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2013

Shunt-Free Treatment for Hydrocephalus

December 12, 2013

Meredith Vitrano was a happy-go-lucky 10-year-old Lacrosse goalie when she got smacked in the head by one-too-many shots. She kept on playing but that night she woke up vomiting with a headache that made her feel like her head was going to explode. Then, after a visit to her pediatrician and an MRI, she found herself at Johns Hopkins Children’s Center undergoing surgery for hydrocephalus, a term her alarmed mother had never heard before.

“I didn’t understand hydrocephalus, I thought it was something you could take medicine for,” says Leslie Vitrano of Cockeysville, Md. “We didn’t know there was no option other than surgery and a shunt.”

The shunt, consisting of a catheter and a valve, she learned, works by draining excess cerebral spinal fluid (CSF) from ventricles in the brain to the abdomen where it’s absorbed and recirculated. Without this device, excess CSF in the brain could build up to dangerous levels and result in developmental delays, intellectual disabilities or even death. But living with a shunt, the mother and daughter also learned, comes with its own set of serious challenges.

“Something was always going wrong, from stuck tubes to infections,” says Vitrano. “She had to undergo some 15 surgeries to repair or replace her shunt.”

“For some patients, it can be like having a chronic illness when your life depends upon a functioning shunt,” says pediatric neurosurgeon Edward Ahn.

Shunts do carry a risk of infection and sometimes fail, requiring ED visits, brain imaging and emergency surgery, explains Ahn, who over the years has taken advantage of innovations like antibiotic-infused catheters and programmable shunts to reduce infection risk and improve drainage. But the most exciting developments, Ahn says, are those that avoid traditional shunts altogether, including a procedure called endoscopic third ventriculostomy, or ETV. In this minimally invasive approach, Ahn uses a camera and miniature endoscopic tools to make a tiny hole in the floor of the third ventricle, allowing CSF to bypass the obstruction and reabsorb around the surface of the brain. How well does it work?

“It’s a tried-and-true procedure and has specific applications for children with a particular type of congenital hydrocephalus, where they have a blockage,” says Ahn. “It works very well with these infants, and we have good success in treating older patients who had a shunt placed at time of birth when this approach wasn’t around.”

Those patients include Meredith Vitrano, now a 24-year-old, who has been shunt free and symptom free since she underwent the procedure two years ago.

“Her whole life has opened up again,” says Leslie Vitrano, noting that her daughter has taken two charitable mission trips to Nicaragua since the operation. “We never would have allowed her to travel internationally with a shunt. We’ve had a wonderful outcome.”

Ahn, meanwhile, is making efforts to improve outcomes for more patients by combining ETV with endoscopic choroid plexus cauterization, or ETV-CPC. In this procedure Ahn sends an electrical current to the choroid plexus to reduce CSF production and thus the need for a shunt.

“We’ve been doing this in certain children with hydrocephalus where ETV alone has not been successful,” says Ahn. “For these patients, we’ve made ETV and life without a shunt a viable option. Our hope is that people who have this condition can live normal lives and not feel like they have a chronic, long-term disability.”
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