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Dr. Andrew Rynne

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Exp 50 years

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Suggest treatment for ventriculoperitoneal shunt malfunction

Answered by
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Dr. Erion Spaho

Neurologist, Surgical

Practicing since :2004

Answered : 3384 Questions

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Posted on Wed, 21 Oct 2015 in Brain and Spine
Question: 55yo family member with congenital hydrocephalus and a VP shunt since 1yo. Deteriorating slowly in cognitive and motor functioning over lifespan but in the past 12 months the decline has become quite rapid. He is now barley able to walk, sporadically incontinent, takes a long time to verbally respond and has had to resign from supermarket work of 17 years. Neurologist says it is stress, possible dementia. I have recently discovered by looking at CT reports that mild long standing ventriculomegaly was observed twice in 2009 by the radiology doctor - but no mention of it in following CT reports by other doctors. Could this be a possible cause of decline?
doctor
Answered by Dr. Erion Spaho 3 hours later
Brief Answer:
Shunt malfunction should be evaluated as a possible cause.

Detailed Answer:
Hello and thanks for using HCM.

I have read your question and understand your concerns.

In my opinion, ventriculoperitoneal shunt malfunction should be evaluated as the more probable cause of deterioration.

If it is possible, a MRI of brain is needed to evaluate if the hydrocephalus is active or not.

If MRI isn't incompatible with the shunt, CT scans done before in the follow up should be evaluated by a Radiologyst and ventricles size should be measured.

If progressive increase of ventricles size, then it is probably shunt malfunctioning and revision surgery needed.

If no active hydrocephalus, then it is probably dementia.

Hope you found the answer helpful.

Let me know if I can assist you further.

Take care.
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Erion Spaho 13 minutes later
It has been said that there has been no progressive increase of ventricle size. But this was only determined by the neologist who viewed CT scans 5 days apart of each other.
I have read articles about patients with hydrocephalus and who where VP shunted in the 50's and 60's that now experience a decline due to long standing ventriculomegaly which has been observed in my family member in the past. Our neologist refused to listen.
I understand and can accept if it is dementia but want other alternatives to be investigated before a conclusion is drawn.
Is it possible if I send you the CT scans you can look and give your opinion?
I am happy to pay your rate.
Although MRI was done in 2006, no copy is available and it is said now it is "unsafe" due to repeat due to the material the shunt is possibly made of (which is unknown).
doctor
Answered by Dr. Erion Spaho 6 minutes later
Brief Answer:
If done once before, MRI can be done again.

Detailed Answer:
Welcome back.

If one MRI is done in the past and there were no complications, it can be done again.

You can upload the CT images too, I will look at them and give my opinion.

Best regards.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Erion Spaho 1 hour later
Thank you very much.
I have uploaded CT scan to this URL. Scans from 2009 and the most recent 2015 scan.
https://drive.google.com/folderview?id=0B3DVE5jkfNIUMXNhWFQ4T1d3d0E&usp=sharing
doctor
Answered by Dr. Erion Spaho 6 hours later
Brief Answer:
Upload DICOM folder.

Detailed Answer:
Hi again.

I tried to open the CT scans images you uploaded, but there were no DICOM images (DICOM folder 0 bytes).

I was able to read only reports of two scans.

If you can, you try to upload only DICOM folders of the two CT scans.

Or you can take screenshots of both scans and upload them.

Awaiting for the CT scans images.....
Above answer was peer-reviewed by : Dr. Neel Kudchadkar
doctor
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Follow up: Dr. Erion Spaho 1 hour later
Thank you for the reply.
I have just done this. Please let me know if you are still unable to open and I will screen shot.

https://drive.google.com/folderview?id=0B3DVE5jkfNIUMXNhWFQ4T1d3d0E&usp=sharing
doctor
Answered by Dr. Erion Spaho 10 hours later
Brief Answer:
Please upload screenshots.

Detailed Answer:
Hello again.

Still the same problem with the DICOM images.

Please upload screenshots or pictures of the CT scans.

Awaiting...,
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
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Follow up: Dr. Erion Spaho 10 minutes later
Thank you for reply.

The 2009 CT scan has a total of 30 images (Brain axial 5mm)

The 2015 CT scan has a total is 275 images (Head axial soft) 60 images
(Head coronal soft) 75 images
(Head sagittal soft) 57 images
(Head axial bone) 60 images

Is there any preference of images you would like me to screenshot or should I screenshot each individual one?
doctor
Answered by Dr. Erion Spaho 3 minutes later
Brief Answer:
Only brain axial images needed.

Detailed Answer:
Hi again.

You can screenshot only axial images of both scans, no need for bone structures.

Awaiting...
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Erion Spaho 48 minutes later
I have just uploaded. Thanks
https://drive.google.com/folderview?id=0B3DVE5jkfNIUMXNhWFQ4T1d3d0E&usp=sharing
doctor
Answered by Dr. Erion Spaho 13 hours later
Brief Answer:
No active hydrocephalus on both CT scans.

Detailed Answer:
Hello again.

I examinated the two CT scans of 2009 and 2015 and the results seem to be the same.

There are no significant changes on both CT scans, ventriculomegaly is present in both of them.

I must say, the decline in cognitive function is more probably to be related to dementia.

Hope I helped you.

Best regards.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Erion Spaho 5 hours later
Thanks for the reply. It is very much appreciated.

I understand dementia is a very likely possibility and can accept it. However, our main concern is not the decline in cognitive function but more so the gait. He went from riding a bike and working 4AM-11AM every morning to now barley able to walk.
He is also sometimes very hard to wake, it is as if he is in a coma. He gets slightly better some days while others he significantly goes downhill.

We recently saw a reputable neurosurgeon who advised that his shunt is likely not functioning and he is dependant without it. Does this mean he possibly had no hydrocephalus to begin with as a child (maybe misdiagnosed due to to agenesis of the corpus callosum) ?? - the shunt was placed in 1963.
If this is the case, could the ventriculomegaly be a newly acquired type of untreated hydrocephalus? NPH??
Or, if the shunt is functioning is there any evidence on CT of over drainage?

Sorry for so many questions - I just want to get a full understanding.

Again thank you very much
doctor
Answered by Dr. Erion Spaho 8 hours later
Brief Answer:
Correct diagnosis needed.

Detailed Answer:
Welcome back.

Since there was decline of consciousness, and gait problems, especially if there is urinary incontinence too, NPH could be considered as a possibility.

There are few tests to do to have a correct diagnosis such, brain MRI, shunt functioning evaluation by a Neurosurgeon, spinal tap, and blood levels of vitamin B12.

At present is not possible to be sure if there was misdiagnosis or not.

Most important for now is to have a correct diagnosis.

Hope this helps. Let me know if I can assist you further.

Take care.
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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