Radionuclide Shuntography for Evaluation of V-P shunt in Hydrocephalus Dr ZM Jawa MBBS, MSc, FMCR, FCNP, FEBNM Senior Consultant Nuclear Medicine Physician European Board Certified in Nuclear Medicine Abuja, NIGERIA

Address Introduction to shuntography Hydrocephalus and Shuntograms Malfunction Available techniques to investigate shunts Radionuclide shuntography technique,interpretations, complications, suboptimal scan Our experiences

Introduction Radionuclide shuntography is a safe and simple method of determining CSF shunt patency and analyze change in CSF flow( functional study) Shunts are permanent treatment option for patient with Hydrocephalus V-P, V-Pleural, V-atrial, V-jugular, V- gallbladder.

Hydrocephalus Prematurity (posthaemorrhagic hydrocephalus) Meningitis Congenital e.g. encephalocele Head trauma Brain tumours

Ventriculoperitoneal Shunt Permanent curative options for hydrocephalus Surgical procedure is invasive and not readily available, requires expertise Shunt tubes are expensive There is significant improvement in the quality of life of patients with hydrocephalus post shunt. Regular assessment of shunt for function is important.

Types of CSF shunts

Ventriculo-Peritoneal Shunt Tube 3 Parts ventricular catheter Reservoir( Valve) Distal catheter

Reservour

Malfunction Infection, usually occurs within 3mt postoperative Mechanical failure Inflammatory debris Fractures of tube Failure of valve system of reservoir

Clinical Presentations of Malfunction V-P shunt tube Progressive head enlargements Shuntalgia syndrome, Headache, pain and tenderness on reservoir site, muscular weakness, urinary incontinence

investigations Plain Xrays CT and MRI Intracranial pressure monitor Transfotanelle Ultrasound Radionuclide shuntography

Technique Under strict aseptic technique Using insulin syringe, tilted at 30-45 degrees at 1-2cm below the reservoir Withdraw CSF ,Inject normal saline to ascertain that needle is insitu Inject radiopharmaceuticals; Tc99m DPTA Acquire dynamic and static images. After care: very important

Complications Puncher of reservoir Extravasations of Radioactivity Bleeding Infection CSF pseudocyst

Suboptimal study Uncooperative child Extravasation Bleeding, early Tc99m uptake in stomach Older children, inadequate volume of Radioactivity

Our Experience; Total of 56 patients, 32 males, 24 females Age range, 5-11yrs Results Normal functioning shunt: 18 Total blocked tube(Mechanical): 7 Partial block tube( infection or debris):29 Inconclusive or suboptimal: 2

Conclusion Radionuclide shuntography is a simple, cheap, safe and non-invasive method of evaluating CSF shunts. No existing protocol for RS but critical attention to details ,observation of strict aseptic technique and close collaboration between the Nuclear medicine physician, Pediatricians and Neurosurgeons would improve diagnostic accuracy.

Attention to details and precision

Conclusion About 45% of our patients with suspected V-P tube malfunction had partial blockage. Patients who are diagnosed with a partial tube blockage will require only flushing of the tube and antibiotics treatment, while mechanically block tube will require replacement. This distinction is critical considering the cost of replacement of tube and manpower time for surgery.

Thank you