31/01/2026
🧠 Hydrocephalus in leptomeningeal disease – Case : serial LPs → VP shunt
Middle-aged patient with advanced metastatic carcinoma and known CNS involvement, now presenting with a classic hydrocephalus symptom triad in evolution: headache + nausea + recurrent vomiting. No focal deficit, fully awake.
🧾 Key facts
MRI (baseline): new ependymal / intraventricular lesion along the lateral ventricle → concern for impaired CSF dynamics
CSF: malignant cells → leptomeningeal disease confirmed
CT (follow-up): ventriculomegaly consistent with hydrocephalus
Clinically: pressure symptoms progressing despite supportive measures
🖼️ Serial imaging (right → middle → left)
Right: initial MRI
Middle: interval CT with hydrocephalus
Left: postop CT control with ventricular catheter in typical position after diversion
🧠 What we did (and why)
We used lumbar drainage pragmatically as a test and as a bridge:
Two therapeutic LPs
After the first, the patient had credible, but short-lived improvement
Symptoms recurred quickly, and ventricles remained enlarged on repeat CT
Larger-volume drainage again gave only temporary relief
At that point the trajectory was clear: this wasn’t going to be managed with repeated punctures. We moved to definitive CSF diversion.
✅ Plan / Outcome
VP shunt placed (postop control shown)
Parallel discussion with oncology: whether there’s a real, actionable plan for intrathecal therapy (and therefore whether an Ommaya makes sense upfront) vs keeping it simple with shunt alone.
❓ Questions for the group
Do you use serial LP response as a “shunt test” in suspected LMD-hydrocephalus, or do you go straight to diversion once CT confirms ventriculomegaly + symptoms?
In your practice, when do you add an Ommaya upfront (vs later, if intrathecal treatment becomes realistic)?
Any pearls on managing shunts in LMD patients (valve choice, overdrainage avoidance, infection risk mitigation)?
