Distal ventriculoperitoneal shunt catheter tightly coiled around the valve in the absence of a subgaleal cerebrospinal fluid collection: illustrative case

BACKGROUND Among the known complications of ventriculoperitoneal (VP) shunts, subcutaneous or subgaleal migration of distal catheters is rare. Prior case reports have proposed several risk factors, including inadequate fixation of the shunt device, presence of a large subgaleal space filled with cerebrospinal fluid (CSF), and repetitive flexion/extension movement of the head producing a “windlass effect.” Tight coiling of a distal catheter around the valve without a large subgaleal space has not been reported. OBSERVATIONS The patient was born prematurely and underwent VP shunt placement for posthemorrhagic ventricular dilatation at 3 months of age with reassuring postoperative imaging. At approximately 3 years of age, shunt radiography and head computed tomography unexpectedly showed excess tubing coiled extracranially around the shunt valve. The patient did not exhibit any clinical symptoms of shunt malfunction and underwent an uneventful revision of the VP shunt system. No CSF-filled subgaleal space was observed intraoperatively. LESSONS Distal catheter migration can occur without the clear presence of a subgaleal CSF collection and symptoms of acute hydrocephalus. Appropriate fixation of the shunt system using nonabsorbable stitches is recommended to prevent catheter migration caused by the windlass effect.

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Evidence for increased intraabdominal pressure as a cause of recurrent migration of the distal catheter of a ventriculoperitoneal shunt: illustrative case

Journal of Neurosurgery: Case Lessons ◽

10.3171/case2032 ◽

2021 ◽

Vol 1 (3) ◽

Author(s):

Christopher Lee ◽

Lucinda Chiu ◽

Pawan Mathew ◽

Gabrielle Luiselli ◽

Charles Ogagan ◽

...

Keyword(s):

Rare Complication ◽

Surgical Techniques ◽

Intraabdominal Pressure ◽

Illustrative Case ◽

Distal Catheter ◽

Vp Shunt ◽

Catheter Migration ◽

Bowel Distention ◽

Increased Risk ◽

Subcutaneous Space

BACKGROUNDPlacement of a ventriculoperitoneal (VP) shunt is an effective treatment for several disorders of cerebrospinal fluid flow. A rare complication involves postoperative migration of the distal catheter out of the intraperitoneal compartment and into the subcutaneous space. Several theories attempt to explain this phenomenon, but the mechanism remains unclear.OBSERVATIONSThe authors report the case of a 37-year-old nonobese woman who underwent placement of a VP shunt for idiopathic intracranial hypertension. Postoperatively, the distal catheter of the VP shunt migrated into the subcutaneous space on three occasions despite the use of multiple surgical techniques, including open and laparoscopic methods of abdominal catheter placement. Notably, the patient repeatedly displayed radiographic evidence of chronic bowel distention consistent with increased intraperitoneal pressure.LESSONSIn this case, the mechanism of catheter migration into the subcutaneous space did not appear to be caused by pulling of the catheter from above but rather by expulsion of the catheter from the peritoneum. Space in the subcutaneous tissues caused by open surgical placement of the catheter was permissive for this process. Patients with chronic increased intraabdominal pressure, such as that caused by bowel distention, obesity, or Valsalva maneuvers, may be at increased risk for distal catheter migration.

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Value of whole-body low-dose computed tomography in patients with ventriculoperitoneal shunts: a retrospective study

Journal of Neurosurgery ◽

10.3171/2017.7.jns17476 ◽

2018 ◽

Vol 129 (6) ◽

pp. 1598-1603 ◽

Cited By ~ 1

Author(s):

Andrej Pala ◽

Fadi Awad ◽

Michael Braun ◽

Michal Hlavac ◽

Arthur Wunderlich ◽

...

Keyword(s):

Image Quality ◽

Radiation Dose ◽

Radiation Exposure ◽

Low Dose ◽

Whole Body ◽

Consecutive Series ◽

Dose Length Product ◽

Shunt System ◽

Distal Catheter ◽

Vp Shunt

OBJECTIVEThe gold standard for evaluation of ventriculoperitoneal (VP) shunt position, dislocation, or disconnection is conventional radiography. Yet, assessment with this modality can be challenging because of low image quality and can result in repetitive radiation exposure with high fluctuation in the radiation dose. Recently, CT-based radiation doses have been significantly reduced by using low-dose protocols. Thus, whole-body low-dose CT (LDCT) has become applicable for routine use in VP shunt evaluation. The authors here compared image quality and approximate radiation dose between radiography and LDCT in patients with implanted VP shunt systems.METHODSVentriculoperitoneal shunt systems have been investigated with LDCT scanning at the authors’ department since 2015. A consecutive series of 57 patients (70 investigations) treated between 2015 and 2016 was retrospectively assessed. A historical patient cohort that had been evaluated with radiography was compared with the LDCT patients in terms of radiation dose and image quality. Three independent observers evaluated projection of the valve pressure level and correct intraperitoneal position, as well as complete shunt projection, using a Likert-type scale of 1–5, where 1 indicated “not assessable” and 5 meant “assessable with high accuracy.” Descriptive statistics and the Mann-Whitney U-test were used for analysis.RESULTSTwenty-seven radiographs (38.6%) and 43 LDCT scans (61.4%) were analyzed. The median dose-length product (DLP) of the LDCT scans was 100 mGy·cm (range 59.9–183 mGy·cm). The median total dose-area product (DAP) of the radiographic images was 3177 mGy·cm2 (range 641–13,833 mGy·cm2). The estimated effective dose (EED) was significantly lower with the LDCT scan (p < 0.001). The median EED was 4.93 and 1.90 mSv for radiographs and LDCT, respectively. Significantly better identification of the abdominal position of the distal shunt catheter was achieved with LDCT (p < 0.001). Simultaneously, significantly improved visualization of the entire shunt system was realized with this technique (p < 0.001). On the contrary, identification of the valve settings was significantly worse with LDCT (p < 0.001).CONCLUSIONSWhole-body LDCT scanning allows good visualization of the distal catheter after VP shunt placement. Despite the fact that only a rough estimation of effective doses is possible in a direct comparison of LDCT and radiography, the data showed that shunt assessment via LDCT does not lead to greater radiation exposure. Thus, especially in difficult anatomical conditions, as in patients who have undergone multiple intraabdominal surgeries, have a high BMI, or are immobile, the use of LDCT shunt evaluation has high clinical value. Further data are needed to determine the value of LDCT for the evaluation of complications or radiation dose in pediatric patients.

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Ceftaroline Cerebrospinal Fluid Penetration in the Treatment of a Ventriculopleural Shunt Infection: A Case Report

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-25.4.336 ◽

2020 ◽

Vol 25 (4) ◽

pp. 336-339

Author(s):

Jeffrey J. Cies ◽

Wayne S. Moore ◽

Adela Enache ◽

Arun Chopra

Keyword(s):

Cerebrospinal Fluid ◽

Case Reports ◽

Fluid Collection ◽

Rabbit Model ◽

Shunt Infection ◽

Adverse Outcomes ◽

Pharmacokinetic Data ◽

Ceftaroline Fosamil ◽

Csf Penetration ◽

History Of

Pharmacokinetic data regarding ceftaroline fosamil (CPT) penetration into cerebrospinal fluid (CSF) are limited to a rabbit model (15% inflamed) and adult case reports. We describe serum and CSF CPT concentrations in a 21-year-old, 34.8 kg female, medically complex patient presented with a 4-day history of fevers (Tmax 39.2°C), tachypnea, tachycardia, fatigue, and a 1-week history of pus and blood draining from the ventriculopleural (VPL) shunt. A head CT and an ultrasound of the neck revealed septated complex fluid collection surrounding the shunt. Therapy was initiated with vancomycin and ceftriaxone. Blood and CSF cultures from hospital day (HD) 1 were positive for methicillin-resistant Staphylococcus aureus with a CPT MIC of 0.5 mg/L and a vancomycin MIC range of 0.5 to 1 mg/L. On HD 3, CPT was added. On HD 7, simultaneous serum (69.4, 44, and 30.2 mg/L) and CSF (1.7, 2.3, and 2.3 mg/L) concentrations were obtained at 0.25, 1.5, and 4.75 hours from the end of an infusion. Based on these concentrations, CPT CSF penetration ratio ranged from 2.4% to 7.6%. After addition of CPT, the blood and CSF cultures remained negative on a regimen of vancomycin plus CPT. On HD 14, a new left-sided VPL shunt was placed. The patient continued on CPT for a period of 7 days after the new VPL shunt placement. This case demonstrated CPT CSF penetration in a range of 2.4% to 7.6%, approximately half of the rabbit model. This allowed for CSF concentrations at least 50% free time > 4 to 6× MIC of the dosing interval with a dosing regimen of 600 mg IV every 8 hours in a 34.8 kg chronic patient and resulted in a successful clinical outcome with no identified adverse outcomes.

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Umbilical hernia causing ventriculoperitoneal shunt dysfunction: illustrative cases

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21455 ◽

2021 ◽

Vol 2 (17) ◽

Author(s):

Lacey M. Carter ◽

Alejandro Ruiz-Elizalde ◽

Naina L. Gross

Keyword(s):

Pediatric Surgery ◽

Umbilical Hernia ◽

Case Reports ◽

Shunt Revision ◽

Peritoneal Catheter ◽

Distal Catheter ◽

Vp Shunt ◽

Umbilical Hernia Repair ◽

Shunt Dysfunction ◽

Csf Absorption

BACKGROUND When ventriculoperitoneal (VP) shunts and umbilical hernias coexist in the same patient, unique complications can occur. Typically, these are readily identified problems such as cerebrospinal fluid (CSF) fistulas or entrapment of the peritoneal catheter in the hernia. The authors present cases of two children whose VP shunt dysfunction resolved after repair of their umbilical hernias. OBSERVATIONS The authors present two cases of infant patients with shunted hydrocephalus and umbilical hernias. In both cases, the patients presented with distal shunt malfunctions not due to infection. Their shunt function improved once the umbilical hernia was repaired by pediatric surgery. Neither has required shunt revision since umbilical hernia repair. LESSONS Although there are case reports of VP shunts eroding through the umbilicus, developing CSF fistulas, or becoming trapped inside umbilical hernias, there is no case of VP shunt dysfunction caused by just the presence of an umbilical hernia. The authors suspect that the catheter may intermittently enter and exit the hernia. This may cause intermittent obstruction of the distal catheter, or inflammation in the hernia may occur that limits CSF absorption.

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The periumbilical approach in ventriculoperitoneal shunt placement: technique and long-term results

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.1.peds1254 ◽

2013 ◽

Vol 11 (5) ◽

pp. 558-563 ◽

Cited By ~ 12

Author(s):

Pablo F. Recinos ◽

Jonathan A. Pindrik ◽

Mazen I. Bedri ◽

Edward S. Ahn ◽

George I. Jallo ◽

...

Keyword(s):

Valsalva Maneuver ◽

Clinical Results ◽

Long Term Results ◽

Shunt System ◽

Invasive Approach ◽

Distal Catheter ◽

Linea Alba ◽

Vp Shunt ◽

Shunt Placement ◽

Operative Revision

Object The aim of this study was to examine the feasibility and safety of ventriculoperitoneal (VP) shunt placement using a periumbilical approach for distal peritoneal access. By using this minimally invasive approach, the authors hypothesized that the cosmetic outcomes would be better than could be achieved by using a traditional minilaparotomy and that clinical results would be comparable. Methods A periumbilical approach was used for distal catheter insertion during a first-time VP shunt placement in 20 patients (8 males and 12 females). Median age at time of surgery was 3.0 months (range 7 days–11.9 years) and mean follow-up time was 17.8 months (range 1.2–28.0 months). The median weight of the patients was 3.99 kg (range 1.95–57.0 kg). A single incision was made along the natural crease inferior to the umbilicus. The linea alba was exposed and a 1-mm incision made while the patient was temporarily held in a Valsalva maneuver. A peritoneal trocar was then inserted through the fascial incision and the distal catheter was passed into the peritoneal space. Results The incision line in all patients healed well, did not require operative revision, and was described as minimally visible by the patients' families. Mean operative time was 35 minutes. Eight patients required revision surgery. One distal failure occurred when the distal shunt tubing retracted and became coiled in the neck; this was repaired by conversion to a minilaparotomy for distal replacement. There was 1 shunt infection (5%) requiring shunt removal and replacement. One patient had significant skin thinning around the valve and proximal catheter, which required replacement of the entire shunt system, and another patient underwent a conversion to a ventriculoatrial shunt due to poor peritoneal absorption. In the remaining 4 patients who required operative revision, the peritoneal portion of the shunt was not involved. Conclusions The periumbilical approach for peritoneal access during VP shunt placement is technically feasible, has low infection rates, and has cosmetically appealing results. It may be considered as an alternative option to standard VP shunt placement techniques.

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Flow characteristics of cerebrospinal fluid shunt tubing

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.11.peds11255 ◽

2012 ◽

Vol 9 (2) ◽

pp. 191-197 ◽

Cited By ~ 7

Author(s):

Joseph T. Cheatle ◽

Alexis N. Bowder ◽

Sandeep K. Agrawal ◽

Michael D. Sather ◽

Leslie C. Hellbusch

Keyword(s):

Cerebrospinal Fluid ◽

Flow Characteristics ◽

Hydrodynamic Resistance ◽

Csf Shunt ◽

Effective Diameter ◽

Cerebrospinal Fluid Shunt ◽

Shunt System ◽

Shunt Valve ◽

Cross Sectional ◽

Distal Catheter

Object Cerebrospinal fluid shunt systems malfunction for a multitude of reasons, including malpostitioning, obstruction of the ventricular or distal catheter, obstruction of the shunt valve, and catheter disruptions or disconnections. The goal of this study was to examine the hydrodynamic resistance and flow in new and explanted catheters and also in catheters with 1 or 2 straight connectors. Methods Explanted catheters of multiple lengths, 2-piece catheters, 3-piece catheters, and new catheters were attached to a proximal and distal manometer. A flask with artificial CSF attached to the proximal end provided flow. The flow was allowed to stabilize over 1 hour; then the change in pressure between the proximal and distal end of the catheter was measured. Results The resistance to flow was calculated for new, never-implanted catheters and compared with the resistance of explanted distal shunt catheters. The resistance of the new catheters was examined after the addition of 1 and 2 straight connectors. Explanted catheters exhibited a slight increase in the resistance to flow of artificial CSF compared with new catheters. Two-piece and 3-piece catheters had a significant increase in resistance to flow compared with new catheters. For all catheters, resistance to flow increased as length increased (new, p = 0.01; explanted, p = 0.009; 1 connector, p = 0.01; 2 connectors, p = 0.03). In this paper, effective diameter is defined as the available cross-sectional area of catheter contacted by the artificial CSF. For new and explanted catheters, a decrease in the effective diameter of the catheter was associated with an increase in the resistance to flow of artificial CSF (new, p = 0.1083; explanted, p = 0.0091). However, after the addition of 1 or 2 connectors, an inverse trend was observed: resistance to flow increased with effective diameter. Conclusions There appears to be some increase in resistance of CSF shunt catheters as they age, altering flow dynamics. In addition, the use of straight connectors within a CSF shunt system increases the resistance to flow of artificial CSF within the shunt system. The increase in resistance appears to be related to the duration of implantation and the length of the catheter and inversely related to the diameter of the catheter. This increase in resistance may be related to sterile shunt malfunction. The addition of straight connectors is associated with a significant increase in resistance in comparison with catheters without connectors (p = 0.005).

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Persistence of communicating hydrocephalus post choroid plexus tumor resection: Case reports and review of literature

Surgical Neurology International ◽

10.25259/sni_681_2021 ◽

2021 ◽

Vol 12 ◽

pp. 483

Author(s):

Sarah A. Basindwah ◽

Basmah S. Alzahrani ◽

Abdulrazag M. Ajlan ◽

Hiasham Alkhalidi

Keyword(s):

Cerebrospinal Fluid ◽

Choroid Plexus ◽

Case Reports ◽

Third Ventricle ◽

Tumor Resection ◽

Communicating Hydrocephalus ◽

Complete Excision ◽

Choroid Plexus Tumors ◽

Vp Shunt ◽

Choroid Plexus Tumor

Background: Hydrocephalus is the most common presentation of choroid plexus tumors; it is thought to be caused either by mass effect obstructing the cerebrospinal fluid pathways or secretory properties of the tumor. In these case reports, we present two cases of choroid plexus tumors with persistence of communicating hydrocephalus postoperatively and review similar reports in the literature. Case Description: Case 1: a 2-month-old baby girl presented with bulging fontanelle, sunsetting eyes. Magnetic resonance imaging (MRI) showed large third ventricle mass with communicating hydrocephalus. She underwent complete excision of tumor through transcortical approach with perioperative intraventricular hemorrhage. Hydrocephalus persisted postoperatively and the patient required permanent ventriculoperitoneal (VP) shunt. Case 2: a 16-year-old boy presented decreased visual acuity, papilledema, and morning headaches. MRI showed a tumor in the right ventricle and communicating hydrocephalus. He underwent transparietal resection of the tumor. In both cases, hydrocephalus persisted postoperatively and patients required permanent VP shunt. Review of similar cases showed the majority of cases required permanent shunting. Conclusion: Choroid plexus tumor patients can present with communicating hydrocephalus that may persist post tumor resection for different etiologies. Careful follow-up to determine the need for cerebrospinal fluid diversion through a permanent VP shunt is important.

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Direct heart shunt placement for CSF diversion: technical note

Journal of Neurosurgery Pediatrics ◽

10.3171/2016.5.peds15638 ◽

2016 ◽

Vol 18 (6) ◽

pp. 663-666

Author(s):

Ziev B. Moses ◽

Alp Ozpinar ◽

Muhammad M. Abd-El-Barr ◽

Luis G. Quinonez ◽

Sitaram M. Emani ◽

...

Keyword(s):

Relevant Literature ◽

Technical Note ◽

Shunt Malfunction ◽

Complex Case ◽

Repeat Surgery ◽

Shunt System ◽

Distal Catheter ◽

Catheter Migration ◽

Shunt Placement ◽

History Of

The authors report a complex case of an 18-year-old male with a history of hydrocephalus secondary to intraventricular hemorrhage of prematurity, with more than 30 previous shunt revisions, who presented to the authors' institution with shunt malfunction. After exhausting his peritoneal cavity and pleural space as possible distal sites of shunt placement, he underwent a direct heart shunt placement when it was discovered he had thrombosis of his subclavian vein precluding a standard wire-guided atrial cannulation. His course was complicated by postoperative distal catheter migration and repeat surgery for reimplantation of the shunt directly into the atrium. At the 16-month follow-up visit, the patient showed no symptoms of shunt malfunction or pericardial effusion. Imaging studies demonstrated a functioning shunt system. This is the second reported successful ventricle to direct heart shunt placement in an adult. The authors report on the technical aspects of the case and review the relevant literature.

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Shunt Migration into the Sphenoid Sinus: Case Reports

Neurosurgery ◽

10.1227/01.neu.0000073993.14329.4f ◽

2003 ◽

Vol 53 (2) ◽

pp. 441-443 ◽

Cited By ~ 1

Author(s):

Khan W. Li ◽

Elisa Ciceri ◽

Giovanni Lasio ◽

Carlo L. Solero ◽

Francesco DiMeco

Keyword(s):

Cerebrospinal Fluid ◽

Sphenoid Sinus ◽

Case Reports ◽

Uneventful Recovery ◽

Dural Defect ◽

Temporal Fossa ◽

Catheter Migration ◽

Cerebrospinal Fluid Rhinorrhea ◽

Shunt Catheter ◽

Shunt Migration

Abstract OBJECTIVE AND IMPORTANCE Shunt catheter migration is a potential complication of cerebrospinal fluid shunting procedures. We report an unusual case of proximal shunt migration into the sphenoid sinus. To our knowledge, there have been no previous reports of shunt migration through the bony structures of the cranial base. CLINICAL PRESENTATION A 41-year-old man who had had a cyst-to-peritoneum shunt placed 21 years earlier for a temporal lobe arachnoid cyst presented with cerebrospinal fluid rhinorrhea. Neuroradiological imaging revealed migration of the shunt catheter through the medial wall of the middle temporal fossa into the sphenoid sinus. INTERVENTION The patient underwent shunt removal and repair of the dural defect. Intraoperatively, the proximal catheter tip was found in the sphenoid sinus with dural and bony erosion. The patient made an uneventful recovery. CONCLUSION We present a unique long-term complication associated with intracranial shunt catheters. We hypothesize that excessive proximal catheter length and chronic cerebrospinal fluid pulsations contributed to migration of the catheter into the sphenoid sinus.

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Spontaneous bacterial peritonitis causing Serratia marcescens and Proteus mirabilis ventriculoperitoneal shunt infection

Journal of Neurosurgery ◽

10.3171/jns.2006.105.2.320 ◽

2006 ◽

Vol 105 (2) ◽

pp. 320-324 ◽

Cited By ~ 5

Author(s):

Luis M. Tumialán ◽

Franklin Lin ◽

Sanjay K. Gupta

Keyword(s):

Serratia Marcescens ◽

Proteus Mirabilis ◽

Spontaneous Bacterial Peritonitis ◽

Bowel Perforation ◽

Fluid Collection ◽

Shunt Infection ◽

High Morbidity ◽

Shunt System ◽

Vp Shunt ◽

Bacterial Peritonitis

✓The authors report their experience treating a polymicrobial ventriculoperitoneal (VP) shunt infection in a developmentally delayed 21-year-old woman. Cerebrospinal fluid (CSF) cultures grew Serratia marcescens and Proteus mirabilis. On admission and throughout her hospitalization, results of physical examination of her abdomen were normal, and radiographic studies showed no evidence of bowel perforation or pseudocyst formation. Contrast-enhanced computed tomography of the abdomen revealed a small fluid collection. After a course of intravenous gentamicin and imipenem with cilastatin in conjunction with intrathecal gentamicin, the infection was resolved and the VP shunt was reimplanted. Although VP shunt infections are not uncommon, S. marcescens as a causative agent is exceedingly rare and potentially devastating. Only two previous cases of S. marcescens shunt infection have been reported in the literature. Authors reporting on S. marcescens infections in the central nervous system (CNS) have observed significant morbidity and death. Although more common, the presence of P. mirabilis in the CSF is still rare and highly suggestive of bowel perforation, which was absent in this patient. Spontaneous bacterial peritonitis was the likely source from which these bacteria gained entrance into the VP shunt system, eventually causing ventriculitis in this patient. The authors conclude that in light of the high morbidity associated with S. marcescens infection of the CNS, intrathecal administration of gentamicin should be strongly considered as part of first-line therapy for S. marcescens infections in VP shunts.

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