TYPE OF SHUNT FOR HYDROCEPHALUS

Hydrocephalus is a condition in the brain in which there is an accumulation of cerebrospinal fluid (CSF) in the
ventricles, which then increases the intracranial pressure within the skull.
There are different treatments available for those with hydrocephalus depending on many individual
factors, but often can involve insertion of a shunt.

A shunt allows the excess CSF to drain to a different part of the body. In the older patient with idiopathic
normal pressure hydrocephalus, insertion of a VP shunt shows improvement rates in between 61-90% of
patients presenting with this condition. Idiopathic normal pressure hydrocephalus is often diagnosed
in older adults and is characterized by gait disturbances, cognitive impairment and urinary incontinence.

Different Types of Shunts-

The different types of shunts used most commonly
include ventriculoperitoneal (VP) shunts, ventriculoatrial (VA)
shunts or a lumboperitoneal (LP) shunts).

Shunts will generally consist of three components:

 An inflow catheter – This drains the CSF from the ventricles. It
leaves the brain through a small hole in the skull, which then runs under the skin.
 A valve mechanism – This regulates the pressure control through the shunt tubing. It is connected to the
catheter and lies between the skin and the skull, usually on top of the head or behind the ear.
 An outflow catheter – This runs under the skin and moves the CSF from the valve to the peritoneal cavity,
heart or other drainage site.

As with any procedure, every shunt and every person with a shunt is different. So what works for one
person may not necessary be ideal for the next. This is why some valves can be adjustable, which means
that instead of having a fixed pressure valve at the same value for everyone, these adjustable valves can
be readjusted by a clinician according to patient need (Hydrocephalus Association 2017).

Ventriculoperitoneal (VP) Shunt

VP shunts are the most common type of shunt for draining excess CSF.
These shunts generally contain a pressure-sensitive valve that releases CSF
once the pressure reaches a certain level . In VP shunts, a catheter is inserted
into the ventricle with tubing tunnelled subcutaneously down the thorax and
then further tunnelled into the peritoneal cavity where the CSF is absorbed.

Ventriculoatrial (VA) Shunt

VA shunts are less common than VP shunts and the only difference between them is that rather than
finishing in the peritoneal cavity, the VA shunt finishes in the right atrium of the heart and CSF is absorbed
via our blood stream.

Lumboperitoneal (LP) Shunt

An LP shunt consists of a catheter inserted between two lumbar vertebras into the thecal space, which is
then tunnelled around the abdomen into the peritoneal cavity for absorption (Rinker et al. 2015).
Complications of Shunts
As with any surgery, the insertion of shunts doesn’t come without risks. These risks include mechanical
obstruction of the shunt, infection, and subdural haematomas.

These complications can be divided into two categories as either arising from:
1. A mechanical complication; or
2. A biological complication.

Mechanical complications of a shunt include:

 Malfunctions such as leaks, obstruction, migration or discontinuity.

Whereas the biological complications of a shunt include:

 Infection
 Abscess
 Pseudocyst
 Haemotoma; and
 Peritonitis.
The complication rates following insertion of a shunt tend to be high, with up to half of people
experiencing some type of complication and needing shunt revisions. Generally with these complications
there is often an overlap of both biological and mechanical factors that cause the problem (Rinker et al.
2015; Saehle et al. 2014).

So what happens when there is an over drainage from the shunt?

Over drainage from the shunt can result in the ventricles decreasing in size and their meninges pulling
away from the skull. This is a condition often called slit-ventricle syndrome. This complication is one
that is more common in young adults who have had a shunt in place since childhood. The person with slit
ventricle syndrome will often complain of severe but intermittent headaches that are often only relieved
when lying down (Hydrocephalus Association 2017).
Under drainage of shunts has the opposite problem and will cause the ventricles to increase in their size.
This will be in conjunction with the individual also not experiencing any relief of their previous symptoms
of hydrocephalus. When this occurs, the patient may need a revision of their shunt, or if the person is able
to adjust their pressure valves externally, they will need to be reviewed and readjusted (Hydrocephalus
Association 2017).
Shunt infection tends to be one of the most common biological complications that occur in these
individuals. They can be quite significant, as infection can have further implications and detrimental
effects on the individual including abscess formation or shunt occlusion. If infection occurs, generally
the shunt will need to be revised (Rinker et al. 2015).
Peritonitis can also occur with VP shunts where the individual displays general signs and symptoms of
infection in conjunction with abdominal pain.
When the patient with a VP shunt complains of abdominal pain, the formation of an abdominal abscess
also needs to be excluded. These abscesses can occur from many different ways including shunt
contamination or from the shunt migrating into the bowel (Rinker et al. 2015).
A CSF pseudocyst is a rare complication of VP shunting and it is unclear as to what causes them. They
will generally develop some time after the shunt has been placed – sometimes up to years down the track.
VP shunts can also become obstructed. This may be due to the catheter disconnecting, migrating or even
fracturing (Rinker et al. 2015). The shunt can become blocked in any part from the ventricular catheter in
the brain, to the distal part of the catheter where it is draining.
Symptoms of a VP shunt obstruction are those seen with increased intracranial pressure, which could
include: headache, vomiting, lethargy, irritability and confusion

Nursing Care of a Patient with a Shunt-

Nurses need to be monitoring the patient with a shunt for any of these complications. If they suspect any
of these complications are occurring, they need to act immediately, as a delayed response can have dire
consequences for the individual.
It is also important to note that some of these complications can occur any time. If your patient has had a
shunt for five years, they can still be at risk of complications occurring. So, with your patient with a
shunt, never stop monitoring for complications.