Question: My daughter is recovering from a traumatic brain injury and had a new shunt put in (shunt revision) on Nov 17, 2015.

Since the shunt revision surgery, she is cognitively Much better, but since the surgery is in constant pain with a throbbing head (she says it hurts inside, consistently a pain level 7) and also has constant throbbing stomach pain (consistently pain level 5) all of which started the day after surgery.

She has never had headaches or stomach pain since the accident almost 2 years ago (April 26, 2014). After the surgery, she was given both Tramadol 50mg and Fioricet 50-325-40mg to take as needed - neither of which touches her head or stomach pain, so I stopped giving them to her.

She's had an ultra sound done, a CT, a Urinalysis, and an X-Ray and they cannot find anything that would cause the headache's or stomach throbbing. They are sending us to a Gastroenterologist for her stomach (her shunt catheter deposits into her stomach) because they do not believe the two pains (head and stomach) are related. I'm her mother and logically it would seem that the head and stomach issues are related being that they both started directly after her shunt revision surgery.

They have her on Keppra (anti-seizure) meds 500mg twice a day, and just added Elavil 10mg to take once a day at bedtime (they said the Elavil will help with her headaches).

*Side question... is it okay for her to be on Both Elavil 10 mg once a day a night, and Lexapro 10 mg once a day in the morning, at the same time?

She also had Zofran to take if she feels nauseous. However, she is not nauseous so does not use the Zofran (because it does not help with her stomach pain, which is throbbing pain below her belly button on both sides and in the center).

She is also not constipated, the x-ray checked for a blockage and there is none (and I was giving her Miralax prior to the x-ray just in case a blockage was causing the pain).

BTW, she had the shunt revision done because she had her first grand mal seizure on Nov. 15th (a year and a half after the car accident) and they discovered that the original shunt was not working, the catheter that went into her ventricle was completely disconnected from the shunt valve and had been disconnected for over a year. It's amazing that she was doing as well as she was over the past year. And like I said, she is doing MUCH better cognitively now after the revision which is why the doctors do not think it is a problem with the shunt. They explained that if the new shunt was malfunctioning, it would be obvious (they said she would be throwing up, have a fever and would have a cognitive decline).

Any ideas as to why her head throbs at a pain level 7 and her stomach throbs at a pain level 5 constantly for the past 40+ days - have you ever experienced these symptoms with a shunt revision - that these pains both started After the surgery?

Any insight and advice you can share would be greatly appreciated.

I've included her current medications below as well as pre-op CT scan, post-op CT scan reports and her ultra sound.

I have a concern based on her post-op CT scans, that the new catheter which goes into her ventricle is too close to her midline and that That could be causing her head to throb...? I should note as well that they replaced the catheter that goes into her ventricle and replaced the shunt valve itself, but they did Not replace the catheter that goes from the valve into her stomach, nor did they do any surgery on or near her stomach or trunk of her body. She also came home from the hospital with a UTI, they gave her Bactrim which she took for the 10 day cycle and just had a urine culture done again and it showed there is now no UTI.

Please share your thoughts and expert opinion.

Thank you kindly,
Alexandra's Mom
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Current Medications:

Prescribed medicine:

Keppra (Levetiracetam) 500 mg - twice daily, morning and night

Depakote (Divalproex SOD DR) - 250 mg - once daily at night (she's weaning off of this medicine - was on 1000 mg for a year, but we've taken a pill away every two weeks since the shunt revision surgery on Nov. 17 2015 - her last dose is on XXXXXXX 5, 2016)

Lexapro (Escitalopram) - 10 mg - once daily morning

Elavil (Amitriptyline HCL) - 10 mg - once daily at night

Amantadine - 100 mg - once daily morning

As Needed prescribed medicine:

Fioricet (Butalbital/APAP/Caffeine) - 50-325-40 mg - every 4 hours as needed for headaches (doesn't take this as it does not help)

Tramadol HCL - 50 mg - every 8 to 12 hours as needed for pain (doesn't take this as it does not help)

Non-prescribed vitamins and minerals that she takes daily:

Iodine/Potassium Iodide supplement - 12.5 mg - once daily morning

Vitamin D3 1000 IU (Cholecalciferol) - 25 mcg - once daily morning

Magnesium - 500 mg - once daily morning

Selenium - 200 mcg - once daily morning

ATP Cofactors - Vitamins B-2 and B-3 - (Riboflavin 100 mg & Niacin as inositol hexanicotinate 500 mg) - once daily in morning

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11/16/2015 CT - PRE-OPERATION (the day before the shunt revision) CT scan report

CT of the head.

History: Tonic-clonic seizure. History of VP shunt.

Technique: Axial CT images of the head with sagittal and coronal reformatting.
Comparison: 11/25/2014.

Findings: No intracranial hemorrhage, mass or mass effect is demonstrated.
Postsurgical findings are noted with surgical changes of bilateral anterior
craniotomies. There is encephalomalacia in the anterior inferior frontal lobes
and to a lesser extent at the anterior temporal lobes. There is also
encephalomalacia in the medial left occipital lobe, consistent with old insult,
and an old left lacunar infarct. Ventricles are prominent and increased
compared to the prior study measuring 3 cm in diameter at the anterior horn of
the left lateral ventricle, were it had measured 2.2 cm. There is a left
anterior ventricular shunt in place. Gray-white matter differentiation is
otherwise maintained. No acute skull fracture is demonstrated. Other than
mild focal mucosal thickening, visualized paranasal sinuses are well aerated.

Impression: 1. Interval increase in the size of the ventricles, which may
reflect developing hydrocephalus and ventricular shunt failure.
2. Chronic postsurgical findings are noted.

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SHUNT REVISION surgery peformed 11/17/2015

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POST-OP shunt revision 11/18/2015 CT report

CT HEAD WITHOUT IV CONTRAST
History: s/p vps placement for shunt failure. Hydrocephalus, Please eval for
hemorrhage, catheter, hydrocephalus, (Hx) / HX OF SEIZURES PREVIOUS ON
11-15-15, MRI ON 11-16-15 (DICOM Hx)
Comparison: 10/07/2014, 11/25/2014, 11/15/2015, MRI brain 11/16/2015

Technique: Axial imaging was performed from the skull base to the vertex
without IV contrast, multiplanar reconstructions.

Findings: There is a left frontoparietal VP shunt. The tip of the shunt abuts
the septum pellucidum in the midline. There is an adjacent epidural and
subdural mixed density fluid at the site of the shunt insertion suspicious for
a hematoma with air. This is new since the previous examination. The maximum
thickness is 18 mm with effacement of the underlying frontal cortical sulci and
gyri. There has been interval development of a mild left-to-right midline
shift and/or deviation of the septum secondary to the shunt measuring 5 mm.
The lateral and 3rd ventricles are enlarged although slightly decreased in size
when compared with the previous examination. There is are in the left lateral
ventricle and there is a small amount of dependent hemorrhage in the posterior
horn of the left lateral ventricle which is new since the previous exam.
There is low density of the parenchyma in the upper inferior frontal region
similar to the previous examination and may represent encephalomalacia
associated with previous trauma or infarct. There is similar change and volume
loss involving the left occipital lobe. There is a normal appearance of the
pituitary gland and fossa. The cerebellar tonsils are normally positioned.
The visualized mastoid air cells and paranasal sinuses are relatively clear.
There is mild focal posterior mucosal thickening of the right maxillary sinus
without change. The orbits appear normal.

Impression:
1. Interval shunt revision on the left with tip abutting and deflecting the
septum pellucidum from left to right
2. Interval development of mixed density epidural and subdural frontoparietal
fluid surrounding the shunt insertional site suspicious for a hematoma as noted
above with partial effacement of the underlying frontal lobe cortical sulci and
gyri
3. Interval development of intraventricular hemorrhage of the left lateral
ventricle with overall decrease in the prominence of the ventricular system
4. Notable change in the appearance of the volume loss and parenchymal
encephalomalacia in the left frontal and left occipital regions
This report was dictated utilizing voice recognition software
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2nd POST OP CT Scan report 11/19/2015

EXAM: Noncontrast CT brain

HISTORY: Status post shunt revision. New epidural hematoma. Evaluate
stability.


Technique: Serial axial images of the brain are obtained without IV contrast.
Coronal and sagittal reformats were obtained.

COMPARISON: Head CT dated November 18, 2015.

FINDINGS:
Left ventriculostomy catheter is seen placed via left frontal approach with the
tip traversing the frontal horn left lateral ventricle and terminating near the
midline.
Left frontal epidural hematoma with mixed attenuation blood compatible with
both acute and subacute its age is unchanged in size. Interval decrease in air
collection within the hematoma. Some peripheral calcifications noted.
Left lateral ventricle is still dilated but unchanged with the frontal horn
measuring up to 2.8 cm in width, previously 2.9 cm. Small layering acute blood
in the left lateral ventricle noted.
Prominent right ventricle is also unchanged.
Encephalomalacia in the right inferior frontal lobe again seen.
Postoperative changes seen in the frontal calvarium, similar to prior study.

IMPRESSION:
Stable postoperative appearance, including left epidural hemorrhage, and small
intraventricular blood and position of ventriculostomy catheter and dilatation
of ventricles as above.
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3rd POST OP CT scan report 11/22/2015

CT head without contrast, coronal sagittal reformats reviewed. Bone windows reviewed.. Comparison prior CT head 11/19/2015.

Again seen left frontal ventriculostomy catheter with tip traversing the frontal horn left lateral ventricle and terminating at the midline. Minimally decreased amount of pneumocephalus within the left frontal horn. Distention of the left lateral ventricle with dependently layering hemorrhage within the trigone lateral ventricle stable. Left frontal horn measuring up to 2.7 cm in XXXXXXX transverse dimension.

Left frontal epidural hematoma with mixed attenuation blood compatible with acute and subacute process measuring approximately 2.1 x 5.1 cm (CC AP) mostly stable. Slight interval decrease of acute component of hemorrhage and air within the hematoma. Therefore calcifications are again noted. Encephalomalacia changes in the caudal aspect white matter frontal lobes stable. No hemorrhage in the right lateral ventricle with practically similar appearance to prior scan. Trace hemorrhage versus artifact along the left tentorium slightly more conspicuous.

Postoperative changes in the frontal calvarium remain stable. Imaged paranasal sinuses and mastoids grossly clear. Small retention cyst/occlusal thickening in the right maxillary sinus. Small remote infarct in the left basal ganglia stable

Impression
Relatively stable postoperative changes including left epidural hematoma and small intraventricular blood. Although the degree of pneumocephalus and acute hemorrhage within the hematoma have decreased.

Left frontal ventriculostomy stable. Appearance of the left lateral ventricles and frontal horns stable with slight decrease of pneumocephalus.

Stable encephalomalacia changes inferior aspect frontal lobes. Postsurgical changes calvarium and soft tissues stable.
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4th POST OP CT scan report 12/08/2015

COMPARISON: 11/22/2015

RELEVANT CLINICAL HISTORY: Injury, Head W LOC, VP shunt

CT HEAD/BRAIN WO CONT

TECHNIQUE: Contiguous noncontrast axial images of the head were acquired.

FINDINGS:

Postsurgical:
1. Chronic bifrontal craniotomy.
2. Left transfrontal BP shunt catheter tip terminates at the foramen of Monro.
3. Resolution of pneumocephalus and subcutaneous emphysema.

Acute hemorrhage/abnormal extra-axial fluid:
1. Interval evolution of subdural hemorrhagic products overlying the LEFT frontal convexity, now isodense to CSF.
2. Bifrontal subdural fluid collections (Unchanged)
3. No new hemorrhage.

Midline shift:Negative.

Gray-white matter differentiation:
1. Bilateral inferior frontal lobe encephalomalacia. Stable LEFT midfrontal encephalomalacia.
2. Left occipital lobe encephalomalacia.
3. Chronic lacunar infarct of the LEFT thalamus.
4. Inferior LEFT temporal lobe encephalomalacia.
5. Remainder of the brain demonstrates normal gray-white matter differentiation.

Midline structures: Normal.

CSF spaces: Moderate lateral ventricular dilatation.

Orbits: Negative.

Skull base:Intact..

Sinuses:Mucosal thickening of the RIGHT maxillary sinus , incompletely assessed

Mastoid air cells:Negative.

Impression
IMPRESSION:

Interval evolution of hemorrhagic products. No new hemorrhage.

Decreased LEFT frontal subdural fluid collection from prior exam. Residual bifrontal subdural fluid is present. Progress multifocal encephalomalacia.
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ULTRA SOUND report 12/23/2015

Abdominal ultrasound: Patient presents with abdominal pain and bloating. Ventriculoperitoneal shunt is in place. No comparison ultrasound studies.

Liver is at the upper limits of normal for size with uniform parenchymal echogenicity. No focal hepatic masses. Main portal vein is normal in caliber and shows normal direction of blood flow by color Doppler evaluation. No intrahepatic or extrahepatic biliary dilatation the common bile duct measuring 3 mm. No evidence of cholelithiasis, gallbladder wall edema or pericholecystic fluid. Lateral pancreatic tail was obscured by bowel gas with the remainder of the pancreas appearing uniform in echogenicity. Both kidneys measure approximately 10 cm craniocaudad length and show no hydronephrosis, cortical masses or shadowing peripelvic calcifications. Spleen is normal in size and uniform in echogenicity. Aorta is normal in caliber with no periaortic adenopathy. IVC dorsal to the liver is normal in caliber with the remainder of the vessel obscured by bowel gas. 4 quadrant evaluation of the abdomen shows a trace of free fluid near the bladder. No loculated fluid collections to indicate a CSF
pseudocyst.

Impression
IMPRESSION:
1. No acute upper abdominal abnormalities.
2. No sonographic evidence of CSF pseudocyst.
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Thank you so much, your response and attention is wonderful!

Is there an over-the-counter medication she could be taking to help with gastric erosion or ulceration - like an antacid - to make her more comfortable before a upper GIT endoscopy can be performed?

I recall reading that some antacid's should not be taken with some of her current medications. Please share your thoughts and expertise.

Thank you again,
xxxxxxx (Mother)