Brain Shunt Surgery

Brain Shunt Surgery: What Is It?

A disease known as hydrocephalus, which is caused by an abnormal accumulation of cerebrospinal fluid (CSF) inside the brain, is treated via brain shunt surgery. CSF typically carries nutrition and eliminates waste while cushioning the brain and spinal cord. Fluid builds up, though, when its flow is obstructed or its absorption is compromised, which raises the pressure inside the skull.

A shunt system may be implanted by neurosurgeons to relieve this pressure. A shunt is a thin, flexible tube with a valve that transfers extra cerebrospinal fluid (CSF) from the brain’s ventricles to a different area of the body, usually the heart or abdomen, where it can be safely absorbed.

Why is it done?

The most prevalent reasons shunt surgery is done are:

• Hydrocephalus congenital (which exists at birth)
• In older patients with memory loss, urine incontinence, and abnormal gait, normal pressure hydrocephalus
• Hydrocephalus following an infection or trauma
• CSF channels are blocked by brain tumours.

A shunt enhances quality of life, alleviates symptoms like headache, nausea, and visual issues, and helps prevent brain injury by lowering intracranial pressure.

Brain Shunt System Types

Shunts come in a variety of forms, each depending on the needs of the patient:

• The most common type of ventriculo-peritoneal (VP) shunt drains CSF into the abdominal cavity.
• CSF is channelled into the atrium of the heart by a ventriculo-atrioventricular (VA) shunt.
• Through a ventriculo-pleural shunt, CSF enters the chest.
• CSF is redirected from the spinal canal to the abdomen by a lumboperitoneal shunt.
• With adjustable or programmable shunts, physicians can alter the drainage pressure settings without causing any harm.

Options Other Than Shunt Surgery

There are other options besides shunt surgery. Neurosurgeons may also take into account the following factors, depending on the location and cause of hydrocephalus:

1. Endoscopic Third Ventriculostomy (ETV): This minimally invasive technique creates a tiny hole in the third ventricle’s floor so that CSF can pass through the blockage and continue to flow properly.
2. ETV with Choroid Plexus Cauterisation (ETV+CPC): This operation, which is frequently performed on children, cauterises portions of the choroid plexus, which is where CSF is produced, hence reducing its production.
3. Tumour or Cyst Removal: Surgery may be able to restore normal CSF flow without the requirement for a shunt if a tumour or lesion blocks CSF routes.
4. Temporary medical management: Acetazolamide and other medications can at times lower CSF production, but they are not lifelong fixes.

Before choosing the appropriate course of action for each patient, these options are carefully considered and evaluated.

 Complication Rate & Risks

Shunt surgery can save lives, but there are dangers and consequences involved:

• Shunt malfunction or blockage (10–20% in the first year)
• 5–10% of infections, with a greater rate in youngsters
• CSF overdrainage or underdrainage that causes bleeding or symptoms
• Mechanical issues like the tube breaking or disconnecting
• Bowel perforation (rare) or pseudocyst are examples of abdominal consequences (in case of VP shunt).

Revision surgery can address the majority of issues; however, since shunts are a management approach rather than a permanent cure, lifelong monitoring is often necessary.

The Process of Consent

The consent procedure prior to surgery includes:

• Describe the illness: the causes of hydrocephalus and the need for therapy.
• Options for treatment include shunt surgery and alternatives such as ETV.
• Benefits of surgery include better everyday functioning, symptom relief, and prevention of brain damage.
• Potential dangers and issues include infection, obstruction, and the requirement for upcoming changes.
• Lifelong care: Families should be aware that many people require shunt monitoring and occasionally several procedures over the course of their lives.

The neurosurgeon makes sure that family members and the patient (if able) receive sufficient information in plain, easy-to-understand language. Instead of making a quick decision, this enables them to make an informed one.

What takes place prior to the procedure?

Certain tests (such blood tests, MRIs, or CT scans) could be necessary.

After explaining the procedure to you, the neurosurgeon will request your signed approval. A general anaesthetic is used to install a shunt. You will be informed of the dangers involved in this surgery.

In order to prepare for the procedure, an anaesthetist will examine the patient and discuss with you when they must fast, or stop eating and drinking.

 What takes place post the procedure?

• Patient will either return to the ward for strict monitoring or be sent to our critical care unit right after the procedure.
• Nurses will keep a careful eye on the patient for the first 24 hours after they are brought back to the ward. Getting  patient up at least once every hour can be necessary for this. Most likely, a machine that tracks patient’s breathing and heart rate will be attached to them. As patients heals, the frequency of observations will decrease.
• A tiny portion of patients’s hair will have been shaved if they have had a VP shunt implanted.
• There will be a drip for the patient that will hold liquids. For comfort, they will also be given painkillers.
• Following the procedure, patient might feel nauseous. The nurse will keep an eye on this and administer medicine as needed. Before you begin feeding the patient, it’s crucial to check with the nurses to make sure they’re not having any trouble swallowing and that patient’s stomach can handle food if they have VP shunts.
• Patient’s drowsiness after a general anaesthetic is normal.
• One dressing will be applied to patients’s head, and another to the area where the lower shunt tubing was installed. This will be the abdomen for VP shunts. With the neurosurgeon’s consultation, the nurses will take care of the wound dressings when it is time to remove them.
• Patient will often need to lie flat (or have their bed head at 30 degrees) for 24 to 48 hours following surgery if they have an LP shunt. When the patient is ready to sit up, the physicians will let you know.
• Before patient is released from the hospital, you will receive instructions on how to care for their wound.

Crucial points to keep in mind

• If the patient is asleep, the nurses will wake them up while they conduct their observations. This is required in order to evaluate brain function.
• Once the shunt is in place, encourage the patient to move their head.

Life after shunt surgery

With regular follow-up scans and clinical assessments, the majority of patients recover well and are able to resume their regular activities. In order to seek medical attention as soon as possible, parents and carers are trained to identify warning indications of shunt malfunction, such as a severe headache, vomiting, tiredness, irritability, or swelling over the shunt location.

FAQ’s on Brain Shunt Surgery

1. What is the duration of a brain shunt?

Although a shunt is made to last, it could require alterations or updates over time. While some patients may need several adjustments throughout the course of their lives, others may have the same shunt for decades.

2. Is it possible to have a regular life following shunt surgery?

Absolutely. After their recovery, many patients resume their regular activities, including work and education. Carers should be on the lookout for signs of shunt issues and do routine follow-up.

3. What are the obvious symptoms of a malfunctioning shunt?

Severe headache, vomiting or nausea, sleepiness, children becoming irritable, impaired vision, seizures, or shunt tract enlargement. You need to get medical help right away if any of these happen.

4. Is shunt surgery permanent?

Since the shunt just controls hydrocephalus rather than curing illness, it frequently needs to be in place for life. The shunt might not be necessary in some circumstances (such as following tumour excision or ETV).

5. Is shunt surgery safe?

Although it is usually safe, risks including infection, blockage, or the need for revision exist, just like with any brain surgery. The majority of problems can be fixed, however the overall complication rate within the first year is between 10% and 20%.

6. What other options are there besides shunt surgery?

Endoscopic Third Ventriculostomy (ETV), ETV with Choroid Plexus Cauterisation, or surgery to remove the blockage’s source (such as a tumour or cyst) are choices that vary depending on the patient’s health.

7. After surgery, will the patient require routine examinations?

Yes. To make sure the shunt is functioning correctly, routine follow-up visits and scans are necessary. Families and patients should also be taught how to spot malfunctions.

8. Can kids with shunts grow up, learn, and play normally?

Generally speaking, yes. Kids with shunts can play, go to school, and lead healthy lives. If there was brain damage prior to treatment, some people could require additional assistance.

9. What is the recovery period following brain shunt surgery?

After surgery, the majority of patients remain in the hospital for a few days. Depending on their general health, many patients return to their regular activities within a month, however full recovery may take a few weeks.

10. Is it possible to see or feel a brain shunt from the outside?

Indeed, the shunt tubing is frequently felt as a thin cord that runs beneath the skin of the head or neck. This is harmless and typical.

11. Can an MRI be performed on a patient who has a shunt?

The radiology team should be notified prior to any scan, even though the majority of contemporary shunts are MRI-compatible. After an MRI, some programmable shunts might need to be adjusted.

12. How much does brain shunt surgery cost?

The type of shunt (programmable vs. standard), the patient’s condition, the hospital setting, and the length of hospital stay are some of the variables that affect the cost of brain shunt operation. The procedure is inexpensive or occasionally free for qualified patients at government facilities like AIIMS Delhi because of the heavy cost subsidisation. The cost of a shunt system and any necessary post-operative care might vary from ₹60,000 to ₹2,50,000 or more in private facilities.

13. What does a shunt system’s reservoir mean?

Numerous valves have a tiny, delicate reservoir beneath the epidermis. It enables physicians to:

• Collect CSF samples for analysis.
• Verify that the shunt is operational.
• Check the system’s pressure.

The reservoir should not be pressed or pumped by patients themselves.

14. How can overdrainage be avoided and what does it mean?

Overdrainage occurs when a person stands or sits and the shunt drains too much CSF. Neurosurgeons may use specialised tools, such as anti-gravity or anti-siphon valves, to control drainage and stop excessive flow in order to avoid this.

15. How can medical professionals determine whether the shunt is operating as expected?

Your physician may perform a shunt flow study, in which a tiny quantity of dye is injected and monitored by X-ray or CT, employ imaging (CT or MRI), or manually inspect the reservoir. This test is rarely required, though, unless a fault is suspected.

16. Is flushing a shunt necessary?

No, usually. Standard valves don’t need to be flushed, and patients should never pump them by hand. Only a qualified neurosurgeon should perform flushing if it is necessary for testing. In the event that flushing is necessary, newer methods are being developed to provide safe flushing.

17. After shunt surgery, how frequently should a patient follow up?

It’s important to follow up. Patients are evaluated within a few weeks following surgery, and then every 6 to 12 months, or sooner if symptoms start to show. Continuous observation helps guarantee the shunt is functioning properly.

Sources:

1. https://www.hydroassoc.org/shunt-systems/#What_Else_Should_I_Know_About_Shunts
2. https://www.childrens.health.qld.gov.au/health-a-to-z/shunt-surgery
3. https://www.hopkinsmedicine.org/neurology-neurosurgery/specialty-areas/cerebral-fluid/shunts
4. https://www.mayoclinic.org/tests-procedures/brain-shunt/about/pac-20588547
5. https://www.nhs.uk/conditions/hydrocephalus/treatment/
6. https://en.wikipedia.org/wiki/Cerebral_shunt
7. https://www.hydroassoc.org/shunt-systems/
8. https://www.thebraintumourcharity.org/brain-tumour-diagnosis-treatment/treating-brain-tumours/adult-treatments/neurosurgery-adults/inserting-shunt/
9. https://www.moffitt.org/cancers/brain-cancer/treatment/surgery/shunt-procedure/
10. https://corewellhealth.org/care-and-specialties/neurosciences/neurosurgery/brain-shunt
11. https://www.ucsfbenioffchildrens.org/treatments/brain-shunts
12. https://www.georgiabrainandspine.com/procedures/brain-procedures/shunt-surgery