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PubMed This is a summary of 23 peer-reviewed journal articles Updated
Neurosurgery

Neurologic Emergencies and Red Flags

At a Glance

For people with spina bifida, repeated vomiting, extreme drowsiness, breathing or swallowing problems, new weakness, or sudden bladder or bowel changes need urgent evaluation. A normal MRI or CT does not always rule out VP shunt failure.

Living with spina bifida means becoming an expert on what is “normal” for you or your child. While not everyone with spina bifida has a shunt, an open lesion, or a Chiari II malformation, certain changes require immediate medical attention to prevent serious complications. This page outlines the specific “red flags” that should prompt a call to your neurosurgery team or a trip to the emergency room.

VP Shunt Malfunction and Infection

For those with a Ventriculoperitoneal (VP) Shunt, shunt failure is a medical emergency.

Symptoms of Malfunction

The signs of a shunt not draining correctly can vary by age [1]:

  • In Infants: A bulging soft spot (fontanelle), extreme irritability, “sunsetting” eyes (eyes always looking down), or a rapidly increasing head size [1][2].
  • In Children and Adults: Severe headache, repeated vomiting (not just once), unusual drowsiness or trouble waking up, personality changes, or new vision problems [1][3].

The “Stable MRI” Trap

One of the most critical facts to remember is that shunt failure can occur even if an MRI or CT scan looks normal [4]. In many people with spina bifida, the brain’s ventricles do not enlarge much when a shunt fails (this is called minimal ventricular change) [5][6].

  • Action: If you or your child are showing clear signs of shunt failure (like repeated vomiting and extreme lethargy), do not let a “normal” scan reassure you. Call emergency services or go to the emergency department immediately, tell the staff about the shunt and baseline symptoms, and ask them to consult neurosurgery [4][2].

Symptoms of Infection

An infected shunt usually requires hospital admission and antibiotics [7]. Watch for:

  • Fever or redness and swelling along the “tract” (the path of the tube under the skin) [8].
  • New abdominal pain or tenderness (since the shunt drains into the belly) [9][10].

Chiari II Malformation: Brainstem Signs

Almost everyone with myelomeningocele has a Chiari II malformation, where the lower part of the brain is positioned lower than usual [11]. While many have no symptoms, some develop life-threatening brainstem dysfunction [12].

Call 911 or Seek Emergency Care Immediately for:

  • Stridor: A high-pitched, noisy sound when breathing in [12][13].
  • Apnea: Pauses in breathing, especially during sleep [13][14].
  • Dysphagia: Severe difficulty swallowing, choking on food/liquids, or a weak, “breathy” cry [15][16].
  • Unresponsiveness, Severe Breathing Difficulty, or Blue Skin: Immediate intervention is required [2].

Symptomatic Tethered Cord

As discussed on previous pages, a tethered cord occurs when the spinal cord is “stuck” to the surrounding tissue. While many people have a tethered cord on an MRI, doctors only treat it if it becomes symptomatic (clinically active) [17][18].

Watch for a progressive decline—meaning a slow but steady worsening over weeks or months [19]—or sudden acute changes:

  • Walking: A child who used to walk well starts tripping, falling, or needing a wheelchair more often [2][20].
  • Strength: New weakness in the legs or feet that wasn’t there before [19].
  • Bladder/Bowel: A child who was potty-trained starts having frequent accidents, or a person using catheters finds they can no longer stay dry between sessions [17][21].
  • Pain: New, persistent back or leg pain that is not related to an injury [22].

If you notice these progressive changes, schedule a prompt evaluation with your neurosurgeon and urologist. Early “release” of the tethered cord may stabilize or improve selected progressive symptoms, but outcomes are not guaranteed and observation versus surgery must be discussed individually [18][23]. Sudden new weakness or abrupt loss of bowel/bladder control is an emergency.

Summary of Emergency Indicators

System Seek Emergency Care If You See:
Brain/Shunt Repeated vomiting, extreme drowsiness, bulging fontanelle, sunsetting eyes.
Breathing High-pitched breathing sounds (stridor), long pauses in breathing (apnea), blue tint to skin.
Swallowing Constant choking or inability to swallow saliva or liquids (dysphagia).
Spinal Cord Sudden new weakness, abrupt inability to urinate, or sudden loss of bowel control.
Infection Fever combined with redness or a “puffy” look over the shunt tubing.

Common questions in this guide

What symptoms can mean a VP shunt is failing in spina bifida?
Repeated vomiting, severe headache, unusual sleepiness or difficulty waking, personality changes, or new vision problems can signal that a VP shunt is not working properly. In infants, warning signs include a bulging soft spot, extreme irritability, eyes that look downward, or rapidly increasing head size. Seek emergency care and tell staff about the shunt.
Can a VP shunt fail even when an MRI or CT looks normal?
Yes. In some people with spina bifida, the brain’s fluid spaces do not enlarge much when a shunt fails, so a scan may look unchanged. Strong symptoms such as repeated vomiting or extreme drowsiness still require immediate emergency assessment and neurosurgical consultation.
What are emergency signs of Chiari II brainstem problems?
High-pitched noisy breathing, pauses in breathing, severe trouble swallowing, choking, a weak or breathy cry, blue skin, severe breathing difficulty, or unresponsiveness are emergency signs. Call emergency services or seek emergency care immediately.
When do changes from a tethered spinal cord need urgent evaluation?
A gradual decline in walking, new leg or foot weakness, worsening bladder or bowel accidents, or persistent back or leg pain should prompt evaluation by neurosurgery and urology. Sudden new weakness or abrupt loss of bowel or bladder control is an emergency. Observation and cord-release surgery are considered individually.
How can I recognize an infection involving a VP shunt?
Fever, redness or swelling along the tubing under the skin, or new abdominal pain or tenderness can indicate a shunt infection. A suspected infected shunt usually requires hospital care and antibiotics. Seek medical attention promptly rather than waiting for symptoms to worsen.
What should I tell the emergency department if I suspect shunt failure?
Tell staff that the person has a VP shunt, describe the symptoms and when they started, and explain what is normal for that person. Mention relevant baseline symptoms and ask the emergency team to involve neurosurgery, especially if severe symptoms continue despite a normal scan.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Is my child showing any of the high-risk 'brainstem' signs of Chiari II, such as stridor or apnea?
  2. 2.If we come to the ER with symptoms of a shunt failure, what information should we provide the staff to ensure a neurosurgical consult is placed?
  3. 3.What is our baseline 'normal' for walking and bladder control so we can accurately spot a progressive decline?
  4. 4.Do we have a direct way to contact the neurosurgery team if we suspect a shunt malfunction after hours?
  5. 5.If my child has a positive urine culture but no fever or change in behavior, is that considered a red flag or asymptomatic bacteriuria?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (23)
  1. 1

    [Semiology of ventriculoperitoneal shunting dysfunction in children - a review].

    Neiter E, Guarneri C, Pretat PH, et al.

    Neuro-Chirurgie 2016; (62(1)):53-9.

    PMID: 26657112
  2. 2

    Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons.

    Alford EN, Hopson BD, Safyanov F, et al.

    Journal of neurosurgery. Pediatrics 2019; (24(5)):539-548 doi:10.3171/2019.5.PEDS18738.

    PMID: 31470398
  3. 3

    Ultra-late cerebrospinal fluid shunt malfunction following an extended interval of regular follow-up: a case series.

    Suzuki H, Sasao A, Sakashita K, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2026; (42(1)).

    PMID: 41949615
  4. 4

    Hydrocephalus in Spina Bifida.

    Blount JP, Maleknia P, Hopson BD, et al.

    Neurology India 2021; (69(Supplement)):S367-S371 doi:10.4103/0028-3886.332247.

    PMID: 35102990
  5. 5

    Prevalence and characteristics of shunt malfunction without ventricular size change at King Abdulaziz Medical City in Riyadh.

    Albugami SM, Alwadi KW, Alrugaib AK, et al.

    Neurosciences (Riyadh, Saudi Arabia) 2021; (26(1)):31-35 doi:10.17712/nsj.2021.1.20200099.

    PMID: 33530041
  6. 6

    The Neuroimaging Studies in Children with Ventriculoperitoneal Shunt Complications: A 10 Years Descriptive Sudy in Tehran.

    Shahi MV, Noorbakhsh S, Zarrabi V, et al.

    The open neuroimaging journal 2018; (12()):1-9 doi:10.2174/1874440001812010001.

    PMID: 29541279
  7. 7

    Clinical Characteristics and Treatment of Early and Delayed Intra-Ccranial Infection After Ventriculoperitoneal Shunt in Adults: Retrospective Analysis of Nineteen Cases.

    Wang HQ, Han P, Huang QB, Zhang ZL

    Surgical infections 2023; (24(1)):66-74 doi:10.1089/sur.2022.269.

    PMID: 36580653
  8. 8

    Distinct Clinical Phenotypes of Infection and Mechanical Dysfunction in Ventriculoperitoneal Shunt Complications.

    Sener H, Durmuş YE, Çokluk C

    Cureus 2026; (18(2)):e103824 doi:10.7759/cureus.103824.

    PMID: 41727797
  9. 9

    A giant monocular intra-abdominal CSF pseudocyst mimicking mesenteric cyst in a shunted child with spina bifida and hydrocephalus: A case report of diagnostic challenge and surgical management.

    Shadrack M, Ali SJ, Rwamuyagaza NS, et al.

    International journal of surgery case reports 2025; (133()):111678 doi:10.1016/j.ijscr.2025.111678.

    PMID: 40674964
  10. 10

    Abdominal complications in patients with a ventriculoperitoneal shunt: proposal for management recommendations from a single pediatric tertiary center.

    Basilotta Márquez YNI, Mengide JP, Liñares JM, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2021; (37(7)):2223-2232 doi:10.1007/s00381-021-05121-y.

    PMID: 33751170
  11. 11

    Impact of surgical timing and concomitant anomalies on neonatal meningomyelocele outcomes: a single-center experience.

    Türk Ç, Çamlar M, Sevgi UT, et al.

    Neurosurgical review 2025; (48(1)):374.

    PMID: 40258966
  12. 12

    Predictors of mortality in children with myelomeningocele and symptomatic Chiari type II malformation.

    McDowell MM, Blatt JE, Deibert CP, et al.

    Journal of neurosurgery. Pediatrics 2018; (21(6)):587-596.

    PMID: 29570035
  13. 13

    [Respiratory complications in children with Chiari malformation type II associated with myelomeningocele].

    Mizuguchi K, Morota N, Kubota M

    No to hattatsu = Brain and development 2016; (48(1)):25-8.

    PMID: 27012106
  14. 14

    Sleep-disordered breathing in patients with Chiari malformation type II: a case-control study and review of the literature.

    Lazzareschi I, Curatola A, Massimi L, et al.

    Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2022; (18(9)):2143-2154 doi:10.5664/jcsm.10062.

    PMID: 35645039
  15. 15

    Significant brainstem dysfunction in neonates with myelomeningoceles: a comparison of prenatal versus postnatal closure.

    Grabb PA, Vlastos EJ, Lundy PA, Partington MB

    Journal of neurosurgery. Pediatrics 2022; (29(5)):497-503 doi:10.3171/2021.12.PEDS21430.

    PMID: 35120322
  16. 16

    Prenatal repair of myelomeningocele is associated with lower need for long-term feeding support.

    Healy J, Liu C, Ehrlich S, et al.

    Journal of perinatology : official journal of the California Perinatal Association 2026; (46(3)):437-444 doi:10.1038/s41372-025-02356-4.

    PMID: 40702155
  17. 17

    The incidence and effect of tethered cord release for tethered cord syndrome in patients with myelomeningocele: a population-based study.

    Borgstedt-Bakke JH, Wichmann TO, Gudmundsdottir G, Rasmussen MM

    Journal of neurosurgery. Pediatrics 2020; (26(3)):269-274.

    PMID: 32470933
  18. 18

    Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society.

    Tuite GF, Thompson DNP, Austin PF, Bauer SB

    Neurourology and urodynamics 2018; (37(3)):890-903 doi:10.1002/nau.23382.

    PMID: 28792087
  19. 19

    Tethered cord syndrome and pediatric scoliosis: workup, natural history, and surgical timing.

    Song J, Huang P, Shah SA

    Spine deformity 2026; doi:10.1007/s43390-026-01487-8.

    PMID: 42334741
  20. 20

    Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Management of Patients With Myelomeningocele: Whether Prenatal or Postnatal Closure Affects Future Ambulatory Status.

    Bauer DF, Beier AD, Nikas DC, et al.

    Neurosurgery 2019; (85(3)):E409-E411 doi:10.1093/neuros/nyz263.

    PMID: 31418040
  21. 21

    Recurrent tethered cord: outcome and follow-up of 20 de-thetering for symptomatic spina bifida: choort study.

    de Almeida VC, Leite MTC, Dastoli PA, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2024; (40(11)):3703-3708 doi:10.1007/s00381-024-06537-y.

    PMID: 39017694
  22. 22

    Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Meta-Analysis.

    O'Connor KP, Smitherman AD, Milton CK, et al.

    World neurosurgery 2020; (137()):e221-e241 doi:10.1016/j.wneu.2020.01.131.

    PMID: 32001403
  23. 23

    Multidisciplinary Management of Tethered Spinal Cord Syndrome in Children: Operationalizing an Outpatient Patient-Centered Workflow.

    Behbahani M, Shlobin N, Rosen C, et al.

    Journal of multidisciplinary healthcare 2020; (13()):1283-1290 doi:10.2147/JMDH.S274296.

    PMID: 33149598

This page is for informational purposes only and does not constitute medical advice. If severe symptoms occur, call emergency services; contact your neurosurgery team for individualized guidance about less urgent changes.

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