Delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion: Case report and literature review

Multifocal intraparenchymal hemorrhages after ventriculoperitoneal shunt surgery in infants

OBJECT

Ventriculoperitoneal (VP) shunt surgery is the most common treatment for hydrocephalus. In certain situations, uncommon complications can occur after shunting procedures. The authors undertook this study to analyze the clinical characteristics of pediatric patients who developed multifocal intraparenchymal hemorrhages (MIPHs) as a complication of shunt surgery. The authors also analyzed the risk factors for MIPH in a large cohort of patients with hydrocephalus.

METHODS

This study included all pediatric patients (age < 18 years) who underwent VP shunt surgery at the authors' institution between January 2001 and December 2012. During this period, 507 VP shunt operations were performed in 330 patients. Four of these patients were subsequently diagnosed as having MIPH. The authors analyzed the clinical characteristics of these patients in comparison with those of the entire group of shunt-treated patients.

RESULTS

The incidence of MIPH was 1.2% (4 of 330 cases) for all pediatric patients who underwent VP shunt placement but 2.9% (4 of 140 cases) for infants less than 1 year old. When the analysis was limited to patients whose corrected age was less than 3 months, the incidence was 5.3% (4 of 76 cases). Of the 4 patients with MIPH, 2 were male and 2 were female. Their median age at surgery was 54 days (range 25-127 days), and in all 4 cases, the patients' corrected age was less than 1 month. Three patients were preterm infants, whereas one patient was full-term. None of these patients had a prior history of intracranial surgery (including CSF diversion procedures). All showed severe hydrocephalus during the preoperative period. Their clinical courses as patients with MIPH were comparatively favorable, despite the radiological findings.

CONCLUSIONS

MIPH is a rare but not negligible complication of VP shunt surgery. This complication might be a unique phenomenon in infants, especially young, preterm infants with severe hydrocephalus. Moreover, the absence of previous intracranial procedures might be one of the risk factors for this complication. The rapid alteration of brain conditions in the setting of immaturity might cause MIPH. To prevent this complication, the authors recommend that pressure settings of programmable valves should be gradually adapted to the target pressure.

Delayed germinal matrix hemorrhage induced by ventriculoperitoneal shunt insertion for congenital hydrocephalus

Germinal matrix hemorrhages (GMHs) are typically seen in preterm neonates during the first 4 days of life. The authors encountered 2 children with late-onset GMH subsequent to ventriculoperitoneal (VP) shunt insertion for congenital hydrocephalus. Both children were delivered at full term with normal body weight, although they were compromised with the preceding hypoxic events prior to shunt insertion. The first case involved a female infant with severe craniofacial deformities. Because of aspiration pneumonia related to the comorbid upper airway stenosis, endotracheal intubation with intermittent mechanical ventilation was necessary. The associated congenital hydrocephalus was treated with VP shunt insertion when she was 35 days of age, and GMH was confirmed 1 week after shunt placement. During a period of conservative observation, the hemorrhage resolved without any neurological deterioration. The second case involved a male infant with a large intraparenchymal cyst on the left parietal portion. He was intubated for pneumonia at 1 month of age. He had associated congenital hydrocephalus that was progressive, and he was treated with VP shunting at 69 days of age, after his pneumonia had resolved. Postoperative GMH was confirmed, although hydrocephalus was well controlled by VP shunt insertion. Observed conservatively, he fared well and the GMH resolved. These 2 cases had unique features in common; both had congenital anomalies in the CNS and respiratory problems before shunting. The hypoxic insults on the residual germinal matrix layer and sudden decrease in CSF pressure may relate to the occurrence of these late-onset GMHs.