Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters

This study aims to review the imaging findings of distal (thoracic and abdominal) complications related to ventriculo-peritoneal (VP), ventriculo-pleural (VPL), and ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt catheter placement. Institution review board-approved single-center study of patients with thoracic and abdominal CSF catheter-related complications on cross-sectional imaging examinations over a 14-year period was performed. Clinical presentation, patient demographics, prior medical history, and subsequent surgical treatment were recorded. The presence or absence of CSF catheter-related infection and/or acute hydrocephalus on cross-sectional imaging was also recorded. There were 81 distal CSF catheter-related complications identified on 47 thoracic or abdominal imaging examinations in 30 patients (age 5–80 years, mean 39.3 years), most often on CT (CT?=?42, MRI?=?1, US?=?4). Complications included 38 intraperitoneal and 11 extraperitoneal fluid collections. Extraperitoneal collections included nine abdominal wall subcutaneous (SC) pseudocysts associated with shunt migration and obesity, an intrapleural pseudocyst, and a breast pseudocyst. There were also two large VPL-related pleural effusions, a fractured catheter in the SC tissues, and a large VA shunt thrombus within the right atrium. Ten patients (33.3 %) had culture-positive infection from CSF or shunt catheter samples. Ten patients (33.3 %) had features of temporally related acute or worsening hydrocephalus on neuroimaging. In four of these patients, the detection of thoracic and abdominal complications on CT preceded and predicted the findings of acute hydrocephalus on cranial imaging. Thoracic and abdominal complications of CSF shunts, as can be identified on CT,  include shunt infection and/or obstruction, may be both multiple and recurrent, and may be predictive of concurrent acute intracranial problems.     

Sonographically guided aspiration of cerebrospinal fluid pseudocysts in children and adolescents

OBJECTIVE: Cerebrospinal fluid (CSF) pseudocyst formation is an uncommon cause of ventriculoperitoneal shunt malfunction in children. Traditional staged treatment consists of shunt externalization, antibiotics, and later shunt revision and internalization. We sought to evaluate whether sonographically guided pseudocyst aspiration to alleviate acute symptoms and to exclude CSF infection could obviate shunt externalization and expedite the care of these patients. CONCLUSION: Sonographically guided CSF pseudocyst aspiration is an effective technique, allowing exclusion or confirmation of infection and providing relief of abdominal symptoms. In patients with sterile collections, staged surgical revision with shunt externalization can be avoided, speeding and simplifying treatment.     

Value of arteriography in the evaluation of a sonolucent pancreatic mass

A pseudoaneurysm of the pancreaticoduodenal artery secondary to chronic pancreatitis was erroneously diagnosed as a pancreatic pseudocyst by abdominal plain films, barium gastrointestinal studies, and abdominal ultrasound. Because of the operative findings, it was necessary to interrupt surgery undertaken to drain the presumed pseudocyst. Angiography is strongly recommended as a preoperative study in patients with sonolucent pancreatic masses to distinguish pseudoaneurysms of pancreatic vessels from pseudocysts.     

Percutaneous drainage of mediastinal pseudocysts

Percutaneous catheter drainage of a mediastinal pseudocyst was performed in two patients. Access was gained through computed tomography (CT)-guided puncture of the abdominal portion of the pseudocyst in one patient, and a transhepatic-subxiphoid approach was used in the other. Guide wires and catheters were advanced into the mediastinal pseudocysts under CT control. Drainage was technically successful in both patients, with no procedure-related complications. Percutaneous drainage is an alternative to the surgical treatment of symptomatic and nonresolving mediastinal pseudocysts, provided that a safe access route can be found.     

Pancreatic pseudocyst: comparative evaluation by sonography and computed tomography

Fifty-four patients were referred to rule out pancreatic pseudocyst. These patients underwent both sonographic and abdominal computed tomographic (CT) examinations for the evaluation of suspected pseudocysts. Among the 54 cases were 24 with proven pseudocysts. CT correctly identified 23 of the 24 pseudocysts with one false-negative and two false-positive studies. With sonography, the studies were technically inadequate in 20 of the 54 patients examined. Sonography correctly diagnosed 18 of the 24 pseudocysts; however, in 10 of these 18 cases sonographic findings were incomplete relative to CT findings. There were one false-negative and three false-positive sonographic studies. On the basis of this study, it was concluded that CT is more accurate than sonography in both diagnosing and demonstrating the extent of pseudocysts of the pancreas.     

Pseudocyst formation in acute pancreatitis: ultrasonographic evaluation of 99 cases.

A total of 99 patients admitted with a diagnosis of acute pancreatitis were studied by abdominal A- and B-mode ultrasonography in an effort to detect pseudocyst formation. Positive ultrasonic scans were noted in 52 cases. In three patients with positive sonography, surgical exploration did not demonstrate pseudocysts, giving a false positive rate of 8.3%. Of the negative studies four were proven incorrect at surgery or autopsy , yielding a false negative rate of 8.5%. Approximately one-fifth with cystic lesions underwent spontaneous resolution. Three additional patients with pseudocysts had spontaneous cyst-enteric fistulization demonstrated by radiography. The sensitivity and accuracy of pancreatic ultrasound demonstrated by this study established ultrasonography as the procedure of choice in detecting pseudocyst formation in patients with acute pancreatitis.     

Pancreatic pseudocysts drained through a percutaneous transgastric approach: further experience

Percutaneous transgastric placement of a drainage catheter under ultrasonographic and fluoroscopic guidance was performed in 12 patients with pancreatic pseudocysts. Complete resolution of the pseudocysts was obtained in eight patients, and the result was indeterminate in one patient due to early death from unrelated causes. Surgical intervention followed in two patients, one with a multiloculated pseudocyst that was incompletely drained and another with a pseudocyst that became infected following drainage. In one patient with metastatic tumor to the head of the pancreas the pseudocyst resolved initially, but a pseudocyst later recurred. There were no pancreaticocutaneous fistulas or other major complications. The transgastric route of pseudocyst drainage is safe and effective, and it offers a low risk of recurrence and fistula formation.     

Computed tomography of pancreatic pseudocysts of the duodenum

The findings of computed tomography (CT) in seven patients with pancreatic pseudocysts involving the duodenum are reported. Specific CT characteristics of duodenal wall involvement by the pseudocysts are tubular configuration of the pseudocyst, extending along the wall and conforming to the course of the duodenum (seven of seven), and abrupt flattening of the otherwise tubular or spherical pseudocyst at the border of the duodenal lumen (five of seven). The second part of the duodenum was involved in all cases; in some cases the first part of the duodenum was also involved (two of seven), and in others the pseudocyst extended to the third part of the duodenum (two of seven). All patients had other CT evidence of pancreatitis in addition to duodenal pseudocysts. CT findings are compared to other imaging methods and clinical and surgical findings. Patients with duodenal pseudocysts should be watched carefully for signs and symptoms of gastric outlet obstruction, since this was a prominent clinical problem in six of seven patients, and gastric outlet obstruction complicating suspected pancreatitis should alert to the possibility of duodenal pseudocyst.     

Lesser sac cerebrospinal fluid collection. An unusual complication of a ventriculoperitoneal shunt

Ventriculoperitoneal shunts provide an effective means of decreasing intracranial pressure and diverting cerebrospinal fluid (CSF). A variety of complications may be seen, however, with the peritoneal limb. This study describes the scintigraphic evaluation of a large intra-abdominal CSF pseudocyst and the migration of the shunt tip into the lesser peritoneal sac.     

Percutaneous drainage of traumatic pancreatic pseudocysts in children

In the past, children with pancreatic pseudocysts have been managed surgically. We report seven children 3-13 years old with posttraumatic pancreatic pseudocysts who were managed with percutaneous catheter drainage. All procedures were performed with local anesthesia and intramuscular sedation under sonographic or CT guidance. Two of the pseudocysts were drained via a transgastric approach, the other five via direct transcutaneous access to the pseudocyst. The catheters were in place an average of 25 days (range, 8-66). There were no serious complications. Six patients became asymptomatic with return of the serum amylase to normal and resolution of the pseudocyst on follow-up sonograms. One patient, in whom the catheter became dislodged after 2 weeks, became asymptomatic, but he had a residual 2-cm pancreatic pseudocyst that resolved over the next 6 weeks. Our experience suggests that percutaneous drainage is a safe and effective method of treatment for traumatic pancreatic pseudocysts in children.     

Lymphocele Mimicking a Pancreatic Pseudocyst: Imaging Characteristics and Percutaneous Management

Lymphocele can be a difficult diagnosis to establish and may be confused for other abdominal fluid collections. Conversely, pancreatic pseudocysts may occur inadvertently from upper abdominal surgery and must be included in the differential diagnosis of virtually all peripancreatic fluid collections. We report the unusual occurrence of an unsuspected postoperative peripancreatic lymphocele that was thought to be a pancreatic pseudocyst. In retrospect, CT findings were evident and diagnostic. The lymphocele responded well to percutaneous drainage.     

The sonographic signs of the peritoneal pseudocyst obstructing the ventriculo-peritoneal shunt in children

Summary The installation of the ventriculo-peritoneal shunt (VPS) is on the rise in the pediatric age. Its obstruction is a major cause for further deterioriation of the already present hydrocephalus. Distal VPS obstruction may be due to a pseudocyst, an infected pseudocyst or an abscess-formation within the peritoneal cavity. These pathologies are identified through an abdominal radiograph and ultrasonography. The sonographic signs are described and its differential diagnosis is discussed in relation to 6 diagnosed cases. One VPS was obstructed by Ascaris lumbricoides clinging to its tip within an abscess.     

胰腺炎并发脾门区及脾脏假性囊肿的CT诊断(附8例报告)

目的：探讨脾门区及脾脏内胰源性假性囊肿形成的解剖学机制及CT诊断价值。方法：收集经手术或临床治疗随访证实的脾及脾门区胰源性假性囊肿8例，对其CT征象进行回顾性分析。结果：8例患者胰尾或胰体尾部发现囊肿，其中5例在随访过程中发现脾内囊肿形成，2例发现脾间囊肿形成；1例单纯发现脾门区囊肿。7例早期均有明确的胰腺炎病史，发病部位以胰体尾为主，囊肿密度早期较高，后期CT值在12HU左右。壁厚薄不一，较大者壁薄。随着囊液的吸收，壁逐渐变厚。脾内囊肿初期表现边界欠清，平均7周左右出现较清晰的边界，结合增强及薄层扫描，有4例脾内囊肿与脾被囊问有明确的裂隙相连通。结论：脾肾韧带及胃脾韧带是脾门区及脾脏内胰源性假性囊肿形成的重要解剖学基础；CT检查对胰腺假性囊肿诊断及其动态监测具有重要临床意义。     

Percutaneous pancreato-gastrostomy in the treatment of pancreatic pseudocysts. Presentation of 2 cases

The authors describe a new method for the treatment of pancreatic pseudocysts using a personal technique: the percutaneous pseudocystogastrostomy. Under US and fluoroscopy guidance at first a percutaneous drainage is introduced in the pseudocyst using a transgastric approach. For seven days the drainage catheter is flushed with antibiotic solution (Rifocin), then under fluoroscopy and endoscopy guidance doubled pig-tail catheter is placed with its curlend ends in the lumen of the stomach and pseudocyst respectively. After 60 days the double pig-tail catheter is removed endoscopically. Two patients with pancreatic pseudocysts were treated successful by this method. No complications or recurrences were observed.     

CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy

Computed tomography (CT) findings that may differentiate walled-off pancreatic necrosis (WOPN) from pancreatic pseudocyst were investigated. CT examinations performed before endoscopic therapy of pancreatic fluid collection (PFC) in 73 patients (45 WOPN, 28 pseudocysts) were evaluated retrospectively by two radiologists. PFC was evaluated for size, extension to paracolic space, characteristics of wall and internal structure. The pancreas was evaluated for deformity or discontinuity, and pancreatic duct dilation. CT findings that were associated with WOPN or pseudocyst were identified. CT score (number of CT findings associated with WOPN minus number of findings associated with pseudocyst) was calculated for each PFC. PFC was categorized as WOPN or pseudocyst using a CT score threshold. Larger size, extension to paracolic space, irregular wall definition, presence of fat attenuation debris in PFC, pancreatic deformity or discontinuity (P < 0.05–0.0001) were findings associated with WOPN. Presence of pancreatic duct dilation was associated with pseudocyst. Using a CT score of 2 or higher as a threshold, CT differentiated WOPN from pseudocyst with an accuracy of 79.5–83.6%. Thus, CT can differentiate WOPN from pseudocysts.     

Pancreatic pseudocysts of the duodenum.

A pancreatic pseudocyst within the wall of the duodenum is presented. Its radiographic features were analyzed and comprehensively compared with 10 proved cases. These pseudocysts can be intramural or extrinsic severely compressive lesions. The occurrence of these pseudocysts at multiple sites throughout the gastrointestinal tract emphasizes the need to consider them in the differential diagnosis of severe extrinsic compressive or intramural lesions.     

Complicated pancreatic inflammatory disease: diagnostic and therapeutic role of interventional radiology

Diagnostic and therapeutic interventional radiology techniques in 41 patients with complications of pancreatic inflammatory disease (noninfected pseudocyst, infected pseudocyst, phlegmon, abscess, hemorrhagic pancreatitis) are described. Computed tomography or ultrasound-guided aspiration or percutaneous pancreatic ductography enabled specific diagnoses in 43 of 45 patients (96%). In almost half the patients, diagnostic aspiration with 22-gauge needles was unsuccessful due to viscous contents or firm cavity walls. Single-step needle aspiration of noninfected pseudocysts was successful in only three of ten patients (30%). Catheter drainage cured six of seven noninfected pseudocysts (85.7%) and seven of nine infected pseudocysts (77.7%). Pancreatic phlegmons were aspirated in five patients to exclude secondary infection and help determine the need for surgery. Pancreatic abscesses were drained successfully in nine of 13 patients (69.2%); temporizing benefit was achieved in the other four who eventually underwent surgery in improved condition. Early diagnosis of the complications of pancreatitis may be established almost uniformly, and at least 70% of patients with infected or noninfected pseudocysts and pancreatic abscesses may be cured by nonoperative drainage.     

CT scanning and ultrasound in the evaluation of pancreatic pseudocysts: a preliminary comparison

A retrospective review of 12 surgically proved cases of pancreatic pseudocyst was performed. CT correctly demonstrated 6/8 uncomplicated pseudocysts and 4/4 infected pseudocysts. Ultrasound identified 7/8 uncomplicated and 2/4 infected pseudocysts. Errors by one modality are due to limitations not shared by the other method. This suggests a basis for the complementary use of CT scanning and ultrasound in the evaluation of suspected pancreatic pseudocysts.     

Percutaneous transgastric snaring for repositioning of a dislocated internal drain from a pancreatic pseudocyst

Pancreatic pseudocysts may occur in up to 10% of patients with acute or chronic pancreatitis. Symptomatic, persistent, and infected pancreatic pseudocysts require interventional therapy. We present the case of a patient with complete dislocation of a double pigtail catheter into an infected pseudocyst and the repositioning of the drainage catheter using a transgastric snaring technique. The combination of CT-guided percutaneous puncture and fluoroscopic snaring permitted minimally invasive management of this rare complication.     

Incarcerated Spigelian hernia: ultrasonic differential diagnosis.

The gray scale ultrasonic findings in a case of incarcerated Spigelian hernia are presented. This hernia is uncommon, and the clinical diagnosis can be difficult. The appearance of the lesion is compared with others in and about the abdominal wall, including rectus sheath hematoma, seroma, abscess, peritoneal tumor implants, and pseudocyst at the end of a ventriculoperitoneal shunt. Clinical and sonographic differentiation is emphasized.