Hidden intra-meatal CSF fistula related to VP shunt as a cause for fatal tension pneumocephalus after vestibular schwannoma resection

✓Spontaneous tension pneumocephalus (TPC) related to shunt surgery has sometimes been reported with reference to the Valsalva maneuver and osseous defects of the tegmen tympani. Here, the authors report on a case of TPC complicated by eustachian tube (ET) insufflation and a ventriculoperitoneal (VP) shunt. This 78-year-old man had undergone VP shunt insertion 3 weeks before readmission to the hospital with a diagnosis of TPC, a left temporal porencephalic cyst, and air accumulation and late leakage of cerebrospinal fluid (CSF) into the left tympanic cavity. The TPC was controlled successfully by ligation of the shunt tube. The authors discuss the pathophysiology of this complicated TPC case, which illustrates the risk of ET insufflation in patients undergoing CSF shunt surgery.

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Case Report: A case report of dry tap during ventriculostomy

F1000Research ◽

10.12688/f1000research.6750.1 ◽

2015 ◽

Vol 4 ◽

pp. 188

Author(s):

Sunil Munakomi ◽

Binod Bhattarai

Keyword(s):

Case Report ◽

External Ventricular Drain ◽

Foramen Of Monro ◽

Shunt Insertion ◽

Gradual Improvement ◽

Vp Shunt ◽

Tension Pneumocephalus ◽

Frontal Horn ◽

Increased Risk ◽

Ventricular Puncture

Pneumocephalus following ventriculoperitoneal (VP) shunt insertion is an exceptionally rare occurrence. We report such an event after attempting ventricular puncture (ventriculostomy) for VP shunt insertion and then discuss the management of the same. Dry tap can lead to multiple attempts for ventriculostomy with the associated added risks of complications, as well as complicating the subsequent management. In addition, there is an increased risk of tension pneumocephalus, seizure and shunt failure due to a blockage by air bubbles. Our patient presented with features of raised intracranial pressure two months following craniotomy and evacuation of traumatic subdural hematoma. External ventricular puncture revealed egress of CSF under pressure. Upon attempting VP shunting for post-traumatic hydrocephalus, we experienced dry tap during ventricular puncture that complicated further management. We placed the proximal shunt in the presumed location of the foramen of Monro of ipsilateral frontal horn of lateral ventricle and did not remove the external ventricular drain. Post-operative CT scan revealed pneumoventriculi as the cause for the dry tap during ventricular puncture. Patient was managed with 100% oxygen. He showed gradual improvement and was later discharged. This case shows that variations in the procedure, including head down positioning, adequate cruciate dural incision prior to cortex puncture, and avoiding excessive egress of CSF can help to prevent such complications.

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Spontaneous umbilical CSF fistula due to migration of the peritoneal end of VP shunt: A case report and review of pathogenesis

Journal of Pediatric Neurosciences ◽

10.4103/jpn.jpn_47_17 ◽

2017 ◽

Vol 12 (3) ◽

pp. 285 ◽

Cited By ~ 1

Author(s):

Siddharth Vankipuram ◽

Somil Jaiswal ◽

Manish Jaiswal ◽

Ankur Bajaj ◽

Anil Chandra ◽

...

Keyword(s):

Case Report ◽

Vp Shunt ◽

Csf Fistula

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Intradural extension of mucocele secondary to giant frontal sinus osteoma: Diagnostic pitfalls

Surgical Neurology International ◽

10.25259/sni_11_2021 ◽

2021 ◽

Vol 12 ◽

pp. 252

Author(s):

Sundus Ali ◽

Adnan Qasim ◽

Bilal Anwar ◽

Nabeel Choudhary ◽

Muhammad Akmal

Keyword(s):

Frontal Sinus ◽

Sinus Surgery ◽

Intracranial Extension ◽

Left Frontal Lobe ◽

Vp Shunt ◽

Tension Pneumocephalus ◽

The Past ◽

Dural Closure ◽

Preoperative Ct ◽

Diagnostic Pitfalls

Background: Paranasal sinus osteoma in association with intracranial mucocele is a rare entity while intradural extension is even rarer. Our aim of presenting this case is to highlight the diagnostic pitfalls and reiterate the importance of prompt treatment of expected complications. Case Description: A 35-year-old known epileptic, for the past 5 years, presented with altered sensorium for the past 2 days. Computed tomography (CT) of the brain plain showed ventriculomegaly and cystic lesion in the left frontal lobe adjacent to a calvarial osteoma. A ventriculoperitoneal (VP) shunt was done which resulted in tension pneumocephalus and led us to discover the origin of osteoma from the left frontal sinus on CT functional endoscopic sinus surgery (FESS) protocol. He underwent left frontal craniotomy. The osteoma and mucocele were excised completely and watertight primary dural closure was done. Postoperative meningitis was treated with antibiotics according to the culture report. Conclusion: Intracranial extension of mucocele led to meningitic hydrocephalus, prompting us for VP shunt. Resulting tension pneumocephalus revealed what was missed on preop CT, a small pocket of air adjacent to osteoma intracranially. Therefore, this case underscores the importance of obtaining a preoperative CT FESS to elaborate the origin of osteoma, thus planning approach differently.

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Case Report: A case report of dry tap during ventriculostomy

F1000Research ◽

10.12688/f1000research.6750.2 ◽

2015 ◽

Vol 4 ◽

pp. 188

Author(s):

Sunil Munakomi ◽

Binod Bhattarai

Keyword(s):

Case Report ◽

External Ventricular Drain ◽

Foramen Of Monro ◽

Shunt Insertion ◽

Gradual Improvement ◽

Vp Shunt ◽

Tension Pneumocephalus ◽

Frontal Horn ◽

Increased Risk ◽

Ventricular Puncture

Pneumocephalus following ventriculoperitoneal (VP) shunt insertion is an exceptionally rare occurrence. We report such an event after attempting ventricular puncture (ventriculostomy) for VP shunt insertion and then discuss the management of the same. Dry tap can lead to multiple attempts for ventriculostomy with the associated added risks of complications, as well as complicating the subsequent management. In addition, there is an increased risk of tension pneumocephalus, seizure and shunt failure due to a blockage by air bubbles. Our patient presented with features of raised intracranial pressure two months following craniotomy and evacuation of traumatic subdural hematoma. External ventricular puncture revealed egress of CSF under pressure. Upon attempting VP shunting for post-traumatic hydrocephalus, we experienced dry tap during ventricular puncture that complicated further management. We placed the proximal shunt in the presumed location of the foramen of Monro of ipsilateral frontal horn of lateral ventricle and did not remove the external ventricular drain. Post-operative CT scan revealed pneumoventriculi as the cause for the dry tap during ventricular puncture. Patient was managed with 100% oxygen. He showed gradual improvement and was later discharged. This case shows that variations in the procedure, including head down positioning, adequate cruciate dural incision prior to cortex puncture, and avoiding excessive egress of CSF can help to prevent such complications.

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Petrous Bone Pneumatization Is a Risk Factor for Cerebrospinal Fluid Fistula Following Vestibular Schwannoma Surgery

Operative Neurosurgery ◽

10.1227/neu.0b013e3181f88884 ◽

2010 ◽

Vol 67 (suppl_2) ◽

pp. ons509-ons515 ◽

Cited By ~ 4

Author(s):

Lennart Henning Stieglitz ◽

Mario Giordano ◽

Venelin Gerganov ◽

Andreas Raabe ◽

Amir Samii ◽

...

Keyword(s):

Risk Factor ◽

Cell Volume ◽

Vestibular Schwannoma ◽

Internal Auditory Canal ◽

Tumor Grade ◽

Petrous Bone ◽

Control Group ◽

Surgical Removal ◽

Csf Fistula ◽

The Mean

ABSTRACT BACKGROUND: For the prevention of postoperative CSF fistula a better understanding of origins and risk factors is necessary. OBJECTIVE: To identify the petrous bone air cell volume as a risk factor for developing CSF fistula, we performed a retrospective analysis. METHODS: From 2000 to 2007 519 patients had a retrosigmoidal surgical removal of a vestibular schwannoma. The 22 who had a postoperative CSF fistula were chosen for evaluation in addition to 78 patients who were randomly selected in 4 equally sized cohorts: male/female with small/large tumors. Preoperative CT scans were analyzed regarding petrous bone air cell volume, area of visible pneumatization at the level of the internal auditory canal (IAC), tumor grade, and sex. RESULTS: Women developed nearly half as many CSF fistulas (2.7%) as men (5.2%). The mean volume of the petrous bone air cells was 10.97 mL (SD, 4.9; range, 1.38-27.25). It was significantly lower for women (mean, 9.23 mL; SD, 3.8) than for men (mean, 12.5 mL; SD, 5.28; P = .0008). The mean air cell volume of CSF-fistula patients was 13.72 mL (SD, 5.22). The difference concerning the air cell volume between patients who developed CSF fistulas and patients from the control group was significant (P = .0042). There was a significant positive correlation between the air cell volume and the area of pneumatization in one CT slide at the level of the IAC. CONCLUSION: The higher incidence of CSF fistulas in men compared with women can be explained by means of differently pneumatized petrous bones. A high amount of petrous bone pneumatization has to be considered as a risk factor for the development of postoperative CSF fistula after vestibular schwannoma surgery.

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