• Ventriculoperitoneal shunt (VP shunt) adalah alat yang dipasang

untuk melepaskan tekanan dalam otak.

• VP shunt direkomendasi bagi pasien yang menderita hidrosefalus.
Kondisi ini disebabkan oleh cairan serebrospinal (CSF) berlebih
yang membuat perluasan ruang dalam otak (ventrikel) menjadi
sangat cepat, sehingga memicu tekanan yang tak semestinya. Jika
tidak segera ditangani, kondisi ini dapat berujung pada kerusakan
otak.
• Cairan serebrospinal adalah komponen yang sangat penting dalam sistem saraf, karena berfungsi
menciptakan bantalan bagi jaringan otak dan menyalurkan zat gizi ke otak. Cairan ini mengalir di antara
tulang belakang dan tengkorak untuk memastikan bahwa volume darah intrakranial dalam kadar yang
tepat. CSF akan terus diproduksi karena mengalir sepanjang ventrikel, menutrisi permukaan otak dan
sumsum tulang belakang. Kemudian, cairan ini keluar melalui bagian dasar otak dan diserap ke dalam
aliran darah. Namun, karena kelainan tertentu, aliran dan keseimbangan CSF akan terganggu, sehingga
terjadi penumpukan.
• Ventriculoperitoneal shunt adalah pengobatan utama bagi kondisi hidrosefalus, yang menyerang satu
dari 500 anak. Kondisi ini merupakan kondisi bawaan (kongenital) atau didapat, dan indikasi yang paling
nyata adalah pertumbuhan lingkar kepala yang tidak wajar.
• Biasanya, gejala pada anak disertai dengan mata juling (strabismus) dan kejang-kejang. Sedangkan pada
orang dewasa, gejala hidrosefalus adalah sakit kepala, mual dan muntah, saraf optik membengkak,
penglihatan kabur atau ganda, mudah marah, lesu, dan perubahan kemampuan kognitif atau ingatan.
Penyebab hidrosefalus belum diketahui secara pasti.
• Operasi VP shunt dilakukan pada pasien yang menderita hidrosefalus. Umumnya, prosedur bedah
dilakukan segera setelah pasien terdiagnosis hidrosefalus untuk mencegah komplikasi serius.
• Untuk memastikan bahwa pasien positif terjangkit hidrosefalus, maka perlu dilakukan serangkaian tes,
seperti USG, Magnetic Resonance Imaging (MRI) atau Computed Tomography (CT) scan. Jika telah
terbukti mengidap hidrosefalus, maka pasien secepat mungkin dirujuk pada prosedur VP shunt.
• Dengan prosedur operasi, kandungan CSF berlebih akan dikeluarkan agar volume otak kembali normal.
Penting untuk diketahui, prosedur ini tidak mampu memperbaiki kerusakan otak yang telah terjadi.
Tujuan utama VP shunt adalah mencegah kerusakan yang lebih parah, yang kemungkinan terjadi bila
penanganan medis tidak segera dilakukan.
VENTRICULAR SYSTEM
FUNCTIONAL CLASSIFICATION

Two main functional subdivisions of hydrocephalus (HCP)

1. obstructive (AKA non-communicating): block proximal to
the arachnoid granulations(AG).

2. communicating (AKA non-obstructive): CSF circulation

blocked at level of AG
SPECIAL FORMS OF HYDROCEPHALUS
AND "PSEUDOHYDROCEPHALUS"
1. conditions that are not actually hydrocephalus "pseudohydrocephalus“
A. hydrocephalus ex vacuo: cerebral atrophy
B. otitic hydrocephalus
C. external hydrocephalus
D. Hydranencephaly

2. normal pressure hydrocephalus (NPH)

3. entrapped fourth ventricle

4. arrested hydrocephalus
NORMAL PRESSURE HYDROCEPHALUS
-ADULT FORM OF HYDROCEPHALUS-
As originally described, the hydrocephalus of NPH was considered to be
idiopathic.
"secondary NPH“ causes:
1. post-SAH
2. post-traumatic
3. post-meningitis
4. following posterior fossa surgery
5. tumors
6. also seen in some patients with Alzheimer's disease (AD)
7. deficiency of the arachnoid granulations
8. aqueductal stenosis
CLINICAL TRIAD HAKIM TRIAD

1. gait disturbance
2. dementia: primarily memory impairment
with bradyphrenia (slowness of thought)
and bradykinesia
3. urinary incontinence
OTHER CLINICAL FEATURES

Age usually> 60 yrs.

Slight male preponderance.

Differential diagnosis
- Alzheimer's disease
- Parkinson's disease
HYDROCEPHALUS CLASSIFICATION

• Congenital
• Acquired
CONGENITAL, USUALLY PAEDIATRIC

A. Chiari Type 2 malformation and/or myelomeningocele (MM)

B. Chiari Type 1 malformation
C. primary aqueductal stenosis of Sylvius aqueduct
D. secondary aqueductal gliosis
E. Dandy Walker malformation: atresia of foramina of Luschka & Magendie
F. X-linked inherited disorder: rare
ACQUIRED
A. infectious
1. post-meningitis
2. cysticercosis
B. post-hemorrhagic
1. post-SAH
2. post-intraventricular hemorrhage (IVH)
C. secondary to masses
1. non neoplastic: e.g. vascular malformation
2. neoplastic: e.g. Medulloblastoma, pituitary tumor
D. post-op: following p-fossa tumor removal.
E. Neurosarcoidosis
F. "constitutional ventriculomegaly": asymptomatic. No treatment required.
G. associated with spinal tumors
TYPES OF SHUNTS
SHUNT TYPE BY CATEGORY
1. ventriculoperitoneal (VP) shunt:
A. most commonly used shunt
B. lateral ventricle is the usual proximal location

2. ventriculo-atrial (VA) shunt ("vascular shunt"):

A. ventricles -> jugular vein -> superior vena cava
B. treatment of choice when abdominal abnormalities are present

3. Torkildsen shunt:
A. shunts ventricle to cisternal space
B. rarely used
C. effective only in acquired obstructive HCP
TYPES OF SHUNTS
4. miscellaneous: used historically or in patients who have had significant problems
with traditional shunt locations:
A. pleural space (ventriculopleural shunt): not a first choice, but a viable alternative if
the peritoneum is not available.
B. gall bladder
C. ureter or bladder: causes electrolyte imbalances

5. lumboperitoneal (LP) shunt

- only for communicating HCP

6. cyst or subdural shunt: from arachnoid cyst or subdural hygroma cavity, usually to
peritoneum
VENTRICULOPERITONEAL SHUNT
Peritoneal catheter
For small children, use at least 30 cm length of intraperitoneal tubing
to allow for continued growth (120 cm total length of peritoneal
tubing recommended).
A silver clip is placed at the point where the catheter enters the
peritoneum so that the amount of residual intraperitoneal
catheter can be determined on later films.
Distal slits on the peritoneal catheter may increase the risk of distal
obstruction, and some authors recommend that they be trimmed
off.
OPEN TECHNIQUE: A VERTICAL INCISION LATERAL AND
SUPERIOR TO THE UMBILICUS IS ONE OF SEVERAL
CHOICES.

Layers
1. subcutaneous fat
2. anterior rectus sheath
3. abdominis rectus muscle
fibers: should be split
longitudinally
4. posterior rectus sheath
5. preperitoneal fat
6. peritoneum
Trocar technique:
1. place a Foley catheter to decompress the bladder
2. 1 cm skin incision above and lateral to the umbilicus
3. pull abdominal skin anteriorly (away from patient)
4. insert trocar aiming toward the ipsilateral iliac crest
5. feel 2 "pops" of penetration: 1 = anterior rectus sheath, 2 = posterior rectus
sheath/peritoneum
6. peritoneal catheter should feed easily through trocar
VP SHUNT, POST-OP ORDERS (ADULT)

1. flat in bed
2. if peritoneal end is new or revised, do not feed until bowel sounds resume (at least 24 hrs)
3. shunt series (AP & lateral skull, and chest/ abdominal x-ray) as baseline for future comparison
DISADVANTAGES/COMPLICATIONS OF VP
SHUNTS:

A. inguinal hernia
B. need to lengthen catheter with growth
C. obstruction of peritoneal catheter
D. peritonitis from shunt infection
E. hydrocele
F. CSF ascites
G. tip migration
- into scrotum
- perforation of a viscus: stomach, bladder
- through the diaphragm
H. intestinal obstruction (as opposed to perforation): rare
I. volvulus
J. intestinal strangulation
K. overshunting: more likely than with VA shunt. Some recommend LP
shunt for communicating hydrocephalus.
MISCELLANEOUS SHUNT HARDWARE
1. tumor filter: used to prevent peritoneal
or vascular seeding in tumors that may
metastasize through CSF (e.g.
medulloblastoma, PNETs,
ependymoma); may eventually become
occluded by tumor cells and need
replacement;
2. antisiphon device: prevents siphoning
effect when patient is erect
3. "horizontal-vertical valve" (H-V valve)
used with LP shunts to increase the
valve resistance when the patient is
vertical to prevent overshunting
4. variable pressure valves that may be
externally programmed
5. on-off device: used to open or occlude
shunt system by external manipulation
of shunt
PROGRAMMABLE SHUNT VALVES
• Components
• Inlet occluder
• Reservoir
• Outlet occluder

One-way valve
Pressure settings
SHUNT PROBLEMS

• Problems associated with shunt insertion

• Problems in patients with established CSF shunt
PROBLEMS ASSOCIATED WITH SHUNT
INSERTION

1. intraparenchymal or intraventricular hemorrhage

2. Seizures
3. malposition
A. of ventricular catheter
B. of distal catheter
4. infection