Intraventricular migration of VP shunt

Intracranial migration of a ventriculoperitoneal shunt: A case report and literature review

Background

The intracranial migration of a ventriculoperitoneal shunt (VPS) has been previously described, it is a very rare event, and the mechanisms of this migration have not yet been elucidated.

Case Description

Newborn at 38 weeks of gestation by cesarean section, with congenital hydrocephalus due to Dandy-Walker malformation that required right Frazier VPS placement. At 2-month follow-up, computed tomography of the skull showed cranial migration of VPS and dysfunction. At evaluation, there were signs of systemic infection. External ventricular drainage was placed and an intravenous antibiotic scheme for Gram-positive bacteria was started. After 3 months, cerebrospinal fluid cultures were negative and definitive VPS was decided.

Conclusion

Different possible mechanisms have been proposed, such as negative intraventricular pressure, positive intra-abdominal pressure, use of valveless catheters, excessive burr hole size, as well as such as occipital ventricular access, thin cortical mantle, incorrect distal and proximal fixation, short distance between the peritoneum and ventricles, and a possible inflammatory reaction to the catheter material (silicone). A combination of these different mechanisms contributes to proximal shunt migration. Although the placement of a VPS is a procedure well taught since the 1^st years of neurosurgical residency, it is not exempt from complications. Although, as was previously stated in this paper, the incidence of a complete cranial VPS migration is extremely rare, and only a few cases are documented, it is still important to report this type of cases and to try to elucidate the possible mechanisms involved.

Ventriculoperitoneal Shunt Failure 3-year after Shunt Surgery Caused by Migration of Detached Ventricular Catheter into the Cranium: A Case Study of Idiopathic Normal-pressure Hydrocephalus

Idiopathic normal-pressure hydrocephalus (iNPH) is a neurological disorder that typically presents with gait disturbance, cognitive impairment, and urinary incontinence. Although most patients respond to cerebrospinal-fluid shunting, some do not react well because of shunt failure. A 77-year-old female with iNPH underwent ventriculoperitoneal shunt implantation, and her gait impairment, cognitive dysfunction, and urge urinary incontinence improved. However, 3 years after shunting (at the age of 80), her symptoms gradually recurred for 3 months and she did not respond to shunt valve adjustment. Imaging studies revealed that the ventricular catheter detached from the shunt valve and migrated into the cranium. With immediate revision of the ventriculoperitoneal shunt, her gait disturbance, cognitive dysfunction, and urinary incontinence improved. When a patient whose symptoms have been relieved by cerebrospinal-fluid shunting experiences an exacerbation, it is important to suspect shunt failure, even if many years have passed since the surgery. Identifying the position of the catheter is crucial to determine the cause of shunt failure. Prompt shunt surgery for iNPH can be beneficial, even in elderly patients.

Complete intraventricular migration of ventriculo-peritoneal shunt: A rare case report

Introduction and importance

A ventriculoperitoneal (VP) shunt is a cerebral shunt used to treat hydrocephalus. This is used to remove the excessive accumulation of cerebrospinal fluid inside the ventricles.

Case presentation

We are reporting a rare case of complete intracranial migration of a ventriculoperitoneal shunt, a potentially fatal complication, presenting to us with hydrocephalous. The baby was taken up for surgery with endoscopic assisted shunt removal and shunt revision.

Clinical discussion

Ventriculoperitoneal shunt is one of the common procedures used in infants and children, however, it is used in all age groups for hydrocephalous. The shunt is associated with multiple large number of complications like obstruction, infection, migration, and separation from the connected site. Etc. Shunt migration is a less common complication of which cranial migration is still less common.

Conclusion

Optimum creation of the sub-galeal space for the shunt chamber, a smaller burr hole, a smaller dural opening, and proper anchorage of the chamber to the pericranium, are some of the measures that may be useful in obviating this complication.

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Incidence of complete intracranial migration was reported to be 0.1–0.4% of the total shunt-related complications with the earliest report of intracranial migration in 1955.

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Our patient was a unique case of complete intracranial migration of a ventriculoperitoneal shunt into the ventricle after 4 months of surgery for myelomeningocele

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The case was managed by endoscopic removal of the migrated shunt with new shunt placement was done

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Optimum creation of the subgaleal space for the shunt chamber, a smaller burr hole, a smaller dural opening, and proper anchorage of the chamber to the pericranium, are some of the measures taken

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Hence, for any case of prior shunt insertion with hydrocephalus in infants, the rare possibility of intracranial shunt migration should be considered a possibility.

Complete intracranial migration of ventriculoperitoneal shunt: a common procedure with a rare complication

Background

Ventriculoperitoneal shunt insertion is widely used in the treatment of different kinds of hydrocephalus. Shunt failure is one of the most common complications; however complete intracranial shunt migration is rarely reported.

Case presentation

We report a case of an eleven-month-old girl with complete intracranial migration of Ventriculoperitoneal Shunt (Chhabra Shunt). We removed this intracranially migrated shunt with the help of an endoscope (GAAB) and inserted a new Ventriculoperitoneal Shunt (Medtronic Shunt) on the opposite side. She had a good clinical outcome.

Conclusion

Complete intracranial shunt migration is an extremely rare complication. It is likely due to raised intra-peritoneal pressure, strong head movements, and inadequate shunt fixation. The best possible approach to prevent shunt migration would be better patient handling along with appropriate operative techniques.

Extrusion of Anterior Abdominal Wall by a Ventriculoperitoneal Shunt - An Uncommon Complication: Case Report and Literature Review

Ventriculoperitoneal shunt (VP-shunt) is a commonly performed procedure for the management of hydrocephalus. Migration of the distal end of VP-shunt is one of the rarest complications. The authors report a case of an 11-year-old boy who presented with a spontaneous extrusion of the distal end of the VP-shunt through an intact abdominal wall. Literature was reviewed regarding the possible causes of such complication and the management approach in similar cases. The suggested phenomenon for this case could be attributed to the continuous hammer effect of the cerebrospinal fluid (CSF) pulsations on the abdominal wall. It is important to assess the future need for long-term CSF diversion, as in this case, the patient did not require reinsertion of a new shunt system because he was shunt independent.

Ventricular peritoneal shunt malfunction after operative correction of scoliosis: report of three cases

BACKGROUND CONTEXT

Two of the most common disease processes associated with hydrocephalus in children are spina bifida and intraventricular hemorrhage of prematurity, both of which are known to be also associated with spinal deformity in later childhood. The occurrence of shunt malfunction after mechanical injury or stress to the hardware has been well documented. Newer techniques in the treatment of neuromuscular scoliosis, including anterior release with segmental fixation, have resulted in more powerful corrections of these large spinal deformities. A new potential cause of shunt malfunction is the aggressive correction of scoliosis.

PURPOSE

To report patients with neuromuscular curves averaging 100° who were subsequently recognized to have perioperative shunt malfunction.

STUDY DESIGN

Three case studies from a university hospital setting were included.

PATIENT SAMPLE

All three children were young adolescents and had-long term shunts. Two of the children had spina bifida and a third had cerebral palsy. All children underwent anterior release of their scoliosis with posterior segmental instrumentation, with unit rods and sublaminar wires. All had significant correction of their scoliosis.

OUTCOME MEASURES

Malfunctioning of the ventriculoperitoneal shunts were recorded.

METHODS

Chart reviews of three cases were analyzed.

RESULTS

Two children had shunt malfunctions within a month of their surgery, and one child had intraoperative recognition and externalization of the shunt.

CONCLUSIONS

Older children undergoing repair of neuromuscular scoliosis are often preadolescents or adolescents who have the same indwelling shunt systems originally implanted in early infancy. The shunt may be brittle and calcified, and the peritoneal catheter may be short. The correction of scoliosis often results in an almost instantaneous growth of a few inches. Because of the potential difficulty in recognizing shunt malfunction in the perioperative period, consideration should be given for elective revision of the peritoneal catheter in children at risk.

Intracardiac migration of a distal shunt catheter: an unusual complication of ventricular shunts. Report of 2 cases

Unusual complications of peritoneal shunts are a well-known occurrence. The authors present 2 cases of intracardiac migration of a distal shunt catheter, summarizing the diagnosis and management of each case. This complication seems to be a rare occurrence; the transgression of the jugular vein leading to intracardiac migration of a shunt catheter has been reported only 6 times previously. The authors highlight the importance of careful and proper placement of the distal peritoneal catheter during the tunneling process, in particular avoiding too deep a penetration of the shunt passer into the neck tissues and too medial a shunt passage near the sternal notch to avoid vascular structures.

Cranial migration of complete ventriculo-peritoneal shunt assembly

A 10-month-old male child with severe congenital hydrocephalus due to aqueduct stenosis presented with cranial migration of the entire ventriculo-peritoneal (VP) shunt. The complete shunt assembly, including the shunt chamber, was noted in the dilated ventricles. The migrated shunt was left in situ. A VP shunt was performed on the opposite side. The complete intraventricular migration of a VP shunt is a rare complication. This complication may be avoided by firm anchoring of the connector sites to the periosteum, and avoidance of large burr holes and dural openings. The possible mechanisms of such an event and the relevant literature are discussed.

Shoulder tip pain: an under-reported complication of ventriculoperitoneal shunt

Ventriculoperitoneal (VP) shunt insertion is the commonest form of treatment for hydrocephalus. Shoulder tip pain after VP shunt insertion is unusual and has only recently been reported. We present a case of excruciating shoulder tip pain due to diaphragmatic irritation after VP shunt insertion.

Traumatic cerebral aneurysm formation following ventriculoperitoneal shunt insertion

INTRODUCTION

Iatrogenic intracranial aneurysms are rare in children.

CASE REPORT

A 15-year-old girl presented in coma with a fixed dilated left pupil six weeks following removal of a long-standing left-sided ventriculoperitoneal shunt. Computed tomography (CT) and cerebral angiography revealed a left temporoparietal intracerebral haemorrhage with a fusiform distal middle cerebral artery aneurysm. The patient underwent image-guided localisation of the aneurysm to enable evacuation of the haemorrhage and resection of the fusiform aneurysm.

CONCLUSION

A high index of suspicion is required for diagnosis and early treatment to prevent unnecessary morbidity and mortality.

Intractable seizures associated with proximal migration of a ventriculoperitoneal shunt. Case report

A 6-year-old girl, who had received a ventriculoperitoneal (VP) shunt using the Codman-Hakim programmable valve system at age 3 months, presented with intractable seizures. Neuroimaging studies showed migration of the proximal part of the system, including the prechamber, into the cranium through the right frontal burr hole. Electroencephalography showed spike-and-wave complexes in the right hemisphere including the site of the migration. The ictus was resolved following revision surgery. The clinical findings suggested the seizures were due to irritation of the brain parenchyma by the migrated system. Proximal migration of a VP shunt may cause both shunt failure and additional focal symptoms.

Shunt migration into the sphenoid sinus: case report

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.