09-JUNE-2026  AMIRA MAHER AL-SHAREEF  28 YEARS INSERTION OF THE MEDTRONIC SHUNT FROM THE EXTERNAL DRAIN.

The patient was operated by me 2 days ago for revision of the craniotomy site and insertion of the external drain. The CSF coming to the external drain is permitting insertion of the Medtronic medium pressure to the abdominal cavity.

Skin incision was made behind the craniotomy site and the intracranial tube was withdrawn around 4 cm  to keep the proximal end away from the pineal gland. The medium pressure Medtronic valve with the abdominal part were inserted to the left side of the abdomen.

The patient showed smooth recovery and sent to the ward.

The patient then came to Emergency 17-June-2026 at 7.30 p.m. due to convulsions which terminated before arrival to the hospital. The patient in bed talking and having verbal contact. All the stitches were removed and and the valve is functioning. CT-scan of the brain was done, which showed acceptable location of the shunt, but shrinking of both cerebral hemispheres more the left with slit upper III ventricle with cerebellar hemisphere pushed down and the previous tonsilar herniation took place and the prepontine space is lacking CSF space. The patient sent home and a plan was explained.

The patient then came 12.00 p.m. and the patient was dead for at least 15 min.

The case is very complicated, because there are no previous MRI data to compare with.

The VPS has small reservoir, and not functioning for unknown period.

The family have controversial information, that the surgeon cannot configure what is going on, but the Jacksonian attack of the right upper limb, which took place 2 years ago and the the drop right foot, can denote that the seizure activity took place from the leg and hand area of the sensomotor strip left hemisphere. 

This case make it clear to not reach the pineal body and to keep at least 15 mm above the target to avoid shifting of the brain after decompression and upward migration of the brain stem.

Do not leave loops outside the bur hole with no proper fixation to prevent slippage of the tube intracranially.

During insertion of the shunt the intracranial part was withdrawn 4 cm to keep away from the pineal body region.

The epiactivity was diencephalic mixed with secondary generalized tonic clonic.

The cause of death still unknown. but could be due events happening at the respiratory cardiac centers of the pons such as dorsal Respiratory Group (DRG): Primarily located within the nucleus tractus solitarius (NTS). It functions as an inspiratory center, receiving sensory input (such as lung stretch and blood chemistry) and triggering the nerves (like the phrenic nerve) that cause the diaphragm to contract.

Ventral Respiratory Group (VRG): Located ventrally in the medulla. It contains both inspiratory and expiratory neurons and controls forced exhalation and accessory muscles. Pre-Bötzinger Complex: Found within the VRG, this specific region acts as the central pacemaker, generating the fundamental, rhythmic electrical drive for breathing. Nucleus Ambiguus and Nucleus Retroambigualis: These nuclei provide motor control for the upper airway muscles (larynx, pharynx, and soft palate) and contribute to both inspiration and expiration. 2. Pontine Respiratory Group (PRG) Located in the pons, this group fine-tunes the rhythm generated by the medulla to ensure smooth, controlled breathing.

Pneumotaxic Center: Associated with the parabrachial nucleus and the Kölliker-Fuse nucleus. It actively inhibits the inspiratory phase, acting as an "off-switch" to limit inspiration, thereby controlling the depth and rate of breathing. Apneustic Center: Located in the lower pons, it stimulates inspiratory neurons to prolong inhalation. It is normally suppressed by the pneumotaxic.