UNDERSTANDING “IIH” – FAQ’S

“(the cranium is) Just like carry-on luggage, only so much can fit…one pair of socks to many, and the seams start to strain.”

I’ve only lived with IIH for a few years – much less time than many, many others I encounter in support forums.  Lately I’ve taken notice of newly diagnosed patients who seem to be as perplexed at the lack of information and explanation of their condition as I remember being in 2017 when I was told “Nobody knows nothing about IIH.” (paraphrase). 

Judging by the bewildered posts of new members of our auspicious group, there hasn’t been much change.

What follows is the beginning of a “Frequently Asked Questions” section of Shuntwhisperer.  The information here is a combination of 1) my personal experience, observation of others with IIH/PTC/ETC, 2) published research that is fairly abundant for a disorder that seems to amount to a Black Hole of Understanding, 3) readily accepted tenets of human physiology, and 4) the babblings and savante-garde notions of a guy with a hole in his head and a tube in his brain.

Fair warning, take it for what its worth ; )

In all seriousness, I pray this helps those seeking answers, and as always, it’s not about me being right, it’s about getting others to think and talk about IIH in the hopes that this dialog will spark understanding and improved quality of life for everyone. 

Thus, with the timelessness of the inspired dialog of Shakespearean-trained actor Patrick Stewart,

“ENGAGE!”

 

FREQUENTLY ASKED QUESTIONS ABOUT IIH

Short Answers First, Technomedical Stuff Second

WHAT IS “INTRACRANIAL HYPERTENSION”?

Short Answer:

“Intracranial Hypertension”, or “IIH”,  is one name for a group of complex disorders in which an individual develops physical signs and symptoms caused by abnormally high pressures of the fluids in and around the brain.* 

 

Geek Stuff:

The adult human brain is enclosed in a protective bony compartment of the skull known as the cranium.  The main contents of the cranium are the brain, connective tissue (meninges), and two fluids: blood and cerebrospinal fluid (CSF).

Because the cranium is rigid and has a fixed volume, net accumulations of either fluid will increase the pressure inside the cranium (Intracranial Pressure, or ICP).

“Intracranial Hypertension” results when an individual’s tolerance for normal pressure variations becomes compromised, especially high pressures.  These pressures can affect the brain itself, becoming stressed with predictable results   It is referred to by several abbreviations which likely represent individual variations of the same “disorder”:

  • IIH – “Idiopathic (‘of unknown origin’) Intracranial Hypertension
  • NPH- “Normal Pressure Hydrocephalus” –  A very misleading term that is contradictory and would only apply to true conditions of hydrocephalus, a condition where Cerebrospinal Fluid becomes trapped due to developmental or traumatic factors, allowing the very slow forming CSF to accumulate in isolated areas under significant pressure, causing deformation and/or damage to the brain tissue
  • BNPH- “Benign Normal Pressure Hydrocephalus” – Another extremely misleading term, as with “NPH”, along with the fact it is anything but “benign” (harmless)
  • PTC – “Pseudotumor Cerebri” – literally, “false brain tumor”, one of the earliest names given to this class of disorders due to the fact that a patient’s symptoms usually mimic those of a brain tumor, but upon CT/MRI, no tumor is evident.

I consider these “different” diagnoses to be representations of a similar disorder, expressing itself differently in individual patients due to their particular physiology.   Consequently, I refer to these disorders as Intracranial Pressure Dysregulation Disorders, or ICPDDs.

427420290-cerebellar-vermis-metencefalon-cerebral-hemisfere-brain-lobe
The Brain and its supporting anatomical structures are encased in a rigid bony protective compartment of the skull known as the cranium.  Just like carry-luggage, only so much can fit inside.  One pair of socks too many, and the seams start to strain.

*Growths of soft tissue such as tumors and cysts may also increase ICP with similar presentation; however these conditions fall into different diagnostic and treatment categories.  For the purposes of discussing the ICPDDs, the focus will be on blood and cerebrospinal fluid, assuming there are no abnormalities of the soft tissues in the cranium, including the brain itself. 

 

WHAT IS THE SOURCE OF “INTRACRANIAL PRESSURE”?

Short Answer:

Intracranial Pressure, or ICP, is the created by high volumes of blood being pumped into an extensive network of blood vessels that support the brain. (This is the foundational principal of Intracranial Pressure Dynamics, hence my appellation “Cerebrovascular ICP Dominance Principal”).**

Geek Stuff:

The brain requires more energy than any other organ in the human body.  That energy is delivered by blood containing oxygen and glucose.  Blood also carries away metabolic waste from brain cells (neurons).

  • Big Numbers Alert: The adult brain has an estimated 100 billion cells called neurons.  Getting blood to each neuron requires a vast and intricate network of blood vessels estimated to be up to 100,000 miles in total length.  The majority of the vessels are so small that blood cells must pass through one at a time.

Blood enters the brain through arteries under high pressure (Average Mean Arterial Pressure of 90 mm Hg) and volume (750-1000cc per minute).  Resistance to the flow of viscous blood (~1.8 times “thicker” than water) through the network of vessels creates pressure in the vessels.  This pressure is transferred from the blood vessels to the brain tissue and ultimately into cerebrospinal fluid in and around the brain and spinal cord, creating what is termed “Intracranial Pressure.”

**Shortly after arriving at and naming this principal “Monro-Kellie 2.0” in Millennial TechnoEvolutionary Credit to the Monro-Kellie Principal, I discovered a cheeky neurosurgeon of “Her Majesty’s Royal College of Medicine, London” had published a paper on this very subject in 2016.  His name is Wilson.  Dr. Mark Wilson.  His publication:

Monro-Kellie 2.0: The Dynamic Vascular and Venous Pathophysiological Components of Intracranial Pressure

This publication, accurate and well written, was obviously composed by MI6 as cover for “Dr. Agent” Wilson.  Subterfuge aside, it does make both Agent…excuse me, Dr. Wilson and myself seem like a pair of bright bulbs.  Nonetheless,  a pair of very stiff upper lipped chaps suggested I change the name by which I referred to this principal, in the name of the Queen…and my kneecaps.

And I do favor mine very, very dry, and of course…

Shaken…not stirred.

XE3_00992_XL
“Dr.” Mark Wilson, Neurosurgeon

 

WHAT IS “NORMAL” INTRACRANIAL PRESSURE (ICP)?

Short Answer:

Intracranial Pressure is not a fixed, unchanging value.   ICP is dynamic by virtue of its origin in the volume and pressure of blood flowing into the brain, which is in turn inside of the rigid cranium with a limited amount of available space.  Factors affecting systemic blood pressure and an individual’s response/reaction to those factors, will cause ICP to vary as well.  “Normal” ICP is a patient-specific range of pressure determined by individual physiology.  Thus, for each of us, “Normal ICP” is any pressure that allows healthy & asymptomatic brain function.

Geek Stuff: 

While scientific studies establish an average of 110 mm of water (defined as the pressure at the base of a water column 1mm in diameter and 110mm tall), the truth is that “normal” ICP varies from person to person, again for reasons of individual physiology.  Furthermore, ICP varies in an individual over periods from as few as a few minutes to as long as years as dynamics of blood flow and CSF production fluctuate.

All aspects of ICP are dependent on the fact that blood is the only fluid that enters the cranium/brain.  Therefore the pressure and flow of that blood directly affect ICP, and hence the fact that an individual patient’s ICP varies within a personal range and is not a static value.

Finally, the brain itself ensures it receives adequate nutrient-rich blood, controlling blood flow through heart rate/contraction, as well as other critical factors including systemic blood pressure, available oxygen in the air (partial pressure of oxygen), a patient’s lung health (presence/absence of fibrosis, COPD, smoker, and other factors that affect gas exchange with blood in the lungs), health of the blood (anemia, hemoglobin, age/size of blood cells), as well as environmental factors including barometric pressure (and hence altitude), heat, humidity…the list goes on.

In a word, any condition that potentially hinders a person’s brain from getting adequate oxygen in the smallest quantity of blood possible, or which makes their tolerance for ICP fluctuations more narrow, or changes the dynamics of those fluctuations to higher ranges for longer periods potentially predisposes them to developing an ICPDD.

Mayfield-Clinic-Pic
Chiari Malformations are essentially brains too big for the available cranium…or vice versa.  The result is less available volume to allow a patient to tolerate ICP fluctations, not to mention the potential interruption of CSF circulation between the cranium and spinal cord, aka “corking” (credit to Dr. Diana Driscoll and her ongoing body of work, “The Driscoll Theory”)

See FAQ Topic “HOW DOES ICP BECOME ELEVATED?” (coming soon to a url near you! 7/30/2019)

 

WHAT CAUSES ICP TO BECOME ELEVATED?

(That was fast!)

Short answer: too many socks in the carry-on luggage.

The adult cranium is a rigid bony case and does not expand or contract. After the bony plates of the skull fuse in adulthood, it has a defined available volume.  If one or more of the contents of the cranium accumulates without a matching decrease in the other contents, the pressure within the cranium predictably increases.*  For the purposes of discussion of ICPDDs, blood and cerebrospinal fluid (CSF) will be the only cranial contents considered to affect ICP.  Growths of soft tissue such as tumors and cysts can also increase ICP, however these conditions generally fall into different diagnoses and treatments.

Looking at blood and CSF, it becomes apparent that blood is the dominant, driving force behind ICP:

  • Blood is the only fluid to enter the cranium, at a rate of nearly one liter per minute at rest, a figure that represents approximately 20% of cardiac output.  This is because the brain demands enormous quantities of oxygen and glucose to function, and actively regulates the amount of blood it receives in real time.
  • By contrast, Cerebrospinal Fluid (CSF) is a by-product of brain function.  It is “distilled” by osmosis in specialized cells lining small hollow (normally) interconnected areas within the brain known as ventricles, as well as by similar tissue along the outside of the brain.  It is produced at a mere 0.35cc/minute from arterial blood, and as such accounts for only 0.0004% of the fluid dynamics within the cranium, with blood accounting for 99.9996%.
  • Blood and CSF are both present in the cranium in approximately equal volumes of 150 cc.  The blood volume enters and exits at approximately 6-7 times per minute; CSF is produced and replaced approximately every 7 hours.
  • CSF flow passively in and around the brain, following pressure gradients from areas of production to areas where it is absorbed by veins and lymphatic tissue.  This passive circulation is aided by pulsations of blood vessels in the brain as well as physical movement of the body.

ICP becomes elevated if blood and or ICP accumulate at a greater rate than they are removed from the cranium.  Due to the high flow rate of blood into the brain, even the smallest deficit in drainage of blood from the brain becomes a potential source for rapid elevations of ICP; this is known as (Chronic) Cerebrospinal Venous Insufficiency, or CCSVI, but could more accurately be termed Cerebrovascular Outflow Insufficiency, Acute and/or Chronic.  This is likely the source of elevated ICP in patients who do not have isolated pockets of non-draining CSF (“Non-Communicating Hydrocephalus”); however, Cerebrovascular (Blood) Dynamics and Cerebrospinal Fluid (CSF) Dynamics are inextricably linked due to the enclosed nature of the cranium**.

NIagara Falls
Cerebrovascular ICP Dynamics
frozen waterfall
CSF Dyamics

 

*Monro-Kellie Doctrine

**”Monro-Kellie 2.0, The Pathophysiology of Cerebrovascular Dynamics in Intracranial Pressure”, Dr. Agent Mark Wilson, Royal College of Medicine Branch, MI6

 

 

 

 

 

NEUROENDOCRINE THEORY FROM AN ENDOCRINOLOGIST – AN EXPERT SPEAKS

Three particular informational sources have played a key role in making sense of disparate symptoms:

  1. The Driscoll Theory by Dr. Diana Driscoll.  Although primarily focused on Ehlers-Danlos/POTS patients and the particular Intracranial Pressure Dysregulatory Disorder these patients often experience – Intracranial Hypotension – especially her observations about the carotid triangle, vagus tone, and cerebrospinal pooling/blockage due to “brain sag”.
  2. Adrenal Fatigue Syndrome by endocrinologist Dr. Michael Lam, MD and Dorine Lam, RD, MS, MPH.  A well written book describing endocrine system interactions as a result of long term, high level stress, how that system begins to become dysregulated, and the hormonal consequences thereof, as well as approaches in dealing them.
  3. Multiple Research Papers that have documented the presence of hormonal receptors in the cells that produce CSF.  In a word, many of these hormones become dysregulated in Adrenal Fatigue/Failure.  Each in its unique way contributes to increases in blood pressure, CSF production – or, as in the case of aldosterone – is responsible for both.  This means increased blood pressure & therefore increased Cerebrovascular Dynamics as well as increased CSF production.  The perfect storm for development of elevated ICP, and if not controlled, an ICPDD in patients with predisposing factors.  Some receptors are estrogen/progesterone sensitive, possibly explaining why patients are more commonly female.   Further,  looking back to Dr. Lam and Dorine Lam’s body of work, it will be interesting to compare the upswing in ICPDD diagnosis with the increase in estrogen-like compounds in everything from food supply to dental fillings.

All these fell in my lap within a two week period in December 2018 while I was hunkeringS down waiting for a shunt revision, and to my surprise, they did not lead me to what I was looking for: why I developed IIH.

Well, sort of.

They actually led me to a conclusion that I cannot emphasize enough, hence the big letters here:

“The Secondary Acquired Adult Onset form of the “disorder” known as IIH is actually a complex symptom of a dysregulated endocrine system, including “Adrenal Fatigue”, which is most commonly caused by chronic stress.  Therefore, I name CHRONIC STRESS to be the main cause of altered/elevated ICP and the onset of ICPDDs, and the ultimate reason I developed an ICPDD.”

Shuntwhisperer’s Neuroendocrine Theory of IIH, Dec 2108

But wait, there’s more:

“Successful treatment of ICPDDs must necessarily involve endocrine function AND CAPACITY* before any ICPDD can be successfully treated.  To treat only the ICPDD is treating only the symptom; without lifestyle/dietary changes and endocrine support can possibly condemn a patient to unnecessary prolongation of their ICPDD.”

Shuntwhisperer Neuroendocrine Theory of IIH Corollary #1 Jan 2019

And just when you didn’t think it could not get ANY better:

“Elevated ICPs cause deformation and damage to key portions of the brain controlling the endocrine regulation, especially the HPA Axis.  The HPA axis must be well regulated to maintain ICP equilibrium.  THEREFORE: TREATMENT OF ICPDDS WITHOUT TREATMENT OF ASSOCIATED ENDOCRINE DYSREGULATION WILL BE SUBOPTIMAL.”

Shuntwhisperer’s Neuroendocrine Theory of IIH Corollary #2 Jan 2019

In other words, endocrine dysregulation that leads to an ICPDD, left untreated, can cause the ICPDD to persist, and more corollaries are coming.

But don’t take my word for it.

Take an expert’s.  I swear, I did not rip this off, but Dr. Lam’s book led me to the same conclusion:

NeuroEndoMetabolic Component Dominance: Stages of Stress

Been a long hot summer day.  I miss Trina.  Leaving you to it.

The ShuntWhisperer

July 11, 2019

 

Stressed-Out-1024x614

 

 

 

 

SHUNTWHISPERER 2.0 – NEW PERSPECTIVES, NEW THEORIES, BETTER OUTCOMES AND QUALITY OF LIFE

“…My last post was in late 2018 regarding an epiphany I had been given regarding a theory about how a person develops acquired adult IIH. Of course, right at that point, the creaking, weak, bottom fell out from under me.

Again….”

Note:  I need to acknowledge something to a person who reached out to me for help.  This person believed they were developing an infection of their shunt and were desperate.  Due to my own recent challenges, I didn’t open that email until a week later, and then due to some strange glitch, lost it entirely.  To that person, I am deeply sorry, and I pray you were able to avail yourself of the ER in time.  FWIW, I just went through the same problem 7 weeks post-revision.  I post my email contact, ShuntWhisperer@ShuntWhisperer.com to help answer questions if possible, but I am not a neurologist or neurosurgeon, and if anyone should find themselves in and emergency situation (infection of the shunt tract qualifies), get to your physician or ER first, then email me if you like.  FWIW, I am making it a point to check my email every morning at the very least as long as I am able.

 

Greetings to all. 

It’s been a minute, to be sure…more like 4 months.

My last post was in late 2018 regarding an epiphany I had been given regarding a theory about how a person develops acquired adult IIH.  Of course, right at that point, the creaking, weak, bottom fell out from under me.

Again. 

I had to devote what little functional capacity I had to managing this new challenge; making new posts here was just not possible.  February was a very, very, very (etc.) difficult month.  Most days I felt like I a lone person in a dark void above a bottomless abyss, clinging by my fingernails to my spiritual, almost tangible touchstone, Jesus Christ.  I can say with complete certainty He is the only reason I am still here to right this story.

The Lord works in His own way(s).  In my case, Dr. Kenneth Liu of Penn State Neurological Services, the neurosurgeon who saved my life by placing my first VP Shunt two years ago, revised my shunt and repaired the inexplicably persistent hole/CSF leak associated with the craniotomy (surgically created hole in my head).  I referenced this problem in the post “Juice Boxes and My Brain…Who Knew?). I can now say with a weird sense of satisfaction that I now have a metal plate in my head.  A small one, but nonetheless, a metal plate.

Cool.

This surgery resulted in an immediate, marked improvement, but still with instability, though not nearly as severe.  There was still a small but noticeable  CSF leak.  At 5 weeks that last leak suddenly stopped, and it was as if my brain had suddenly been switched back “ON”.  Most notable was that extreme sensitivity to certain triggers, especially barometric pressure, was either drastically reduced or eliminated altogether.   Before the revision surgery, I could not stay at my new retreat in the mountains at a modest 2200’ elevation if the barometer dropped below 940 mb.  I would become bedridden with fatigue, pain, and ‘brain fog’.  I would be forced to leave the mountain for lower elevations, and I began to be able to predict at which turn in the road I would start to feel improvement.  I would stay at a lower altitude for a week, and when I felt better, I returned, only to have the scenario play out over again within the next 7-10 days.  Was this real, or was it some perverse trick of my psyche?  I decided to find out, and with a prescription from Dr. Liu, I bought a home hyperbaric chamber.  Expensive, but it was the only way I knew to answer the question about the effect of barometric pressure on my personal form of this disorder.

I’ll go into more detail about the chamber later; for now I’ll just say I ran a series of controlled experiments.  The results were undeniable: climbing in the hyperbaric chamber and simply increasing the pressure inside to 30mb above local pressure reduced or eliminated by pain and feelings of fatigue.  However, no matter how long I stayed in the chamber, once I exited, those symptoms returned in 1-6 hours depending on local conditions, so there was no doubt that this small change in barometric pressure was enough to drastically affect my well being.

I also noticed something else: when I got out of the chamber, I could feel my shunt flowing.  If you have a shunt, you know what I mean.  More importantly, I noticed that swelling developed along the shunt components under my scalp starting at the craniotomy and eventually proceeding back to behind my ear.   I interpreted this as a CSF leak.  The catheter that connects to the shunt valve is a surgical silicone; human tissue does not adhere to this material.  I also discovered these catheters are further treated make them even more resistant to the adhesion of cells in order to prevent stray bits of protein and brain tissue from adhering to the inside of the catheter and eventually blocking it; this treatment is intended to prolong the life of the shunt.  In my case, bone had failed to fill back in the craniotomy, leaving a path for CSF to leak between the outside of the catheter and the dura and along the catheter and shunt under my scalp.  This resulted in overdrainage of CSF as it was drained not only from inside my brain as intended, but from outside the brain as well.  This caused me to experience intracranial hypotension, and was a truly miserable test of my personal belief that a more appropriate term for this disorder is Intracranial Pressure Dsyregulatory Disorder (ICPDD). 

I took this information to Dr. Liu and ultimately the decision was made to revise the shunt and repair the craniotomy.  Now that this unwanted leak has been stopped I have experienced increasingly stable improvement of my disorder, including greater functional capacity and dramatically reduced ‘fibro’ pain.  I still have challenges from the effects of almost 2 years of wild swings in my ICP, including physical deconditioning.  Spring weather patterns here have been brutal, with at least 4 “bomb-grade” storms (defined as a weather system with at least a 24 mb drop in barometric pressure in 24 hours) in the last month.  Prior to the March surgery, these systems invariably laid me up for at least three days; now, their effects on my disorder are greatly diminished, and seem to be continuing to diminish with each passing day.  Only one recent freak set of back-to-back storms really hit me hard, but in that case there was also a potentially serious late postop complication that I was fortunate to recognize and address before it got out of control.

All this preamble brings us to now.  ShuntWhisperer started as merely a “this is my story, maybe it will help you” type of blog.  Over the course of two years, I’ve learned more as I’ve continued research and experienced new challenges that while very difficult, contributed to a better understanding of my disorder.  The structure of the original site was never intended to present this material of this depth in a coherent and orderly manner.  I never expected it to be more than a few pages, but it has blossomed well beyond that.  Thus I will be  restructuring the site “on the run” as ShuntWhisperer 2.0.  It is intended to be concise, presented in lay language to the degree possible, and accompanied by references to existing research, with a reference section for physicians.  Please don’t expect a visually dazzling site; I simply don’t have the time to post anything but pertinent information.   Also, the original ShuntWhisperer site and its contents will still be available, accessible from the new landing page.

SW 2.0 is still intended to be based on my personal experiences and research.  I can’t claim anything I post applies to any other person with a disorder of altered intracranial pressure, although there are certain immutable laws of human physiology that lead me to suspect that is indeed the case; I just can’t make that claim.  I’m not sponsored, I don’t get paid for this, and don’t care to receive any credit for any good that comes of what I post.  I am doing this in Service to God in an attempt to help others, as well as in memory of my wife Trina.  My contact email is Shuntwhisperer@shuntwhisperer.com for anyone who has a question, feedback, or suggestion. 

As always, prayers to all for comfort, support, and a better quality of life.

 

Wes

The ShuntWhisperer

April 26, 2019

 

Today’s storm and rain has passed; it’s a gorgeous spring day on the mountain, and I’m going to take a break to enjoy it, wishing Trina was with me.

“But ask the animals, and they will teach you, or the birds in the sky, and they will tell you; or speak to the earth, and it will teach you, or let the fish in the sea inform you.  Which of all these does not know that the handoff the Lord has done this?” 

           Job 12: 7-9

 

#CROWDHEALING VALIDATED: IIH, EDS, & POTS: THE DRISCOLL THEORY (AND NOW, ADRENAL FATIGUE: TAKING IT ON THE LAM)

Starting this weblog over a year ago was primarily borne out of a desire to help with a disorder that even the doctors I consulted had little grasp of, much less the patients.  My theory was that by making my experience available, others might benefit.  Along the way I started noticing certain correlations in my disorder.  Perhaps this might cascade and multiply, bringing better understanding to this potentially crippling class of disorders more quickly than the glacial pace of research and publications – “Evidence Based” science, which is still an important tool in Medicine.  Thus the notion of “CrowdHealing” was borne.

The last 18+ months have been brutal.  Shunt treatment was maddeningly unstable; I now know it was because there was a CSF leak around the proximal catheter for over 9 months.  After healing stemmed the leak, I went rapidly from unstable ICP where I vacillated between too much and too little pressure, to a short period of relative stability, then to a brutal return of symptoms of unbearably high ICP where I vacillated between misery and agony.  After finally getting an adjustment to my shunt, the pressure was reduced, but my brain felt like it had been used to play soccer.  It was my sincere hope that a period of R&R would restore balance, this disorder would stop ruling my life, I could possibly return to practice, properly mourn Trina…

It was not to me. 

I now find myself suddenly extremely sensitive to barometric pressure.  I have always been sensitive to the barometer, but this new condition mimics my post-shunt condition: a few days (at best) of stability at a given altitude/pressure, followed by a gradually reduced ICP.  Worse, it seemed that I could not tolerate the mere 2100 feet altitude of my new home for more than 2 days before my head began to feel empty; after a week I was all but incapacitated by a feeling I associate with excessively low ICP.  Traveling off the mountain to lower altitudes always rapidly alleviated my symptoms of fatigue, weakness, and pain.  A change of a mere 1000 feet was enough; I could almost tell at which turn in the road I was going to start to feel better.

This seemed insane.  After all I’d been through, now I couldn’t rest and grieve in a place that was paradise to me.  Was it real or psychological?  I decided to put it to the test by acquiring a hyperbaric chamber (note: these are not toys.  I don’t recommend anyone else do this at this point.  A doctor’s clearance and order is required to purchase one, and they are expensive, like $5K+ for a basic model (thank you, PayPal Credit).  If you’re not careful, there are a number of ways you can cause harm to yourself.

All that said, within a week of getting the chamber, I had my answer:  it was, without a doubt, the barometric pressure at the altitude of my new home in the mountains that was the source of my New Misery, apparent intracranial hypotension (Intracranial Pressure Dysregulation Disorders are not just high ICP).  A mere 20mb increase in pressure began to alleviate my symptoms; I could feel my spine and head “pressurize”. 

WTF. 

Consultation with Dr. Liu ( I know he winces seeing his name here) led to the possibility of one or more CSF leaks.  At the time I write this, I’m waiting on a call from a CSF Clinic for an appointment.  Yes, I’m living at my mother’s house, 1100 feet lower in altitude, at the age of 59.  It’s actually one of the better things to happen to me in the last 18 months.

Still, it seemed insane that I went from feeling as if my head was going to explode and a return of my pre-shunt symptoms in June/July to not having enough ICP after a mere 50mm reduction in my shunt valve pressure.  It made no sense to me based on what I’d learned to this point.  These numbers are small, but here I was, isolated from  my new home by a tiny change in altitude and pressure that even my damaged physiology should be able to account for…

So I thought.

Some months back, I was contacted by a ShuntWhisperer reader who had an ICPDD attributable to Ehler-Danlos Syndrome, a disorder characterized by loose connective tissues believed to have a genetic component.  EDS patients have a high incidence of ICPDDs, both Intracranial Hyper-and Hypo-tension  She told me about Dr. Diana Driscoll, an optometrist who had EDS as well as a family of EDS?ICPDD sufferers.  Dr. Driscoll relates suffering 10 years of disability due to her condition that left her physicians confounded.  Unwilling to sit on the sidelines, more than 5 years before the idea of #CrowdHealing entered my mind, Dr. Driscoll all but invented the concept (ShuntWhisperer Theorom #242: If I can think of it, it’s already old news).  Dr. Driscoll ran with it, and is now running a clinic patients who suffer from a related disorder, POTS (Postural Orthostatic Tachycardia Syndrome).  I briefly browsed Dr. Driscoll’s website, PrettyIll.com, was impressed, ran it through my Priority List (Spoon Pile), and filed it.  I just got around to that spoon, reading her publication “The Driscoll Theory” after my appointment with Dr. Liu (aka The Man). 

My jaw still hurts where it hit the ground.  Let me be very clear: if you are suffering from one of the alphabet soups of ICPDDs (PTC/IIH/BPH/NPH/PB&J), The Driscoll Theory is an absolute MUST READ.  Forget if you have been diagnosed with Ehlers-Danlos or not.  Buy a copy for your family, your doctor(s), anyone else you can think of.  The $9.95 goes directly to research:  The Driscoll Theory addresses sound physiologic conditions that can explain the onset of altered intracranial pressure, in my current opinion, independent of any connective tissue disorder such as Ehlers-Danlos.  It goes back to neuroendocrine stress I originally referenced in the ShuntWhisperer post “You’re Fat And That’s Why You Have IIH – Lose Weight and You’ll Get Better“.

I have a “Mind Map” of my disorder; there are outlying symptoms that I had yet to connect to the main map.  I also had one for Trina that was essentially a jumble.  Two other close ICPDD patients as well in varying degrees of connected dots.  Two hours after opening The Driscoll Theory, I’ve pretty well completed those mind maps, and believe I may be seeing the very early stages of altered ICP in another person in my circle for reasons that are clearly outlined in Dr. Driscoll’s work.  In her Theory, Dr. Driscoll she believes (backed up by already accepted medical and physiologic tenets) is responsible for the ICPDDs seen in EDS patients.  (Note: 12/26/2018 – small test doses of acetazolamide yielded positive impacts on symptoms of this patient – more to follow).

I see way more than that.  I see the potential cause of secondary(?) ICPDDs in general.  Like the Missing Link, The Rosetta Stone, the CryptoSkeletonKey of dyregulation of intracranial pressure.  I’m early into this, but I believe Dr. Driscoll has broken the #CrowdHealing barrier of the cause of secondary alterations of ICP alterations. 

As Dr. Driscoll’s work is copyrighted, I want/need to contact her before I start expounding on what I’m seeing outside of her site, but suddenly I’m very hopeful, as well as very concerned.

 It’s a new game now, folks.  Enough of my meanderings and mumblings, there is something to sink our collective teeth into here.

12/26/2018: Note:  Another giant piece of this puzzle is now available: the effects of long-term stress (“Adrenal Fatigue Syndrome”) on the human body, especially the female physiology.  I refer you to: DrLam.com

The ShuntWhisperer

Trina, I finally have answers….I’ll look out for him/them.

Welcome To The Shunt Whisperer 2.0

Welcome to The Shunt Whisperer.  I’m a 57 year old professional forced into retirement and disability as the result of a sports injury over 10 years ago.   I was treated with a VP shunt in May 2017 as treatment for an Intracranial Pressure Spectrum Disorder (ICPSD).  In my case, it the initial diagnosis was Idiopathic Intracranial Hypertension, the result of a neck injury.  At least that’s when the symptoms that seem to be relieved by the shunt appeared.  This purpose of this site is to tell the story of what having a shunt has been like, insights I’ve had as a shunt patient with medical training, and where I think shunt treatment needs to go.  I want to help others understand their condition better and hopefully live a better quality of life.  Having a hole in your head and a tube in your brain isn’t much help if you can’t get out of bed or engage in activities that bring you satisfaction. 

Nothing herein is intended to be critical.  ICPSDs have only recently been recognized as real, explaining a handful of conditions that have confounded medicine for over 20 years.  The reality is that right now, there are only a handful of specialists, chiefly neurosurgeons and neurologists, at a few centers around the nation, that are willing to step in and treat this condition.

The reality of ICPSD treatment is this:  it is in the early stages.  Methods and devices are evolving to meet the need of an adult population with an ICPSD.  Basically, diagnosis of an ICPSD means too much blood and/or cerebrospinal fluid is being retained in our central nervous system (brain and spinal cord).  Excess fluid leads to excess pressure which can damage the brain directly including the optic nerves/auditory nerves, as well as stress parts of the brain that control our bodies’ functions including blood pressure, body temperature, weight, sleep cycles, and others, and is linked to conditions such as fibromyalgia and dementias.

My experience thus far has been the equivalent of Alice falling down the Rabbit Hole.  I’m told I fall in what is believed to be 20% of patients who develop secondary symptoms after shunting.  The experience has not been without positive results, however, including a significant drop in a severe and debilitating chronic “fibromyalgia” pain, as well as an improvement in my physical function.  Understand that I have been dealing with symptoms that were relieved with the shunt in March 2017 since a neck injury in mid 2007.   There is no doubt the shunt helped me, no doubt it was the best option at the time.  It hasn’t been perfect, but after six months of living with it, I believe I know a few things that can help.

It’s my hope that telling my story helps somebody else be more informed and less surprised/confused by their ICPSD and it’s treatment.  Don’t use this information to make major health decisions without consultation with your physician.  It’s just here to give a little more understanding into this condition and treatment from someone who has and is currently undergoing it.  I have a fear that if I don’t put this information out there, it might not get to somebody who needs it.  It takes a lot of my available energy to do this; as such, it may take a while between additions and updates.

Prayers and Blessings to everyone,

The Shunt Whisperer

October 6, 2017

How Intracranial Pressure Becomes Elevated: Part 2, Short and Sweet

Intracranial Hypertension is the elevation of pressure  of fluids and tissue inside the fixed volume of the rigid intact skull.   This elevation of pressure has two basic mechanisms*:

  • Cerebrospinal Fluid Dynamic Imbalance: A net accumulation of of Cerebrospinal Fluid (CSF).
  • Cerebrovascular Dynamic Imbalance: A net accumulation of blood in the brain caused when veins are not capable of draining the volume of blood pumped into the brain by the heart (Monro-Kellie 2.0, Dr. Mark Wilson, Royal College of London, 2016)

*soft tissue tumors can also occupy space inside the skull and potentially raise ICP but are considered a separate causative mechanism from those that are considered in ICPDDs

The cause of these imbalances can be either genetic/developmental (primary) or related to trauma (secondary).  They are closely interlinked and may both be present to a certain degree.

One example of CSF Imbalance would be non-communicating hydrocephalus.  CSF is produced from arterial blood in small hollow areas of the brain called ventricles.  Ventricles are normally interconnected with one another and the space around the brain.   CSF circulates through these areas passively due to the pulsation of blood vessels and also likely movement of the body.  If one or more of these ventricles does not communicate with the rest of the system, the CSF it produces accumulates and displaces the brain outward.

Another exmaple of CSF Imbalance illustrates the interrelationship between CSF and Blood dynamics:  obstructed veins may not absorb enough CSF out of the skull to prevent a net accumulation of CSF, as well as leading to this example of:

Cerebrovascular Dynamic Imbalance: would be Chronic Cerebrovascular Venous Insufficiency, or CCVVI.  In simple terms, damage or constriction (stenosis) of one or more of the veins that drains blood from the brain compromises the ability of blood to leave the brain.  At a certain critical level of blood flow and pressure, blood begins to accumulate in the brain as it is pumped through arteries at a greater volume than it can drain.  This accumulation of blood causes the thin-walled veins to swell, which in turn pushes on brain tissue.  Brain tissue may become displaced as a result, being pushed into areas occupied by CSF.  Since an intact skull is rigid and does not expand, the pressure of the CSF becomes pressurized (Newtons’s Third Law)  while simultaneously trapping brain tissue between a vise of swelling veins.    As focal areas of brain tissue that control specific physiologic functions become stressed, their functions become altered.  This pressure on brain tissue is likely the cause of symptoms associated with IIH.

THE MECHANISMS OF ICPDD: HOW INTRACRANIAL PRESSURES BECOME ELEVATED: PART ONE

 

 

Everybody knows the old adage about how to eat an elephant.   ICPDDs and their nuances certainly qualify, and the goal here is to present information in easily digestible bits.  This is the first bite.

While the reason/reasons (“etiology” it doctor-speak) a person develops IIH/PTC/etc. remain unknown and controversial, the physiology of how the pressure develops is actually quite straightforward:  ICPDDs reflect an increase in the pressure of fluid in and around the brain.  Thus, they are a result of a disruption in the dynamics of the fluids in and around the brain.  While CSF is most commonly discussed and treated, there is another fluid that actually rules everything, including CSF:

Blood.

FLUID DYNAMICS

Blood is the 800 lb Gorilla of the brain.  It is pumped into the brain primarily through the

Coronal view of Brain and Carotid arteries
The Carotid Arteries and their branches supply enormous volumes of blood to a nutrient-hungry brain. Note how close the brain is to the heart, which is just out of the bottom of the frame. Image courtesy of The Mayfield Brain Foundation.

carotid arteries at a rate of 750 to 1000 cc/minute when we are at rest; it courses through an estimated 100,000 miles of blood vessels delivering nutrients and oxygen to brain tissue.  Depleted blood is drained via the venous sinuses, a network of veins around the brain, and eventually through the jugular veins back to the heart.

Blood enters the brain at an average pressure (“Mean Arterial Pressure”, or MAP) of 90mm Hg.  It drains from the veins at a pressure of 15-20 mm Hg. Because the same amount of blood that flows into the brain has to flow out, and because venous pressure is lower than arterial pressure, the blood flow in veins must be higher to compensate (fluid dynamics, Bernoulli, a couple other Italian guys in there).  Suffice it to say that veins have to be able to carry away ALL blood that is pumped into the brain.  In addition to that important necessity, there are TWO factors of blood that must be considered in ICPDD: pressure (as expressed by MAP), and flow.  For the sake

venous sinuses
A very basic illustration of the venous sinuses responsible for carrying blood away from the brain and back to the heart.

of simplicity we will use heart rate as an indicator of blood flow.

 

 

 

 

 

 

 

 

 

 

CSF is a plasma like fluid that is made from blood in an interconnected network of small hollow areas in the brain known as ventricles.   It is produced at a very low

Ventricles of the brain
Blue areas represent CSF filled spaces. The approximate volume of the ventricles is 30 cc; total CSF in and around the brain is ~150cc. Image courtesy of the Mayfield Brain Foundation

rate of ~0.35 cc/minute from arterial blood.  Its rate of production is dependent on the am

ount of blood flowing into the brain.  CSF circulates through the ventricles and around the brain; this circulation is slow, with pulsations from blood vessels and body movement being the primary motivators.  It is primarily absorbed back into the blood circulation in the venous sinuses.

CSF is something of a Mystery Fluid.  Aside from cushioning and supporting the brain, it is thought to play a role in delivering nutrients and cleansing dead cells from the outer surface of the brain.  Deficiencies in CSF are associated with accumulations of these dead cells, known as plaques, which are themselves associated with dementias such as Alzheimers and Lewy Body.  Anyone with an ICPDD can tell you that “overdrainage”, ie, not enough ICP and/or CSF makes them feel weak and lethargic.   Again, suffice it to say that CSF is Very Important; otherwise, it would not be in our heads.

SUMMARY, PART ONE:  THE TWO FLUID POSTULATE

The dynamics of blood and CSF lay the groundwork for understanding ICPDDs.  ICP is a result of the interaction of these fluids inside the watertight, airtight, non-expandable skull.  These facts lead to what I call the Two Fluid Postulate:

“There are only two fluids inside the skull: blood and cerebrospinal fluid (CSF). Both are present in approximately equal volumes, 150cc. Only one flows in and out of the brain:  blood.  CSF is made from blood that enters the brain and absorbed back into the veins that drain blood away from the brain.  Intracranial pressure is the sum of the forces exerted within the skull by these two fluids.  Changes in the balance of CSF production/absorption and/or blood flow into and out of the brain will necessarily affect ICP.  Most critically, because the brain is encased in a rigid, non-expanding skull, ANY INCREASE IN ICP TRANSLATES INTO INCREASED PRESSURE DIRECTLY ON THE BRAIN.”

This is just a restatement of what is known as the Monro-Kellie Hypothesis from the 1890s by two Scottish physicians to explain what goes on inside the skull.

THE TAKE-AWAY:

CSF, while the most often discussed fluid in ICPDDs, is not the only fluid in the brain.  Blood, in fact, rules everything inside the skull, including CSF.  Because the volume inside the skull is fixed, and because there practically zero extra space in the skull, any net accumulation of CSF OR Blood will cause increased ICPs, and those increased ICPs exert direct pressure on the brain itself.

In Part 2, we will look at how the dynamics of blood and CSF become disrupted. 

 

 

 

 

 

 

Juice Boxes And My Brain: Who Knew?

“…March 2017 until I’m guessing November-ish 2017, I had a CSF leak that mucked up the attempts to control my ICP…”

 

Communication over the internet can be challenging.  Not like talking face to face; it’s easy to misunderstand what is being said, or why somebody is saying it.  That said, I want to lead with this:  ShuntWhisperer is just my story for about my ICPDD for whatever it’s worth.  ICPDDs and their treatment are poorly understood, doctors do the best they can with what is available now.  I think I’ve stumbled on to something…interesting… for no other reason than weird coincidence, and I don’t believe in coincidence.  Maybe this story it will help somebody, maybe it will spark conversation or thought, but it is absolutely, positively not intended to point fingers or place blame.  Despite the challenges of the last year, I would not change anything.  I’m just trying to make the most of it for the possible benefit of anyone who finds my experience useful in their journey, both patient and doctor.  I try to keep this as light as possible; any humor is just that, never intended to be irreverent.  The fact is I’m still here to type this because of the efforts of my neurosurgeon and the Grace of God.

Now, we return to our irregularly unscheduled post:

 

Is it seriously this “simple”?

So, last year, after I received my shunt, I had a pretty wild ride to put things mildly.  Despite all of it, I’m seriously grateful for everything.   There seem to be so many unknowns in ICPDDs; all through my experience I’ve tried to learn as much as possible about what is going on in my head and pass that information along.  It seems invaluable to me, and I pass it along not for my benefit, but in the hopes that it helps somebody else, and maybe fills in a small part of the overall puzzle.

#CROWDHEALING.

My Biggest Issue: wild swings in my ICP, with a distinct trend towards overdrainage. The higher the shunt was adjusted, the worse it got.   I never felt like I had enough CSF/ICP/MysteryFluid in my head.  Ever.

Until November, when thing began to change…

I was using the Whisperer Method to monitor blood flow into my head.  The numbers I got were deadly accurate both in how they related to my SOTD (Symptomology Of The Day).   The Cerebral Perfusion Coefficient (a figure that gave me a relative idea of how much blood was flowing into my brain along with the static pressure in the blood vessels) numbers stayed within a fixed range.  On the low end of the scale I considered myself “underperfused”, that is, not enough blood going into my brain to make enough CSF to keep up with normal losses along with…some other loss of CSF, someplace.  I thought it might be through my shunt, but I don’t think so now.  On the high side of the scale I felt like my head was going to burst, my shunt felt physically swollen, but perversely, I still felt as if I had no CSF in my head.  The “no CSF” feeling is one that I was well accustomed to as it was the same set of overdrainage symptoms for which I was hospitalized in June 2017, 3 months after getting my shunt.

The Deadly Accuracy of the numbers and symptom correlation held up until the end of November, when I noticed numbers and symptoms starting to diverge a little. Then a bit more. This divergence continued up until Christmas day, the last “BAD” day I had according to the old pattern.  Suddenly the numbers and symptoms no longer seemed to match.  I had no answer.

From Christmas on, suddenly the wild instability rapidly diminished.  Extremes of high and low ICPs became closer together.  No more apparent swelling of my shunt which is

Sophysa polaris
Propaganda Pic of My Shunt. The “Reservoir” is thick silicone, the rest inflexible plastic/metal. My baby.

made largely of rigid materials incapable of expansion.   It was as if either a blockage in my shunt had been cleared, or a leak in my head had been closed off.   Curiouser (TheWhisperers Unabridged Dictionary), the Cerebral Perfusion Numbers started climbing to new highs, up to 20% higher, without the usual symptoms high ICP symptoms of feeling like my head was going to explode.   January into March I actually felt pretty stable, still with bad days, but the best I had felt since getting the shunt.  This left me scratching my head, and that’s where I found The Answer To It All.

I’ve never been accused of being the sharpest knife or having a full picnic basket, etc.  A little slow at times.  So, a few days ago, I’m rubbing my head where the shunt catheter goes into my skull.  A slightly larger than dime sized hole created in my skull to allow the catheter to be poked into the hollow area in my brain.  No jokes about how easy it should be to hit a hollow area in my brain, please.  I’m delicate…

The skin over this hole, a.k.a. “craniotomy”, is slightly indented, normal for a surgical wound.  What I noticed is that I no longer noticed it anymore, because it was no longer changing shape.  All last year it changed contour with my ICP.  Sometimes it was like it was being sucked/pressed into my skull, other times, it was almost as if it was being pushed out under  conditions of high ICP.  It had become a sign I used to make note of in recording what was going on with my disorder, but now it was no longer changing….

Then, slowly, reality crept up on me.  I like to blame the fact that I have a tube in my brain for all these issues of slow comprehension; rather convenient really.  Never mind the fact I was slow before I got the shunt, but now I can point to it and say “See?  I have a tube in my brain.  I’m slow for a reason”, which sounds infinitely better than “I’ve always been slow.”

It was about the hole in my skull; a hole in bone.  A dime-ish sized hole was made in my skull, exposing the dura underneath.

9569
Rendering of how the shunt is placed into the brain. Gruesome Reality.

The dura is carefully opened, and a 3D guidance technique,  a catheter over a needle, sort of like an IV catheter for the brain, was then inserted through the  into the immense hollow area in my brain to drain CSF, after which the dura was sutured around the catheter and, my scalp repositioned and stapled shut. Joking aside, I have always appreciated the precision of this particular aspect of the procedure.  I had employed guidance techniques generated from 3D scans to place dental implants with extreme precision; the shunt cath placement is another level of precision entirely.

endoscopic-third-ventriculostomy-lg
Catheter inserted into ventricle in brain. Catheter is placed over a rigid metal guide tube which is withdrawn after the catheter is properly placed.

I joke that placing a shunt is not unlike poking a straw into the foil hole of a juice box.  No adult can put a straw in a juice box as well as a kid, who with a deft poke can stick that straw through the foil like a kung-fu master, creating an almost perfect hole to match the straw.  Perfect enough to suck juice through the straw, but we all know what happens if you squeeze the box with the straw plugged: juice seeps out around the straw, and the ratio of juice-leakage-to-squeeze is directly dependent on the cost of the shirt that is being stained, and inversely dependent on the time since same shirt was laundered.

Doubling factor if dry cleaning is involved (see: Whisperer’s Laws of Life 301).

If I have failed in my wordsmithing to create a clear mental image of this condition in your head, let me invite you to get a juice box, a bag of Capri Sun, a Corona Beer Pouch

Corona Juice Pouch
Too much time on my hands ; ), but a great idea nonetheless.

(see: Whisperer’s Intellectual Property Item 526), poke the straw through the foil (or get a child to do it for you, except for the Beer Pouch, of course), plug the end of the straw and squeeze the box/bag of juice.  See where it leaks – between the foil and the straw, right where the straw goes through the foil.  Except in my case, it was not juice, but CSF, leaking around the catheter where it penetrated the dura.  There is no magic seal here, and if ICP exceeds the pressure/flow settings of the shunt system, here is a place where CSF can leak.

I’ve been crafting, honing, polishing this for 3 days now, and each time I think about it, I keep wondering how many other shunt patients this might be a factor for, with any type of shunt, VP or LP.  The good news is there is a way to mitigate this leakage, or at least reduce the period of time it occurs through a simple surgical method to encourage faster growth of bone into the craniotomy.

As a dentist in my Previous Life, I was intimately familiar with the tissue of Bone.  Drilled a lot of holes in bone, grafted a lot of bone, moved bone from one place to another, bone, bone, bone, all day long, bone.  But, it paid the bills.  I know about bone in the human body, how it reacts to injury, how it heals – or doesn’t.  Without the fancy “bone bandage” known as a guided tissue membrane, bone may never fill in a defect completely, and if it does, it takes much longer.  A hole in the skull heals from the sides in and from the bottom up, over top of the dura, which by the way makes a dandy guided tissue membrane, at least on the brain side.  The issue here is the scalp tissue is a source of soft tissue that fills the hole in the skull well before bone has a chance.

Short story:  I didn’t get the fancy bandage for whatever reason.    I got a hole “stabbed” (actually carefully incised and then sutured, but for the sake of sensationalism…) in my dura (I wonder now if a child was brought into the operating room to do that part), a catheter inserted into my brain (with great care an precision), the latter hooked up to the shunt valve, and my scalp flopped back into place and stapled as the neurosurgeon asked the charge nurse if he still had time to make the late morning round of golf while the kid that poked the catheter into my brain sucked on a juice box under his surgical mask while sitting on a stool in the corner.  In all seriousness,  I can’t find a thing that says that shunt craniotomies should be grafted over; maybe they should be.

Bottom Line: March 2017 until I’m guessing November-ish 2017, I had a CSF leak that mucked up the attempts to control my ICP.  Ironically, whenever the shunt was “turned up” to a higher pressure setting, it made the problem worse.  Nothing sealed the dura to the tube.  CSF seeped between the tube and the dura, under the surgical flap, finding its way under my scalp, along the tube and around the shunt body, and likely farther.  In surgery the phenomenon is called tunneling, and the leakage of CSF around the catheter created what is known as a pseudomeningocele.  Finally in November a stage of healing of the craniotomy was reached that mitigated significant leaks.  The timing is right for the size of the hole.  However, since to guided tissue membrane/Bone Bandage was used, there is also a good chance the hole isn’t filled with bone, but with a thick scar tissue that may eventually turn to bone.  Whatever is in the hole, my head isn’t leaking from an unwanted place anymore.

Now:

Google the term Intracranial Hypotension (not “hypertension”) .  It’s a real thing.  Usually caused by an unwanted, unpredicted leak in the dura.  I believe this was a large part of the reason for my “wild ride” I went on after my shunt last year.  My concern now is who else may be suffering from it or may potentially suffer from it; possibly by posting this, a surgeon may be persuaded to add 10 minutes to the procedure and graft a VP shunt: I don’t know about LP shunts.

This theory also explains a new phenomenon:  the return in the last six weeks of my pre-shunt symptoms that were associated with high ICPs, the reason I got the shunt in the first place.  Not as bad yet, but getting there.   Fibro pain coming back, other bad stuff, BUT:  there is a clear silver lining. Regaining proper ICP balance may be as simple as turning my shunt down a notch.  As I write this I’m awaiting a CT to check my meninges, and I’ll post the results here.

(edit to add 5/22/18:  those symptoms are definitely back.  Time to check in with the neurosurgeon.)

The silver lining here is that I’ve gotten this far and have avoided at least one procedure that would likely have made things worse.  Early on last August when I was still having overdrainage symptoms despite having a shunt set at 200mm H2O PLUS a 250mm shunt assist, my neurosurgeon graciously offered to revise me to a higher pressure shunt valve.  I declined that offer because my personal situation was not amenable to having the surgery at that time, and I believed I could hold on until another option became available.  In retrospect, that higher pressure shunt would have likely made me worse.  I consulted with other neurosurgeons for their opinions, but I was never satisfied with their explanations based on nothing better than “gut feeling” and the personal records I had kept.  Now I believe I have that explanation, and I’m hopeful that a simple pressure adjustment in my shunt will restore some or all of the reduction in fibro pain, stop the return of the exercise intolerance which is again threatening to leave me bedridden for days after engaging in any physical exertion, and the sleep cycle disorders/insomnia which is back.  It is also my hope that this story helps somebody else, or sparks a thought process somewhere in the minds of doctors wrestling with a disorder that has so many unknowns attached.  I was told by one surgeon I was the “Unicorn” of this disorder (!); if so, at least now I know from whenst my horn grew…

Bottom Line:  without a good seal, CSF can and does leak around shunt catheters.  Pseudomeningoceles are a known postoperative possibility with shunts, but their frequency of occurrence is controversial. Secret or not, the answer may be a few added minutes to a shunt placement and a few hundred bucks for a bone bandage.  The bandage keeps soft tissue from the skin flap out of the craniotomy, encouraging more rapid and predictable bone healing around the shunt catheter.  Bone grafting material made from the patient’s own blood (Platelet Rich Fibrin), can be used to further seal the craniotomy before the bandage is placed and everything sewn/stapled shunt.  This is just an opinion I toss out there as a Disabled Dentist With a Hole In My Head.

It is my fervent hope that this clicks with ShuntWhisperer fans (both of you), maybe some docs, and that maybe, just maybe, addressing this small issue will make the post treatment course of other ICPDD patients and VP shunt recipients in general better.   As always, prayers to all.  Questions can now be sent via email to whispers@shuntwhisperer.com, and I am have setting a Twitter Feed specifically for ShuntWhisperer.

 

The Shunt Whisperer

May 19, 2018

Missing my wife in my life more and more every day: I love you, baby.

 

A Caregiver’s Thumbnail Guide to “Intracranial Hypertension”

If you are the caregiver, spouse, partner, or friend of someone who has been diagnosed with what is currently referred to as “Intracranial Hypertension” or “Pseudotumor Cerebri”, it is important that you understand what this disorder is and the effects it may cause in the patient.

I speak as both an IIH patient with a VP shunt and the caregiver to my wife.  Yes, we both were diagnosed with IIH.  We both followed what I refer to as the Neuroendocrine Theory of IIH;  tragically, before she could be treated, she succumbed to they physiologic and psychologic effects of her disorder despite my pleading with physicians to help her.  I have experienced everything I am conveying here with complete honesty and sincerity.

Forget what you  think you know about “Intracranial Hypertension”.  “IIH” patients are very ill.  Cancer Ill, in my opinion .  We’re talking about a disorder that damages the physical structure of the brain.  Very, very serious.  Don’t let anyone tell you otherwise.

The major problem faced by “IIH” patients: it just doesn’t show on the outside.  No bloody bones protruding, no disease process that is well understood and routinely treated.  Just the person telling you “I don’t feel well!” and acting strangely, which may alienates you and others.  Most “Normals” don’t know how to take this, or pull away from what is simply a very ill person who is hurting – or worse.  This is a subjective disorder surrounded by controversy in the medical field.  In late 2017, a neurosurgeon offered this opinion:  “if you had 100 neurosurgeons/neurologists, 50 of them would deny this condition exists.  Of the remaining 40 would acknowledge there was a problem but offer no treatment.  Of the remaining 10, 7 or 8 would treat the disorder with medications and lumbar punctures; only 2 of the original 100 would offer any direct (surgical) intervention.  Plus, nobody is sure of what causes the disorder to develop.

Hopefully this Guide gives you an idea of what is really going on.

Start with the term “Intracranial Hypertension”; it’s misleading.  This is not “hypertension” like “high blood pressure”.  This is increased pressure of the two fluids, blood and cerebrospinal fluid (CSF) inside the skull.  A more accurate term I  use is Intracranial Pressure Dysregulation Disorder (ICPDD).  The basic outline:

The brain and spinal cord are encased in a tissue sac called the dura.  They are further encased and protected in a hard shell of the skull (cranium) and the spine.  There is a limited amount of space for the contents of the brain, spinal cord, and two fluids; this space is essentially watertight and airtight, with minimal extra room for anything else.  ICPDD patients experience a disruption in the balance of fluids flowing in and out of the brain/dura.  The patient’s normal physiology that regulates this balance is disrupted.  The end result is an abnormal accumulation of either or both fluids inside the very confined space of the skull and spine.  This results in increased pressure in that very confined space.  The brain is literally squeezed in a liquid vise in the confines of the skull.  Evidence of this is seen when the optic nerve(s) are visibly damaged by fluid pressure, threatening eyesight.  Other patients have deformation and damage to their pituitary gland, potentially crippling a critical endocrine system and leading to pain, fatigue, and intolerance to exercise and exertion.

To say that pressure on the brain is a problem is understatement.   The brain is an organic computer with the consistency of firm tofu.  It’s mostly fat and water. It is divided into areas that control nearly all of the functions of a person’s body such as temperature regulation, energy, blood pressure, and thyroid function to name only a few.  Additionally, areas of the brain control memory, mood, thinking ability (cognitive function), and sleep cycles.  Increased I pressure on these areas understandably causes alteration of the function(s) those areas control; yet, in my experience, the response of physicians has been to tell me I’m “Hypervigilant” (pay too much attention to the symptoms of my disorder; these symptoms frequently keep me bedridden, have cost me my livelihood, financial stability, by wife…so, yeah, I sorta pay attention to them).  Other labels are “psychosomatic”, “Munchausen-esque”, and “hysterical”, the irony of which would be hysterical if it wasn’t so tragic.  All while telling me there is little understanding of “IIH”.  Probably the most epic experience was when I was seeking emergent care from a neurologist; as I vacillated between misery an agony on one side of the desk, the neurologist read my MRI report and said “well, your MRI doesn’t show any changes in your brain structure, so I don’t believe your symptoms are due to your Intracranial Hypertension, if you actually have it.  Besides, I can’t take your account of your symptoms into consideration because you’re the patient.  I have to rely on test results.”

True story.  More common than I could have ever believed.

The result in a patient with an ICPDD is a group of symptoms that would be expected to mimic damage to the brain, which is exactly what is happening .  This is the basis for the origin of another term for an ICPDD, Pseudotumor Cerebri (PTC): literally, False Brain Tumor.   Doctors treating the earliest ICPDD patient noted them to exhibit symptoms that would normally be associated with a brain tumor, but no such tumor can be found on MRI or CT scan).  Referring to my experience with the neurologist who told me I couldn’t be sick because my MRI “looked good”:  changes in brain structure don’t happen overnight.  It takes time, and are preceeded by symptoms of increased intracranial pressure, some listed below.   A short list of these possible symptoms include:

  • Memory Difficulty: searching for words
  • Cognitive Difficulty: performing simple math, taking longer than normal to process information
  • Mood Alteration/swings
  • Weight Gain (often thought to be the cause of ICPDDs, may actually be a symptom of increased pressure on an area of the brain that controls metabolism
  • Difficulty walking (Gait Disturbance)
  • Intolerance to hot/cold
  • Vision problems due to pressure and/or pressure-related damage to the optic nerve.
  • Anhedonism, or lack of interest in pleasure activities, including sex
  • Ringing in the ears (tinnitus)
  • Insomnia, which if prolonged, causes further difficulties associated with sleep deprivation
  • Fibromyalgia Pain/Exercise Intolerance
  • Fatigue
  • Increased risk of Hemorrhagic Stroke due to increased pressure in the blood vessels of the brain*
  • Nausea/Vomiting*
  • Sensitivity to light/Intolerance to light/photophobia*

*These symptoms were suggested by readers to be added to this “short list”; a reminder that symptoms vary among ICPDD patients; more significantly, this is an example of my hope that by sharing our personal understanding of these disorders based on our actual experience as ICPDD patients will advance and improve treatments more quickly. #CrowdHealing (before anyone asks, yeah, the Twitterfeed is coming…)

These are but a few of the more common symptoms  There are many more. Try this exercise.  Buy a block of firm tofu; Its about the consistency of the brain.  Squeeze it, release it.  See how much pressure is required to leave a dent.  How much is required to make tear in the surface, to deform it beyond its ability to return to original shape. Now imagine each damaged area as controlling a part of your loved one’s body.  That is literally what is happening in their skulls as cerebrospinal fluid both expands the brain from within and presses on the brain in the space around it.  Blood swells the vessels of the brain and further adds to the pressure that has no release because of the watertight, airtight manner that the Central Nervous System is enclosed.

Further, changes in conditions such as barometric pressure and temperature (aka weather) can cause aggravation of the symptoms.  Certain foods or activities can worsen symptoms as well.  Each patient has both commonalities and unique individual consideration.  Perversely, the medications used to treat increased ICPs can cause some of the symptoms of ICP.

Your loved one will experience fear at being betrayed by their own brain as well.  They may look “normal” on the outside, but inside, the most critical organ in their body is being subjected to conditions that can cause them to seem to be a different person.  And since the brain is the CPU for the functions of the entire body, their miseries are not confined to “headaches”.

What they need from you is unconditional love.  Drop everything else, give them the support they need.  I’ve been on both ends, a patient, and a caregiver.  The frustration, the fear is paralyzing when you’re the patient wondering what is happening.  The tendency is to dismiss the patient because there are no bloody bones sticking out anywhere, but trust me, that would actually be a blessing because it would likely get more attention.

Causes of ICPDDs are controversial, although recently, after 18 months of research, I have a working theory of how I developed IIH.  In my case I can pinpoint the day and the event that started mine.  Same for my wife.  Incidents of trauma to the neck with later aggravation.  For others, it can be prolonged use of certain drugs such as birth control or antibiotics.  If you’re reading this, you’re likely a male in your early to mid 40s, as the most common ICPDD patients present as female, in their 40s,  considered overweight by the medical profession.  That weight is often blamed for the disease, but don’t be so easily swayed.  Remember that block of tofu?  Imagine if you squeezed too hard on the part that controls metabolism…most ladies say their weight “just came on” in a short period of time with no change in their eating or activity habits.  Unfortunately the extra weight becomes an issue, and losing the weight helps most patients significatly, but don’t blame the weight or the patient for the disorder.

And after being diagnosed with an ICPDD? Consider this pull quote from this publication:

“…pseudotumor can cause chronic disabling headaches and visual complications.  Therapy is sub-optimal, symptomatic,  insufficient, and often complicated by side effects…”

Pseudotumor Cerebri and Ciprofloxacin: A Case Report

Fernando, et. Al

https://fqresearch.org/pdf_files/cipro_and_pseudotumor_cerebri.pdf

I know this to be the truth all too well.

Treatments for ICPDDs currently consist of drugs that often have aforementioned significant side effects, or international surgeries to relieve pressure on the brain such as shunts or venous stents.  All options are difficult and life changing.  You need to love the person, support them, understand they can’t control what is happening to them, and are frustrated at not being able to do what the used to do, want to do, or what other people want them to do.

More information can be found here on ShuntWhisperer. Com, as well as the Intracranial Hypertension Research Foundation (IHRFoundation.org), the National Organization of Rare Disorders (RareDiseases.org), and others that can be found under search terms such as “Intracranial Hypertension Research”.

The bottom line is that your loved one is suffering from a disorder that is literally squeezing their brain, the organ that not only controls their bodies, but also houses their personality, the invisible pattern of electrical activity that is them, that is their soul.  Put yourself in that position for a moment, or longer, and imagine feeling like an unseen force is pulling the strings and you’re the puppet forced to respond…or not.

As if this isn’t enough of a challenge, the current “Opioid Crisis” is making pain associated with “IIH” an inconvenient symptoms to treat.   Some physicians even go so far as to tell patients their pain is no big deal, just live with it.   “I’d rather see you in pain than give you a prescription for a narcotic” is a phrase I’ve heard on more than one occasion.  What I have found, however, is that the pain created by pressure on the pain centers of the brain responded best to small doses of acetozolamide;  maybe this is an answer for someone else reading this.

What to do for a loved one who has suddenly and seemingly inexplicably lost their ability to function, work, be a parent, partner, or engage in leisure activities?  Simple:  Give them love, unconditional love.  Give them space to be sick.  Give them support.  Give yourself space, find support for yourself.  This is a serious disorder, every bit as serious as cancer, but not nearly as well understood, and currently, IMHO, not yet nearly as well managed.  Hopefully this will improve in the near future.  God’s Blessings to all.

 

The ShuntWhisperer

February 3, 2018, revised May 1, 2019

Thinking of you every day, baby.  I miss you so much…

Defining Your Disorder: Quality of Life by the Numbers

“Ultimately the ability of a person to live a “normal” life may be impacted, and this tool is intended to better give a value to a “feeling” or sum of different conditions.”

ICPDDs affect the lives of patients according to its unique set of symptoms, and how those symptoms apply to each patient.  Pain may be a component, but also, so may fatigue, insomnia, mood alteration, memory, cognitive function, and more.  Ultimately the ability of a person to live a “normal” life may be impacted, and this tool is intended to better give a value to a “feeling” or sum of different conditions.  In my opinion, not enough attention is given to Quality of Life and Functional Capacity.  I’ve lived 11 years with the fallout of a severe neck injury, surgery, and IIH, and seen my ability to function vary from being able to almost be normal to barely being able to do laundry and shop for groceries.

This scale was developed to allow a patient to assign a 0-5 value to their impression of the sum of their Quality of Life and Functional Capacity.  Each of  these is described in the short instruction section below.  This Index is best used in a diary that 1) has regular entries 1 to 4 times a day (I use phone apps, of course), and 2) keeps track of a predetermined set of activities, medications, or condition that you notice or suspect to affect your specific condition, along with specific symptoms.  Note that you get to designate what you want to keep track of.  If you think the price of Bitcoin plays a role in your disorder, record it and chart it along with anything else you feel is important.  Better to start with a manageable number of things to record, usually no more than 5 well chosen factors that you know to be an issue in your particular condition, believe to be an issue based on research, or just want to keep track of.  Very important to record all of your factors in every entry so that any trends or connections associated with graphing your entries are noticeable and accurate.  Be prepared to invest at least two weeks before any hints of a connection are revealed, and a couple of months to confirm any possible relationships.

As an example: I routinely monitor my blood pressure, the barometric pressure, pain level (using an existing standardized scale such as found here), plus notes about any activity I feel is important, but it’s the numbers that make the connections: over time, plotting graphs of hard numbers may show relationships between symptoms and certain conditions.  In my case I was able to expose a direct relationship between barometric pressure and my symptoms of Intracranial Pressure, as well as some interesting trends in blood pressure metrics as well.  I’ve been at it since 2017 started, beginning with just checking the weather, adding barometric pressure, then blood pressure…it was a learning experience for me, and consequently took me a while before I saw any correlations.  In order to get you off to a quicker start, here are some recommendations for variables that you might begin with:

1)  Weight

2)  Blood Pressure/Pulse/MAP (Mean Arterial Pressure): I use and app called Blood Pressure Companion.  Enter your blood pressure and it calculates your MAP (average pressure in your arterial system during one heartbeat)

3)  Barometric Pressure: again, an app: Bar-O-Meter, uses a sensor in most smartphones to give the barometric pressure in your exact location.

4)  Ambient Temperature

5)  Pain Level according to the pain scale

6)  …and last but not least: the Quality of Life/Functional Capacity Index.

Other variables may be food such as caffeine, carbonated beverages, intake of certain medications – its up to you what you put in as long as you have the time to manage the diary well to make the effort bear as much information for you and your doctor as possible.  It is my sincere hope that this helps others better understand their disorder and to be able to communicate it as well as possible to their physicians.  Prayers for all, without further rambling, I give you the Official ShuntWhisperer Life Index:

 

QUALITY OF LIFE/FUNCTIONAL CAPACITY

COMFORT INDEX SCALE

ICPDD (Intracranial Pressure Dysregulation Disorder)

copyright 2018 ShuntWhisperer Media

 

 

Purpose of this Index: This index is intended to give a simple, standardized indication of any impact your disorder is having on your life.  A regular diary is kept recording vital signs and environmental factors, and this index is employed to give an indication of the your ability to perform the Basic and Necessary Activities your life requires or that you desire to perform.  Over time, it may become possible to determine factors that impact your disorder and make changes/improvements to your treatment approach.  It also helps physicians understand how your disorder is impacting you as an individual above and beyond the results of medical tests and examinations.  Ultimately the goal is that your data can be pooled with the data of other patients and used to guide improvements in the future treatment and management of your disorder.

“Quality of Life”: The single most important metric in a person’s life. Quality of Life varies between individuals and is defined as how good or bad you feel about how you are able to fulfill activities and ability to live out your life as independently as you desire.

“Functional Capacity” – the ability to perform activities and tasks, Basic or Pleasure, without assistance

“Basic Activities” – activities related to fulfilling your basic needs to live and maintain your living space.  These include but are not limited to: obtaining food/shopping; obtaining/maintaining clothing including washing, folding, and storing clothes, regular personal hygiene, and any other activity related to keeping yourself healthy, properly nourished, neatly clothed, clean, a sense of organization, and ability to maintain your living area (meet financial obligations, perform or pay for residence maintenance such as trash disposal, yardwork, housekeeping, and similar), and ability to avail yourself of ancillary services such as medical appointments for general health, dental, vision, and other similar services.  Basic Activities fall within a relatively common set of obligations, varying primarily by your individual living area (house vs. apartment vs. farm), your obligation towards any dependents (children, animals, gardening), and other factors of your personal lifestyle.

Pleasure Activites:  Activities that bring you enjoyment, pleasure, and relaxation and give you a sense of fulfillment, activities that your perform after you have completed your Basic Activities.  Pleasure Activities can include any of this very limited list of examples: physical activity and exercise (tai chi, workout at the gym, sexual activity), pursuit of a desired goal (writing a book, coding/programming) mechanical/artistic activity, visiting friends, taking vacations.  Pleasure activities are wide and varied and primarily depend on your own personal interests and desires – “The things that make you tick.”

 

Index Scale Description

0)  You feel no symptoms or affects that you relate to your disorder. You have your complete Functional Capacity, able to perform basic activities ranging from Necessary chores to pleasure activities; your Quality of Life is not affected or reduced.

1)  You begin to become aware of the symptoms that you relate to your disorder, but there is minimal to no impact on your Functional Capacity; Quality of life is not significantly affected.

2)  Your symptoms require intervention. Intervention may be in the form of medication, momentary periods of rest, or time taken to perform a therapeutic procedure.  Your Functional Capacity is impacted to a minimal degree; your Quality of Life is still very good but you begin to have to make choices about which activities, Necessary or Pleasure, are reduced or eliminated.

3)  Symptoms require both intervention along with periods of rest. Functional Capacity is reduced up to 25% of normal; Pleasure activities begin to be sacrificed in favor of therapeutic procedures and/or rest periods required to cope with symptoms.

4)  Symptoms require intervention along with significant periods of rest or bed rest in addition to therapeutic procedures. Functional activity is reduced by up to 50%; all pleasure activities are sacrificed due to lack of energy, physical limitations, and/or lack of interest.

5)  Symptoms require all possible interventions and bedrest.  Functional Capacity is reduced up to 100%.  Basic activities are significantly impacted and if improvement in Functional Capacity is not possible without prolonged periods of rest, advanced Intervention (may include doctor’s appointment or Emergency Department visit).

Note: in addition to recording a number from the list below in your diary, add a “+” if you feel your symptoms are related to high intracranial pressure, ““ if you feel the symptoms are related to low intracranial pressure (CSF overdrainage or cerebral underperfusion)*.  Symptoms of low ICP include lightheaded/emptyheaded feeling, a headache that is worse when standing and gets better when lying down, possibly sleepiness and lethargy.  Symptoms of high ICP include sensation of pressure inside the skull, increased vision disturbance, gait disturbance (difficulty walking).

*”overdrainage and underperfusion” are based on the Cerebrovascular Edema/Venous Outflow Insufficiency Theory of Intracranial Hypertension.  Underperfusion refers to a condition where blood flow to the brain is not sufficient to allow adequate Cerebrospinal Fluid (CSF) to keep up with normal absorption by the body and the additional losses through an unnatural CSF leak (this includes a shunt or leak from a lumbar puncture; CSF flow through the shunt is minimal.   Overdrainage  is excessive leakage  through a shunt pathway due to Cerebrovascular Edema as a result of Venous Outflow Insufficiency.   As brain tissue swells due to undrained blood backing up in brain vessels, areas containing CSF become pressurized, This includes the subarachnoid space and ventricles of the brain.  As CSF becomes pressurized by expanding brain tissue, it begins to flow heavily from a shunt system and may be very noticeable.  Either condition causes lower than necessary levels of CSF in the brain along with associated symptoms of lethargy/sleepiness/cognitive reduction.