Miami Beach Woman's Symptoms Reversed after Surgical Placement of Programmable Shunt in Her Brain

Miami Beach resident Marcia Zitelli, now age 78, was always a very active person. She enjoyed exercising, walking, and socializing. Around her 70th birthday, she suddenly became extremely unsteady on her feet and would often fall. This unsteadiness became so severe that she needed to use a walker.

At the same time, Zitelli became confused and had difficulty remembering things.

"I even had trouble remembering what I had for lunch the previous day," she said.

Zitelli consulted with a neurologist who diagnosed her with Parkinson's disease and prescribed medications. A short time later, Zitelli began having problems with bladder incontinence and was forced to wear adult diapers. After several years of being on Parkinson's medications with no improvement of her symptoms in fact they seemed to be getting worse Zitelli was referred to internationally recognized neurological surgeon Santiago Figuereo, M.D. of Miami Neurological Institute (www.miamini.com), a private practice specializing in minimally invasive surgeries for spine and brain disorders.

Thankfully, for Zitelli, Dr. Figuereo was quite familiar with her debilitating symptoms.

"When these three symptoms confusion, incontinence, and balance issues present themselves in an older patient, they can be indicative of a condition called normal pressure hydrocephalus (NPH)," said Dr. Figuereo.

Definition and Diagnosis

NPH mainly occurs in people over the age of 60 and involves the buildup of cerebrospinal fluid (CSF) in the brain. Normally, CSF circulates around the brain and spinal cord, but when CSF does not properly drain, it accumulates in the ventricles and interferes with healthy brain function.

"NPH is very difficult to diagnose due to its symptoms being similar to other disorders, such as Parkinson's disease, Alzheimer's disease, or dementia," said Dr. Figuereo. There is no diagnosis test available to distinguish between them, therefore a differential diagnosis is based on a combination of clinical signs and symptoms, radiographic findings.

NPH most commonly affects the areas of the brain that control leg movement, bladder function, and memory. With proper diagnosis and treatment, many of these symptoms can be controlled or greatly reduced. In many cases, a complete recovery is possible.

Treatment

Increased pressure in the brain from excess CSF cannot be released by the body. Consequently, an alternative draining system " shunt" is necessary to relieve the pressure.

Dr. Figuereo treated Zitelli's NPH by surgically implanting a valve-regulating shunting system device called a programmable ventriculoperitoneal shunt. It is designed to prevent both under- and over-drainage of CSF from the brain by diverting the excess CSF to where it can be tolerated elsewhere in the body, such as in the abdomen. The system can also be regulated externally with a magnet control.

A general anesthetic was administered to implant the shunt. Dr. Figuereo made two incisions: a small incision in the abdomen and a curved incision in the scalp. The shunt was inserted through the ventricles in Zitelli's brain into the abdomen where her CSF is now absorbed. The system is completely contained inside Zitelli's body and cannot be felt.

Regulating the proper flow of CSF takes a period of time after shunt placement surgery. Sometimes the flow is too slow. Sometimes it is too fast, which can cause the patient to become symptomatic. In the past, some patients would require several surgeries to properly regulate the flow of fluid out of the brain. Now, Dr. Figuereo programs the shunt via remote control to regulate the CSF flow instead of taking the patient back into surgery.

Successful Outcome

Dr. Figuereo used a unique technique called craniotomy with hair preservation to avoid clipping and shaving Zitelli's hair before surgery. Experiencing brain surgery is an emotionally traumatic event for a patient even without the distress of living with a bald head post surgery.

"Dr. Figuereo was able to separate my hair and make the incision without shaving my head," said Zitelli. "I was so happy that I did not have to be hairless for several months after surgery."

Zitelli is now walking without assistance, and her bladder incontinence and confusion are significantly improved.

"It is a miracle that my symptoms are gone," said Zitelli. "I now have the ability to enjoy my life again."

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