Pneumocephalus Following VP Shunt Placement Secondary to Normal Pressure Hydrocephalus: A Case Report

Case Diagnosis: Pneumocephalus following VP shunt placement secondary to normal pressure hydrocephalus

Case Description or Program Description: A 77 year old male with a pertinent past medical history of normal pressure hydrocephalus (NPH) status post ventriculoperitoneal (VP) shunt placement was admitted to inpatient rehabilitation following VP shunt placement. He initially presented to a neurologist with complaints of imbalance secondary to NPH refractory to two large volume spinal taps. His condition worsened and he was referred to neurosurgery for placement of a right paraoccipital VP shunt. At recent baseline, the patient was wheelchair bound with no ambulation for the prior few months. Following shunt placement, the patient’s condition further worsened and CT head revealed bifrontal pneumocephalus with mass effect on the underlying brain. The patient was started on alternating oxygen therapy and his shunt was functionally turned off. Repeat imaging showed a decrease in pneumocephalus and acute rehabilitation was consulted. While admitted to inpatient rehab, the patient progressed well. Repeat CT Head was obtained on day 8 of rehab admission due to declines in physical and cognitive status, which demonstrated resolution of pneumocephalus. The rehab course was complicated by a urinary tract infection treated with antibiotics. The patient was discharged back to his assisted living facility on rehab day 15.

Setting: Inpatient Rehabilitation

Assessment/Results: On admission, the patient required moderate assistance with activities of daily living (ADLs) and an Eva walker with moderate to minimal assistance. On discharge, the patient improved to minimal assistance with ADLs and walked at contact-guard level with a front-wheeled walker.

Discussion (relevance): This is the first reported case, to our knowledge, detailing the rehabilitation course of pneumocephalus, a rare complication of VP shunt placement.

Conclusions: Providers must be aware of VP shunt placement complications such as over-shunting, under-shunting, and more rarely, pneumocephalus with a low threshold for imaging when the rehabilitation course becomes variable.