For professionals

Abstract

Long-term disorders of consciousness (DOC) are considered to be one of the most serious consequences after acquired brain injury. Medical care for these patients is primarily focused on minimizing complications, as treatment options for patients with unresponsive vigilance or minimal awareness remain scarce. The complication rate in patients with DOC is high, both in the acute hospital setting and in the rehabilitation or long-term care phase. Hydrocephalus is one of these known complications and usually develops rapidly after acute changes in cerebrospinal fluid (CSF) circulation after various types of brain damage.

However, hydrocephalus can also develop with a significant delay, weeks or even months after the initial injury, reducing the chances of natural consciousness recovery. In this phase, hydrocephalus is likely to be missed in DOC patients as their limited behavioral responsiveness camouflages the classic signs of increased intracranial pressure or secondary normal pressure hydrocephalus.

In addition, the development of late-onset hydrocephalus may exceed the period of regular outpatient follow-up. Several controversies remain regarding the diagnosis of clinical hydrocephalus in patients with ventricular enlargement after severe brain injury. In this article, we will discuss both the difficulties in diagnosis and the dilemmas in the treatment of CSF disorders in patients with long-term DOC and review evidence from the literature to promote an active surveillance protocol for the detection of this late, but treatable complication. In addition, we advocate for a low threshold for CSF diversion when hydrocephalus is suspected, even months or years after brain injury.

Keywords
cerebrospinal fluid disorders, disorders of consciousness, secondary normal pressure hydrocephalus, traumatic brain injury, ventriculoperitoneal shunt