LAUSR

Prolonged disorders of consciousness (DOC) are considered to be amongst the most severe outcomes after acquired brain injury. Medical care for these patients is mainly focused on minimizing complications, since treatment options for patients with unresponsive wakefulness or minimal consciousness remain scarce. The complication rate in patients with DOC is high, both in the acute hospital setting as in the rehabilitation or long-term care phase. Hydrocephalus is one of these well-known complications and usually develops quickly following acute changes in cerebrospinal fluid (CSF) circulation after different types of brain damage. However, hydrocephalus may also develop with a significant delay, weeks or even months after the initial injury, reducing the potential for natural recovery of consciousness. In this phase, hydrocephalus is likely to be missed in DOC patients, since their limited behavioral responsiveness camouflages the classic signs of increased intracranial pressure or secondary normal-pressure hydrocephalus. Moreover, the development of late-onset hydrocephalus may exceed the period of regular outpatient follow-up. Several controversies remain about the diagnosis of clinical hydrocephalus in patients with ventricular enlargement after severe brain injury. In this article, we discuss both the difficulties in diagnosis and dilemmas in treatment of CSF disorders in patients with prolonged DOC and review evidence from the literature to advance an active surveillance protocol for the detection of this late, but treatable complication. Moreover, we advocate a low threshold for cerebrospinal fluid diversion when hydrocephalus is suspected, even months or years after brain injury.