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1618 - Don’t miss the forest for the trees: A case of improved cognition following VPS adjustment

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

AP

Aliza M. Perez, DO

Resident Physician
The Mount Sinai Hospital- NYC
new york city, New York, United States

Co-Author(s)

LG

Luigi P. Gonzales, BS

Medical Student MS4
University of California, Irvine School of Medicine
Irvine, California, United States
KW

Kaitlyn Wilkey, DO

TBI Fellow
The Mount Sinai Hospital-NYC
New york city, New York, United States
MA

Megan Andrews, MD

Attending Physician
The Mount Sinai Hospital-NYC
new york city, New York, United States

Case Diagnosis: Right subdural hematoma

Case Description: A 72 year-old female with history of normal pressure hydrocephalus (NPH) status post ventriculoperitoneal shunt (VPS) placement experienced a fall and was admitted to the emergency department for altered mental status. Imaging showed a right subdural hematoma (SDH) with midline shift and dilated left ventricle. She underwent right craniotomy for SDH evacuation with adjustment of VPS Performance Level (P/L) from 1.5 to 2.5 and bilateral medial meningeal artery embolization. Patient was previously independent with her activities of daily living and functional mobility. During rehabilitation, significant decrease in processing speed and inattention was noted. Her husband described a similar episode years ago when her VPS was originally optimized. Her VPS P/L was adjusted back to her baseline of 1.5 leading to significant, immediate improvements in mental status and functional performance.

Discussions: NPH is a rare condition with prevalence ranging from 10 to 22 per 100,000. These patients are often admitted to acute rehabilitation due to functional and cognitive deficits. Typically, they present with headache, nausea/vomiting and significant changes in mental status, vision, motor strength, balance, and gait prior to requiring shunt adjustment. Clinicians should acknowledge the possibility that these patients may instead present with subtle, minor changes in cognition, which may be difficult to distinguish in the presence of additional neurological deficits. Neurosurgical consult for VPS adjustment should be considered in these types of patients and addressed prior to the addition of stimulants or other cognitive therapies.

Conclusions: Rehab physicians should be aware that minor changes in cognition can indicate the need for VPS adjustment, especially in patients that have been stable on the same setting for years. Prior to initiation of alternative treatment modalities, it is imperative for physiatrists to rule out or address the need for possible VPS adjustment in both the outpatient and inpatient setting.