I'm approaching this from a patient's point of view.  My 63 year old wife has had 12 shunt revisions in the last 4 years.  They did a one month follow up and told her to let her know if she has any further problem.  No other recommendations regarding diet, exercise, etc.  I had to do a lot of work and research on my own.

Dr. Dennis Woggon, DC

[email protected] - email

It is important to know patient age, etiology and other medical comobidities.

Under age 1, 3, 10 and adult, senil, management plan are different.

Routine folow up for any age, don't forget full length XP with abdominal Xp (for constaption) .

1, prevention of over and under drainage; obesity or weight loss needs adjustment change.

2,  treatment of brain function, improve development, not ventricular size.

3, risk of infection, epileptic seizure, etc. for patient and family education, management system in need.

Shunt insertion is  needed  in many circumstances (congenital hydrocephalus, with brain tumors where CSF pathway is interrupted, in some case after head injuries, also with some hemorrhagic brain insult and others conditions)and  in each case there is precautions and instructions.Also Follow up depends on  many factors as,age,,shunt indication ,intellectual performance.and it differes from group to group,  

In general infection, shunt malfunction and rejection are the main complications faced in shunt surgery

-To guard against over drainge, posture position is advice, avoid sudden uprising from rest, overobesisty and severe weight loss showed be looked

-avoiding brain damage is by proper timing of shunting , avoiding infection , family education of patient intellectuality pre and post shunt insertion and early reporting also by patient and family education about malfunction shunt signs and symptoms

-Physical and mental rehabilitations should immediately start as early as could be

insertion

For adult patients with normal pressure hydrocephalus for whom an optimal shunt adjustment has been achieved, ambulatory visits may be scheduled after 6 and 12 months postoperatively and then once yearly. During the visits, you may wish to pay special attention to headaches, if any, to wound integrity, fluid collections along the shunt, meningism and fevers. By taking a thorough history and by simple positioning tests, you may be able to clinically differentiate between symptoms related to overdrainage, underdrainage or non-specific origin. The patient should be educated about the rationale of your questions and tests to acquire some competence in self-monitoring in-between visits. CT scanning and abdominal ultrasound may be helpful to confirm or rule out a clinical suspicion of malfunction but may not be necessary on a routine basis. This is different for pediatric patients where an MRI should be scheduled to detect a potential relative "shortening" of the ventricular catheter in time to schedule elective replacement, if necessary. Potentially the most important technical means to avoid overdrainage is the selection of the valve, which should be gravity-assisted for this purpose and accompanied by a so-called shunt assistant.

For adults with non-normal pressure hydrocephalus, different rules may apply depending on the underlying cause (e.g., more frequent surveillance with tumor-related hydrocephalus etc.).

As far a rehabilitation, the need for this may vary widely and should be individually assessed and addressed. Finally, if deemed necessary, rehabilitation should not be delayed.

Kind regards,

Marc

I am happy to have a variety of good answers.

Dr. Dennis, What are the results of your own research to help your wife? What was the medical indication to insert a shunt and do you accept the hard 12 revisions over 4 years? You must got insights regarding your wife management? Do you think she got optimal adjustment?

Dr. Satoko; I liked your defining of answer according to age, etiology and co-morbidites. Suppose you have an adult with NPH or IH, do you have clear indicators to know that your patient is optimal? What are the tests you are doing in case you suspected over or under drainage. How often do you see your patient?

I would comment on Drs Raef and Marc separately.

Many thanks and best regards

Thank you for your comments.

Depending on the pre-shunt examination,such as tap test, CT,or MRI, you will estimate how much volume of CSF is needed to drain.

Routine follow up, 1,3,6 month after shunt followed by 2 times /year, and

headache, vomitting, or seizure, unreasonable fever of unknown orign,

it would better to check CT and shunt line.Xp.

In each programmable shunt system, patient hight and weight will lead recomendable setting using table.(ref.)

For under drainage, improvement of symptoms, such as gait, mental state or incontinece. would give suggestion. If tap test was positive.

My wife had viral meningitis 4 years ago.  There was a blockage between the 3rd and 4th ventricle so lumbar punctures were normal.   It took them a week to figure it out and she almost died.  Since then, the shunt to the brain became clogged a few times,  the shunt was exposed twice, drainage changed from the pleura to abdominal resulted in a buildup of scsf and required a thoracotomy to drain a gallon, then she got an infection in the hospital which resulted in bacterial meningitis. I had her checked for inflammatory foods and put her on a diet and exercise with nutritional supplements.  She now has short term memory loss but is doing fine.

Dear, Dennis Alan Woggon you have written

It took them a week to figure it out and she almost died. So how this question in your mind why not you asked this question to Senior professor in Neuro Surgery. Now you realizing or asking this question for the sake of the knowledge let me know.Second may read bacterial meningitis,Neurocystecercusis, thoracotomy to drain a gallon and how to put shunt to the brain. You naturally realize how it effects to CNS.Kindly referred to my teacher and now Director. Professor. Ashok K Mohapatra written by A text book of Neurosurgery. In my knowledge take guidelines from him. I am sure your problem be short out easily.

Dr. Satoko, I like your answer. Some neurosurgeons are doing the tap test by draining some CSF (like 50 ml). Calculating the amount of CSF before shunting is a key point for better result. So you are a neurosurgeon who supports siphoning which is needed in many patients to squeeze out the brain from accumulated CSF, and to be followed by a draining shunt to drain out an amount of CSF equal to the amount produced daily. The first step (siphoning) is the curing step and the second step (a well balanced shunt) is the maintaining step which prevents a relapse (under drainage) or complications (over drainage).

I see only one problem in your follow up plan: (1,3,6 month follow up visits). I got a paper telling that over drainage can happen at 11 months.

What are your precautions to avoid over drainage and what are your clinical indicators to come to safe optimal.

My second question is, what are your research ambitions for your patients: to be satisfied with above optimal for safety reasons or to achieve optimal safely?

Many thanks

Thank you for your reply.

1, my plan of follow uo is, 1,3,6 month and every 6month. ie 1~2/yr. for long. Befoer 11 months, there might be signs of over drainage, and you can check.

2, I thing any symptoms of overdrainage, such as headace afternoon, on sitting position, etc.postural headache or radiological signs of subdural space will lead the diagnoisis, in cases of needs.Better to prevent  overdrainage, rather than underdrainage, because slit like ventricle is difficult problem. Shunt with antisiphon system helps to avoid overdraiage. Not to move setting too often, is one adviee to young neurosurgon.

3, In child hydrocephalus patients, I used to check EEG and MEG, before and after treatment, which I had presented international hydrocepahlus conference.

Best wishes, and hoping it could make any help for your patients.

S.O

Dr. Raef, Thank you very much for your good answer. I made a mistake in my question not specifying the reason of shunting. I apologize for this.

1)For your NPH or IH patients, do you achieve good maintainable results? What is your method in the 3 days drainage test before shunting?

2) Could you kindly comment on my above questions to Dr. Satoko?

Dr. Marc, Thanks too much for your good answer.

1) Could you  kindly be more generous by referring me to the details of:

a thorough history and by simple positioning tests, you may be able to clinically differentiate between symptoms related to overdrainage, underdrainage or non-specific origin.

2) Could you comment on my above questions to Dr. Satoko?

3) In your rehabilitation plan: do you prescribe any psychotropic drugs? What?

4) What is your opinion in giving cerebrolysin in hydrocephalus?

Dr. Dennis, My simple impression is that the 12 revisions are justified because of infection and as you mentioned the final result is fairly very good. You have to discuss the disagreements of Dr. Barik very openly with him, as you might got important lights for future management of you wife. I hope the best for her. Please follow the advice of Dr. Marc regarding early rehabilitation and you can ask the sharing neurosurgeons more comments about her case. Finally I have to raise my cap to you with respect for your sincere care of your sick wife.

Many thanks to all.

Thank you Omar,

I agree the revisions were necessary.

I'm not finding much on on rehab and prevention and follow up plans.

We will wait for sharing neurosurgeons comments and I will search the internet and email you.

My best wishes

My answers to your questions, Dr. Elsabbagh:

If the patients wakes up with headaches in the morning and these improve after getting up and moving around, this may indicate relative underdrainage during nighttime.

If the patients wakes up without headaches and these develop after getting up and moving around, this may indicate relative overdrainage during daytime.

Not rarely, you will be able to corroborate the anamnestic information during ambulatory visits using positional changes (between lying flat and standing upright and vice versa) and asking the patient about the evolution of headaches (observe for a sufficient period of time, e.g, up to 15 minutes).

If headaches occur in a random fashion unrelated to postural position, they may be non-shunt-related (exceptions still apply).

Precautions to avoid overdrainage should primarily be technical (I already mentioned gravity-assisted valves with shunt assistant) and not mainly be targeted at the patient’s behavior. Ideally, the patient should be encouraged to do whatever he or she likes in everyday life, and the shunt system should perform to allow exactly that.

I would tentatively define optimal shunt function by subjective and externally confirmed well-being and absence of the above clinical symptoms as well as absence of radiological signs of under- and overdrainage (this definition certainly also includes absence of meningitis/encephalitis/ventriculitis).

I never prescribe psychotropic drugs for hydrocephalus per se, only in select cases for defined and confirmed psychiatric symptoms. Along these lines, I do not prescribe cerebrolysin for hydrocephalus.

The question of how often to see a patient with a shunt is an interesting one. Even with 3- or 6-months intervals, the patient needs to be educated about self-assessment and encouraged to visit the office if in doubt, and if that understanding is established, 12-months intervals may be sufficient after the first year has passed.

To Professor Satoko and Professor Marc,

I am impressed by your answers and your positive attitudes towards my questions.

This is encouraging me to ask both of you to try to help me to get a job as a researcher in this field. I need:

1) To have contact with hydrocephalus patients without clinical responsibility.

2) To update my knowledge in CSF and hydrocephalus.

3) I hope that the above 2 combined with my unique experience of passing through 15 CSF levels can give clues which can help to improve management of hydrocephalus. I think all agree that there are important chances to improve diagnosis and treatment of this potentially curable condition.

My specific points for research would be:

1) Improving fine tuning of valve and finding a sensitive indicator to do it effectively and safely.

2) Better description of intracranial hypertension and earlier diagnosis.

I recognize very well that it is an odd request because of my age. I tried to kick this  idea out of my mind, but I failed. My experience led me to know like many others that CSF secrets are still uncovered.

Kindly take a look at my profile and tell me if my request is possible or not.

Best regards and many thanks,

Omer

Dear Omer:

I have no immediate idea in terms of how to accomodate your request. You may wish to have a look at https://www.srhsb.com/ and contact them for suggestions.

Good luck!

Marc

 Could you post your CV and I will contact hospitals in my area!

Thank you too much Professor Marc. You were very generous with me by adding precious answers to my questions.

My best wishes and many thanks,

Omer