On shunt types and a bit about her today...

I just want to share the look of the programmable and non-programmable shunt (as mentioned by Jiey) in this entry. One of the well-known manufacturers is Johnson & Johnson's CODMAN® (others are Medtronic, NeuroCare Group - manufacturers of Heyer-Shulte shunts, NMT Neurosciences and Phoenix Biomedical). You can see the programmable shunt as below:

Neurosurgeons can pre-select one of 18 different pressure settings. After implantation, the valve can be adjusted non-invasively to adapt to changes in patient condition. That means surgeons are able to make precise pressure adjustments to help control intracranial pressure and ventricle size at any time."

This is actually to avoid a patient from having multiple surgeries. But according to Monica, a 34-year-old shunt recipient, there's a side affect that she called 'bruised feeling headache'. She was previously used a non-programmable shunt for 19 years! Perhaps, she's adapting to her new shunt.

More info please feel free to visit here and here (PDF format). Also to Monica's site - here.

Another type is non-programmable, the one my daughter is using (not sure from which company).

OSV II® Smart Valve™ System by Integra.

It's not a sole manufacturer. There are others too.

This is the advantages that I read in its web:

1- Automatic Pressure Response: Automatically adjusts to conditions present, eliminating the need for pressure range changes or programming.

2- MRI-safe: Materials of construction allow for compatibility with MRI and are not interfered with by household magnets, as many programmable valves are.

3- Anti-siphoning stage: Balances the CSF secretion rate with drainage rates automatically, regardless of patient position, and is unaffected by position or subcutaneous pressure or fibrosis.

4- Minimized Ventricular Catheter Obstructions: Avoids rapid decrease of ventricular size, minimizing the risk of proximal obstruction.

5- Physiological Response: Maintains physiologically negative ICP when patient stands.

6- Time and Cost-Saving Advantages: Eliminates the need for additional surgeries for pressure adjustment or for stocking a range of valves.

7- Easy-to-Use Design: Tests easily to assess patency. Available in a variety of configurations, including a choice of separate or integral ventricular catheters.

As I spoken to her father this afternoon, he said that the specialist has chosen the low pressure shunt this time. He was spoken to Dr. Huang. Haven't had the chance to see that yet as I'm not fully ready physically (what a selfish mom! I'm not feeling A-ok right now. *Sigh*).

She was in the OT room around 10.30 am and finished around 1.00 pm something just before my husband told the nurses that he wanted to go out for the Juma'at prayer today. Alhamdulillah, she's safe and he sent me her picture through GPRS. Until now, she's still sleeping and the drip is on, meaning that she's not breaking her fast yet.

I'm eager to see her as I miss her so much! And I miss to shoot her photo after the operation by myself too!!

Serba-sedikit tentang shunt...

Pada mulanya saya ingin menjawab komen Anon di entry sebelum ini pada ruangan komen saja. Tapi rasanya ruang terhad. Lagi pun pendedahan kepada masyarakat itu perlu agar masyarakat yang kurang arif dapat sama² memahami. Supaya maklumat yang mereka terima juga betul. Walau macamana pun, thanks to him or her for suggesting that.

Untuk pengetahuan semua, pakar neuro di Malaysia ada di banyak tempat antaranya HKL (yang tertua), HSB, Hospital Besar Pulau Pinang dan termasuk jugalah di USM Kubang Kerian, Kelantan.

Ada lagi di tempat lain yang tidak perlulah saya senaraikan tapi pakar ini tidak ramai dan tidak semua hospital ada. Penyakit yang berkaitan dengan neuro juga banyak. Antaranya hydrocephalus (tak sukar nak tahu penyakit anak saya, bukan... di sub-tajuk blog jelas tertera). Kena tahu ke mana harus kita pergi untuk mendapatkan rawatan.

Untuk makluman juga, shunt bukanlah bergantung kepada pakar neuro. Shunt ini banyak jenisnya. Yang kecil, yang besar. Jenama dan design juga pelbagai. Walau pun begitu, prosedur yang digunapakai oleh setiap pakar neuro adalah sama. Tanam dari kepala sampai ke perut (yang biasa).

Pemakaian shunt bergantung kepada kesesuaian. Untuk mencari kesesuaian itu, pakar perlu mencuba ke atas seseorang pesakit tanpa mengetahui apakah natijahnya pada si pemakai. Maksudnya mana² pakar sekali pun takkan tahu sampai bilakah shunt itu akan bertahan. Tak kiralah dia di HSB ke, di USM Kubang Kerian ke, hatta di mana² saja di muka bumi ini.

Apa dia sebenarnya shunt ni?

It is a drainage system which will transport the excess of CSF collected in the head to other parts of the body where it can be reabsorbed. The most frequent places are the abdomen and the heart."

Saya bagi satu contoh. Di dalam salah satu entry saya telah menceritakan tentang Kak Rosliza dan anaknya yang berusia 23 tahun, salah seorang penerima shunt (simply just type her name to search for the entry). Sepanjang hidup anaknya, hanya 2 kali dilakukan pembedahan untuk menukar shunt. Shunt yang pertama ditanam di kepalanya pada usianya 4 bulan. Dia menukar shunt pada usia 5 tahun di HKL (sama tempat). Dan kali kedua di HSB pada usia 18 tahun.

Lihatlah... adakah ia bermaksud HSB tidak competent? Tidak... kerana shuntnya yang terakhir telah bertahan selama 5 tahun. Ia juga bermaksud kami boleh bertukar hospital. Tapi bukannya senang untuk memindahkan 5 fail Syafiah yang rata²nya setebal 4 inci setiap satu.

Ada satu lagi kisah yang saya tidak pernah ceritakan. Iaitu cerita kak H. Anaknya lahir di HSB dengan IVH. Jadi hydrocephalus juga. Dia menolak dengan keras untuk dilakukan shunt pada bulan² terawal kelahiran. Alasannya, untuk mencuba rawatan alternatif.

Pada satu peringkat, dia membawa anaknya ke HKL untuk 'membuka fail baru'. Tapi HKL juga merujuk semula kes berkenaan kepada HSB. Akhirnya, anaknya tidak memakai shunt. Mungkin kerana alah malu dengan pakar di HSB.

Bukanlah mudah untuk memindahkan kes dari satu hospital ke hospital yang lain. Tambahan pula saya tinggal di Sungai Buloh. Nak pindah kes ke Kelantan dah satu hal. Kalau shunt dia tak perlu tukar lagi tak pe la juga, tapi kalau perlu macamana? Tidak perlukah saya memikirkan tentang suami saya, tentang anak² saya yang lain?

Dalam salah satu entry juga saya menceritakan tentang Sherman Alexie, Noah dan William dalam entry 'They Cut Open My Head'. Dengan mengambil kata² Dr Avellino:

We do have a treatment but shunts are like used cars. They actually break down. That's why many times so many surgeries are needed. Some children might have to have two or three repairs. Other kids, 30 or 40!"

Macamana ia berfungsi?

Each shunt has 3 parts:





1- Ventricular catheter: a small flexible tube which goes in the brain, in one of the cavities where the CSF is being retained.

2- Reservoir : a small pump which regulates the amount of fluid that goes out. Through this the doctor can also check the working state of the shunt, as well as take CSF samples, when necessary, with a needle.

3- Distal catheter: another flexible tube that will take the fluid to the place where it is going to be absorbed. It is usually left with sufficient length, thinking in the child's growth..

The shunts regulates the draining pressure. There are different levels of pressure, as high, medium and low. There are also some differences in the design but the means is always the same.

Kenapa shunt gagal berfungsi?

Ingat... shunt merupakan "foreign body" di dalam pesakit dan tiubnya diperbuat daripada bahan sintetik. Oleh yang demikian, kegagalan untuknya berfungsi boleh disebabkan beberapa perkara di bawah:

- halangan yang disebabkan oleh CSF atau apa² debris.
- kebarangkalian komponen²nya yang tidak bersambung.
- ia patah (usually the distal end).
- mana² catheter atau reservoir keluar dari tempatnya (happened to 1st revision. Reservoirnya terkeluar dari tempat yang sepatutnya).
- shunt mengalirkan CSF yang kurang dari sepatutnya (happened to this time revision).
- jangkitan kuman (happened to 2nd revision).

Setiap ibu yang mempunyai anak yang memakai shunt memang berharap agar tiada lagi shunt revision. Setiap hari ibu² seperti kami akan berasa risau, tertanya-tanya sampai bilakah shunt yang ditanam itu akan bertahan, adakah jika memegang si dia begini akan menyebabkan shuntnya rosak? Dan lain² lagilah. Anak terasakan begitu rapuh (seems like she's fragile).

Semuanya bergantung kepada janji Allah jua. Jika Allah takdirkan shunt Syafiah yang sebelum ini bertahan tak sampai sebulan, ia tetap akan rosak bila sampai waktunya walau pun yang membedah tu pakar dari USM Kubang Kerian sekali pun. I just pray that this time will last long... ameen.

So, for people out there.. please.. please get informed. Jadikanlah kita bangsa berilmu!


p.s. : Glad to read that Violet, Sarah's daughter has been using the same shunt for 3 years! Go go Violet! Glad that I'm emotionally stable too today...