Cerebrospinal fluid edema associated with shunt obstruction

Periventricular cyst as a complication of ventriculoperitoneal shunting in the context of intracranial haemorrhage: a case report and review of the literature

Spontaneous intraventricular haemorrhage with hydrocephalus frequently requires neurosurgical intervention, including ventriculoperitoneal shunting. We describe a periventricular cyst following the placement of a ventriculoperitoneal shunt in a 67-year-old female patient. The patient was admitted for rehabilitation after a spontaneous left basal ganglia and diffuse intraventricular haemorrhage with hydrocephalus. Initial management included an extraventricular drain, followed by a ventriculoperitoneal shunt. On Day 5 of rehabilitation, the patient was urgently reviewed for reduced level of consciousness. A cerebrospinal fluid cyst was identified around the shunt catheter, with subacute haemorrhage within the cyst. The patient underwent a successful shunt revision, with rapid improvement in consciousness and resolution of the cyst. This case highlights the importance of pericatheter cyst as a differential diagnosis in patients with altered neurological status following ventriculoperitoneal shunting. Early detection and surgical revision can lead to rapid resolution of symptoms and a favourable prognosis.

Odd presentation of shunt malfunction: a case series and review of literature

OBJECTIVE

Children with previous ventriculoperitoneal shunt (VPS) insertion due to hydrocephalus may refer to the hospital with various clinical complaints. Shunt malfunction is frequently diagnosed in these children necessitating shunt revision. Although increased head circumference, setting sun eye in younger children, and headache, nausea/vomiting, loss of consciousness, visual disturbance, and other signs of intracranial hypertension are common clinical manifestations of shunt malfunction, some patients may present with odd or unusual symptoms. Here, we present a series of patients with shunted hydrocephalus who presented with odd and unexpected clinical manifestations of shunt malfunction.

METHODS

Eight children with shunt malfunction were enrolled in this series. The age, sex, age of shunting, etiology of hydrocephalus and management, post-shunt insertion symptoms/sign, revision surgery, outcome, and follow-up were evaluated.

RESULTS

Patients were aged from 1 to 13 years (mean, 6.38 years). There were 5 males and 3 females. The odd presentation associated with shunt malfunction included facial palsy in three children, ptosis in 3 children, and torticollis and dystonia each in one child. All patients underwent shunt revision except for one patient in whom a new shunt was inserted. Follow-up showed improvement of the symptoms in all patients.

CONCLUSION

In this series, we reported eight patients with unusual signs and symptoms following shunt malfunction that were successfully diagnosed and managed.

Intraparenchymal pericatheter cyst as an indicator of ventriculoperitoneal shunt malfunction: A case-based update

Background:

Intraparenchymal pericatheter cysts (IPCs) are a rare ventriculoperitoneal shunt (VPS) complication, with only a few cases recorded in the literature.

Case Description:

We report a 22-year-old woman admitted with headache, papilledema, vision loss, and a history of leukemia. Lumbar puncture revealed idiopathic intracranial hypertension (IIH). Three months after VPS implantation, she was readmitted with headache and worsening of visual impairment. CT evidenced a IPC with perilesional edema. Intraoperatively, a shunt revision and cyst drainage were opted for. We present a discussion and literature review on this unique complication of VPS, with emphasis on management.

Conclusion:

It is important to understand and consider IPCs as complications of VPS surgery, including in adult patients and IIH cases.

Porencephalic cyst after endoscopic third ventriculostomy and Ommaya reservoir placement: case report and review of the literature

BACKGROUND

A 13-year-old female patient was diagnosed with a tectal glioma (TG), a subgroup of astrocytoma that can result in obstructive hydrocephalus secondary to aqueductal stenosis. Endoscopic third ventriculostomy (ETV) is used to treat this type of hydrocephalus with a good success rate. Our institution performs ETV and Ommaya reservoir (OR) placement in these cases. The OR allows measurement of intracranial pressure (ICP) and cerebrospinal fluid (CSF) access and a method for performing ventricular dye studies to evaluate third ventricular stoma (TVS) patency. In this case, a porencephalic cyst (PC) developed around the OR's ventricular catheter (OVC) two and a half months after surgery.

CONCLUSION

The PC is thought to have developed in association with TVS stoma closure and resolved after ETV revision.

Intraparenchymal Pericatheter Cyst after Cerebrospinal Fluid Shunt: A Rare Complication with Challenging Diagnosis - Case Presentation and Review of the Literature

An intraparenchymal pericatheter cyst is a rare complication of ventriculoperitoneal shunt, which is not well described yet. Due to its rarity, lack of characteristic symptoms and radiological features that often mimic brain tumors or abscesses, especially in head computed tomography without contrast can be easily misdiagnosed. We report the case of a 9-year-old girl who was admitted to a peripheral hospital due to severe headaches and vomiting. The child had a history of craniotomy and ventriculoperitoneal shunt for posterior fossa tumor, performed in our department, 4 years earlier. The patient underwent a brain magnetic resonance imaging (MRI) scan and transmitted to our hospital with the diagnosis of brain tumor. However, a closer look at the MRI established the diagnosis of intraparenchymal pericatheter cerebrospinal fluid cyst; hence, the patient underwent shunt revision and cyst drainage. We researched the literature and described 20 reported cases, discussing the pathophysiological mechanisms, the radiological features, and the optimal treatment of this interesting, yet a challenging complication.

A porencephalic cyst formation in a 6-year-old female with a functioning ventriculoperitoneal shunt: a case-based review

INTRODUCTION

Porencephalic cysts and cerebrospinal fluid (CSF) edema around the intracranial shuntcatheter are rare complications of ventriculoperitoneal shunt (VPS) surgery. Possible mechanisms leading to a porencephalic cyst formation in a patient with a VPS include taut ventricle, dysfunction of distalcatheters, and irreversible damage to the brain parenchyma caused by shunt insertion, chemotherapy, or radiation. Most of the previous reports were due to shunt malfunction and treatment consisted of shunt revision or removal.

CASE REPORT

We present a case of porencephalic cyst formation in a 6-year-old female as a result ofcerebrospinal fluid under-drainage that was promptly improved with shunt valve adjustment.

COCLUSIONS

A heightened index of suspicion is required to prevent misdiagnosis of porencephalic cysts astumors or abscesses that may lead to unnecessary surgical explorations. Further research is needed toelucidate the pathophysiological mechanism that causes a porencephalic cyst formation.

Intracranial Perishunt Catheter Fluid Collections with Edema, a Sign of Shunt Malfunction: Correlation of CT/MRI and Nuclear Medicine Findings

Fluid collections with edema along the intracranial tract of ventriculoperitoneal shunt catheters in adults are rare and are more frequently seen in children. The imaging appearance of these fluid collections is frequently confusing and presents a diagnostic dilemma. We present 6 cases of adult patients noted to have collections with edema along the tract of ventriculoperitoneal shunt catheters. To our knowledge, there are no previous studies correlating the CT/MR imaging findings with nuclear medicine scans in this entity. We hypothesized that when seen in adults, the imaging findings of a CSF-like fluid collection around the intracranial ventriculoperitoneal shunt catheter on CT/MR imaging may suggest areas of CSF accumulation with interstitial edema. It is important to recognize this rare ventriculoperitoneal shunt complication in adults to prevent misdiagnosis of an abscess or cystic tumor.

Isolated left homonymous hemianopia secondary to a pericatheter cyst-a rare presentation of a ventriculoperitoneal shunt failure

A 26-year-old woman developed a left homonymous hemianopia 1 week after placement of a ventriculoperitoneal shunt through a right parieto-occipital approach. Computed tomography demonstrated a parenchymal cyst in the right occipital lobe. After shunt revision, there was concomitant resolution of the cyst and visual field defect over 1 month. The literature is reviewed regarding this unusual complication of ventriculoperitoneal shunt failure.

Cerebral Edema Associated with Ventricular Reservoirs in Two Patients: A Case Report

Placement of ventricular reservoirs is a common practice to treat various tumors of the central nervous system (CNS). Ventricular catheter-reservoir-associated edema has been noted in the literature, but a thorough review of this literature identified no articles that examine this particular complication in neurooncology patients, specifically. We report two cases of ventricular catheter-reservoir-associated edema in patients receiving treatment for CNS metastasis.

Transient binocular visual loss: a rare presentation of ventriculoperitoneal shunt malfunction

The authors report the case of a 27-year-old male with ventriculoperitoneal shunt (VPS) for hydrocephalus presenting with episodic transient binocular visual loss (TBVL) and headache. Complete physical, bedside shunt examination and funduscopy were unremarkable. Laboratory investigation, shunt series and imaging studies failed to reveal any acute abnormalities. Interrogation of the shunt system identified a valve malfunction which was corrected with resultant symptomatic relief and the patient was discharged home in stable condition. VPS malfunction occurs secondary to infection or mechanical failure such as obstruction, tubing fracture, shunt migration and over drainage. Resultant raised intracranial pressure leads to symptoms of headache, nausea, vomiting and gait abnormalities. Visual defects including blindness has been occasionally reported from shunt malfunction. Rare complications include cerebrospinal fluid oedema, colonic perforation, paraparesis and parkinsonism. TBVL due to shunt malfunction remains an uncommon presentation and requires a high index of clinical suspicion while evaluating these patients.

Intraparenchymal pericatheter cyst as a complication of a ventriculo-peritoneal shunt in a premature infant

A ventriculo-peritoneal shunt is a standard surgical management for hydrocephalus, but complications may impede the management of this disease. Obstruction of the catheter is one of the most common complications and manifests clinically in various ways. Intraparenchymal cyst development after shunt malfunction has been reported by several authors, but the underlying mechanism and optimal treatment methods are debatable. The authors report a case of intraparenchymal cyst formation around a proximal catheter in a premature infant after a ventriculo-peritoneal shunt and discuss its pathogenesis and management.

[Cerebral fluid edema: a rare complication of ventriculoperitoneal shunt]

Physiopathologic knowledge of hydrocephalus allows progress in the conception of modern shunts. With better controlled surgical techniques, shunting has revolutionized the prognosis of hydrocephalus. However, peritoneal or atrial shunting is not harmless, as illustrated by the large number of reported complications. We describe here an unusual complication of ventriculoperitoneal shunt dysfunction revealed by focal cerebral edema in a 60-year-old patient. Preoperative cerebral CT scan showed the focal brain edema with diffusion of cerebrospinal fluid around the trajectory of the ventricular catheter. Abdominal CT scan demonstrated distal shunt dysfunction. Clinical and radiological outcome was good after surgical revision of the shunt, confirming the diagnosis.

Reexpandability of the ventricular system of hydrocephalic children in the event of shunt occlusion

INTRODUCTION

To estimate intracranial volume-buffering capacity in the event of shunt occlusion, the reexpandabilty of the lateral ventricles and clinical manifestations were examined in shunt-dependent hydrocephalic children.

MATERIAL AND METHODS

This retrospective study was performed in 38 children who displayed acute deterioration due to spontaneous shunt obstruction. At the time of shunt obstruction, patients with small lateral ventricles [small ventricle (SV) group: Evans' index <or=35, n=13] showed significantly more rapid deterioration into lethargy after onset than those with large lateral ventricles [lateral ventricle (LV) group: Evans' index >0.35, n=25]. All patients in the SV group were 3 years or older at the time of shunt obstruction or had a long period (5.2 years) between initial shunting and shunt occlusion. Their Evans' index was less than 0.33 prior to shunt obstruction.

CONCLUSIONS

While a shunt is functioning, the factors predictive of reduced ventricular reexpandability include (1) a lateral ventricular size smaller than 0.33 on the Evans' index and (2) either an age of more than 3 years in children who have undergone initial shunting at less than 1 year of age or over 5 years of the period after initial shunting.

Reversible CSF cyst related to a functioning ventriculo-peritoneal shunt

Although the occurrence of CSF oedema and cyst has been described in presence of a blocked ventriculoperitoneal shunt, especially distal end block, its occurrence in presence of a well functioning shunt has not been described so far. We report a case where a 51-year old lady developed an insidious onset and gradually progressive CSF cyst without any clinical or radiological feature of shunt block over a period of about 2 years. The changes started about 6 months after a course of radiation therapy for an extensive residual supra and infratentorial meningioma. Following surgery, where the cyst was punctured and a new ventricular catheter was inserted, despite well functioning upper and lower end, the cyst gradually disappeared. We review the literature and hypothesize that the radiation-induced changes were responsible for initiation and progression of the cyst.

Isolated diastasis of cranial sutures: unusual presentation of a blocked shunt in an infant

INTRODUCTION

Ventriculo-peritoneal (VP) shunt malfunction is usually due to blockage of the ventricular catheter and this is typically apparent as enlarged ventricles on a CT scan of the brain. We describe a less common radiological finding in an infant with a blocked shunt.

CASE REPORT

A male infant presenting with hydrocephalus in the neonatal period underwent insertion of a VP shunt. He represented at 17 months of age with the clinical features of raised intracranial pressure. A CT scan of the brain revealed that the ventricles were smaller compared with his previous scan, but X-rays taken as part of the shunt series revealed diastasis of the sagittal, coronal and lambdoid sutures. The shunt was explored and the ventricular catheter was found to be blocked and was replaced. Post-operatively there was complete resolution of the symptoms and the suture diastasis.

CONCLUSIONS

Suture diastasis with small ventricles on a CT scan of the brain is an unusual radiological finding in an infant with a blocked shunt. Suture diastasis in this patient suggests raised intracranial volume and this may be due to the transependymal absorption of CSF into the white matter.

Cerebral fluid edema: an unusual complication of ventriculoperitoneal shunts

INTRODUCTION

A case of accumulation of CSF into the brain parenchyma simulating a brain tumor, secondary to an obstructed ventriculoperitoneal shunt, is presented. Until now, only seven cases of this rare complication have been described.

CASE REPORT

Magnetic resonance showed an expansive, low-density intracranial lesion on the right frontal and parietal lobe. This mass was biopsied, but no tumor was found and the diagnosis was brain edema.

CONCLUSION

The mistake in the diagnosis was due to the clinical symptoms and to the MR images.

Clinical significance of ventricular size in shunted-hydrocephalic children

For maintaining the intracranial buffering capacity against shunt obstruction, we tried to seek the most suitable size of the lateral ventricles in hydrocephalic children. Thirty-seven shunted-hydrocephalic children who required emergent revision of the shunt were analyzed. At the time of shunt obstruction, the lateral ventricle remained small (0.35 or less than 0.35 on the Evans' index) in 13 patients (Slit-like group), but it enlarged (more than 0.35 on the Evans' index) in 24 patients (Dilated group). The mean age in the Slit-like group was significantly older than in the Dilated group and there was no patient younger than 3 years in the Slit-like group. Compared with the Dilated group, the Slit-like group showed significantly rapid deterioration into lethargy after shunt obstruction. Also, at the time of obstruction CT scans showed a significantly higher rate of narrowing of the ambient cistern. While the shunt was working well before shunt obstruction, the Evans' index was less than 0.33 in all patients of the Slit-like group. In conclusion, because small ventricles after shunt strongly suggest the presence of ventricular tautness, the lateral ventricular size should be maintained at more than 0.33 on the Evans' index in shunted children at an age of 3 or more than 3 years.