2014, Part 1

I started writing this blog in 2013. In the spring of 2013, I started a Master's degree in Social Work. Because of what happened with my shunt in 2009, I decided to stay 1 to 2 months ahead of my homework assignments out of paranoia. This way, if I needed surgery and/if would be out of school for 3 weeks I would at least be caught up by the time I returned to school.

In August 2013, I was standing up and felt a vibration throughout of spinal cord and head. I almost fell on the floor involuntarily. This only happened once. The vibrations in my head continued...

I saw Dr. I and told him about this and he said the following:

'"If it continues to happen in December, We'll fix it." 

Now he was having me do a X Rays like every three months. I'm surprised I didn't glow green from the radiation. 

At that time I was starting to loose my appetite.  I would only eat when I got hungry which was once a day.

Anytime you have a lack of appetite and vibrations in your head and you have a shunt it is a medical emergency. Why? Because it means the shunt could be broken. 

I had more tests done and Dr. I didn't know what to do.

In the middle of February 2014 I had an MRI  because things were getting worse.  The radiologist had mentioned there was a 5ml stroke developing on the right side of my brain. I didn't know this at the time.

When I saw Dr. I again at the end of February, I had insisted I needed surgery. 

VB:" I need to have a full revision. It's suppose to go on the right side." - A full revision is when they change the shunt valve, the catheters in my stomach and neck. The last time I had this done was in 1993 when I was 11 years old.

*I had never had this thought prior to seeing him, I just blurted it out. I suspect it was divine intervention or my late grandmother whispering in my ear or something...

Dr I - "It is on the right side."

VB: "No it isn't. You need to fix that."

Remember, in 2011 Dr I. had moved the valve to the right side and left the distal catheter on the left side.  

Dr. I - "I've done a million of these surgeries and I know when shunts aren't working." 

VB: "I'm sure you're very good at what you do. I've had this in my body since I was a baby and I know when it's not working and you need to fix it."

More divine intervention. 

Dr. I - "You could have a stroke."

I realize now he was saying this because of the MRI results. 

VB - "That's the risk for any surgery."

Dr. I - "Ok. We'll schedule surgery for March 6." 

My mother and I had brought in my x rays from 1995 (I was 14 at the time) We wanted him to see them and as soon as we mentioned this he said:

Dr. I - I don't need to see those." 

VB and Mom: "What do you mean?!''

Dr. I - "I don't need to see those."

He literally put his hand up before we even took the x rays out of the envelope. Prior to the use of digital imaging -You were given the actual X Ray images on large sheets.  

Again, I realize Dr. I ( Dr. Incompetent ) didn't want to see them because had we been able to compare the 1995 images to the February 2014 ones it would have been obvious something was wrong.

When I was being taken into the operating room on 3/6/14 - I was talking to Dr. I for a few minutes asking about what everything looked like. He was confused as to why I would be curious about this. ( I didn't tell him or anyone I was making a short film about my shunt.) Next thing I knew - Everything went black. 

I suspect my shunt stopped working at that moment.  

Operative Report 

Date of Surgery: March 6, 2014

Preoperative Diagnosis: Ventriculoperitoneal shunt failure 

Postoperative Diagnosis: Ventriculoperitoneal shunt failure

Anesthesia: General Endotracheal Anesthesia

Estimated Blood Loss: 25 mL

Findings: Opening Pressure approximately 15 mm of water.  

Complications: None *This was not true as we will see later..

Procedure:

The patient is a 32 year female who presents with signs, symptoms and radiographic evidence of slit ventricle syndrome.  The patient had had increasing headaches and unchanged ventricular size on CT imaging.  The patient underwent ICP monitoring and was found to have no elevation ICP verses headaches. Given these findings, it was recommended that the patient undergo exploration of her VP shunt under presumed diagnosis  of a partial proximal obstruction.  

Anesthesia: The patient was sedated and intubated without difficulty by the anesthesia service. Eyes were taped shunt after ointment was applied to prevent corneal abrasion. 

Operative Technique:  

We first began by disconnecting the valve from the distal catheter. Once this was accomplished, a manometer was then inserted. Once this was accomplished, attention was then turned to the left frontal area, which was then opened sharply  with a #15 scalpel blade using a combination of blunt and sharp dissection as well as monopolar electrocautery. The left front bur hole was then identified. The ventricular catheter was then disconnected from the valve on the right frontal incision and minimal CSF was noted to be dripping. At his point, the neuroenddoscope was then brought into the field.  The NeuroPEN was then navigated through the left frontal catheter and was found to be stuck; however, the ventricular system could successfully be navigated. Once this was accomplished, it was noted. However, there was slow pulsation of CSF through this catheter. Given these findings, we decided to proceed with a right frontal ventricular insertion using an 8 drill bit, a burr hole was then created in the right frontal region. Once this was accomplished, the dura was then bipolarized and incised with a #11 scalpel blade. The ventricular catheter was then inserted to a depth approximatley 6 cm. Brisk CSF flow was noted upon entry. Next, the NeuroPEN endoscope was then brought into the field adn the ventricular system was navigated critical landmarks including the right sided choroid plexus. formamen of monroe, and septal epllucidum were identified.  The catheter was then inserted through the right formen of monro. The third ventricle catheter was left withing the third ventricle.

Next, the programmable valve was brought into the field along with a 10 cm anti siphon device. The valve was then connected to the distal catheter and then connected to the proximal catheter. The shunt was again tapped verifying the patency.  The wound was then copiously irrigated with an antibiotic solution until clear. Both wounds were then closed with sequential 2-0 Vicryl suture followed by running 3-0 Monocryl suture for the skin. Sterile dressing consisting of Mastisol, Steri Strips, Telfa and Tegaderm and Coban was then applied. All needle counts, sponge counts and instrument counts were correct at the end of case x2.

Admitting Physician: Dr. I. 

Signed by Dr. G at 12:15PM. 

Dr. I had told my family while I was in a coma in the ICU that when they moved the distal catheter to the right side was when I had a stroke.  

This was not true.

Dr. G the other physician in the OR had written the following:

The patient is status post VP shunt revision with removal of the left frontal approach ventricular catheter and placement  of the right frontal approach ventricular catheter with tip near the froman of Monroe to anterior third ventricle, there is expected postoperative pneumocrephaly, intraventricolar air within the frontal horms of the lateral ventricles, and subcanous emphysema within the right frontal scalp, T=

There is a focal hemorrhage in the region of the left thalmus measuring 7x10 mm at the site of the tip of the prior ventricular catheter Acute 5 mm intraparenchymal hemorrage in the right paraedian pons has developed since 2/22/2014. The size and configuration of the ventricular system is similar to prior exam.  No hydrocephalus. no depressed calvarial fractures. 

Impression:

1. Shunt revision as described above.

2. Focal acute 10 mm hemorrhage in the left thalmic region.

3. Focal acute 5mm intraparaenchymal hemorrhage in the right paramedian pons has developed since 2/22/2014. 

There was blood coming out of my right ear - I know this because  I heard a nurse make a comment that there was dried blood in my right ear. 

In summary I had the following:

10 ml hemorrhage on the left side of my brain followed by a hemorrhagic brain stem stroke and a Traumatic Brain Injury. Then on the right side of my brain, I had a 5ml stroke. Technically the injuries I had were what you would get from external head trauma. I.e car accident, blunt force trauma to the head. 

When I woke up in the operating room, my entire body was stiff and numb.  I thought when I died I would go back to a spaceship. (I like science fiction and I think I came from one.) Or I would see a white light or hearing music playing, maybe see a dead relative and there was none of that. I was just in this room with one eye shut closed. My right eye was pointed down and inward toward the inside of my left eye.  I was able to move it out a little. My first thought was: What happened and can I still breathe? I took a breath through my nose - When that worked, I thought, Ok! This is good, this is good I can still breathe, let's try that again. I took another breathe through my nose and thought 'Good! I can still breathe" 

 Dr I came to me and said "You had a stroke you're going to rehab."

 VB: (thinking) What?!

I was still confused about what had happened. I was trying to analyze the situation, do an assessment. 

Moments later, my mom walked up to my left side and I told her the following:

VB: Everything is numb. Everything is numb. 

When I told her this, I could just barely lift my arms up ( they were stiff as a board like the rest of my body) 

Then everything went black (again).

While I was in a coma....I saw all these pretty swirling colors of green, blue, pink and violet. I learned later those were the same colors in the machine I was hooked up to. 

Dr. I told my family the following:

Dr. I: "We did what you told us to do. At least she didn't have a stroke in her forehead."

Meaning that he was only following my instructions. Yes, having a stroke in my forehead (prefronal cortex) would have meant I wouldn't remember how to speak. 

Why would Dr. I tell my family and myself that I only had a stroke? 

I learned while in rehab, that I had multiple brain injuries during surgery...I would have surgery again in May 2014...

 

 

 

 

2011

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...