Delayed intrapleural migration of a ventriculoperitoneal shunt

Supradiaphragmatic intrathoracic migration of ventriculoperitoneal shunt with “double bending sign”

Ventriculoperitoneal shunt (VPS) is a common treatment for hydrocephalus. An 80-year-old woman presented with subarachnoid hemorrhage caused by rupture of an aneurysm of the right middle cerebral artery. Emergency clipping was performed. Hydrocephalus occurred shortly after and VPS placement was performed. She improved and was transferred to a rehabilitation hospital. She presented with dyspnea 5 months later. Chest computed tomography (CT) showed extensive pleural effusion and intrathoracic migration of the distal VPS catheter. Chest CT confirmed that the distal catheter had penetrated into the pleural cavity under the second rib, and the catheter tip was located at the bottom of the right thoracic cavity. Review of chest CT right after the shunt surgery found the distal catheter passing only under the second and third ribs and otherwise located in the subcutaneous layer to the abdominal cavity. Chest radiography showed that the distal shunt tube was distorted in a characteristic “double bending sign.” This rare case of supradiaphragmatic intrathoracic migration of VPS indicates a possible mechanism of this migration, based on the anatomical physiology, and that “double bending sign” indicates the need for further investigation.

Lung destruction secondary to intrapulmonary migration of a ventriculoperitoneal shunt catheter: report of an unusual case and literature review

Ventriculoperitoneal shunt placement for the treatment of hydrocephalus is one of the most common pediatric neurosurgical procedures. Complications, including infections, catheter obstruction, shunt breakdown, and hemorrhage, have been described in the literature. Occasionally, however, uncommon and devastating complications occur. We report a case of a 10-year-old female patient who at birth underwent surgical closure of lumbar myelomeningocele and placement of a CSF shunt at another center. Her neurosurgical follow-up was poor. She presented at our institution with a history of recurrent pneumonia. Control chest X-rays showed a right pulmonary infiltrate with lung retraction and mediastinal shift. Chest and brain CT scans confirmed the intrapulmonary location of the distal catheter tip and ventricular dilation. Surgical shunt revision was performed with removal of the intrapulmonary catheter and placement of a new intraperitoneal catheter. Subsequently, right pneumonectomy was performed with good postoperative recovery of the patient. Intrathoracic migration of the distal catheter of the CSF shunt is an extremely rare complication that may produce severe morbidity. To our knowledge, there have been no previous reports on extensive lung destruction secondary to intrathoracic and intrapulmonary ventriculoperitoneal shunt migration. In patients with CSF shunts and pulmonary symptoms, intrapulmonary catheter migration should be considered.

Intrathoracic migration of ventriculo-peritoneal shunt via Morgagni hernia

We present the case of a 5-month-old patient presenting with pleural migration of ventriculo-peritoneal shunt catheter who returned 2 months later with respiratory distress. Ultimately, the diagnosis of a Morgagni hernia was made. This diagnosis, though rare, should be entertained in certain clinical settings.

Pleural effusion in a child with a ventriculoperitoneal shunt and congenital heart disease

We present the unique case of an 8 month old infant who required extracorporeal membrane oxygenation (ECMO) after neonatal repair of tetralogy of Fallot. While on ECMO, he developed grade 3 intraventricular hemorrhage resulting in hydrocephalus requiring ventriculoperitoneal (VP) shunt placement at 5 months of life. He presented to cardiology clinic with a 2-month history of poor weight gain, tachypnea, and grunting and was found to have a large right sided pleural effusion. This was proven to be cerebrospinal fluid (CSF) accumulation secondary to poor peritoneal absorption with subsequent extravasation of CSF into the thoracic cavity via a diaphragmatic defect. After diaphragm repair, worsening ascites from peritoneal malabsorption led to shunt externalization and ultimate conversion to a ventriculoatrial (VA) shunt. This is the second reported case of VA shunt placement in a child with congenital heart disease and highlights the need to consider CSF extravasation as the cause of pleural effusions in children with VP shunts.

Migration and coiling of peritoneal catheter into the subgaleal space: a very rare complication of subgaleoperitoneal shunt

Upward migration of the peritoneal catheter of a subgaleo-peritoneal (SP) shunt and coiling into the subgaleal space is an extremely rare complication of a SP shunt. A 32-year-old male patient visited our hospital presenting with a large skull defect due to a prior craniectomy performed elsewhere. The patient underwent a cranioplasty with methylmetacrylate, but subsequently developed progressive pseudomeningocele and subgaleal cerebrospinal fluid (CSF) collection. The patient underwent CSF diversion via a SP shunt. After SP shunting, the pseudomeningocele disappeared completely. Six months later, the patient presented with progressive scalp swelling. Skull X-ray showed migration and coiling of the distal catheter of the SP shunt. The patient was treated by removing the entire shunt catheter and the dura was covered with a subgaleal flap. We would like to report our experience with a very rare complication of subgaleo-peritoneal shunting.

Unusual complications of ventriculo peritoneal shunt surgery

Ventriculo peritoneal (VP) shunt surgery is one of the common neurosurgical procedures employed in the management of hydrocephalus. Numerous complications related to this procedure are reported in the literature. Peritoneal catheter-related complications are the usual causes of the shunt malfunction. We report three unusual cases of peritoneal shunt catheter migration in children. Two cases are of anal and one vaginal extrusion. Possible mechanisms of migration and management strategies were discussed.

CSF hydrothorax: neither migration of peritoneal catheter into the chest nor ascites. Case report and review of the literature

INTRODUCTION

Complications of ventriculoperitoneal (V/P) shunt surgery are generally due to infection, or mechanical or dynamic dysfunction. Thoracic complications like cerebrospinal fluid (CSF) hydrothorax are rarely seen.

PATIENT AND METHODS

We present a CSF hydrothorax patient as a rare complication of V/P shunt surgery and review of the literature. The patient was a 7-month-old girl who had V/P shunt surgery for hydrocephalus. Six months after surgery, she was admitted to hospital with the complaint of cough. As the chest X-ray revealed hydrothorax, a chest tube was inserted. Although her shunt tip was in the abdominal cavity in shuntograms, positive beta-2 transferrin in liquid sample and Tc 99m cisternography proved that it was CSF. After we replaced her V/P shunt with a ventriculoatrial shunt, the liquid coming from the chest tube progressively diminished and disappeared, and her chest tube was removed.

RESULTS

There are 36 CSF hydrothorax cases, including the present case, in the literature. There is peritoneal catheter migration into the chest in 22 of them (61.1 %). Half of the remaining 14 cases (38.9 %) without catheter migration have also CSF ascites. But, in the other half (seven cases), there is neither catheter migration nor CSF ascites as in the present case.

CONCLUSION

CSF hydrothorax following V/P shunt surgery is a very rare complication that may cause serious respiratory distress. It is important to keep in mind that peritoneal catheter migration into the chest may or may not occur. Even ascites may not accompany CSF hydrothorax in a patient without peritoneal catheter migration.

Recurrent pneumonia caused by transdiaphragmatic erosion of a ventriculoperitoneal shunt into the lung. Case report

To the best of the authors' knowledge, this report represents the first description of a ventriculoperitoneal (VP) shunt that migrated into the chest cavity where it caused recurrent pneumonias. This 15-year-old boy with a history of hydrocephalus treated with VP shunt therapy as an infant presented with a 2-year history of chronic coughing and recurrent pneumonia. A high-resolution chest computed tomography scan revealed a right lower lobe infiltration and evidence of migration of the peritoneal shunt tubing through the diaphragm into the lung parenchyma. The catheter was pulled back into the peritoneal cavity via a simple abdominal incision. The patient's long-term outcome was excellent, and there was complete cessation of the pneumonia.

Fibrothorax in adulthood caused by a cerebrospinal fluid shunt in the treatment of hydrocephalus

Ventriculopleural shunts have been used as an alternative to ventriculoperitoneal shunts in the treatment of hydrocephalus. Although recurrent pleural effusion is a known complication of this procedure, severe fibrothorax requiring decortication has been described only once, in a case involving a child. The authors report a case of a severe fibrothorax with an entrapped lung presenting in an adult patient.

Hydrothorax: transdiaphragmatic migration of a ventriculoperitoneal shunt catheter

Symptomatic hydrothorax following ventriculoperitoneal shunt insertion is a very rare complication. The patient was a 5-month-old child known to have had shunted congenital hydrocephalus two months before. He presented to the emergency room in respiratory distress. Chest X-ray and computerized tomography images confirmed left hydrothorax and showed transdiaphragmatic migration of the tip of the peritoneal catheter to the thoracic cavity. After the catheter had been shortened and replaced to the peritoneal cavity, the patient's symptoms abated.

Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review

INTRODUCTION

The decision-making process when we compare endoscopic third ventriculostomy (ETV) with shunts as surgical options for the treatment of hydrocephalus in infants is conditioned by the incidence of specific and shared complications of the two surgical procedures.

REVIEW

Our literature review shows that the advantages of ETV in terms of complications are almost all related to two factors: (a) the avoidance of a foreign body implantation and (b) the establishment of a 'physiological' cerebrospinal fluid (CSF) circulation. Both these kinds of achievements are particularly important in infants because of the relative high rate of some intraoperative (i.e. abdominal) and late (secondary craniosynostosis, slit-ventricle syndrome) shunt complications in this specific subset of patients. On the other side, the main factor which is claimed against ETV is the relatively high risk of immediate mortality and neurological complications. Clinical manifestations of neurological structure damage seem to be more frequent in infants, probably due to the more relevant effect of parenchymal and vascular damage in this age group; however, both the immediate mortality and neurological damage risk of ETV procedures should be weighted against the long-term mortality and the late neurological damage which is not infrequently described as a consequence of shunt malfunction and proximal shunt revision procedures. Infections are possible in both ETV and extrathecal CSF procedures, especially in infants. However, the incidence of infective complications is significantly lower in case of ETV (1-5% vs 1-20%). Moreover, different from shunting procedures, infections in children with third ventriculostomy have a more benign course, being generally controlled by antibiotic treatment alone.

Nonfunctional abdominal complications of the distal catheter on the treatment of hydrocephalus: an inflammatory hypothesis? Experience with six cases

INTRODUCTION

The peritoneal cavity is the most common site of cerebrospinal fluid absorption in hydrocephalus treatment. Many distal catheter complications are the result of this type of treatment, and these have been extensively described in the neurosurgical literature.

MATERIALS AND METHODS

In our study, six cases of distal catheter migration with visceral perforation and/or extrusion are presented: three through the umbilicus, two through the scrotum, and one through the anus. An extensive review of the literature was performed.

RESULTS

The studies of peritoneal dialysis models for the treatment of chronic renal failure patients provide important data about solute absorption in the peritoneal cavity and reactivity of the peritoneal membrane.

CONCLUSION

This model, when compared to distal catheter complications on a ventriculoperitoneal (VP) shunt, presents similarities that could help understand the mechanism of the nonfunctional complications of the distal VP catheter (complication with functional shunt), providing valuable data to support an inflammatory mechanism.

Subgaleal migration of a ventriculoperitoneal shunt

Blockage of a ventriculoperitoneal (VP) shunt is very common. Here, we describe an unusual case of shunt blockage in an infant. He was shunted for hydrocephalus associated with a Dandy-Walker malformation diagnosed at birth. At surgery, the entire VP shunt was found to have migrated into the subgaleal space, which clinically presented as shunt obstruction. We suggest techniques to avoid this rare, but preventable, complication of shunt surgery.

Cerebral ventricular shunts

Cerebral ventricular shunts are siphoning devices used to treat hydrocephalus. They are placed within cerebral ventricles and peripheral cavities such as the ventricular atrium or peritoneal cavity. Complications include obstruction of cerebral spinal fluid (malfunction) and infection. Morbidity and mortality rates are high when shunt malfunction and infection are not treated emergently. This report summarizes the physical examination of patients with ventricular shunts, reviews the type of shunts commonly used, discusses shunt malfunctions (causing overshunting or undershunting of cerebrospinal fluid) and infections, and makes recommendations concerning empiric antibiotic therapy for shunt infection. The technique of tapping a shunt is presented for management of patients with elevated intracranial pressure that does not respond to non-invasive maneuvers to lower the pressure.