For about two weeks this month I had elevated pressure in my forehead and nausea from the shunt adjusting itself as it does at times. I also had a headache in the back of my head from the chiari malformation in addition to pain behind both eyes. Medication reduced some of the pain and then it just returned again. It's for this reason why I don't bother with pain medication unless it's really making me uncomfortable.
Let's continue reading about my shunt revisions leading up to 2014:
In out last exciting adventure, I had surgery in 2009 after my shunt became obstructed weeks before I was to graduate with a Master's in Art Education. I started seeing Dr. I at a different hospital since Dr. RH never returned my multiple phone calls after I had experienced concerning complications post surgery. My shunt had been moved to the opposite side of my brain and I almost died. I didn't know at the time the shunt was on the wrong side of brain.
The morning of February 16, 2011 my shunt became obstructed. The night before I had felt a pain behind my right ear which I had never experienced before and I didn't suspect anything. The morning of 2/16/11 I was unable to walk and I was vomiting everywhere. I couldn't lift up my head because of intracranial pressure. I went to the emergency room for another shunt revision surgery:
Preoperative Diagnosis: VP Shunt Malfunction
Postoperative Diagnosis: Same as above.
Operation: Exploration of VP shunt and placement of new left ventricular catheter and new medium pressure valve.
Anesthesia: General Anesthesia
Estimated blood loss: 20 cc
Specimen: Old ventricular catheter and old medium pressure valve sent to lab
Counts: All sponge, needle and instrument counts for this were correct.
Complications: None.
Findings:
Indications:
The patient is a 29 year old female who had intraventricular hemorrhage at birth and was premature. The patient had a VP shunt placed after birth. The patient has had multiple VP Shunt revisions. The last revision was done approximately two years ago.
The patient came to the ER and a CT scan showed that the ventricular system was enlarged compared to the previous rapid MRI done in March 2010. The patient also had a shunt series which showed that the shunt was intake. I had a shunt tap done at that time. ( this is when they insert a needle inside the top of the shunt is to determine how CSF is flowing. I've had these done before like in 1992 when I had a partial revision in the summer.)
The patient had a shunt tap done and there was very poor proximal flow seen. CSF was sent to the lab for routine gloucose, cell count and gran stain culture. The patient was preoped and taken to the operating room for VP shunt revision.
Procedure:
The patient was brought to the operating room and placed under general anesthesia. Once the patient was intubated and sedated all the appropriate lines were placed. Patient's head was placed in a horsehoe head holder. The head was turned to the right. The hair was clipped with a hair clipper. The patient was known to have a left ventricular catheter and the ventricular catheter crossed midline to the right of the frontal valve. The distal catheter ran down the right side into the peritoneal cavity. The patient was prepped out for an entire VP shunt revision. (This refers to a full revision, like the one I had in 1993).
The head was turned to the right and alcohol and Chloraprep were used to clean the skin. We planned to use the two scalp incisions, one on the right and one on the left. We also planned to use the previous abdominal incision if necessary. Chloraprep was used to prepare for the final incisions.
The drapes were placed in the usual sterile fashion. Once the drapes were on, the head midline. We used a scalpel blade to open the two scalp incisions. The Bovie cautery was used to dissect down to the skull.
The tissue was quite adherent and scarred. We irrigated thoroughly with antibiotic irrigation. We placed two self-retaining retractors to gain exposure to the proximal ventricular catheter as well as the valve. We cut the proximal catheter at the left sided incision and saw that we had very poor proximal CSF flow. We therefore diagnosed a proximal shunt obstruction. We clamped off the proximal catheter. The fluid column ran very poorly through the valve and distal catheter. We then cut the distal catheter at the right scalp incision. We discarded the valve at that point. Then we connected the manometer to the distal catheter with no valve. The fluid column ran down fairly well and therefore the distal catheter was working.
We irrigated copiously with irrigation. We connected a new medium pressure vale to the distal catheter We secured it with a 2-0 silk tie. We then removed the proximal ventricular catheter. It was slightly difficult to remove so we passed a stylette first through the old ventricular catheter. we coagulated the stylette with the Bovie catuery and gently removed the ventricular catheter. Once it was removed we passed a new antibiotic coated ventricular catheter in a similar trajectory but we used a stylette and aimed slightly more medial. We saw good clear CSF proximal flow. The catheter was then tunneled from the left scalp incision to the right scalp incision. The new ventricular catheter was cut to the appropriate length so it could be connected to the new valve. It was also secured with a 2-0 silk tie.
We then took a 25 gauge needle and inserted it into the reservoir of the valve. We had good proximal flow. We then irrigated again with antibiotic irrigation.
We closed the two scalp incisions with 2-0 Vicryl suture. We closed the skin with 3-0 Monocryl. We placed the antibiotic ointment and Telfa over the incisions. We placed Tegaderm on the Tefla. The patient was extubated and taken to the PACU in stable condition.
During the surgery, the shunt valve had been moved from the left side to the right side where it belonged. However, the distal catheter remained on the left side. Dr. I had told my mother this during an update phone call. When we saw him for my follow up appointment, I had brought him a small box of cookies to say thank you. We had thought at the time that only the valve had been moved to the wrong side during the 2009 surgery. After this surgery, I didn't have issues with my shunt again until 2013. I started writing this blog that year as I didn't know what was going on at the time. Something felt 'off' to me. As mentioned above, I only have hydrocephalus when my shunt isn't working. When it is working I am 'cured' until it stops working again. Make that make sense.
There's a reason why I refer to Dr. I as Dr. I - I'll explain more later...
