What is it ?
Hydrocephalus is the buildup of fluid (cerebrospinal fluid) in the normal cavities of the brain (ventricles). This buildup of fluid will increase the size of the fluid spaces causing pressure on the surrounding brain, which can begin to cause damage to the brain. Under typical circumstances this fluid is created in the center part of the brain and then circulates around the brain and spine to protect and provide nutrients to these structures and then is reabsorbed by the brain. Hydrocephalus occurs when there is an imbalance between production and reabsorption or block in the natural flow of the fluid. There are many causes of hydrocephalus; children can be born with it while others acquire it later from trauma or infection.
Regardless of its cause the overall treatment remains the same. The excess fluid needs to be diverted to another space so the body can handle it without causing pressure on the brain. This can be achieved in a number of different ways. The most common way is to place a shunt. A shunt is a small tube that is placed in the fluid spaces of the brain (ventricles) and then travels down to the cavity in the abdomen that protects the abdominal organs (peritoneal cavity) or into the blood stream via the top chamber of the heart. Once the excess fluid is in one of these two spaces the body will reabsorb naturally. This restores the balance and gives the fluid a pathway away from the brain so build up or pressure on the brain tissue does not occur. These devices are commonly known as Ventricular peritoneal Shunts (VPS) or Ventriculoatrial Shunts (VAS), depending on which part of the body they drain into.
The second way to treat hydrocephalus is to perform an endoscopic third ventriculostomy (ETV). In some instances of hydrocephalus it is not an issue of imbalance but an obstruction in the middle part of the brain that occurs. In these specific cases a small camera device is used to identify and re-open the natural pathway in the brain that has closed. Not all cases of hydrocephalus can be managed in this way; it is important to be evaluated by one of our Neurosurgeons to see if your child is a candidate.
Finally, a different type of shunting device was pioneered by the Pediatric Neurosurgery Group here at Children’s Hospital of Michigan, and this device is placed in the back rather than the brain. Dr. Sandeep Sood established a different way to treat hydrocephalus that was life changing for many of our patients. By placing the shunt in the lower spinal canal, which is part of the natural pathway for the fluid, instead of the brain this led to improved outcomes for many of our complex hydrocephalus patients. This device is known as a Lumbar peritoneal Shunt or LPS. Again it is important to note not all cases of hydrocephalus can be managed in this way; it is important to be evaluated by one of our Neurosurgeons to see if your child is a candidate.
What to expect during your office visit:
Pediatricians will often measure the head size of babies as they grow. If they observe the head is growing quicker than the rest of the body this may be a sign of hydrocephalus and families are often referred to a Neurosurgeon at that time. In addition to head size it is important for our Neurosurgeons to obtain pictures of the fluid spaces and brain anatomy to get a better understanding of the condition and this is achieved in 3 ways:
Head Ultrasound: A head ultrasound uses sound waves to obtain images of the brain. Babies still have areas of the skull that have not completely closed referred to as the soft spot. Using the soft spot as a window to the brain an ultrasound machine sends out sound waves which can be recorded on a computer. The images can show our surgeons the fluid spaces and some basic anatomy of the brain. For babies it is a quick test with the only discomfort being a small amount of cold gel placed on the soft spot. A head ultrasound may not always provide the detailed anatomy required to make a surgical plan, but it is good tool to get a better understanding of the fluid spaces and follow changes that may occur.
Head computed tomography (often referred to as a head CT): This technology uses a thin x-ray beam that rotates around the head and provides detailed pictures of the brain and fluid spaces. There is a small amount of radiation associated with a head CT but at Children’s Hospital of Michigan our new CT scanner provides detailed pictures with very low dose radiation to help protect our young patients. A CT scan is minimally invasive as nothing touches the child and can be obtained in just a few minutes. Some age groups may find the equipment a bit intimidating.
Brain magnetic resonance imaging (often referred to as an MRI): An MRI uses strong magnetic fields and radio waves to create extremely detailed images of soft tissue like the brain and spine. An MRI is the longest of the 3 exams requiring approximately 45 minutes to complete. During this time children must remain extremely still, which means it often requires some sedation or anesthesia to obtain.
During your visit your Neurosurgeon will discuss the best imaging options for you and your child. If your child has ever undergone any of these tests it is helpful to bring the imaging on a disc as well as the radiology report to your first appointment. We would be happy to review and discuss them and it may help guide what tests may be beneficial to obtain.
What to expect from surgery:
If families decide with the guidance of their Neurosurgeon that a shunt procedure is required here is what to expect. Families will be given a date and time during their appointment. It is standard that children do not have anything to eat past midnight on the day of surgery. We understand this is difficult for our very young patients and take special care to schedule those surgeries as early in the day as possible. It is important you bathe your child and wash their hair either the night before or the morning of surgery to help prevent post operative infections.
On the morning your surgeon will review everything discussed in the office and be sure to answer any questions caregivers or children have. For longer surgeries, the OR staff will try to give periodic updates to the caregivers. There is some additional time required at the beginning of your child’s surgery while the anesthesia team places an IV and helps your child fall asleep.
A shunt requires two small (1 inch) cuts (incisions) be made on the head. We are careful to keep them within the hairline so that once the child recovers and the hair grows back they will not be detectable. An additional incision is made either near the collar bone (VAS) or beside the belly button (VPS). We are very careful to use small internal stitches to minimize scarring in an effort to be sensitive to children’s body image.
Following surgery you can expect a visit from your surgeon to discuss the operation. The children are often very sleepy still and you can rejoin them in our wake up area (PACU). Once they’ve begun to wake up they will head to our Neurosurgical floor. Following surgery there can be some incisional pain that is easily managed with pain medication. Our Nurse Practitioners and Physician Assistants remain in the hospital 24 hours a day to continuously evaluate your child’s recovery and address any pain they may have.
The Pediatric Neurosurgery Group has taken great pride to reduce infections following shunt surgery. Our surgeons completed a thorough evaluation of our entire process and applied many factors to protect your child from infection. Following surgery your child will receive three doses of antibiotics that specifically target the skin. This allows for healing to begin without creating antibiotic resistance. We continually reevaluate our infection practices and remain below national averages.
Most children will be discharged home from the hospital in 1 to 2 days following a shunt surgery or placement. Prior to discharge all follow up appointments will be made and reviewed with the family. A member of our team is also available 24 hours a day to provide teaching with all and any of a child’s caregivers. We understand this can all feel overwhelming and will support not just your child, but all caregivers and siblings every step of the way.
To care for the incision wash daily with a mild soap and dry gently. The incision on the head will have small clear sutures that will dissolve on there own in approximately 10 days. Patients should avoid submerging the incision completely underwater for 14 days following surgery, so this means taking modified baths and no swimming in pools or lakes.
On the incisions on the abdomen or collar bone you may notice small bandages or steri-strips covering the incision. These too are intended to get wet and can be washed with warm and soapy water the day after surgery. These will often fall off in 7-10 days and no further covering is required.
Caregivers and patients should monitor for any redness or swelling that occurs in the days or weeks following surgery. Rarely a superficial wound infection could occur and is easily treatable if detected early. Please notify the Neurosurgery department at (313)833-4490 of any redness, swelling, or drainage and one of Advanced Practice Providers will provide you immediate guidance, and a same day appointment if necessary.
A scheduled “wound check” appointment will be made 10-14 days after surgery with one of our Advanced Practice Providers. This is a good time to talk about returning to school, day care, or other activities. This is another great opportunity to sit and answer any and all questions now that the stress of the hospital is behind you. In addition to the wound check, a scheduled follow up with your surgeon will be scheduled for 4-6 weeks after surgery.