A 12 yo F w/ past medical history of partial complex seizures and congenital hydrocephalus s/p VP shunt (last revised 2 years ago)- presents w/ to the ED with headaches. Per parents, she has been complaining of headaches x 3 days. They have been giving her Tyelnol, which improves her symptoms for a few hours only. Today she had 2 episodes of vomiting. A shunt series is obtained. What's the diagnosis?  (scroll down for answer)

Answer: disconnected VP shunt

• Ventriculoperitoneal shunt basics
• Proximal catheter (in lateral ventricle), valve, reservoir, distal catheter (ends in peritoneal cavity)
• Shunt drains CSF when the pressure in the ventricles is greater than a set presure controlled by the valve
• Ask patients/families about initial shunt placement/history of shunt revisions!
• Complications can be divided into 3 categories
• 1. Mechanical Failure: obstruction of drainage, break/disconnection of shunt, migration of shunt out of ventricle or peritoneum
• shunt series are most used to assess for disconnections/fractures of the shunt
• in the patient case above, a disconnection occurred, likely due to a recent growth spurt (in children, normal growth commonly leads to disconnections or migrations)
• 2. Infection: 90% of shunt infections occur in first 6 months
• 3. Functional failure: overdrainage of CSF or failure of peritoneum to absorb CSF
• Impairment in CSF circulation --> hydrocephalus -->  increased ICP
• Symptoms include headache, nausea/vomiting, change in mental status
• In young children the symptoms may be nonspecific and include irritability, poor PO intake
• Check fontanelles in babies

References:  Bober J, Rochlin J, Marneni S. Ventriculoperitoneal Shunt Complications In Children: An Evidence-Based Approach To Emergency Department Management. Pediatric Emergency Medicine Practice. February 2016:1-24.