If patients with arrested hydrocephalus are not experiencing symptoms, they may not need immediate treatment. However, because their condition could change suddenly, they will benefit from being monitored regularly by a specialist. If these patients develop symptoms, they may require treatment at some point.
Endoscopic third ventriculostomy – called ETV for short – is often used in patients with aqueductal stenosis, which is a narrowing or blockage of the cerebral aqueduct that keeps the cerebrospinal fluid from flowing properly through the ventricles. During this procedure, the surgeon makes a hole in the bottom front part of the third ventricle to allow spinal fluid to circulate and be re-absorbed in spite of the blockage at the level of the cerebral aqueduct.
Neurosurgeons perform the ETV procedure in an operating room at the hospital. The procedure usually takes about 30-45 minutes.
Before the procedure, your neurosurgeon will talk with you to make sure you understand everything that will happen.
The nursing staff will shave a small section of hair on your head. They will also thoroughly wash your head with a special soap to ensure it is sterile. You will be completely asleep for the procedure.
When you are asleep, the neurosurgeon will make a small incision in your scalp. Then he or she will make a small hole in your skull and in the protective covering of the brain.
The surgeon will use a special intra-operative navigation system to see inside your brain and assist in moving the endoscope to the proper position. Once the endoscope is in the proper position, the surgeon will make a small opening where the third ventricle joins the aqueduct. This opening will allow the CSF to move through the aqueduct into the subarachnoid space, which is located between the thin layers of tissue below the skull and the protective lining of the brain tissue.
After the procedure, the doctor will cover the incision with sterile bandages and the OR nursing staff will move you to the recovery room. Once you are awake, the transport team will move you to a room in the hospital. You will stay overnight in the hospital, so we can monitor your recovery. Most patients go home after one or two days.
Recovering after surgery
You will be able to resume your daily activities after you leave the hospital. During the first few months the clinic scheduler will arrange for several appointments at our clinic. During these visits, we will check to make sure the spinal fluid continues to flow correctly. After the first few months, you will have checkups once a year.
Sometimes scar tissue will develop around the opening the surgeon made. Scar tissue will cause the opening to narrow again and slow the flow of CSF. If that happens, the neurosurgeon may suggest another ETV to remove the scar tissue or the insertion of a shunt to keep the CSF flowing properly.
3. Implanting a shunt
This procedure consists of implanting a small tube (shunt or catheter) into chambers in your brain called ventricles. The shunt allows the CSF to drain into your abdomen, where it is absorbed. A valve is attached to the shunt to control how much CSF drains. The shunt:
- Controls how much CSF is in your brain
- Helps prevent CSF from building up
- Reduces pressure on your brain
- Improves your symptoms
What is a shunt?
The shunt is a system that moves fluid from one place to another. The system includes:
- Two tiny tubes (catheters)
- A one-way valve that connects the two tubes
The valve is about the size of a silver dollar from one end to the other, but it is very thin and narrow. The valve allows fluid to move only one way – away from your brain.
How does a shunt work?
Shunts can be placed in various locations. Your surgeon will talk with you about these options.
- Typically, one of the tubes runs from the ventricle in your brain to the valve, with the other tube running from the valve to your abdomen. This is called a ventriculoperitoneal shunt.
- Sometimes the first tube may be placed into the lower spine, where CSF also circulates, and the second tube placed in your abdomen. This is called a lumboperitoneal shunt.
- The second tube may also end at a blood vessel near the heart or in the space around the lungs, instead of the abdomen.
The shunt system allows extra spinal fluid to drain into an area where it can be safely absorbed by your body. The valve can be adjusted to control the flow of fluid. This keeps fluid from building up, but also ensures the right amount of fluid is still available to protect and cleanse your brain.
What happens during the surgery to implant the shunt?
Before surgery, your neurosurgeon will talk with you about the procedure to be certain you understand everything that will take place. Your anesthesiologist will also talk with you.
The shunt implant surgery takes place in an operating room at the hospital. The procedure takes about 30 minutes. The anesthesiologist will give you medicine so you are completely asleep during the procedure, and will monitor you throughout the procedure.
If you are undergoing a ventriculoperitoneal (VP) shunt placement, the nursing staff will shave a small section of hair on your head. They will also thoroughly wash your head and abdomen with a special soap. This ensures the area is sterile.
When you are asleep, the neurosurgeon will make a small incision in your scalp, and a small hole in your skull and one in the protective covering of the brain. The surgeon will use special imaging equipment, called intra-operative navigation, to see inside your brain and locate the correct place for the shunt. The neurosurgeon will make an additional incision (usually above or behind your ear) to assist with placement of the tubing.
One end of the shunt is placed in the ventricle. The other end is connected to the valve. The second tube is connected to the other end of the valve. This tube is then tunneled just beneath your skin down to the abdomen below your ribs. The tubing is inserted into the abdomen either through a small incision, or with the assistance of a general surgeon using a laparoscope and two tiny incisions.
After placing the shunt and valve, the doctor will cover the incisions with sterile bandages.
After the procedure, the OR team will move you to the recovery room. Once you are awake, the transport team will move you to a room in the hospital. You will stay overnight in the hospital, so we can monitor you during your recovery. Most patients leave the hospital after one or two days.
Will the shunt be visible after surgery?
You will notice a small lump behind your hairline and above your ear where the valve is located. Your hair will grow back in that area, so it will not be noticeable to most people.
Recovering after surgery
Some of your activities will be limited when you first leave the hospital. For example, you should not lift anything heavier than 10 pounds for two to four weeks, and you should not resume driving if you are taking narcotic pain medication. Although the valve is beneath the skin on your head and protected, you should be careful not to bump it. You should have someone look at your incisions every day. You should call your surgeon’s office if they notice any signs of infection, such as:
- Redness and hardness around the incision
- Hot to the touch
- Green or yellow discharge
- Excessive bleeding
- The incision is getting bigger
- The incision has a bad smell
During the first few months our clinical scheduler will make several follow-up appointments for you at the clinic. During those visits, we will check the valve and ensure you are recovering well. Your doctor will also check to make sure the spinal fluid is flowing correctly. We use special equipment that allows us to adjust the valve in the clinic – even though it is beneath your skin – to make the flow just right. After the first few months, you will have checkups once a year.
The neurosurgeon also may prescribe physical therapy or an appointment with a rehabilitation specialist if you have any problems with walking, standing or balancing.
Will all of my symptoms go away after surgery?
After inserting a shunt, patients usually experience the greatest improvement in walking, standing and balance. It is more difficult to know how much improvement you will see with memory and bladder-control problems. How much you improve will depend on how serious those symptoms were by the time you had surgery and whether you have other medical problems that may be contributing to the symptoms.
A reminder: A magnet, like the magnets in an MRI, can affect the valve and possible change the setting. If you need an MRI, please let the doctor know about your valve. After you have an MRI, you will need to schedule an appointment for us to check your valve setting in the clinic.