CSF hydrothorax after ventriculoperitoneal shunt without catheter migration: a case report

Ventriculoperitoneal (VP) shunting is the most common procedure performed for the management of hydrocephalus. VP shunt related complications remain a persistent problem in current clinical practice. Five-year-old female patient was admitted to our hospital with persistent dyspnea complaint. The patient was operated at the age of 3 months and a VP shunt established in a different clinic due to hydrocephalus associated with Dandy-Walker malformation. The patient’s chest X-ray revealed right sided pleural effusion. Thorasentesis was performed and the effusion was drained with a chest tube. The discharged liquid was consistent with CSF. Scintigraphic radionuclide shunt analyses were performed and CSF passage from abdomen to chest and lower mediastinal region was determined in the late static images. The patient was operated and the incorporated ventriculoperitoneal shunt was removed. Hydrothorax was completely resolved after early postoperative stage. CSF hydrothorax especially without catheter migration is an unusual but potentially serious-clinical complication.     

Intracardiac migration of the distal catheter of ventriculoperitoneal shunt: a case report

Introduction

Migration of the distal catheter into the heart is an extremely rare complication of ventriculoperitoneal shunt, with only 11 cases reported in literature; in only four of them, there was also the migration into the pulmonary artery. The authors report the case of a young patient with this rare complication that was managed simply converting the ventriculoperitoneal shunt into a ventriculoatrial shunt.

Discussion

The migration of the distal catheter occurred through the internal jugular vein probably as the consequence of direct damage of the vessel during tunneling. Venous flow and negative intrathoracic pressure may have gradually pulled the catheter up into the heart; the upward migration may also be encouraged by the continuous movements of the patient that was agitated in the postoperative period as the consequence of her psychiatric disorder. The authors review the literature regarding migration of distal tubing into the heart and pulmonary artery. Diagnosis and management of this complication is discussed.     

Spontaneous extrusion of peritoneal catheter through intact abdominal wall

A rare occurrence of spontaneous extrusion of a Denver peritoneal catheter through the right flank in a 14-year-old boy is reported. The firm texture and short length of the catheter coupled with its movements with respiration produced a hammer effect and eroded the abdominal wall. Disconnection of the peritoneal catheter from the chamber and pulling out the extruded catheter is suggested as a simple and effective method of removal of the shunt.     

Spontaneous peritoneal catheter knot formation: A rare cause of ventriculoperitoneal shunt malfunction

Ventriculoperitoneal (VP) shunting remains invaluable in the management of hydrocephalus. It is a common procedure that can be complicated by shunt malfunction due to infection, blockage and disconnection. Spontaneous peritoneal catheter knot formation causing CSF flow obstruction is a rare phenomenon. We present a case of a 12 years old boy with spontaneous knot formation in the peritoneal catheter causing VP shunt obstruction and hydrocephalus.     

Chronic ossified epidural hematoma after ventriculoperitoneal shunt insertion: a case report

Chronic calcified/ossified epidural hematoma is an uncommon complication of ventricular shunt surgery. There are only 4 cases related to valve-regulated shunt operations in the literature. It may be seen especially in young patients with chronic hydrocephalus, probably due to craniocerebral disproportion. The precise mechanism of the calcification or ossification of the hematoma is not known, however, the dura mater seems to play a part in this process. A 17-year-old girl with triventricular hydrocephalus was treated with a ventriculoperitoneal shunt system including a medium pressure flow control valve. She was admitted with a complaint of severe headache after three years and a bifrontal calcified/ossified epidural hematoma was seen. The calcifying hematoma was removed and the patient's headache resolved. Although the use of high or medium pressure valves, valves with an antisiphon device, adjustable pressure valves or flow control valves have been recommended to prevent this complication in previous reports, it was seen that our case had been treated with a medium pressure flow control valve.     

CSF fistula through the left lumbar region in adult following a ventriculoperitoneal shunt surgery: a rare case report

A cranial spinal fluid fistula through left lumbar region following a ventriculoperitoneal (VP) shunt is an extremely rare complication. We report a 25-year-old man who presented with the leakage of clear fluid from the left lumbar region, 3 years after a VP shunt surgery. Computerized tomography scan of abdomen revealed that the distal end of the catheter penetrated into the inner layer of the wall of left lumbar region. He was managed successfully with abdominal part of shunt catheter removal from primary cervical and abdominal incision, a new abdominal part of VP shunt catheter replacement and prophylactic antibiotic.     

Protrusion of a peritoneal catheter via abdominal wall and operated myelomeningocele area: a rare complication of ventriculoperitoneal shunt

Background

Ventriculoperitoneal shunting is mostly used in the treatment of hydrocephalus, and many complications have been reported with this method. These complications include obstruction, mechanical shunt failure, infection, and abdominal complications. Abdominal complications include intestinal obstruction, volvulus, peritonitis, peritoneal cyst, cerebrospinal fluid ascites, as well as migration of the distal catheter via the intestinal tract, umbilicus, scrotum, and vagina. Various mechanisms have been suggested with regards to the catheter migration.

Case report

We present a case of a 21-month-old female patient who had myelomeningocele at birth. She underwent repair of the myelomeningocele at the age of 10 days. After 4 months, cranial computed tomography revealed hydrocephalus, and ventriculoperitoneal shunt was placed. Because of shunt dysfunction, a new ventriculoperitoneal shunt system was installed at the age of 12 months. Eight months later, her mother noticed the protrusion of peritoneal catheter via abdominal wall and repaired myelomeningocele area. Revision of the lower end of the shunt was done, and myelomeningocele area was repaired again.

Conclusion

We report a unique patient with the protrusion of the distal catheter through repaired myelomeningocele area and abdominal wall in the lumbar region.     

Sterile ascites from a ventriculoperitoneal shunt: a case report and review of the literature

Background Symptomatic, sterile cerebrospinal fluid (CSF) ascites is a rare complication of ventriculoperitoneal (VP) shunt surgery. To date, reports in the literature have linked this unusual circumstance to various intra-abdominal, CNS, or nonspecific inflammatory causes.Case report We present the case of a four-year-old boy with a recently fenestrated arachnoid cyst and VP shunt, who presented with sudden-onset, sterile CSF ascites. The ascites resolved with conversion of the preexisting VP shunt to a ventriculoatrial shunt.     

Urinary bladder perforation, intra-corporeal knotting, and per-urethral extrusion of ventriculoperitoneal shunt in a single patient: case report and review of literature

Background

Ventriculoperitoneal shunt (VPS) surgery is the most common procedure performed for the treatment of hydrocephalus. Erosive bladder perforation by a peritoneal catheter is an extremely rare complication of VPS. Only ten cases involving the normal (non-augmented) urinary bladder have been reported so far.

Case

We report a case of erosive bladder perforation, intra-corporeal knot formation, and perurethral extrusion of the distal end of VPS. This is the second only case report so far in the world literature showing triad of uncommon VPS complications in a single patient.

Conclusion

Prompt management could avoid further complications. Patient’s parents should be aware about this rare complication, so that they can seek timely medical help.     

Tension pneumocephalus complicating ventriculoperitoneal shunt for cerebrospinal fluid rhinorrhoea: case report.

A case of spontaneous nontraumatic cerebrospinal fluid rhinorrhoea secondary to aqueductal stenosis is reported. The patient required direct repair of the fistula after the insertion of a ventriculoperitoneal shunt for aqueductal stenosis. We emphasise an unusual complication of tension pneumocephalus in a case where the shunt patency had been substantiated. Intracranial pressure fall due to the siphon effect in the ventriculoperitoneal shunt tubing in the erect position might be responsible for ingress of an excessive amount of air.     

Late-onset erythema along a sterile functioning ventriculoperitoneal shunt: case report and review of the literature

CASE REPORT: A 6-year-old boy presented with erythema along the tract of his ventriculoperitoneal shunt 6 years after its insertion; there was no associated CSF infection or shunt malfunction.DISCUSSION: The question of what to do in such a situation is addressed. The possible causes of the erythema are discussed, as well as its management, and the literature is reviewed.     

Transient ventriculoperitoneal shunt malfunction after chronic constipation: case report and review of literature

Background Significant constipation in patients with shunt-dependent hydrocephalus may often be enough to bring a subclinical shunt malfunction to clinical attention or even to be the cause of temporary distal peritoneal shunt malfunction. The treatment of the constipation may address the symptomatic shunt dysfunction so as to avoid operative intervention. The pathogenesis of distal shunt malfunction and its management in such a situation are discussed, and the relevant literature is briefly reviewed. Case report A 16-year-old young boy had shunt-dependent hydrocephalus secondary to prematurity and intraventricular hemorrhage at birth. He was chronic flaccid paraplegic and had a neurogenic bladder and bowel involvement. He presented with acute dull aching intermittent headaches, nausea, and constipation of short duration. There was no underlying shunt infection. CT brain showed dilated lateral ventricles. Shunt survey revealed a convoluted course and kink in the distal peritoneal catheter. After administration of a bowel enema, the headaches and nausea resolved over the next few hours, and the posttreatment CT showed significant decrease in ventricular size. Conclusion Chronic constipation is an important predisposing factor for distal malfunction in shunt-dependent hydrocephalus and should be ascertained in evaluation of a ventriculoperitoneal shunt malfunction. Appropriate treatment of significant constipation can relieve shunt malfunction and reestablish cerebrospinal fluid circulation. A shunt exploration can be avoided in such a situation. A close neurological monitoring of the patient is essential during the course of treatment. An interdisciplinary approach between concerned medical specialities and enhanced awareness is mandatory to ensure appropriate bowel management.     

Complications of a pressure sore of the chest wall: case report

A female tetraplegic patient developed a pressure sore of the chest wall leading to an empyema of the lung and respiratory failure. The pressure sore resulted from the commonly practised habit of grasping the upright of the wheel chair with the upper arm in order to gain stability.     

Symptomatic pleural effusion without intrathoracic migration of ventriculoperitoneal shunt catheter

Background Symptomatic pleural effusion following ventriculoperitoneal (VP) shunt insertion is very rare. The patient was an 8-year-old girl who had VP shunt for hydrocephalus as a result of aqueductal stenosis. Six weeks after surgery, she presented with headache, vomiting and drowsiness. She developed respiratory distress with pain in the right lower chest region and right hypochondrium on admission.Methods Chest X-ray confirmed right hydrothorax and showed the tip of the peritoneal catheter in the right suprahepatic subphrenic space. Her symptoms abated after the catheter was repositioned from the subphrenic region to the general peritoneal cavity. Repeat chest X-ray confirmed the resolution of the hydrothorax.Discussion Shunt review without thoracocentesis or thoracostomy is an effective treatment of symptomatic hydrothorax following VP shunt, especially when there is no intrathoracic shunt migration.     

A ventriculoperitoneal shunt catheter wrapped around a right mammary prosthesis forming a pseudocyst

Breast cerebrospinal fluid pseudocysts are a rare complication of ventriculoperitoneal (VP) shunting. It is very unusual for the peritoneal catheter of a shunt to become wrapped around a prosthesis a previously augmented breast. Three previously reported patients developed an enlarging breast lump and were diagnosed with shunt migration around the prosthesis. Our patient underwent bilateral breast augmentation and subsequently a VP shunt. We observed on frequent follow-up chest X-rays performed for pneumonia and mechanical ventilation that the peritoneal catheter had gradually wrapped around her prosthesis. She developed a progressively enlarging breast lump which resolved with drainage of the cerebrospinal fluid collection and revision of the VP shunt.     

脑室-腹腔分流管移位至心脏二例报告及文献复习

目的 探讨罕见的脑室-腹腔分流管移位至心脏的发病机制、临床特点、诊治方法及并发症.方法 分析2例脑室-腹腔分流管移位至心脏的诊治过程,并结合文献对本病的预防及诊治进行讨论.结果 通过临床表现及影像学检查明确诊断,手术顺利拔除了移位的分流管,术中及术后患者病情平稳.结论 首次在国内报道了脑室-腹腔分流管移位至心脏的病例;在脑室-腹腔分流术中注意通条打皮下隧道时不宜过深或过浅,通条头部不宜过尖;术后出现异常应复查头部CT、胸片及腹片;直接从头部原切口处切开拔除分流管是简单、可行、安全的手术方式.

Abstract：

Objective To discuss the mechanism, clinical features, complications, diagnosis criteria and treatment of intracardiac migration of the distal catheter of ventriculoperitoneal shunt. Method The diagnosis criteria and treatment of 2 cases of intracardiac migration of the distal catheter of ventriculoperitoneal shunt were studied, and relative literatures were reviewed. Results The migratory catheter was successfully extracted after definite diagnosis according to clinical features and imaging findings. There was no postoperative abnormality. Conclusions This is the first report of migration of the distal catheter of ventriculoperitoneal shunt into heart in China.The possible measures to minimize the incidence of the migration include avoiding deep or superficial neck tunneling and using blunt tunneling devices. Head CT, chest and abdominal x - ray are needed if postoperative abnormality is noticed. Percutaneous removal of the catheter from the retroauricular fomer incision is simple and safe.