Superficial Siderosis and Hydrocephalus

Having superficial siderosis is one thing, but sometimes like me, it’s possible to have other disabling neurological conditions as well. In late 2001, three years after the removal of a benign brain tumour, I was diagnosed with Hydrocephalus, which translates from Greek to English as water and head. 

Hydrocephalus is a condition usually caused by the obstruction of the flow of CSF within the central nervous system. A ventriculoperitoneal shunt is the most common way to treat this. A VP shunt is a mechanical device that drains excess CSF from the head into an area in the abdomen (the peritoneal), reducing the abnormally raised pressure in the head. A valve on the shunt opens when the pressure gets too high and drains CSF through a plastic tube (catheter) into the peritoneal area to be absorbed.

I had a VP shunt fitted to drain excess cerebrospinal fluid (CSF) from my head. The reason for this was because I was suffering increased pressure within my head, which if left untreated, could have been fatal. Prior to having a VP shunt fitted, the pressure in my head would build to such high levels it brought symptoms such as dizziness, vomiting, lethargy, blurred vision and often caused me to lose consciousness. At only eleven years old, I did not understand what was going on and was worried that I had another brain tumour because the symptoms were strikingly similar.

The operation to fit the VP shunt was a success and gave me instant relief from the raised pressure. It took a few weeks to recover from the procedure, but I was back to school shortly afterwards. The shunt, however, didn’t come without its problems; it was very prone to blocking, and each time caused an onset of the same symptoms that I had before having it fitted. Every episode of shunt blockage required another brain operation to relieve the pressure as well as the symptoms. In 2002 I underwent four shunt revision operations, so in total, I had five brain operations within the space of a year; this was a rough time for me.

Raised protein levels in the CSF can cause a VP shunt to block. Having blood in the CSF is a known cause of increased protein; so it’s possible the bleed at the back of my head contributed to the blocking of the VP Shunt, but still unknown.

In 2015 at aged twenty-five, I was in hospital with hearing and balance issues when my shunt suddenly blocked for the first time in over ten years. Little did I know this was going to lead on to my Superficial Siderosis diagnosis. The shunt blockage came out of nowhere, and suddenly I was unconscious. I never expected it, and neither did the doctors looking after me. The next thing I remember is waking up in another hospital after having had surgery to unblock the shunt. The hearing in my right ear was nearly completely gone; my left ear hadn’t changed at all. I began to experience a popping sensation in my right ear soon after discharge, as well as the dizziness and balance issues caused by the Superficial Siderosis. The popping in my right ear felt like I was 20,000 feet in the air on a plane, but I remained helpless to stop it from happening.

In October 2016, I was diagnosed with superficial siderosis, and continued to get popping in my right ear. The shunt blocked again around May 2017 after I had been exercising on the treadmill. Further brain surgery once again unblocked the shunt, and my surgeon told me he would call me back in a few weeks later to monitor the pressure in my head. This monitoring required a minor operation to insert an ICP (Intracranial Pressure) ICP bolt at the front of my head. The ICP Bolt was connected to a device on a stand which was recording my intracranial pressure in real time. It wasn’t a painful procedure as such, just uncomfortable. 

The monitoring results revealed the pressure in my head was too low (intracranial hypotensionOverview Craniospinal Hypotension, also known as Intracrania... More). My surgeon said he would first look to rule out my VP shunt as the cause of my problem. It had been in place for many years and could be draining too much CSF. The plan was to replace the shunt valve with a newer programable type that could be adjusted with a special magnet. The magnet adjustments could change the resistance of the shunt valve, so CSF only drained when the pressure got to a certain level. The shunt valve also had an anti-siphon device in it to prevent a syphoning effect which could have been causing the low pressure. Once the new valve was fitted, I was back and forth the hospital multiple weeks in a row to have the valve adjusted. Unfortunately, neither increasing or decreasing the resistance on the valve had any benefit on my low pressure symptoms.

The doctors and surgeons were finding it difficult to distinguish between the Superficial Siderosis symptoms and the VP shunt issues. A Superficial Siderosis impairment of my Neurological ReserveOverview Neurological reserve refers to the brain's ability ... More contributed to needing a much longer time to recover from the anaesthetic of the operations to unblock/revise the shunt. Both the intracranial hypotension and Superficial Siderosis played a part in my hearing lossOverview In approximately 95% of superficial siderosis patie... More.

In August 2018 a CT cisternogram (a brain scan in which contrast dye is inserted directly into the CSF via a lumbar puncture) showed that I was leaking CSF at the back of my head, and it was also presumed to be the cause of the low pressure syndrome. My surgeon operated on the back of my head to insert a Polyether Ether Keytone, ‘PEEK’ implant (a type of medical grade plastic implant) into a cavity I had from a brain tumour removal when I was 8 years. Following this surgical procedure, another cisternogram showed there was no longer a leak at the back of my head. This leak was thought to be the site of the blood infiltration into my spinal fluid which caused my Superficial Siderosis.

ETV – Endoscopic third ventriculostomy – where a hole is made in the third ventricle of the brain so that CSF can drain to relieve the pressure

Unfortunately, I now suffered relentless popping in both of my ears and developed an instability of the pressure in my head. In early 2019, further neurosurgery was carried out, and the VP shunt was removed from the right-hand side of my head and a new VP shunt was inserted into the left-hand side of my head. The new left handed sided VP shunt had a different brand of programmable valve. The new shunt did not help in the slightest, and further pressure monitoring showed that the pressure in my head was still low. My surgeon consulted an expert in low-pressure hydrocephalus. The expert recommended removing the shunt and carrying out an Endoscopic third ventriculostomy (ETV). 

Today the pressure appears to have gone in the opposite direction, and I now have the feeling of high pressure in my head The ETV is keeping the pressure down, but it doesn’t seem to offer as much pressure relief as I need. Whenever I’m doing anything physical such as my balance exercises, I feel raised pressure in my head and behind my eyes. Each time this happens, I need to stop what I’m doing. Sometimes it can be so bad that I feel like I’m losing consciousness. I’m also dealing with slight swelling and pain adjacent to my 2018 operation scar. 

The surgeons performed a CSF Infusion test so they could get an idea of the pressure tolerance threshold in my head. It was concluded that I have a ‘brittle tolerance’ to pressure change. One of the surgeons carrying out the procedure found it interesting that when I stood up, the pressure in my head appeared to increase, when it is supposed to do the opposite and decrease whilst upright. During the ETV operation earlier in the year, the surgeons left a ventricular access point at the front of my head in case the pressure got dangerously high, they would be able to insert a needle and drain off some CSF.

Currently, I’m waiting for a follow-up appointment with the consultant neurosurgeon to discuss my results and the possibility of having a new VP shunt inserted to assist the ETV with managing the pressure in my head.