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reprogramming guide for pressure adjustment of codman hakim programmable valve in a patient of normal pressure hydrocephalus

My mother Mrs. Bela Mitra,73 years  was a patient of Normal Pressure Hydrocephalus with pituitary adenoma (size 1.5 cm) and was having problem in gait,urinary incontinenance and dementia. She was operated with codman Hakim programmable VP shunt on 3.4.2009 at CMC Hospital, Vellore,India. During operation it was noted that at 200 mm pressure the CSF drainage was slow. So,neurosurgeon adjusted the pressure at 180 mm during operation.Post-operatively she responded well within a week regarding her gait,cognition and urinary incontinenance. But after one week she detoriated after coming back to Dhanbad. She was unable to swallow orally and became drowsy. So, a CT scan of brain was done in my hospital (Central Hospital,Dhanbad) as per suggestion of our neurosurgeon. On CT scan features of overdrainage of CSF was noted with subdural effusion and chin ventricles and accordingly the pressure was readjusted to 200 mm and then she improved again by walking,talking and swallowing and also urinary incontinence. But remaining well for approximately one month, she again showed features of NPH. So the pressure was again readjusted to initial 190 mm for 5 days and as there was no remarkable improvement she was again readjusted to 180 mm. But again she showed features of overdrainage and consequently pressure was readjusted to 200 mmm with which she remained well for another 25 days and after that again showed features of NPH. Then naturally pressure was initially adjusted to 190 mm for 5 days at which she showed some improvement but not full as it was with 200 mm. The pressure was readjusted to 180 mm for 2 days with which again showing gross overdrainage. Naturally, now she was readjusted to 200 mm on 20.07.09 with which she is improving gradually in respect of alertness, gait and swallowing solid and liquid both except water.

Now, I am confused regarding final adjustment of programmable shunt specially regarding actual timing, condition of the patient (i.e.in which she is doing well or when the condition is detoriating) and also pressure of the shunt.I shall be highly obiliged if you kindly give your valuable opinion in this case.

The programmable valve of my mother is without Siphon guard (Model:- Micro Valve with RICHAM Reservoir and Unitized Distal Catheter.

At present my mother(pressure setting to 200mm done on 20-07-09 ) is improving in relation to posture i.e. is better in sitting & standing.

Lastly I would again like to mention you that now my mother is improving at pressure setting of 200mm( Done on 20-05-09 ) but she is unable to sustain it for a longer period.

I shall be grateful if you can kindly give your valuable opinion regarding my mother after evaluating the given information.

Expecting early reply in this matter.

Thanking You.
With Regards,
Dr.P.K.Mitra
Child Specialist,
Co-Operative Colony,Nutandih,P.O.BCCL Township,
Dhanbad-826005,JHARKHAND.
PH:0326-2230122(R).09430152301(M).

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