How should I manage a patient with hydrocephalus who presents with acute symptoms?

Management of a patient with acute hydrocephalus presenting with acute symptoms should focus on prompt diagnosis and urgent intervention to prevent neurological deterioration.

Diagnosis should be based on clinical symptoms and signs combined with comparison of current and previous brain imaging, typically CT scans, to confirm acute hydrocephalus NICE NG228.

For patients showing neurological deterioration due to acute hydrocephalus, consider urgent cerebrospinal fluid (CSF) drainage or diversion to relieve raised intracranial pressure and prevent further damage NICE NG228.

Temporary CSF drainage can be used as an initial measure to stabilize the patient and assess response, especially if the need for permanent diversion is uncertain NICE NG228.

In cases where hydrocephalus is related to underlying causes such as subarachnoid haemorrhage, multidisciplinary discussion involving neurosurgeons and interventional neuroradiologists is essential to address both the hydrocephalus and the primary pathology NICE NG228.

Recent literature highlights the importance of recognizing acute low-pressure hydrocephalus, a variant where symptoms occur despite low CSF pressure, which may require tailored management strategies including careful CSF drainage and monitoring Keough et al. 2021.

Post-intervention, close neurological monitoring is critical to detect any deterioration or complications, and follow-up imaging should be considered to evaluate treatment efficacy and guide further management NICE NG228; Janjua et al. 2017.

Overall, the priority is rapid identification and intervention with CSF drainage or diversion in acute symptomatic hydrocephalus, supported by multidisciplinary care and ongoing monitoring to optimize outcomes NICE NG228; Keough et al. 2021; Janjua et al. 2017.