VP shunt complications

[tiki1023]

I am writing in hopes of getting some advice for my 55 yr old mom who has a history of Arnold Chiari Malformation, and hydrocephalus.  Five years ago she had decompression surgery for the ACM and and a VP shunt placed.  In March she underwent surgery to remove adhesions in her abdomen which had been causing her severe abdominal pain and bowel obstructions.  Immediately after the surgery she starting experiencing extreme weakness and neurological issues, such as being off balance and headaches.  She was hospitalized and her NS found that her ventricles were smaller in size as compared to before the surgery and determined that the shunt was overdraining (despite the fact that it was set on the lowest setting).  He thought that it might have to do with the fact that the adhesions which were removed, were causing a barrier of sorts for the csf and now that they were gone, too much fluid was draining.  After waiting and hoping that things would get better with time, her NS recommend further action.  Two weeks ago she underwent another procedure where he added a device to help slow down the drainage of csf (he said that there was no valve currently available which would allow him to set the drainage at a lower setting).  She was told that she should start to feel better in a few days time.  It's been over two weeks since this procedure and she has yet to feel strong enough where she can tolerate being out of bed for an extended period of time.  We are a bit concerned because she really has not shown any signs of improvement, despite the fact that her ns reports that her ventricles have indeed increased in size.  She has also been having severe GI issues, such as severe reflux, pain, and feeling like food is not "going down" properly after eating.  What is a reasonable amount of time for which we can expect her to feel better, or is it possible that she may no longer require the shunt at all?  Also, is it possible that her GI issues are related to the overdrainage of csf?

[tiki1023]

Thanks so much for your input- I really appreciate it.  To give a bit more info- mom had many neurological issues for a large portion of her life before they were able to finally diagnose the ACM.  We will never know if she really needed the shunt because she had the decompression surgery two days after having the shunt placed.  Either way, her symptoms and quality of life were dramatically improved post both of those procedures.  Not really sure that I understand what you mean by setting the shunt to its highest barrier- her current setting is a 2.5, which we were told is the lowest (meaning draining the least amount of fluid) that it could go.  Her ns said the next option may be to somehow close off the shunt completely.  Not sure if this is commonly done, or if there are any risks involved with this.

Thanks again!

[Dr_Nassim]

hello, first of all:

the normal pressure in a human cerebrospinal fluid is between 90 and 120 mmHg!

A vp shunt with valve MAYBE needed but not obligatory after an Arnold-Chiari malformation!

The decision to insert or not is helped by an intraventricular pressure measurement, less by the lengh of the frontal horns (done in other types of hydrocephalus!)
why? Because in my opinion, a patient with Arnold-Chiari malformation treated with decompression at age of 50 is no longer requiring a VP-shunt because this patient was in a hydrolic equilibrium despite the form of his/her ventricules! That what your mom created through years؛‎ she did a ''climatization''. I am not aware about her symptoms before the surgery, but maybe the VP-shunt was not needed or the VP-shunt was just needed but without a skull base decompression procedure, one of them was suffucient!

She had a vp shunt with valve inserted but maybe that valve was not functioning until an incident like a head shaking or trauma happened during her last hospital stay or maybe the valve is too sensitive it changes settings near an MRI device or near a mobile phone...
Most of valve could be regulated between 30 and 200 mmHg.
if a valve is set on 60 mmHg thats mean WHENEVER THE PRESSURE IS ABOVE 60, THE VALVE WILL DRAIN FLUID ! thats mean that your mom at the lowest valve settings she was draing too much! At the time when she needs to be not drained at all! So the settings should be the highest lets say 150... Now once she has a valve inserted (plus anti-syphon device implanted) i will not tell you to remove, but let the NS just stop its functioning by setting it to the highest barier, I mean 170-200, then wait and see. Let him forget about the shape of the ventricules on the CT scan because it has little to say for the patient  who had a very large ventricules for almost 50 y. Your moms neural pathways were formed during years in a shape to maintain good voltage indepandently of the shape of her ventricules.

The remnant question is: what your mom presented before the discovery of her ACM, and does she really had a symptomatic ACM (not just an incidental finding) to be treated at age of 50?
Does her symptoms were a ACM???

You are welcome for any further information. Please expect a normal state in 5 days after valve closure. She will be fine :)
Your mom's case is a teaching case for the whole world.
Nassim Abi Chahine, Medhelp Medical Expert in Neurosurgery, International Neurosurgery Forum