hearing loss. Chronic over-drainage of CSF can cause subdural haematoma, headache, and tinnitus. One study found that gravitational valves avoid one additional over-drainage complication in approximately every third patient, compared with other valve types.[33] One Cochrane review concluded that the use of flow-regulated or differential pressure-regulated valves did not influence the outcome of shunting in this condition.[34]

Shunt malfunction can often be managed by external adjustment of the valve settings; however, shunt revision is usually required, and approximately 75% of these patients will respond positively.[30]

Consider – control of cardiovascular risk factors

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suitable for surgery
Consider – 

control of cardiovascular risk factors

Additional treatment recommended for SOME patients in selected patient group

All patients should be offered treatment aimed at controlling their vascular risk factors, such as blood pressure control with antihypertensive drugs, smoking cessation, and cholesterol-lowering drugs. See Essential hypertension (Management approach), Smoking cessation (Management approach), and Hypercholesterolaemia (Management approach).

not suitable for surgery

1st line – control of cardiovascular risk factors

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ONGOING
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not suitable for surgery
1st line – 

control of cardiovascular risk factors

Patients who refuse surgery, or those who are unsuitable for surgery, should be offered treatment aimed at controlling their vascular risk factors, such as blood pressure control with antihypertensive drugs, smoking cessation, and cholesterol-lowering drugs. See Essential hypertension (Management approach), Smoking cessation (Management approach), and Hypercholesterolaemia (Management approach).

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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