SHUNT FAILURE Goals of Treatment Accurate identification of the pathology of a child in distress with a shunt versus other etiology CLINICAL PEARLS AND PITFALLS Clinicians depend heavily on radiographic imaging to evaluate for shunt malfunction The diagnosis may be challenging for even the most experienced clinician, especially in nonverbal patients Unfortunately, shunt malfunction is one of the most common clinical problems in pediatric neurosurgery Children with hydrocephalus, and a CSF shunt, often have significant neurologic abnormalities and developmental delays Symptoms are nonspecific making shunt obstruction a routine consideration in this patient population Moreover, the neurologic examination may be limited and unreliable in these patients Clinical Considerations Clinical Recognition Shunt malfunction can manifest with a multitude of acute or chronic signs and symptoms ( Table 122.1 ) The most notable signs and symptoms of shunt failure are nausea and vomiting (positive predictive value 79%), irritability (positive predictive value 78%), decreased level of consciousness (positive predictive value 100%), and a bulging fontanel (positive predictive value 92%)