A long-term complication of burying a shunt valve in the skull

Surgical drain induced subgaleal hematomas and skin necrosis in pediatrics: a case report

INTRODUCTION

Subgaleal drainage is often being used in craniotomy procedures. It's not only offers advantages but also carries a risk of life-threatening complications. Here, we present a rare case of subgaleal hematoma and skin necrosis caused by placement of subgaleal drainage in a pediatric patient after a craniotomy procedure.

CASE REPORT

We reported a 6-months-old child who came to our institution complaining of uncontrolled eye movements which occurred 4 months earlier. From the CT scan and MRI, it was found that the patient had a mass in his suprasellar region, which suggested a suprasellar tumor. She underwent a mass resection procedure, but unfortunately, 3 days after the surgical procedure, the wound appeared necrotic, with a blackish color around the drain. The necrotic wound was suspected due to vacuum subgaleal drain placement. The wound was cleaned and the suture removed, but the necrotic area was still there. Four days after the surgery, the patient clinical condition got worse. After 17 days of treatment with no significant improvement, unfortunately, the patient died.

DISCUSSION

The mechanism of subgaleal hematoma and skin necrosis induced by the Redon drain possibly related to mechanical compression by the drain, which damage perforating vessels and subsequently disrupt skin vascularization, combined with vascular stasis as given by negative pressure of the drain. This induced skin ischemia lesion which later contributes the necrotic formation.

CONCLUSION

The subgaleal hematoma and skin necrosis as a complication of subgaleal redon drain in pediatric are rare phenomenon and likely under reported. The possible underlying mechanism was that drain's negative pressure disrupt subgaleal tissue and induce necrotic formation. Even the complication is rare compared to older children, yet it has been linked to an increased risk for infection, morbidity, and mortality.

First-in-Human Experience With Integration of a Hydrocephalus Shunt Device Within a Customized Cranial Implant

BACKGROUND

Implantable shunt devices are critical and life saving for hydrocephalus patients. However, these devices are fraught with high complication rates including scalp dehiscence, exposure, and extrusion. In fact, high shunt valve profiles are correlated with increased complications compared to those with lower profiles. As such, we sought a new method for integrating shunt valves for those challenging patients presenting with scalp-related complications.

OBJECTIVE

To safely implant and integrate a hydrocephalus shunt valve device within a customized cranial implant, in an effort to limit its high-profile nature as a main contributor to shunt failure and scalp breakdown, and at the same time, improve patient satisfaction by preventing contour deformity.

METHODS

A 64-yr-old male presented with an extruding hydrocephalus shunt valve and chronic, open scalp wound. The shunt valve was removed and temporary shunt externalization was performed. He received 2 wk of culture-directed antibiotics. Next, a contralateral craniectomy was performed allowing a new shunt valve system to be implanted within a low-profile, customized cranial implant. All efforts were made, at the patient's request, to decrease the high-profile nature of the shunt valve contributing to his most recent complication.

RESULTS

First-in-human implantation was performed without complication. Postoperative shunt identification and programming was uncomplicated. The high-profile nature of the shunt valve was decreased by 87%. At 10 mo, the patient has experienced no complications and is extremely satisfied with his appearance.

CONCLUSION

This first-in-human experience suggests that a high-profile hydrocephalus shunt device may be safely integrated within a customized cranial implant.

A Retrospective Study on Ventriculoperitoneal Shunt Complications in a Tertiary Care Centre

Background Ventriculoperitoneal shunt (VPS) is a common technique employed to treat the second most common congenital brain malformation, “hydrocephalus.” Postshunt insertion, the consequent complications and factors contributing to shunt malfunction are much fought occurrences. The current study was planned to assess the effectiveness of the procedure, analyze the complications of VP shunt, and recognize the factors influencing shunt malfunction.

Materials and Methods The present study was a retrospective observational study, which was conducted at the Department of Neurosurgery, PGIMER RML Hospital, New Delhi, from August 2016 to July 2018. Patients with hydrocephalus requiring shunt intervention were included in the study. A Chhabra “slit n spring” hydrocephalus shunt system was inserted in all patients. All patients with VP shunts were followed to assess for any postshunt complications.

Results Out of 541 patients for whom VP shunt was inserted over a period of 2 years, 126 (23.3%) patients developed complications. The most common cause of hydrocephalus for which VP shunt was done was tubercular meningitis (39.3%, n = 63), followed by ventriculitis (12.38%, n = 20), congenital hydrocephalus (8.87%, n = 14) and aqueductal stenosis (5.54%, n = 03). The most common complication in our study was obstruction of proximal end of the catheter by debris, which was noted in 50 patients (39.68%). The second most common complication was poor peritoneal absorption or obstruction of lower end (21.43%, n = 27 cases). Abscess along the shunt was seen in 21 patients (16.67%). Complications were mostly documented in cases with hydrocephalus due to tubercular meningitis (TBM) (39.3%, 63 patients) and ventriculitis (12.38%, 20 patients). Other complications were hyperemia with superficial ulceration or complete exposure of skin overlying the tube (11.9%, n = 15), overdrainage of the ventricles leading to chronic subdural hematoma (n = 14, 11.11%), and infection around the distal catheter (4.76%, n = 6).

Conclusion VPS procedure led to a complication in several patients, with the most common being obstruction of proximal catheter and poor peritoneal absorption or obstruction of lower end followed by abscess and infection.

Neonatal Hydrocephalus Treatment with Ultrasmall Valve Implantation

OBJECTIVE

Neonatal hydrocephalus remains a difficult condition to manage, due to high failure rates among all management strategies. Neurosurgeons commonly manage hydrocephalus with ventriculoperitoneal shunt (VPS) implantation, and valves of variable sizes and profiles are available for implantation. This study examines primary ventricular shunt valve implantation complication rates based on valve profiles in pediatric patients with hydrocephalus.

METHODS

This study retrospectively reviews pediatric patients younger than 1 year of age who underwent ventricular shunt placement at a single institution from January 2001 to January 2017. Patients were classified by valve profile and categorized as either ultrasmall valves or regular-sized valves. Time until complication and type of complication were studied.

RESULTS

A total of 156 patients met the inclusion criteria. Forty-eight (31%) patients received an ultrasmall shunt valve, while 108 patients received a regular valve. On average, patients undergoing ultrasmall valve placement were younger (2.1 months) than patients undergoing placement of regular valves (3.1 months) (P = 0.03). The overall complication rate within 2 years of VPS placement was 37.5% in patients with the ultrasmall valve and 41.7% in the regular valve population. There was no difference in 1-year shunt survival rate between the 2 cohorts.

CONCLUSION

Our review did not find a significant difference in complication rates between ultrasmall and regular valves in patients under 1 year of age. However, the etiology of shunt malfunction did differ between the groups. This work further supports evidence suggesting a surgeon's preference for shunt hardware alone does not significantly impact outcome.