Don’t lose your head: Ventriculoperitoneal (VP) shunt issues

Aims/Objectives/BackgroundVP shunts are used to drain CSF from the cranial vault because of a wide range of pathologies and, like any piece of hardware, can fail. Traditionally investigations include SSR and CT. This project examines the role of SSR in evaluating children with suspected VP shunt failure.Primary outcome: Sensitivity and specificity of SSR in children presenting to the CED with concern for shunt failure.Methods/DesignConducted in a single centre, tertiary CED of the national Irish Neurosurgical(NS) referral centre (ED attendance:>50,000 patients/year). 100 sequential SSR requested by the CED were reviewed. Clinical information was extracted from electronic requests. Shunt failure was defined by the need for NS intervention(Revision).Abstract 332 Figure 1Abstract 332 Figure 2Results/ConclusionsSensitivity and specificity is presented in figure 1 (two by two table).100 radiographs performed in 84 children.22% shunts revised (see flow diagram).7 SSR’s were abnormal.85% (n=6) shunts revised. [5 following abnormal CT].Of the normal SSR’s; 16 had abnormal CT and revised.85/100 received CT.64 of 85 CT’s (75%) were normal.□6 of the 64 had focal shunt concern.SSR’s shouldn’t be used in isolation. NPV&PPV, Sensitivity&Specificity is low.SSR’s are beneficial where there’s concern over focal shunt problems (injury/pain/swelling) or following abnormal CT.VP shunt failure is not well investigated with SSR alone.SSR’s could be omitted where there is no focal shunt concern/after normal CT (without impacting clinical outcome) reducing radiation exposure and reduce impact on CED’s.59 SSR’s could have been avoided without adverse clinical outcome.

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Unilateral mydriasis in a child with a ventriculoperitoneal shunt for obstructive hydrocephalus: a diagnostic dilemma

BMJ Case Reports ◽

10.1136/bcr-2020-237257 ◽

2020 ◽

Vol 13 (12) ◽

pp. e237257

Author(s):

Monidipa Banerjee ◽

Eiman Haj Ahmed ◽

Kathryn Foster ◽

Arundoss Gangadharan

Keyword(s):

Ipratropium Bromide ◽

Obstructive Hydrocephalus ◽

Sudden Onset ◽

Unique Case ◽

Diagnostic Dilemma ◽

Vp Shunt ◽

Life Threatening ◽

Unilateral Mydriasis ◽

The Brain ◽

Rule Out

There are several causes for sudden onset unilateral mydriasis, however impending transtentorial uncal herniation needs to be ruled out. This unique case highlights an uncommon adverse response to a common mode of treatment that leads to a diagnostic dilemma. A 3-year-old boy with a ventriculoperitoneal (VP) shunt for an obstructive hydrocephalus presented with an acute respiratory distress. He developed unilateral mydriasis with absent light reflex during treatment with nebulisers. An urgent CT scan of the brain did not show any new intracranial abnormality. A case of pharmacological anisocoria was diagnosed that resolved completely within 24 hours of discontinuation of ipratropium bromide. Although ipratropium-induced anisocoria has been reported in children, but to our knowledge none in a child with VP shunt for hydrocephalus. This emphasises the urgency in evaluating unilateral mydriasis to rule out life-threatening conditions. Clinicians should remember that ipratropium administered through ill-fitting face masks could cause this completely reversible adverse effect.

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Overshunting-Related Cervical Myelopathy Causing Progressive Gait Disturbance: A Case Report

Case Reports in Neurology ◽

10.1159/000514551 ◽

2021 ◽

pp. 312-317

Author(s):

Eva Vister ◽

Sebastiaan Hammer ◽

Rudolf W.M. Keunen ◽

Astrid L. Rijssenbeek ◽

Niels A. van der Gaag

Keyword(s):

Cerebrospinal Fluid ◽

Cervical Myelopathy ◽

Complete Resolution ◽

Late Complication ◽

Gait Disturbance ◽

Shunt Revision ◽

Proper Treatment ◽

Cervical Stenosis ◽

Vp Shunt ◽

Associated Symptoms

A complication of ventriculoperitoneal (VP) shunting is overdrainage or overshunting of cerebrospinal fluid, which can cause formation of hygroma but in rare cases also cervical myelopathy at a later stage. In this article, we describe a very late complication of VP shunting. We present a 75-year-old man, previously given a VP shunt at the age of 46, who developed a progressive gait disturbance and ataxia of the limbs after 27 years. MRI showed a cervical stenosis and myelopathy as a result of venous engorgement due to chronic overshunting of the VP shunt. Revision of the VP shunt resulted in complete resolution of his neurological symptoms and the cervical myelopathy. Cervical myelopathy due to chronic overshunting is a rare and potentially very late complication of a VP shunt. Our case underlines the importance of awareness of this complication while proper treatment can reverse the associated symptoms fully.

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Hemorrhagic abdominal pseudocyst following ventriculoperitoneal shunt: a case report

BMC Surgery ◽

10.1186/s12893-021-01161-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Hong-Cai Wang ◽

Yi-Lei Tong ◽

Shi-Wei Li ◽

Mao-Song Chen ◽

Bo-Ding Wang ◽

...

Keyword(s):

Fibrous Tissue ◽

Clinical Signs ◽

Chronic Subdural Hematoma ◽

Normal Pressure ◽

Cystic Mass ◽

Shunt Revision ◽

Subdural Effusion ◽

Palpable Mass ◽

Vp Shunt ◽

Abdominal Pseudocyst

Abstract Background Abdominal cerebrospinal fluid (CSF) pseudocyst is an uncommon but important complication of ventriculoperitoneal (VP) shunts. While individual articles have reported many cases of abdominal CSF pseudocyst following VP shunts, no case of a hemorrhagic abdominal pseudocyst after VP shunts has been reported so far. Case presentation This article reports a 68-year-old woman with a 4-month history of progressive abdominal pain and distention. She denied any additional symptoms. A VP shunt was performed 15 years earlier to treat idiopathic normal pressure hydrocephalus and no other abdominal surgery was performed. Physical examination revealed an elastic palpable mass in her right lower abdomen, which was dull to percussion. Abdominal computed tomography (CT) scan indicated a large cystic collection of homogenous iso-density fluid in the right lower abdominal region with clear margins. The distal segment of the peritoneal shunt catheter was located within the cystic mass. Abdominal CSF pseudocyst was highly suspected as a diagnosis. Laparoscopic cyst drainage with removal of the whole cystic mass was performed, 15-cm cyst which found with thick walls and organized chronic hematic content. No responsible vessel for the cyst hemorrhage was identified. No further shunt revision was placed. Histological examination showed that the cyst wall consisted of outer fibrous tissue and inner granulation tissue without epithelial lining, and the cystic content was chronic hematoma. The patient had an uneventful postoperative course and remained asymptomatic for 8-mo follow-up. Conclusion To the best of our knowledge, this is the first report of hemorrhagic onset in the abdominal pseudocyst following VP shunt. Such special condition can accelerate the appearance of clinical signs of the abdominal pseudocyst after VP shunts, and its mechanisms may be similar to the evolution of subdural effusion into chronic subdural hematoma (CSDH).

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Ventriculoperitoneal shunt failure causing myelopathy in a patient with bilateral jugular vein occlusion

Journal of Neurosurgery Spine ◽

10.3171/spi.2007.6.1.60 ◽

2007 ◽

Vol 6 (1) ◽

pp. 60-63 ◽

Cited By ~ 10

Author(s):

William E. Humphries ◽

Peter M. Grossi ◽

Linda G. Liethe ◽

Timothy M. George

Keyword(s):

Spinal Cord ◽

Ct Angiography ◽

Jugular Vein ◽

Cervical Spinal Cord ◽

Venous Drainage ◽

Shunt Revision ◽

Shunt Failure ◽

Vp Shunt ◽

Physiological Importance ◽

Vein Occlusion

✓The authors describe the case of a 36-year-old woman with bilateral internal jugular vein occlusion, hydrocephalus, and Dandy–Walker variant who presented with myelopathy that was ultimately attributed to ventriculoperitoneal (VP) shunt failure. Computed tomography (CT) angiography of the head and neck revealed epidural venous engorgement within the cervical spine, greater that 50% narrowing of the C2–5 spinal canal, and compression of the cervical spinal cord. After successful shunt revision, postoperative CT angiography revealed decreased venous engorgement as well as decompression of the cervical spinal cord, and the patient’s myelopathy improved. This case represents a fascinating clinical presentation of VP shunt failure, highlighting the physiological importance of the external jugular pathways involved in cerebral venous drainage.

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Brain Studded with Innumerable Larger Stones: Starry Sky at Night Appearance: Multiple Calcified Giant Tuberculoma with 15 Years of Follow-up

Indian Journal of Neurosurgery ◽

10.1055/s-0037-1601365 ◽

2017 ◽

Vol 06 (02) ◽

pp. 155-158

Author(s):

Guru Satyarthee ◽

P. Chandra ◽

A. Mahapatra

Keyword(s):

Central Nervous System Involvement ◽

Definitive Diagnosis ◽

Shunt Surgery ◽

Unique Case ◽

Major Health Problem ◽

Major Health ◽

Vp Shunt ◽

Cranial Ct ◽

Rising Incidence

AbstractTuberculosis is rapidly reemerging as a major health problem due to rising incidence of HIV cases across the globe. Central nervous system involvement is rare, but rarely multiple intracerebral granulomas can occur or occasional solitary tuberculoma also develops. The authors report a unique case of 24-year-old woman suffering from pulmonary tuberculosis developed headache and vomiting. Cranial CT scan revealed multiple widespread deposit of intracranial granuloma of sizeable lesion mimicking starry sky at night appearance. Excision of one tuberculoma was done for confirmation of definitive diagnosis, and histopathology was suggestive of tuberculoma. The patient also underwent VP shunt surgery. At last follow-up at 15 years following surgery, she was doing well.

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Cerebrospinal Fluid Pseudocyst Complicating Ventriculoperitoneal Shunt: Report of Four Cases

Indian Journal of Neurosurgery ◽

10.1055/s-0038-1668470 ◽

2018 ◽

Vol 07 (02) ◽

pp. 135-138 ◽

Cited By ~ 1

Author(s):

Pradyumna Pan

Keyword(s):

Cerebrospinal Fluid ◽

Clinical Presentation ◽

Abdominal Distension ◽

Surgical Removal ◽

Ultrasound Guided ◽

Vp Shunt ◽

Multilocular Cyst ◽

Computed Tomographic ◽

Abdominal Pseudocyst ◽

Uncommon Complication

Abstract Background Cerebrospinal fluid (CSF) abdominal pseudocyst (APC) is an uncommon complication following ventriculoperitoneal (VP) shunt. Aim To study the clinical features and management of this entity. The authors present their experience with cases of CSF pseudocyst in children. Materials and Methods Retrospective analysis of four cases diagnosed to have APC following VP shunt between 2005 and 2015. Results Clinical presentation was with progressive abdominal distension, highlights of intestinal obstruction, and signs of raised intracranial pressure (ICP). Diagnosis is readily made with ultrasonography and computed tomographic (CT) scan of the abdomen. The duration between insertion of the shunt and the presentation ranged from 4.11 to 12 years. In three patients, the cyst was unilocular and of varying size. The fourth one had a multilocular cyst. In three patients, the treatment involved was surgical removal of the catheter with excision of the pseudocyst wall and placement of a new catheter intraperitoneally in a different quadrant. Ultrasound-guided aspiration of the cyst and relocation of the distal end was done in one patient. Conclusion Initial suspicion with appropriate investigation and early treatment can avert morbidity and mortality.

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