Pseudotumor cerebri is a rare medical condition that afflicts approximately 1 in 272,000,000 persons and is sometimes treated through Pseudotumor cerebri surgery or emergency surgical intervention. It has symptoms similar to that of a brain tumor and in layman terms means “false brain tumor.” This condition occurs due to the buildup of elevated pressure in the cerebro-spinal fluid inside the skull. Left untreated, this can cause severe headaches and vision problems.
Conventional forms of treatment:
- Medications such as acetazolamide or furosemide
- Corticosteroids may be used in some cases
- A weight loss regimen that emphasized on a low-sodium diet
- An aerobic exercise regimen
- Periodic lumbar punctures to remove excess cerebrovascular fluid
While most physicians attempt to treat pseudotumor cerebri through medication and weight loss, severe cases that do not respond to traditional treatment, may require surgery.
The most common type of surgical treatment involves the use of ventriculoperitoneal shunts. These shunts are used to drain out excess cerebro-spinal fluid which in turn relieves the pressure on the brain. In cases where the condition is causing optic nerve compression doctors may press the button for the Endoscopic Endonasal Approach.
Since this condition, can lead to blindness when left untreated, it is prudent that those experiencing the symptoms of pseudotumor cerebri must be evaluated by a specialist who has dealt with such cases in the past.
Based on the severity of the condition, the specialist may suggest various approaches.
Pseudotumor cerebri surgery on the eye
Vision loss is a common symptom and complaint among those who suffer from psuedotumor cerebri. So, if your primary symptom is trouble seeing things, rather than a nagging headache, you must consult an ophthalmologist.
A neuro-ophthalmologist will assess your symptoms and may recommend surgical intervention in order to bring down the swelling in the optic nerve. This procedure is known as optic nerve sheath fenestration. In many cases, this surgery is performed on an emergency basis when the doctor feels you are rapidly losing eyesight and to protect your vision.
What happens in an optic nerve sheath fenestration surgery?
An anesthesiologist and neuro-ophthalmologist will be present at the surgery. They will talk with you before the surgery begins to explain the entire process. While this procedure certainly reduces the risk of blindness, it may not cure the condition. Therefore, the surgeon may also mention the need for continued treatment post the surgery. If you are losing vision in both eyes, you may need to undergo surgery for both eyes, which will be done on different days.
The Pseudotumor cerebri surgery is performed in an operating theater. You will be made to lie on your back on an operating table and an anesthetic will be administered. Once you are asleep, the surgeon will prepare the eye, he is operating such that it remains open throughout the procedure.
A clasp may be used to keep it open. The surgeon then goes through a series of medical procedures and exposes the sheath of the optic nerve. Next, a number of small incisions will be made to release the pressure being exerted on the optic nerve.
What happens post surgery?
Once your surgery is complete, you will be moved to the recovery room where your vital statistics will be monitored till you gain consciousness. Once the anesthetic effect wears off and you are awake again, you will be moved to a room. You may have to spend one night at the hospital, so that your progress is monitored. Your vision as well as function of the pupil too will be checked. You will be prescribed an antibiotic to ensure your eye doesn’t contract an infection.
Your doctor may also prescribe anti-biotic steroid drops that will keep infection at bay and also alleviate pain. You will have to use this for the first week. Usually the recovery is rather pain free, and you will not need, an analgesic of pain killer additional to the drops. A follow up visit with the doctor will be scheduled one or two weeks post-surgery.
Pseudotumor cerebri surgery to implant a shunt
In certain severe cases of psuedotumor cerebri, doctors may suggest the placement of a shunt in order to drain the extra fluid. This procedure involves the implantation a small tube also known as a shunt or catheter into the chambers of your brain called ventricles. This shunt that is implanted allows the cerebro-spinal fluid to drain out into your abdomen, where it is absorbed by the body. A valve will be attached to the shunt so as to control how much CSF drains. This shunt basically does the following:
- Controls the amount of CSF is in your brain
- Prevents CSF from building up
- Helps in reducing pressure on your brain
- Alleviates your symptoms
What exactly is a shunt?
A shunt is used to drain out excessive cerebro-spinal fluid from the brain. It is a system that moves the fluid from one place to another. The system comprises of:
- Two tiny tubes also known as catheters
- A one-way valve that connects the catheters
This one way valve is similar to the size of a silver dollar when measured from one end to the other. However, it is quite thin and narrow. This valve plays an important role as it allows fluid to move only in one direction – away from your brain.
What is the mechanism of a shunt?
Shunts can be used in various locations to drain out excess CSF. Talk to your surgeon to understand more about the options available to you.
In most cases, one of the tubes is made to run from the ventricle in your brain towards the valve, while the other tube runs from the valve and into your abdomen. This sort of valve is known as a ventriculoperitoneal shunt.
In certain other cases, the first tube is placed into the lower spine, while the second tube is placed in your abdomen. This type of valve or shunt is called a lumboperitoneal shunt.
The second tube may also be made to end at a blood vessel near the heart or in the space surrounding the lungs, instead of the abdomen.
This shunt drains the extra spinal fluid and forces it to move into an area where it is safely absorbed by the body. The doctor can adjust the valve to control the flow and amount of fluid. This allows for the CSF build up to be monitored at all times. When excess amounts of CSF builds up in the brain, it will be drained using the valve. The valve also allows enough fluid to remain in your body to protect and cleanse the brain.
How is a shunt implanted?
You will need to undergo a surgical procedure for the shunt to be implanted in the body. Before the Pseudotumor cerebri surgery is performed the neurosurgeon will brief you about the procedure and also make you understand the risks involved. The anesthesiologist may also have a quick word with you before the surgery.
The shunt implant surgery too takes place in an operation theatre and takes no more than 30 minutes. The anesthesiologist will administer the right dose of anesthesia to put you to sleep through the procedure. He will be present from the start to finish, so as to monitor you through the entire surgery.
If you have been suggested a ventriculoperitoneal shunt implant, a small section of hair on your head will be shaved off. Your head as well as abdomen will be washed thoroughly so that the area is made sterile.
While you are under the effect of anesthesia, the neurosurgeon will make a small incision in your scalp. A small hole will be bored into your skill and one onto the protective covering of your brain.
A special imaging equipment known as intra-operative navigation will allow the surgeon to view the insides of your brain and help him locate the right place for the shunt to be implanted. An additional incision may be needed above or behind your ear that will help assist with the right placement of the tubing.
Once the preparations to place the shunt is made, one end of the shunt is lowered into the ventricle while the other end is connected to the valve. A second tube is connected to the other end of the valve before it is tunneled just under your skin and passed down to the abdomen below the ribs. This tubing is inserted into your abdomen via a small incision, or with the aid of a general surgeon who will use a laparoscope and two incisions.
Once the valve and shunt are implanted, the surgeon will bandage the incisions using sterile bandages.
This completes the procedure. You will then be shifted to the recovery room and monitored till the anesthesia wears off. Once you are fully awake, you will be moved to your room in the hospital. You may have to stay for a day or two for your progress to be monitored before you are discharged.
Are shunts visible after surgery?
A small lump just behind your hairline and right above your hair may be felt. This is where the valve is located. It will take but a few days for the hair to grow back in the area and cover it up. The shunt will not be noticeable to most people.
The doctor may advise you to limit certain activities in the first few days after discharge. For instance, you may not be allowed to lift anything that is 10 pounds or more in the first 4 weeks after surgery. You will also be advised not to drive if you are under narcotic pain medication.
Though the valve is placed beneath the skin and is protected, you must be cautious not to bump it. Have a medically trained person check your incisions every day and call the surgeon if you notice any signs of an infection. A few signs of infection include:
- Hot to touch
- Excessive bleeding
- A yellow or green discharge
- Incision emanating a foul odor
- Redness around the incision
- Incision getting bigger
- Redness and hardness around the incision
During the first few months after the surgery, you will be required to go for a number of follow up appointments. Your incisions and valve will be checked during the visits. The doctor will also inspect to ensure that the spinal fluid is draining correctly. Special equipment will be used to adjust the valve, which is something you cannot do on your own. Once the doctor is convinced that everything is alright, your checkups will be once a year.
In certain cases, the surgeon may also recommend physical therapy by a rehabilitation specialist if you are experiencing trouble in standing, walking, or even balancing.
Note: A magnet, such as the magnets used in an MRI, can affect the valve implanted beneath your skin and can also alter the setting. Therefore, it is important to let any doctor who writes out an MRI know that you have a shunt implanted. If you do go through an MRI, schedule an appointment with your surgeon’s clinic to have your valve inspected.
Will all the symptoms fade after surgery?
Once a shunt is implanted, you are bound to find awesome relief from recurrent headaches, nausea, vomiting, and dizziness. However, how much these symptoms will really improve depends on how serious they were before you had the surgery. In most cases the shunt improves vision dramatically.
All in all, a shunt implantation surgery will do wonders for you, if you suffer from psuedotumor cerebri that is affecting your quality of life. Contact a neurosurgeon to discuss your options and whether surgery will help your case.