Year : 2019 | Volume
: 14 | Issue : 3 | Page : 113-
Shunt care: More than what beats the eye
Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
Dr. Dattatraya Muzumdar
Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai 400012, Maharashtra.
|How to cite this article:|
Muzumdar D. Shunt care: More than what beats the eye.J Pediatr Neurosci 2019;14:113-113
|How to cite this URL:|
Muzumdar D. Shunt care: More than what beats the eye. J Pediatr Neurosci [serial online] 2019 [cited 2020 Jan 17 ];14:113-113
Available from: http://www.pediatricneurosciences.com/text.asp?2019/14/3/113/267977
Cerebrospinal fluid (CSF) diversion is one of the most commonly practiced surgeries in pediatric practice. Although endoscopic third ventriculostomy is in vogue, it has a steep learning curve, and complications can be devastating. Shunt surgery is still commonly performed in most centers in India. It can be easily performed and learned relatively earlier than endoscopic third ventriculostomy.
In most academic centers, the junior residents perform shunt surgery, and it is usually carried out as the last case on the day's operation list. The senior resident does the supervision, and very occasionally, a consultant would assist the junior resident performing the case. The main reason behind this is the increasing load of complex cases in high-volume academic centers, which consume more attention and relatively less number of dedicated pediatric neurosurgery consultants. It is very well known that shunt surgery has many components, which if not properly and judiciously performed can lead to an unsatisfactory outcome. Shunt infection and repeated shunt blockages requiring revisions can be frustrating.
Although the indications and the necessity of shunt surgery are explained to the relatives, it may not be assumed that the family has understood the implications of shunt dynamics. A common query is whether the device would be permanently inserted or be removed after a certain period. The family needs to be educated that the shunt is a permanent device, necessary for maintaining normal fluid pressure in the brain, and is rarely removed unless it is blocked or infected. The patient needs to be nursed in upright position for a considerable time in the initial period to aid the drainage of CSF by gravity, which in turn helps in maintaining the patency of the shunt.
Shunt blockade is commonly observed in clinical practice. It is a clinical diagnosis. Shunt survey is carried out easily and is important to rule out disconnection of the assembly. A computed tomography (CT) of brain is performed to confirm the position of the ventricular catheter and the dilatation of the ventricles. However, repeated use of CT should be avoided for fear of long-term effects of radiation, including pediatric brain tumors. During revision of the shunt, the ventricular catheter should be removed gently and with caution. There have been reports of massive intraventricular bleed due to long-standing adherence of ventricular catheter to the choroid plexus. Alternatively, an opposite side placement of new shunt assembly is a good option to prevent this tragedy.
Programmable shunts are used in patients who have differential or variable intraventricular pressures. They certainly have an indication. However, they are expensive and unaffordable to the majority of poor patients in our country. Moreover, in case of a shunt blockade, if the valve gets malfunctioned or if proper setting cannot be restored due to infrastructure and geographical constraints, the patients may succumb due to persistent elevated intracranial pressure before reaching the appropriate hospital. Hence, all these factors need consideration in case of programmable shunt.
CSF diversion in cases of hydrocephalus due to tumors should be temporary and the primary surgery for tumor should be performed at the earliest as the CSF planes become obliterated. The tumor becomes densely adherent to the brain making further resection challenging and can be fraught with potential morbidity.
It is said once a shunt, always a shunt. The normal intracranial CSF dynamics or pathways become nonfunctional and the patient becomes shunt dependent. Hence, a decision for shunt insertion should be carried out judiciously, proper selection of patient is crucial and regular surveillance is mandatory.