Standing adjustment took most attention as it might cause serious overdrainage. Considering recovery, both standing and supine are equally important. The common supine adjustment is 5 cm H2O. It is considered by many that 5 is low enough. I am putting this question to doubt this.
Omer Elsabbagh Agreed. 5 cm H20 is considered favorable. However, this article might help understanding more Article Paradoxical response of intracranial pressure to shunt valve...
Thank you Dr Nida for referring me to the article of London active group of researchers. It shows that lowering adjustment can have a paradoxical effect. So we donot know what to do with our patients.
If CSF dynamics is a mystery, I can suggest they should work first on a homogeneous pathology. Do do you expect that CSF would behave the same in IH equal to NPH or Budd Chiari. CSF is really a mystery.
The second problem is the indicators: headache was denied as a comorbidity and I disagree this. The second is ICP: they did not mention their optimal target of adjustment.
Let us now return to the question. Why 5 was chosen? Why not 3 or 2 or zero. Many papers say that the lower the adjustment the better as long as it is safe.All agree that supine position is safe to be at zero. So shunt assistant adjusting standing position is enough and no need for for differential valve.
Tell us how do you adjust your patient (Your protocol)?
Did you lower adjustment and ICP came up unexpectedly?
Best regards,
Omer Elsabbagh I second your thoughts/opinion. I believe we need to do some serious research collaboration to come up with a definitive answer. It's a very valid point and well-questioned.
@Nida Fatima
Thanks for your answer. I hope other neurosurgeons will share this discussion and share their researches. After diagnosis and shunt implanatation, without optimal adjustment there would be no recovery. That is why you will find neurosurgeons who believe that there is no use of shunt surgery !
I think it is easier to have consensus on supine adjustment. For the standing adjustment new valves are helping neurosurgeons much now, but what is needed are sensitive objective indicators and I have suggestions.
@ Nida Fatima ,
I had proSA + proGAV implanted since 2013. On 2019 proSA was adjusted up to 17 from a lower number to deal with overdrainage. The target was 20, but proSA stopped working. ProGAV was zero but adjusting it to 3 was obligatory to come to 20. Since then I was symptomatic supine. Shunt changed on 9 May 2021. The preoperative MRI on April 2021 showed deterioration compared to MRI on May 2019. I have no other explanation of this deterioration except that of the 3 supine adjustment. Also durin 2019 - 2021 I had headaches supine and bad sleep. Now my supine is zero again with the new shunt. Repeat MRI after 1 year from now if showed improvement will confirm that proGAV adjustment to 3 during 2019 - 2021 was causing significant deterioration.
To be objective; the above MRI changes are related to a change from zero supine uo to 3. I do not know if this applies to adjusting supine to 5 from the start.
But research of course can give the answers.
I am not sure, but I feel that research protocols are not tailored enough to fit our target. Our target is recovery. To achieve this we need 3 things. All the three are essential. One missing will lead to failure to achieve our goal:
1 Brain should be emptied from accumulated CSF before adjustment starts. Before shunt implantation, this can be done through the 3 days drainage test. If shunt is already implanted, the only way is well calculated siphoning (controlled siphoning). This can be dangerous if not well controlled and calculated.
2 Supine adjustment: I hope consensus will agree the zero supine by all neurosurgeons. If research concludes variations and individuality among different patients, we will of course follow this.
3 Standing adjustment: we will start higher and come slowly down according to sensitive objective indicators. Research should concentrate on these indicators.
So successful outcome is expected if brain tissue (white and grey matters) are CSF free. Supine is Zero and standing is Optimal as proved by objective sensitive indicators. The net result would be CSF daily secreted should be equal to amount absorbed + excess amount drained by shunt.
Best regards,
@ Nida Fatima,
I donot want to be misunderstood; I am highly evaluating the works of London group as well as other hydrocephalus researchers. I feel deeply debted to them all.
Regarding your proposal for collaborative research: I suggested and declared openly long long before to all of them that I am ready to join any group to be closer to researchers and patients. My aims were to first to increase my understanding of current CSF knowledge. Second to be in contact with other patients without having clinical responsibility. The last is to watch the results of managements and incidents. Hopefully we might come up to sensitive and specific objective indicators through the three above.
Regarding shunts, I am not blaming industry and biomedical engineers. They are offering patients and clinicians updated good tools. I feel more related to clinicians; trying to motivate them for better outcomes.
The artcle you are referring to is putting more question marks. They say that on opening the valve in 40% of patients ICP rises up unexpectedly !! Their results complicate adjustment process. Here also the importance of ŕesearches on ventricular catheters. I will mention here the project of Marcelo Galarza as an example.
- Badges
- Science topic
- Similar topics
- Psychology