Our next speaker is Christy DeLamos. She is a nurse practitioner out of UC San, Davis. She is the director of advanced practice at UC Davis Medical Center in Sacramento, California. She oversees 174 advanced practice providers within the UC Health Network. She also serves as president of the World Federation of Neuroscience Nurses, a non-profit international organization with 8800 members whose goal is to promote the professional practice of neuroscience nursing worldwide. She is a graduate of UCSF with a post-master's in acute care nurse practitioner training, and she also serves as a clinical associate professor at UCSF. Christy is one of our speakers tomorrow at the luncheon, and she's actually going to be speaking about her experiences with traveling and working with neuroscience nurses throughout the world. So, I really encourage you and hope that as many of you as possible will come to our luncheon tomorrow. It should be a fantastic, we have two great speakers. But for now, Christy is going to speak to us about shunts. Now, I know that all of you have been waiting for this lecture, right? You love shunts, and you've been sitting there saying, oh my God, I can't wait for this shunt talk. Well, it's here, good news. So, I'm going to give you a broad overview first of just CSF and how it works, and the reasons why people have trouble with hydrocephalus. So, CSF itself, hydrocephalus is characterized by excess CSF. It can be caused by obstruction, and there are a lot of different ways we can end up with obstruction, but usually it's outflow, outflow obstruction or inability to resorb CSF, like in the setting of subarachnoid hemorrhage. And then it can be congenital, present at birth, or acquired, developing sometime after birth. So, it's produced by the choroid plexus, and you guys can see that on your CT scan as something that brightly lights up. It cushions the brain and supports brain metabolism. We make about 15 to 25 mils per hour, so we know if we're draining off too much more than that, then we end up with trouble. And if we have much more than that, we're in trouble. It has to be resorbed by the arachnoid villi, and then there is, of course, tumors of the choroid plexus that can cause overproduction. So, this is the problem, right? The Monroe Kelly Doctrine, that if you put too much stuff in the box, then you get into trouble. So, in the box, you have 80% is brain, 10% is blood, and 10% is CSF. We play with that last 10% all the time, right? With using our external ventricular drainage systems to try to drain off CSF so we can make more space for too much stuff in the box. That happens in the setting of traumatic brain injury. That happens in subarachnoid hemorrhage in a number of situations. But when we get too much CSF, that's a whole other problem, and that's what we're going to talk about today. So, the acquired causes, you can have brain tumors that are intraventricular that gum up the works or intraparenchymal subarachnoid hemorrhage, which blocks up the arachnoid villi, and also germinal matrix hemorrhage in the setting of neonates. How many of you work with a lot of pediatric patients? So, you guys know this is like the bane of your existence. It's a really, really difficult thing. There's nothing like trying to change a shunt setting in a child that's moving their head. So, a lot of my practice is adults. I see some kids, but I always think, oh, no, you know, because it's such a challenge when they're little guys and they're moving constantly. So, congenital causes, aqueductal stenosis, which causes dilation of the lateral ventricles and dilation of the third. Congenital malformation like Dandy Walker and also obstruction of the foramen munro are also other common congenital causes. And then this is my other favorite diagnosis, right? Idiopathic intracranial hypertension. These are generally overweight women. The etiology still remains unclear, but it is a serious problem. And I have had patients actually come in with near blindness as a result of undermanaged idiopathic intracranial hypertension. There's a number of different things that we try. Medical management initially sometimes, which may or may not with Diamox. And how many of you, I start low and then kind of work my way up because oftentimes they'll complain that they're getting numbness or tingling in their fingertips. If you warn them ahead of time about some of those side effects of Diamox, some people will tolerate it a little bit better and not be so frightened of it. So, if you're having trouble with the medical management side, I would highly encourage to start low and then make sure that they have a really good idea as far as pharmacologic side effects of that drug. It should be taken seriously. And then we also always, always send them to ophthalmology for a formal evaluation and do an LP with opening pressures. Now, opening pressures, as you know, are highly variable. So, if someone's like bearing down or screaming or, you know, whatever during this LP, that can really change your opening pressure. And so, be aware of that. So, NPH is another reason why we commonly place shunts. And these are our wet, wobbly, and wild people who are incontinent, having trouble with gait and balance, and also difficulty with cognition. And the theory behind that is actually scarring of the pia arachnoid and arachnoid villi preventing the resorption of CSF. So, clinical management, this is something you really need to get used to in neurosurgery because it's the number one reason to present back to a neurosurgeon is actually shunt failure. Forty percent fail within three months. And another 80% are going to fail within 10 years. As you know, they undergo dozens and dozens of hospitalizations and surgeries. And it's not really usually a simple problem. So, how many of you have gone in to evaluate a patient? I've gone in the hospital setting, and there are multiple shunts. So, you're trying to figure out which one is the one that's functional. Many, several are tied off, or they have more than one shunt in place. So, it's really important to take a very thorough history, get a better idea of what's working, what's not working. And then there's that deep dive into the medical record, trying to figure out what the history of this patient truly is. There is an app put out by the Hydrocephalus Association. How many of you have used that app or encouraged your families? They're great, right? It at least gives you what they do is they're able to enter information in about their shunt. And I actually have had the emergency department call me and say, I have a shunt patient down here. I need you to come and look at them. And I came down, and it was an AV shunt in a renal patient, totally not mine. But that's an example of the emergency department's like flash decision right away. They hear the word shunt neurosurgery, shunt neurosurgery. And so, it doesn't matter what kind of shunt it is. Apparently, it's a neurosurgical problem. And I think that providers often lack understanding of childhood disorders and the nuances of shunt management. So, even as these kids get older, you're going to find that they have, there's a lot of trouble in the neurosurgery community with transition of care to an adult neurosurgeon, because they've had so much work done in that pediatric realm. And then, of course, the emergency department has speed dial neurosurgery. So, the presenting findings I want to go over because these are things you should easily recognize. So, and I want to also tell you, the mom knows. So, if this is a kiddo, these mothers have gone through this numerous times. I always pay attention to the parent. If the parent says, this is, this is, I really feel like this is shunt failure, I have a much, much, much lower threshold of making sure that I move forward quickly with a good diagnostic workup and be able to move that child to the OR if we need to, because the mother often does know. So, increasing headache, nausea, vomiting, changes in neuro exam, gaze abnormalities, poor up gaze, if infection, if we're thinking about the shunt being infected, there's often fever, malaise, and then mental status changes. So, presenting symptoms in an infant, you're looking for a bulging fontanel, increasing head circumference, apnea, bradycardia, and often seizures. In children, you're looking for high-pitched cry, poor feeding, abnormal eye movements, sun setting of the eyes, and a change in LOC or headache. In adults, headache, changes in vision, nausea, vomiting, mental status changes, and unsteady gait. So, the diagnostic workup, the most important thing is really a complete history. Onset, duration, is there a positional component to this? Is it worse when they lay down or better when they get up? So, under drainage headache is usually worse when they're lying supine, and then over drainage headache increases when they're up or later in the day. And then, the presence of fever, nuchal rigidity, or meningeal signs, we should be worried about infection, right, about meningitis. And then, mental status, cranial nerve exam, optic disc, we have them take a look and make sure that they don't have trouble with increased pressure. And then, gait and balance exam. So, this is an interesting idea using the noninvasive. How many are using shunt check or have used that device? Do you know about it? I'll show you in just a minute, but that's a noninvasive way of looking at whether or not the shunt is flowing. It's an interesting concept. I think it's probably more practical in adults than in children. In children, you actually, I'll show you how the device works and you'll see. There's also, of course, shunt series, and I'll show you some examples of those. Ultrasound of the head in babies, MRI rapid acquisition series, and then a shunt tap. How many are tapping shunts? Yeah. So, do you, like, use it as a last resort? I try not to tap shunts right away, only because I worry about the risk of infection. Infecting the shunt, if you infect it, then we have to take the whole system out. So, that's something that I usually wait on until I'm pretty sure there's something really wrong. So, this is the way shunt check works, and it's actually, it's based on the idea of thermodilution. So, you have the shunt catheter that you can feel as it's coming down, traversing down, and you actually, right as it meets the clavicle, you put this device right over the clavicle where the tubing is. And what you do is you put an ice pack over the shunt tubing that's proximal to that. And what you're looking, the sensor actually monitors the skin temperature between the two, and it looks at how cool the temperature is. And you actually get a waveform. And so, what you're looking for is a gentle waveform down so that you can see that the fluid was running through that because you put it on. You have to leave it on for several minutes, and then you take it off for several minutes and leave this device in place to track. Now, if you have a kiddo, you can imagine that that's not so practical. And also, the short distance between their neck and the clavicle does not make that easy to measure. I think in an adult, it's much more practical, and the whole thing takes like six minutes. You have a little device that you hold, and then it gives you this waveform. And for patients where there's a low threshold, you're pretty sure there's nothing wrong with the shunt, and you just want to be able to prove that it's actually flowing distally, and that's all it's measuring. It's measuring whether or not CSF is coming down and flowing distally, and it's looking for thermodilution. It's an interesting idea and perhaps useful in patients that are low risk. That does not rule out infection, right? That doesn't do anything to rule out infection. It just asks you whether or not there's fluid coming down the column. So, imaging findings, this is something that we all know about, but I remember at the beginning of my career, I don't think that we were as aware of how harmful ionizing radiation, particularly in children, is. And so, really carefully consider the indication for the CT. Children with shunts really face a lifetime of imaging, and the lifetime risk of fatal malignancy is one in 1,000 for children under one from a single CT. So, that's really, we think of how often we image them. That's a lot of risk. Two scans in a child triples the risk of leukemia and brain tumor. And so, one CT scan is 1,100 times the radiation of an X-ray or one year's worth of exposure to background radiation. So, just be aware of that when you're thinking about your diagnostic workup. So, these are some measurements on CTE. You can be very technical about how you look at the ventricle size. We all probably pick an indices and then measure that consistently each time, and I think that's fine. I think as long as you pick the same exact measure and you're going back and you're looking at your scans over a period of time over maybe four years or two years depending on the person, you want to make sure that you're looking at the same exact indices each time. And so, in this situation, A is the maximal diameter of the frontal horn. You can certainly choose that. B is the maximal cranial diameter at the level of the frontal horn. C is the occipital horn. And then, D is the maximal cranial diameter at the level of the occipital horn. And then, E is the maximal cranial diameter. So, we know that ventricular volume is strongly associated with these CT indices. There are several indexes where it's an index measurement where you take one and you divide it by another. And so, Evans and something called FOHR and then the bicotate index are the most common. FOHR is considered the most reliable of those indices. And the normal range of that is 0.37. And so, what FOHR is, it's that A plus B divided by 2E. So, it's the maximal frontal horn diameter plus the maximal occipital divided by 2 times the biparietal diameter. And why is that important? Because we can potentially predict what's going to happen based on those values. So, interestingly, the morphological pattern of the ventricles is not specifically correlated with outcome. So, because it's so individual, you've seen 1,000 CTs and they all look slightly different. But an overall reduction in the FOHR index is actually associated with good outcome. The matricular size reduction is similar in ETV and shunt. But shunted patients may continue to improve over time and actually shrink more. Whereas, ETV is usually static after about six months. And when we talk tomorrow, if you come to the luncheon, we'll talk about ETV versus shunting. And in countries that have poor resources, ETV is totally the way to go. They are not able to manage shunts that fail over time. This is much, much more practical for them. And it's definitely the route of treatment. Significant reduction in ventricular size immediately after surgery is actually associated with early shunt failure. And so, that's important to know. And the mechanism of that is actually thought to be over drainage that actually of the compliant ventricle that actually leads to a low flow state and then obstruction. So, keep an eye on that and see if in your own practice if that actually turns out to be true. Shunt tubing fracture, I've seen this a handful of times. It's not something I see every day. I probably see pseudocysts a little bit more than I see fracture. But if you look at this, and actually there's a. So, here you have a nice shunt system going all the way down here and curled up in the belly the way it should be. And you can follow that very, very easily down. This is actually terminating right here in the neck. And so, that's clearly just, you know, a shunt fracture. And you'll often see like a little bubble of fluid there. And I actually had a patient that came in. And checking the shunt when you're coming for a routine visit actually turns out to be really important. Because I had a patient that came in and she said nothing. And I saw this gigantic ball on her neck. And I said, what is this? How long has this been there? And she said, oh yeah, it's been there probably, I don't know, six months. It just didn't occur to her that there's any sort of problem with a big ball of something being on her neck. And as it turns out, she did have a fractured tubing. And so, just be aware. I mean, and following it all the way down too, I've had pseudocysts patients who have big balls in their belly. And they also don't tell you. So, make sure that you. They tell you, I have no headache. My vision's good. And there's a big ball in their belly when I pull their shirt up. Gosh, what's this? Oh yeah, yeah, that's been there. So, just be aware that doing a full exam does turn out to be important. So, managing shunts. This is the way I feel most of the time. I don't know if you guys feel this way. But the emergency department has a patient in the ER. And this is the sort of decision tree that I think I get. So, the patient comes in with an ortho issue. Oh, you need to call neurosurgery. Because they have a shunt in place. They have a UTI. Nope, call neurosurgery. The shunt is tied off completely. Call neurosurgery. So, hopefully you're not getting this so much in your emergency department, we've tried really hard. We've tried shunt-tastic training. We've tried O-shunt in the emergency department to teach them. I think all of those type of educational programs for emergency department providers to increase their comfort level with shunts makes a huge difference. So if you haven't done that yet and you're getting tons and tons of calls, try reaching out to them and doing some education so that they understand what they do need to call about and what's not as worrisome. So a urinary tract infection in a shunt patient does not require neurosurgery intervention. So this is more what I'd like to see happen in the emergency department is they suspect shunt malfunction and that's why they're calling. And then I wanna know, is the patient altered? Yes, we need to see them right now. If the patient's not altered, we can come down and see them, but the emergency department can begin to work up the patient and we can see if indicated. If they have a headache, nausea, vomiting, these are very nonspecific symptoms. These are not always a shunt malfunction. Yes, they do have that. We're happy to see them. It's not something we have to see immediately. Labs, imaging, and we consider a shunt function study if indicated. And if they don't have those symptoms, the emergency department can work them up and let us know if something more happens. Shunt infection is suspected or fever. Yes, we need to see them. And we certainly wanna get labs and send off some CSF for culture and Gram stain and then begin empiric antibiotics if that's indicated. If they have abdominal pain, I'm much more worried that this is urosepsis and I see that a lot. I don't know if you guys see that, but urinary tract infection absolutely can present with fever and headache and a number of other things and it ends up being a UTI. If they don't have that, the emergency department continue to work them up and then let us know. So reasons for shunt failure, almost always blockage. Blockage is the most common reason why. Mechanical failure is not that common. Sometimes we don't know why, and then infection is a lesser common cause too. So practical things, again, I think just really starting at the top and being very thorough is important. Don't ever rely on someone else's diagnosis. So if someone's telling you the shunt's the problem, I always start at the beginning and try to figure out what's going on from my own perspective. I take a complete history. I review all the diagnostic data. We think about neurology, PT if we need them to look at the overall picture from the standpoint of gait and balance. If this is a MPH patient and we're looking at TINETI scoring, imaging findings, ophthalmology, and then really good record keeping. If they have a shunt in place, I want to know what type of shunt they have, what the settings were previously, and I'm going to remeasure the settings. Sometimes the setting's been changed and maybe that's part of the problem. So ongoing management, we always want to look at the type of valve and the shunt setting. And sometimes people will tell you they have a programmable valve, but in fact they have a fixed valve. So that's important. If they have no idea what they have in and I don't know what's going on, I'll sometimes just get a shunt series because I can clearly see on x-ray what type of device they have in. Are the symptoms the same, better or worse? Is there any relationship to change in position? Has there been problems with constipation? That actually increases the intra-abdominal pressure and reduces shunt function. So they actually can end up with just mechanical obstruction from a significant bowel problem and so we'll do bowel care. Visual changes associated with the symptoms, nausea, vomiting, and then of course inspection. So look at the proximal, the distal, a good exam of visual fields, cranial nerves, and gait and balance. So we know that there are three different kinds we commonly encounter. Who loves the lumboparotoneal shunt? Because if you do, you can tell me your tricks afterwards because I think those are really super difficult, particularly the programmable ones in an idiopathic intracranial hypertension patient because you have a lot of adipose tissue and I find them incredibly difficult to reprogram. So if you have tricks on that, I'd love to hear it. Ventricular peritoneal is what we typically deal with and they're usually in the right frontal position unless they've had multiple revisions and they can be in a number of positions. And ventricular atrial, when they've kind of exhausted some of the VP shunt options and they all operate exactly the same way based on change in differential pressure. So settings as far as your shunt, if it's a fixed pressure, they generally have three to five settings if it's adjustable. So like the Codman programmable valve has what, 18 different settings. So there's a lot of different options with that shunt and who doesn't like to hear the dun, dun, dun? And you're like, no, no, no, no. And so just a little trick on that, if you're using that shunt, I always use the templates and I mark the area where the programmable valve is supposed to be. So they have actually a little thing that you can place at the level of the reservoir. And then you can clearly mark and put a dot on the skin so that you're right on top of it every time. And that'll significantly reduce your time in programming. And by the way, if you're not billing for programming, oh my gosh, you definitely should be. So write a procedure note, it's $143 every time you reprogram a shunt. And so that's important to know as well. So siphon guard, what that does is it actually prevents excess drainage when you change position. So it does nothing when you're laying flat. When you stand up, it actually engages the siphon guard. And what the siphon guard does is it actually allows that CSF to actually kind of spin or goes through a second circuit so that it doesn't go straight down and it prevents it from over draining. So adjustable valves, you always, always wanna confirm the shunt setting. They usually tell you, oh, it was set at this. Always confirm. Get out your measurement tools, and whether you're using Medtronic, which is a super easy device to use. And the new tools with Codman, they're MRI resistant, look quite similar. And then for Codman, you'll have that silver suitcase that many of you know. So what this actually does is it allows us to titrate CSF to individual patient needs. It becomes particularly important like in MPH, I think. And we usually start at about 120 or 150 in an MPH patient and then make small titrations because, of course, we don't wanna end up with a subdural. And they can require repeated attempts to localize the valve when you're programming. So if you're having trouble, always, if you're pretty sure I'm right on top of this valve and it's not giving me an audible confirmation if you're using the Codman program, keep in mind that that may be programmed perfect. And so you may wanna send the patient down for an X-ray just to confirm, and that's happened to me several times. So it may be that it's absolutely fine, just send them down for an X-ray. And then as you know, settings are often affected by magnets. In particular, there are two valves now, maybe a third out that have MRI resistance. And so what those do is they actually increase the amount of pressure it takes to pick that shunt setting up and turn it. And some of them, the way that they work is they actually, you can't, it doesn't just turn the dial, it actually requires that you pick it up and turn it, and that's how it's MRI resistant. So reading films, this is an example who, you know, you obviously cannot read this. So I, and when you see this, you always wanna sigh and go, oh no, I can't read that. So I send them down with instructions now on how to shoot the film, because I don't wanna end up with this. The patient comes back to the office and you go, really? Okay, yeah, so I have to send you back down. And that's never popular. It takes a long time to get them back. And if you're in the emergency department, equally unfun to find out that they've shot it wrong. So this is an example of just a Codman product. There are several products on the market, but this just shows you how, when you're looking at the X-ray, you should be seeing this circle with the line through it, and then that localization dot on the other side, and then there's a notch for where the programming is. And so I'll show you that. So this particular film, you can see that the notch should always, that, or the dot should, localization dot should always be on the right. So in this particular shunt film, it's actually shot backwards, but it doesn't mean you can't read it. It's still easy to read, because you can see the notch right here. We just know that it's shot backwards. And so the reading is 50. So shunt infections are another thing that we run into pretty routinely, and they can occur postoperatively due to a wound infection, or preoperatively, or perioperatively during surgical implantation. The early shunt infections, there are specific bugs that actually are a problem in those, and it's usually gram-positive bacteria, coag-negative staph in particular, and then late infections are gram-positive bacteria or gram-negative bacteria. So it's generally strep, or, and then if it's a gram-negative bacteria, you can look at pseudomonas as a number one player in that. So here are some examples of common pathogens, and if we look at ANLS data, we actually know that we want to start a third-generation cephalosporin and vancomycin, and that's such an easy regimen to remember, third-generation cephalosporin and vancomycin, as your initial drugs until you get sensitivities back. Once you get sensitivities back, you want to narrow your focus of your antibiotic regimen. We typically externalize, and there are certainly people that treat in place, but we're always worried about that shunt system really being contaminated at that point, and then we re-implant the entire system once the antibiotics are complete. How many of you leave the system in place and treat through it? Nobody. Okay, I have seen centers that actually do, and that scares me a little, because I worry that it's actually seeded, and you're never really truly, you may not be free of the infection. So this is just a quick case. This is an 84-year-old male who presents with a history of MPH. He comes to the office three weeks after his last adjustment with complaints of increasing headache. He's not better with lying down or with sitting up. His wife says he's foggy, and she gave him some aspirin for his headache, but when he didn't improve, she gave him some Norco, and so when you see him, he's slightly confused. He's oriented times two. He's unable to name the date or the location. Cranial nerves look okay. He has a tiny left upper extremity drift, and his sensation is intact. His gait is wide-based and unsteady. So what do you guys think? What do you think is going on? So we reprogrammed his shunt. Maybe that's part of it. I would want to know, okay, did we go up or down, right? So I would also want to know, what was his exam last time? So if I didn't see him last time, someone else saw him, I'd want to know, is it the same, or is it different, is he worse? Does he have cognitive impairment intermittently? Is this something that's been going on a long time? We know he has NPH, so that's a common component, and so is he someone who waxes and wanes? Is this a new finding for him? Was his shunt adjusted to increase resistance, or was it adjusted down? So adjusting down, what is our worry with adjusting down? So I'm changing, let's say he has a Codman in place, and I go from 130 to 100. What is our worry with doing that? What are we doing? We are opening up the shunt, right? We're gonna get more flow. So what is our worry? Yep. So we know that in these elderly people that come in with NPH, they have those bridging veins that actually connect their brain to the subdural space, and so as you pull down on the brain, because we're draining off CSF, the natural thing to have happen is for them to actually bleed into that area, to tear one of those bridging veins, and it just bleeds very, very slowly. And so on exam, he is a little bit more cloudy than he was at your previous exam, but his wife says he just gets the sway with narcotics. Every time I give him Norco, he's the sway. So how many would adjust his shunt back down to the previous setting? So if he was at 100 this time, but at 130, how many of you would do that? Nobody? I might readjust, but I would send him for a scan. Yep, for sure, for sure. I would send him for a scan. So how many would scan him? Yeah, most people, yeah, definitely. So here's your scan, which is as predicted, right? And his wife is so helpful giving the aspirin. Thank you, right? And so here we have a big subdural all the way down, holohemispheric subdural, and so the other thing that is nice about programmable valves is turn it off. Go up to the highest setting possible. Turn it off. This is an NPH patient. The purpose of that was to improve his cognitive function, but now he has a serious problem, so I wouldn't want any more CSF being diverted. So you can actually turn it off until you can get this patient to the hospital, get them admitted, get their subdural taken care of, and then you can reevaluate whether or not he's appropriate for shunt. But you can go all the way up to the highest setting on any one of those systems, and that will at least stop more drainage or reduce it significantly if you don't have a virtual off. There are a couple of manufacturers that have virtual offs, so just keep that in mind. So just in summary, shunt problems are some of the most common things that we see, the reasons why we return to a neurosurgeon. It's really critical to complete a full diagnostic workup before committing to shunt removal or any sort of additional diagnostics. And we want close follow-up with titration of programmable valves. That can make a really big difference in patient management, and just get comfortable with it, because it's something you're going to see the rest of your practice. Are there any questions? No? No burning shunt questions? Okay. All right. Thank you. We have one question. We have one question. With the shunt check thermosensor, do you get a sense at all of how fast it's blowing? Is it a sense at all? Are you getting a sense or is it just basically telling you how much it's coming up? It doesn't tell you how fast the shunt is flowing. You just see, you get a trend. You actually get a curve. There's a curve going down, because it's looking at how cold it was initially, and then when you remove the ice or the ice pack from their neck, you get a curve going downward, showing that it was cold initially, and now the fluid is no longer cold, but it's flowing through there. You actually get a kind of a flat line if there's nothing flowing through it, because it should be far enough distal from that ice that if there was nothing coming down, you wouldn't get a curve at all. I assume that if there was very little flow in it, you would have a curve, but not as robust, a curve that's a little bit more flat. Yeah. Yes. I didn't hear the question. I'm sorry. So, we do use those, but we actually work them up completely first before we do that. So, if we admit them, and we have a high suspicion of shunt malfunction, then it'll be ordered, you know, within the first 12 hours of admission, and we get it right away. What about your center? Right. Right. Yeah. We only get them if we're, you know, there are probably rare patients from the clinic where we're sending them for shunt function studies, but we have to have a pretty low threshold at that point, right? We're not going to send them out if we're convinced that there's something really wrong with their shunt, and they're declining. If the patient is admitted, we're more likely to get that as a diagnostic measure, because we want to know, do we need to take them to the OR, yes or no? Do we have a proximal problem or a distal problem? That will influence our management, because if distally everything's fine, but we have a proximal occlusion, then that's important to know. Are you guys, is neurosurgery the ones accessing the shunt every time in nuclear medicine? Us too. How many of you just have nuclear medicine, if you're doing shunt function studies, it's just the neurosurgery department that's accessing that? Okay. Because we've had some pushback that they would like to access them themselves. They have to wait for us, and I said that's too bad. We're not going to have you access our shunts. So, I was just curious. Any other questions? No? Okay. Thank you. Thank you.

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Shunt Check