An alternative approach for management of abdominal cerebrospinal fluid pseudocysts in children

Background Cerebrospinal fluid (CSF) abdominal pseudocyst is an uncommon but important complication of ventriculoperitoneal shunts. From the collected series, several features about the etiology and management become apparent. Retrospective data were obtained from 12 children treated with cerebrospinal fluid abdominal pseudocyst defined an alternative approach for management of these patients.Methods There were eight girls and four boys who ranged in age from 12 days to 18 years old (mean 7.7 months). The most frequent etiology of the hydrocephalus was Chiari type II malformation in six cases. Initial presentation with shunt malfunction was detected in nine cases. Abdominal distention and/or pain were the most frequent finding in our series (10/12). In only one case, infection was detected for all cerebrospinal fluid abdominal pseudocysts (8.3%). Ventriculoperitoneal shunt (VPS) externalization, antibiotics, and cyst aspiration was performed in 8/12 cases as initial management of abdominal pseudocyst. Ventriculoperitoneal shunt reinsertion in abdominal cavity and/or endoscopic third ventriculostomy (ETV) was performed as final management in 9/12. Ventriculoatrial shunt was used only in three cases. Recurrence of the abdominal cyst was observed in two cases.Discussion Based on the success rate (75%) in our series submitted to this management, a ventriculoperitoneal shunt can be safely reinserted in the majority of the patients. Endoscopic third ventriculostomy could be performed in selected cases as an alternative approach. Although infection has been reported as responsible for pseudocyst formation, it was only exceptionally found in our series.     

Reversible porencephaly

The cases of four infants (five lesions) are reported, where porencephalic cysts, located along the ventricular catheter after shunt malfunction and ommaya reservoir insertion, disappeared after ventriculoperitoneal (VP) shunt revision and combined cyst peritoneal (CP) shunt, or after VP shunt alone. This pathological state is thought to be a rare postoperative complication. Its pathogenesis and therapy are discussed. Shunt malfunction or Ommaya reservoir insertion may result in a hypertensive hydrocephalic state. Cerebrospinal fluid (CSF) flows out through a catheter penetrating the site of the ventricular wall and expands in the surrounding white matter to form a porencephalic cavity. Once this porencephalic state occurs, it will not disappear spontaneously because the CSF flows in one direction. As treatment for closed porencephaly, CP shunt following a VP shunt revision was markedly effective; for communicating porencephaly, a VP shunt revision alone was effective.     

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.     

Abdominal cerebrospinal fluid pseudocysts

Abdominal cerebrospinal fluid pseudocyst is an infrequent complication of ventriculoperitoneal (VP) shunts. We reviewed ten patients with abdominal pseudocyst. There were five girls and five boys, aged between 4 months and 14 years. The number of shunt procedures prior to the presentation varied between one and five. Only one patient had had a previous shunt infection. No patients had undergone prior abdominal surgery other than VP shunting. The time from the last shunting procedure to the development of abdominal pseudocyst ranged from 3 weeks to 5 years. Presenting symptoms and signs were mainly related to abdominal complaints in all patients. Three patients also had the signs of shunt malfunction. The diagnosis was made by ultrasound in all patients. Shunt infection was determined in six patients. Repositioning of the peritoneal catheter seemed to have a higher rate of recurrence. The diagnosis of abdominal pseudocyst should be considered in VP-shunted patients presenting with abdominal complaints.     

Abdominal cerebrospinal fluid pseudocyst in a severely handicapped patient with hydrocephalus.

We present a case of an abdominal cerebrospinal fluid pseudocyst as a rare complication of a ventriculoperitoneal shunt. The patient is a severely handicapped bedridden spastic quadriplegic with hydrocephalus. He underwent surgical reconstruction of a shunt tube because of shunt disconnection at the age of 12 years. Fever and frequent vomiting developed 2 months after surgery, and abdominal fullness gradually became severe. He was diagnosed as having an abdominal cerebrospinal fluid pseudocyst on abdominal ultrasonography. If a shunt dysfunction is suspected, this type of cyst should also be considered, and abdominal ultrasonography should be performed as one of the screening tests for determining the cause of the shunt dysfunction.     

Abdominal cerebrospinal fluid pseudocyst: a comparative analysis between children and adults

Purpose

Abdominal cerebrospinal fluid (CSF) pseudocyst is a rare but important complication in patients with ventriculoperitoneal shunt (VPS). In addition to presenting our experience, we performed a comparative analysis between children and adults with this entity. To the author’s knowledge, there are no studies in which this condition has been compared.

Methods

The PubMed database was searched for all relevant reports published from 1954 to 2012. The differences were statistically compared, especially regarding clinical investigations, etiology of the hydrocephalus, shunt revision, CSF infection, treatment, and recurrence. Chi-square test or Fisher’s exact test was used to find associations among the variables.

Results

Compiled from literature, we found 393 cases of abdominal pseudocyst: 295 children, including our cases, and 55 adults, with age not informed in 43 cases. In children, 33 % of the patients have a positive culture on presentation, with higher incidence in children younger than 10 years. In contrast, only 15 % among adults were positive CSF culture. In total, 287 abdominal pseudocyst cases who underwent shunt revision have been reported; 78.4 % of children and 62.2 % of adults. The main occurrence of this complication according to the etiology of hydrocephalus in children was different from adults. The recurrence of pseudocyst occurred in 19.8 and 24.2 % of children and adults, respectively.

Conclusions

The differences between children and adults might represent distinct trends on the etiology and treatment of this entity. Hence, additional well-designed cohort studies will be necessary to strengthen our findings.     

Hepatic cyst associated with ventriculoperitoneal shunt in a child with brain tumor

A 12-year-old boy with a thalamic grade IV astrocytoma and ventriculoperitoneal (VP) shunt developed epigastric pain and symptoms of increased intracranial pressure. The SGOT and alkaline phosphatase levels were markedly elevated and the radiological studies showed a cyst in the right lobe of the liver, extending to the porta hepatis. Simple repositioning of the shunt resulted in complete resolution of clinical findings and disappearance of the cyst. Although abdominal pseudocysts associated with VP shunts have been reported, this is the first report of a cyst involving liver and causing hepatic dysfunction.     

Ventriculoperitoneal shunt-associated abdominal cerebrospinal fluid pseudocysts and the role of laparoscopy and a proposed management algorithm in its treatment: A report of 2 cases

Abdominal cerebrospinal fluid pseudocyst (APC) is a rare complication associated with a ventriculoperitoneal shunt (VPS) placement. Abdominal cerebrospinal fluid pseudocyst is defined as a cyst surrounded by a non-epithelial lining and filled with the cerebrospinal fluid (CSF). In general, 1% - 4.5% of all patients treated with a VPS develop CSF pseudocysts. Here, we have presented 2 cases of APC complicating VPS placement and a proposed treatment management algorithm. The cases pertained to 7-year-old and 5-year-old children who had undergone VPS placement during infancy and presented with progressive abdominal distention and vomiting and fever, respectively. Both cases were assessed using similar investigations and imaging modalities and diagnosed with APC. However, the treatments were individually tailored based on the algorithm; successful outcomes were achieved in both patients. Abdominal cerebrospinal fluid pseudocyst treatment is difficult considering the presence of adhesions and infection and is associated with a high recurrence rate.

Ventriculoperitoneal shunt (VPS) placement is one of the most common cerebrospinal fluid (CSF) diversion procedures performed by neurosurgeons globally. It is the most commonly used procedure among surgeons with different levels of expertise in managing hydrocephalus of various etiologies. In this procedure, excess CSF is diverted from the lateral ventricles to the peritoneum.1 Less commonly, the CSF may be diverted to other sites such as the right atrium, and to a much lesser degree, to the gallbladder, pleural space, and ureter. However, because of the lower rates of serious complications, it is considered advantageous to divert the CSF into the peritoneal cavity.2 Ventriculoperitoneal shunt placement has been associated with several complications, such as infection, VPS malfunction, and intestinal perforation as well as abdominal pseudocyst formation.3 Abdominal CSF pseudocyst (APC) is defined as a cyst surrounded by a lining that is devoid of epithelial cells and is filled with the CSF.4 Abdominal CSF pseudocyst formation is of unknown etiology and its incidence is 1% to 4.5%.5 Here, we report 2 pediatric cases of APC that were treated using the treatment management algorithm proposed in this report.     

Extrahepatic pseudocyst in an adult

Ventriculoperitoneal (VP) shunts are commonly used in neurosurgical procedures to treat hydrocephalus. Although shunt-associated abdominal complications are well documented, extrahepatic pseudocysts are a rare shunt complication in adult patients. Therefore, we herein report the case of a 54-year-old male patient who presented with a bulging mass around the previous surgical site at the right upper quadrant of the abdomen. He had a 4-year history of VP shunt surgery for posthemorrhagic hydrocephalus. A computed tomographic scan revealed a large extrahepatic pseudocsyt. Our case represented a rare entity of extrahepatic pseudocyst in adult patients underwent VP shunt surgery. The clinical presentation, diagnostic tools, and treatment methods were discussed.

Ventriculoperitoneal (VP) shunts are commonly used in neurosurgical procedures to divert excess cerebrospinal fluid (CSF) from the ventricular system into the abdominal cavity, which is indicated for hydrocephalus related to congenital hydrocephalus, trauma, hemorrhage, neoplasms, infection, and various other conditions.1 Several abdominal complications are common in patients undergoing VP shunts, including pseudocysts, infection, and hollow organ perforation.2, 3 Catheter migrations may occur into the abdominal cavity including abdominal wall, small bowel, large bowel, gall bladder, liver, stomach, vagina, fallopian tube, urinary bladder, or scrotum.4-6 Abdominal pseudocysts occur in less than 10% of all patients receiving VP shunts and occur primarily in pediatric populations.7Hepatic pseudocyst secondary to shunt operation is a rare entity, which is classified as intra-axial and extra-axial types.8 The intra-axial hepatic pseudocysts commonly demonstrate that the tip of the shunt can be dislodged into the liver parenchyma.9 By penetrating the Glisson’s capsule, the distal tube cause subcapsular pseudocyst formation in patients with extra-axial hepatic pseudocysts.3 However, extrahepatic pseudocysts are rare shunt complications in adult patients, and only several cases have been reported in the relevant literature.10-15 Therefore, we herein report the development of extrahepatic pseudocysts following VP shunt surgery in a 54-year-old male patient. The clinical presentation, diagnostic tools, and treatment methods are also discussed to manage this rare complication.     

Cerebrospinal fluid galactorrhea: a rare complication of ventriculoperitoneal shunting.

In this report we describe a 26-year-old woman who had an intra-abdominal pseudocyst located at the peritoneal catheter tip following ventriculo-peritoneal (VP) shunt implantation. Retrograde cerebrospinal fluid (CSF) flowed outside the catheter and communicated with the right breast lactiferous ductal system and leaked from the nipple orifice. CSF galactorrhea only occurs when the lactiferous duct is injured during VP shunt implantation, in combination with the formation of an intra-abdominal CSF pseudocyst prior to lactiferous duct healing. Leakage of CSF from the nipple orifice can be successfully treated by simply guiding the peritoneal catheter tip into the peritoneal cavity through a new laparotomy; that is, shunt revision is not always required.     

Ascites following ventriculoperitoneal shunting in children with chiasmatic-hypothalamic glioma

OBJECT: Optic pathway gliomas in children can involve the optic nerve, chiasm, and hypothalamus. This uncommon, slowly growing tumor can cause hydrocephalus, which usually requires placement of a ventriculoperitoneal (VP) shunt. Symptomatic ascites may occasionally develop as a complication of the VP shunt procedure. The purpose of this study was to assess the risk factors associated with CSF ascites in children with optic pathway gliomas. METHODS: Twenty-two children (ages 4 months to 20 years) with chiasmatic-hypothalamic optic gliomas participated in this study. Four children were diagnosed with a chiasmatic glioma, 7 with a hypothalamic glioma, and 11 with a glioma involving both the optic chiasm and hypothalamus. Twelve children (55%) developed hydrocephalus and required VP shunt placement. Of the 12 shunted children, 4 (33%) developed CSF ascites. The incidence of ascites was not associated with infection, tumor metastasis, or multiple shunt revisions. There was no correlation with the size of the tumor. All 4 children with ascites had tumor involving the optic chiasm or optic nerve. None of the 5 children with pure hypothalamic glioma who underwent VP shunt placement have developed ascites. Among the 7 children suffering from chiasmatic or optic nerve gliomas who developed hydrocephalus, the risk of developing ascites as a complication of VP shunt placement was 57% (4/7). Ventriculoatrial (VA) shunt was the treatment of choice for children with VP shunt-induced ascites. After placement of a VA shunt the ascites subsided. The children did not develop further complications. CONCLUSION: We conclude that glioma involving the optic chiasm or nerve is associated with a high risk of developing ascites following VP shunt placement. VA shunt may be the treatment of choice for children with chiasmatic or optic nerve gliomas who require a CSF diversion procedure.     

Arachnoid cyst as a complication of ventricular shunting

Overdrainage of cerebrospinal fluid (CSF) is a well-known complication of shunting procedures. Several clinical manifestations of excessive drainage of CSF have been documented, such as subdural hematoma, subdural effusions, slit ventricles, isolated IV ventricle, etc. To the authors' knowledge, this is the first report of an arachnoid cyst due to the excessive function of a VP shunt.     

CSF ascites: a rare complication of ventriculoperitoneal shunt surgery

CSF ascites is a very rare complication of ventriculoperitoneal (VP) shunt procedure. No definite explanation has been offered for the inability of the peritoneum to absorb the CSF. Two children who underwent VP shunting for hydrocephalus, presented with ascites 3 (1/2) years and 4 months respectively, after the shunt was placed. The treatment of choice is conversion of the VP shunt to a ventriculoatrial shunt.     

Abdominal cerebrospinal fluid (CSF) pseudocyst presented with inferior vena caval obstruction and hydronephrosis

Purpose  

Abdominal cerebrospinal fluid (CSF) pseudocyst is an uncommon complication of ventriculo-peritoneal shunt placement. A large pseudocyst may exert a significant pressure effect, but vascular or urological symptoms are extremely rare. We report an unusual case of a CSF pseudocyt causing inferior vena caval and ureteric obstruction.     

A case of abdominal CSF pseudocyst associated with silicone allergy

Case report The authors present a case of a patient with an abdominal CSF pseudocyst that resulted from an allergic reaction to silicone. The patient underwent repair surgery of the meningomyelocele associated with the Chiari II malformation, and the V-P shunt was instituted at 6 months of age. A formation of the abdominal CSF pseudocyst and the consequent shunt malfunction were observed 40 days after the V-P shunt. An increase in the number of the peripheral eosinophils and serum immunoglobulin E (IgE), and an infiltration of eosinophils in the specimen harvested from the pseudocyst wall suggested an allergic reaction as the cause of the pseudocyst. A sixth operation to revise the V-P shunt was performed using the shunt system made of extracted silicone, which was produced extracting the allergic substances.Outcome The serum IgE was normalized after surgery and the abdominal CSF pseudocyst has not recurred for 22 months.     

Transumbilical approach for shunt insertion in the pediatric population: an improvement in cosmetic results

Objective In spite of the recent interest in endoscopic third ventriculostomy, ventriculoperitoneal (VP) shunt is still the gold standard in treating non-obstructive hydrocephalus in children. The peritoneal cavity remains the optimal site for cerebrospinal fluid (CSF) diversion. Shunt insertion and re-interventions carry a high risk of inaesthetic abdominal scars and long-term morbidity. We report a technique of transumbilical shunt insertion, which provides better cosmetic results and without many more complications. This approach has been performed for a long period in a wide variety of intra-abdominal conditions by pediatric surgeons.Methods Between March and October 2003, we inserted 12 VP shunts in children. For eight consecutively treated children the follow-up is more than 3 months. All the shunts were inserted through the umbilicus. These eight children are the subjects of this study. Indications for shunting were: communicating hydrocephalus (6 cases), subdural hematoma (1 case), and hygroma associated with an arachnoid cyst (1 case). The population consisted of 7 boys and 1 girl, ranging in age between 6 weeks and 47 months (mean age: 15 months), and their body weights varied between 2,110 g and 18,000 g (mean weight: 8,470 g). All children were examined twice a day for 3 days, and wounds were examined daily to check for the absence of sepsis or dehiscence. Clinical controls were performed 1 month after discharge. The operating surgeon was invited to comment on any difficulties encountered in making or closing this incision afterwards.Results The average length of clinical follow-up was 6 months (range 4–7 months). One infection of the VP shunt occurred. It was treated with external drainage and antibiotics. After 1 week, a second VP shunt was inserted using the same technique without particular difficulty and with a nice cosmetic result. Concerning the seven other children, the cosmetic results were optimal, with no puckered abdominal scars or wound dehiscence, and with no perioperative or long-term complications related to the umbilical approach.Conclusion At this early follow-up, umbilical incision for shunt insertion is a safe and easy technique. It provides an optimal cosmetic result, even in cases of re-intervention. This minimally invasive surgery does not require long specialized training. We have not shown an increase in complications associated with a learning curve. Longer follow-up is needed to evaluate the risk of infection.     

Bilateral sixth cranial nerve palsy following lumboperitoneal shunt

Lumboperitoneal (LP) shunt is considered as a unique procedure in neurosurgical practice. The over drainage of Cerebrospinal fluid (CSF) is considered a usual side effect of the procedure that usually manifests in the form of subdural collection, headache, or nausea and vomiting. However, cranial nerve palsy, particularly abducens nerve palsy, is a rare manifestation of CSF over drainage. We describe our experience with a patient that has developed bilateral sixth nerve palsy followed by LP shunt insertion, with resolution of the symptoms upon removal of the shunt. This shades the light on a rare but significant complication related to Lumboperitoneal (LP) shunt insertion that necessitate the modification in the hardware of valve or insertion technique to decrease the risk of CSF over the drainage.

Lumboperitoneal (LP) shunt, in neurosurgical practice, is a unique procedure. ¹ Cerebrospinal fluid (CSF) over drainage is an often-encountered side effect of this procedure along with shunt failure. ¹ Cerebrospinal fluid over drainage can manifest as headache, subdural collection, subdural hematoma, or epidural hematoma. ² Abducens palsy is a rare complication of various CSF diversion procedures. ³ Sporadic case reports, case series, and systematic reviews have discussed cases of abducens palsy following diagnostic LP shunt, lumbar drain, spinal/epidural block and ventriculoperitoneal (VP) shunt. ² However, there has been no evidence of any such case in the past literature about bilateral sixth cranial nerve palsy following by LP shunt. We describe our experience with the recognition, management, and follow-up of a patient having bilateral sixth nerve palsy following by LP shunt insertion. ^2,4 These shades the light on a rare but significant complication related to Lumboperitoneal (LP) shunt insertion.     

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.     

Pseudoquistes abdominales,una complicación rara de los sistemas de derivación ventrículo-peritoneal: revisión sistemática de la literatura

Since the first report in 1954, abdominal pseudocysts have been recognized as a particularly uncommon complication of ventriculoperitoneal shunts of CSF, so their etiology, diagnosis, and therapeutic management remain very controversial.Our objective is to offer a critical and updated systematic review of those controversial points, using a thorough search and review of the most relevant literature available.The clinical presentation of pseudocysts is normally through non-specific abdominal symptoms. The most validated etiology consists on the existence of a concomitant infection of the CSF shunt system, and so, treatment needs of antibiotherapy and total or partial substitution of the system. However, the pseudocyst itself doesn’t need an active treatment, except for some specific cases. This management, algorithmically presented in the present work, achieves a lower recurrence rate than other options, but this one is still important, and is also associated with other complications of those shunts related with several other factors which need to be taken in account.     

Advantages of delayed VP shunting in post-haemorrhagic hydrocephalus seen in low-birth-weight infants

The optimal timing of ventriculo-peritoneal (VP) shunt insertion in a neonate with post-haemorrhagic hydrocephalus (PHH) is uncertain. During the 8-year period from January 1989 to December 1996, 41 patients had VP shunts inserted for PHH at Red Cross War Memorial Children's Hospital. Data on 36 patients were sufficient for review in order to determine whether the timing of surgery in any way influenced the complication incidence of this intervention. Nine of the 36 patients had a serious complication, either infection or mechanical shunt obstruction, during their initial hospital admission (early period). Nineteen patients had surgery performed before day 35 after birth and all those with early complications were in this group. Seventeen patients had surgery delayed until after day 35, and none of these patients had an early complication. In this study a higher complication incidence was noted when a VP shunt was inserted prior to day 35 (Chi-square test P < 0.01). This most probably correlates with a high concentration of blood breakdown products in the cerebrospinal fluid during the first month after intra-ventricular haemorrhage.