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A 19-year-old woman with a history of hydrocephalus treated at age 2 weeks with a ventriculoperitoneal shunt, last revised at age 15, presented to the emergency department with 2 weeks of diffuse abdominal pain and increasing girth and 2 days of right frontal headache relieved by lying supine. She initially had nausea and vomiting, which resolved after several days, leaving her with anorexia. There had been no fever or change in her bowel movements. Her blood pressure was 101/58 mm Hg, and her neurological examination was normal.
An abdominal ultrasound examination showed extensive ascites and normal ovaries and uterus. Computed tomography revealed a cystic accumulation of fluid in the lower abdomen. Because of a slow irregular pulse, an electrocardiogram was recorded and showed sinus bradycardia and arrhythmia with occasional junctional escape complexes (Figure).
At craniotomy, the proximal catheter from the fourth ventricular Dandy-Walker cyst was found to be obstructed and was replaced. The distal catheter was then replaced. Postoperatively, the patient's abdominal pain resolved, and her headache decreased.
The Dandy-Walker deformity is a congenital malformation that occurs in approximately 1 in 20,000 newborns. Noncommunicating hydrocephalus is often part of the syndrome and is usually treated with ventriculoperitoneal shunting, as in this patient (1).
One hundred and fifteen years ago, Harvey Cushing, Dandy's and Walker's predecessor in neurosurgery at Johns Hopkins, described high blood pressure, bradycardia, and terminally a slow respiratory rate in patients with increased intracranial pressure (2). Although this patient may have had increased intracranial pressure, in the absence of high blood pressure this cannot be called Cushing's phenomenon. In fact, no definite abnormality is noted in the electrocardiogram shown here. Sinus bradycardia and arrhythmia with occasional junctional escape complexes are not rare in healthy young adults. Also, the T-wave inversion in leads V1 to V3 is fairly common in normal young women.