Case (3):

(In 5 most famous hospitals in china)

A long-term delay for

1). frequent incorrect diagnoses

And

2). treatments of shunt and revision failures

(Revisional treatments of them)

Website:www.csfneurosurg.com

Case3：a long-term delay for frequent incorrect diagnoses

and treatments of shunt and revision failures in 5 famous

hospitals in china

1. Case3: female,19 years old(杨飘琪);

2. Her first VR-P shunt at 6/ 1/,2009: because her headache and walking difficultly for 3 days with

cerebral ventricular enlargement

3. 10 months and 25 days delay of diagnosis of shunt complications in total:

1. 7 months delay of a diagnosis of 1st shunt failure （occipital horn approach）

2. 1 month and 8days delay of diagnosis of 1st shunt revision failure （frontal horn approach）

3. 2 months and 15days Delay Of diagnosis of 2nd shunt revision failure in 2 famous hospitals

7 months delay of undiagnosed 1st shunt failure

(proximal catheter obstruction)

1. At 2/5/2010 (8 months later) : 1. fever plus headache with ventricular enlargement again,

2. treated by 3 days of influenza treatment and frequent shunt valve pressing . with a good result of an almost totally recovery

2. At 8/30/2010(2 more months later ): 1. she collapsed (fall on ground )again suddenly ，after a first fall on

ground several days earlier

2. In this time, much worse symptoms with strong tremors of upper and lower extremities ; change into an unconscious state for 3.5 hours ; unable of walking after conscious recovery

3. Recurred Hydrocephalus suggested and confirmed by Valve irresponsible to “pressing test” and brain CT san

3. At 9/1/2010： – 1st revision by changing a new cerebral shunt with a result of almost

total recovery for later 6 days after 6 hours of the revision

7 months delay of undiagnosed 1st shunt failure

(changes of neuroimmagings)

8/30/2010(2nd fall on ground)

2/25/2010(10 days after shunt failure)

7 months

(pressing valve?)

No “Valve” rebounding

After pressing

(Obstructed Proximal shunt

needed to be changed)

1 month and 7 days delay

for undiagnosed 1st revision failure

（by untypical neuroimmageing and clinical symptoms)

• At 9/6/2010(from 5th day to 3months after revision）:

– conscious confusion ; Urinary Incontinence; unable of sitting and standing

• Between 9/12/ and 9/17/ 2010(later 5 days in Shanghai): – After an MRI showing Enlarged Ventricles ,

– some symptoms becoming improvements and worsening in turns (playing cards all day or a extra long sleep )

– but some other symptoms still persisted: Eyes’ inactiveness (in a Daze）; drowsiness (somnolence) , and Hypersalivation (=sialorrhea= excess water out of mouth )

• Between 9/17 and 10/13/ 2010(in 26 days in Hangzhou): 1. All above symptoms appeared and became worse progressively later on

2. CSF pressure by lumbar puncture:140mmH2o

3. negative CSF culture

4. Leukopenia treated by proper drugs 5. CT: Slit ventricle （“water absent in ventricle ” or small ventricle ）

6. At 10/13/ 2010: Removal of the whole shunt system due to shunt exposed in the surgical wound of the head

1 month and 7 days delay for undiagnosed 1st revision failure

(changes of neuroimmagings)

9/7/2010(5th day of clinical

worsening after 1st revision) 9/12/2010(in shanghai )

9/29/2010

(shunt exposure in wound)

10/142010(1day after shunt removal)

In Zh2

Hospital

In danger!

Why is 2nd revision performed in emergency

and is 2 months and 15days delay for undiagnosed

2nd revision failure?

1. At 10/14,2010(in Hangzhou): 2nd revision (frontal horn approach): Inserting a programmable V-P shunt again in emergency because

removal of the shunt only one day before caused ventricular enlargement again and for approximate 3 hours of persistent behaviors:

1. Strong shaking or tremor-like actions of both upper and lower extremities,

2. Firmly closed Mouth

3. Loud noises made by strongly chewing

2. After 2nd revision: No clinical improvement at all even for any time;

3. 2 months and 15days Delay of diagnosis of 2nd revision failure in 4 famous hospitals of China in total

Why is 23 days Delay Of diagnosis of 2nd revision failure in 1st hospital

(in Hangzhou)? (undiagnosed Valve obstruction)

1. Pressure-down adjusting of shunt for “ underdrainage ” (10/16/2010,1day after revision) :

1. because no improvement at all after the revision plus CT scan of Ventricular enlargement or Normal Ventricles

2. Adjustment from high to low pressure and pressing of the Valve for 5 hours

3. with good resultant respects in “normal Ventricles” and abilities of eyes' opening and liquid-food seating

4. Without any good respects in motor inability of both upper and lower extremities ; strong shakings and tremor of right upper and left lower (Cruciate ) extremities (cervicomedullary junction?) ; expressionless (amimia) ; Aphasia (speechlessness )

2. Actually failed adjustment of pressure-up adjusting of shunt for “overdrainage- Slit Ventricles ”(10/18/2010 ) (Actually failed adjustment conformed by X-rays )

1. 1 day later: Clinical improvement with a recovered ability of opening eyes and answering some simple questions

2. 2 day later: Clinical improvement with a recovered ability of writing, but remaining tremor and hypertonia of both upper and power extremities

3. “Successful ” adjustment of pressure-up re-adjusting of shunt for “overdrainage- Slit Ventricles ” ”(10/24/2010 ): (“Successful ” adjustment un--conformed by X-rays )

1. A Back-adjusting try from medium to high pressure

2. “Normal Ventricle” (a meaning of ventricular enlarged from a “slit to normal” state)

3. All the improved symptoms returning back to worsen with lost abilities of opening eyes and answering some simple questions again

4. 3 days later (10/27/2010): “Normal Ventricles” by CT re-exam ,and in conclusion: “akineticmutism belonging to neurologist” after discussion by all the (more than 60 neurosurgeons) of its 10 subunits of neurosurgical department

Why is 23 days Delay Of diagnosis of 2nd revision failure

in 1st hospital (in Hangzhou2)? (changes of neuroimmagings)

10/27/2010(“normal” by up-adjusting)

10/18/2010 10/20/2010

10/24/2010

The worst clinical behaviors

“Akinetic mutism?”

in the final conclusion 11/6/2010 (still “normal” ventricle)

Why is 23 days Delay of undiagnosed 2nd revision failure in

2nd hospital (in Beijing)? (undiagnosed Valve obstruction)

Two different opinions form two famous neurosurgeons, based on CT scan at 11/12/2010, in a famous-in-neurosurgery hospital :

1. One expert good at shunting for hydrocephalus having the opinion:

1. Totally successful for the shunt and no need for ETV revision;

2. Asking the patient go to consult neurologist and Rehabilitation physician

2. An another expert good at neuroendoscopic surgeries having the opinion: :

1. slit ventricle syndrome

2. So, Need to treat by 3 steps:

1、Making “slit ventricle” larger enough to perform ETV under neuroendoscopy

2、Making a ventriculography to differentiate a communicating or obstructed hydrocephalus

3、Doing a ETV under neuroendoscopy (try to get rid of shunt )

11/26/2010

First CT

In Tiantan hospital

Problems in making “ silt ventricle ”larger

and maybe in getting a failed ventriculograghy

12/3/2010(up to 2.0) 12/7/2010(up to 2.5) 12/13/2010

(having to waiting )

12/16/2010 12/21/2010

12/30/2010

Fortunately, a planed ETV at 12/29/2010

is refused by patent’s father

(so low rate of success:1/6 or fewer ):

“ slit ventricle” recurred again

3 days fever

At 1 day before beginning CSF treatment after

10 days delay of diagnosis by ourselves

ballet dancers

On Pointe

or

“en pointe feet”

1/13/2010(1 day before treatment)

Good results by CSF treatment

(neuroimmagings)

2/24/2011(treatment for 1month)

8/1/2011

5/10/2011(obstruction of Monro)

5/20/2011 (much recovery in all respects)

By pellucid septostomy

By shunting

8 months of CSF treatments

with a significant clinical recovery when discharge

(total recovery 2 months after discharge)

8/10/2011(At discharge) 8/13/2012(1yr after discharge)

6/7/2011(5 months treatment)

7/8/2011

(6months

treatment )