Ventricular shunt is a surgical procedure in which a tube is placed in one of the fluid-filled chambers inside the brain (ventricles). The fluid around the brain and the spinal column is called the cerebrospinal fluid. When infection or disease causes an excess of this cerebrospinal fluid in the ventricles, the shunt is placed to drain it and thereby relieve excess pressure.
Purpose
Ventricular shunt relieves hydrocephalus, a condition in which the ventricles are enlarged. In hydrocephalus, pressure from the cerebrospinal fluid usually increases. It may be caused by tumor of the brain or of the membranes covering the brain (meninges), infection of or bleeding into the cerebrospinal fluid, or inborn malformations of the brain. Symptoms of hydrocephalus may include headache, personality disturbances and loss of intellectual abilities (dementia), problems in walking, irritability, vomiting, abnormal eye movements, or a low level of consciousness.
Normal pressure hydrocephalus is associated with progressive dementia, problems in walking, and loss of bladder control (urinary incontinence). Even though the cerebrospinal fluid is not thought to be under increased pressure in this condition, it may also be treated by ventricular shunting.
Precautions
As with any surgical procedure, the surgeon must know about any medications or health problems that may increase the patient's risk. Because infections are both common and serious complications, antibiotics are often given before and after surgery.
Description
The ventricular shunt tube is placed to drain fluid from the ventricular system in the brain to the cavity of the abdomen or to the large vein in the neck (jugular vein). Therefore, surgical procedures must be done both in the brain and at the drainage site. The tubing contains valves to insure that fluid can only flow out of the brain and not back into it. The valve can be set at a desired pressure to allow cerebrospinal fluid to escape whenever the pressure level is exceeded.
A small reservoir may be attached to the tubing and placed under the scalp. This reservoir allows samples of cerebrospinal fluid to be removed with a syringe to check the pressure. Fluid from the reservoir can also be examined for bacteria, cancer cells, blood, or protein, depending on the cause of hydrocephalus. The reservoir may also be used to inject antibiotics for cerebrospinal fluid infection or chemotherapy medication for meningeal tumors.
Preparation
The diagnosis of hydrocephalus should be confirmed by diagnostic techniques that make images of the brain, such as computed tomography scan (CT scan) or magnetic resonance imaging (MRI), before the shunting procedure is performed. These techniques will also show any associated brain abnormalities. Cerebrospinal fluid should be examined if infection or tumor of the meninges is suspected. Patients with dementia or mental retardation should undergo neuropsychological testing to establish a baseline psychological profile before the shunting procedure.
Patients with normal pressure hydrocephalus may experience a temporary improvement in walking and mental abilities upon removal of a moderate amount of cerebrospinal fluid. This improvement may be an indication that shunting will improve their condition. However, patients who do not improve after temporary cerebrospinal fluid drainage may still benefit from ventricular shunt. When a case is in doubt, continuous monitoring of cerebrospinal fluid pressure (which in itself requires a surgical procedure) may indicate whether shunting is likely to be helpful.
Aftercare
To avoid infections at the shunt site, the area should be kept clean. Cerebrospinal fluid should be checked periodically by the doctor to be sure there is no infection or bleeding into the shunt. Cerebrospinal fluid pressure should be checked to be sure the shunt is operating properly. The eyes should be examined regularly because shunt failure may damage the nerve to the eyes (optic nerve). If not treated promptly, damage to the optic nerve causes irreversible loss of vision. Patients or caregivers should understand the life-threatening nature of shunt problems. All symptoms and signs of potential shunt failure or infection must be taken seriously.
Risks
Complications of shunting occur in 30% of cases, but only 5% are serious. Serious and long-term complications are bleeding under the outermost covering of the brain (subdural hematoma), infection, stroke, and shunt failure. Infection at the shunt site may cause a loss of intelligence. When shunts drain to the abdomen (ventriculoperitoneal shunts), fluid may accumulate in the abdomen or abdominal organs may be injured. If cerebrospinal fluid pressure is lowered too much, patients may have severe headaches, often with nausea and vomiting, whenever they sit up or stand.
Normal results
Of patients with normal pressure hydrocephalus who are treated with shunting, 25-80% experience long-term improvement. Normal pressure hydrocephalus is more likely to improve when it is caused by infection of or bleeding into the cerebrospinal fluid than when it occurs without an underlying cause. Walking difficulties and bladder control are more likely to improve than dementia is.
After shunting, the ventricles get smaller within three or four days. This shrinkage occurs even when hydrocephalus has been present for a year or more. Clinically detectable signs of improvement occur within a few weeks. The cause of hydrocephalus, duration of hydrocephalus before shunting, and associated brain abnormalities affect the outcome.
BOOKS
Black, P. M. "The Normal Pressure Hydrocephalus Syndrome." In Concepts in Neurosurgery: Hydrocephalus,ed.R. M. Scott. Baltimore: William & Wilkins, 1990.
PERIODICALS
McLone, D. G., and K. E. Aronyk. "An Approach to the Management of Arrested and Compensated Hydrocephalus. (Re-view)." Pediatric Neurosurgery 19, no. 2 (1993): 101-103.
Raftopoulos, C., et al. "Prospective Analysis by Computed Tomography and Long-Term Outcome of 23 Adult Patients with Chronic Idiopathic Hydrocephalus." Neuro-surgery 38 (1996): 51-59.
Vanneste, J., et al. "Shunting Normal-Pressure Hydrocephalus: Do the Benefits Outweigh the Risk? A Multicenter Study and Literature Review." Neurology 42 (1992): 54-59.
ORGANIZATIONS
American Academy of Neurology. 1080 Montreal Ave., St. Paul, MN 55116. (612) 695-1940. <http://www.aan.com>.
Laurie Barclay, MD
KEY TERMS
Cerebrospinal fluid—Fluid bathing the brain and spinal cord.
Computed tomography (CT) scan—An imaging technique in which cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures.
Dementia—Progressive loss of mental abilities.
Magnetic resonance imaging (MRI)—An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures.
