Delayed intracerebral hemorrhage after CSF shunt for communicating "normal-pressure" hydrocephalus. Case report

A case of early intraventricular haemorrhage following ventriculoperitoneal shunt: An entity requiring consideration

The ventriculoperitoneal shunt (VP shunt) is one of the most common neurosurgical procedures performed in daily practice. Various complications following a VP shunt are as follows: post-procedure shunt-related infections, shunt block, shunt displacement or exteriorisation and haemorrhage associated with it. Delayed intraventricular haemorrhage is a relatively uncommon complication following the aforementioned procedure. Here we present an atypical case of a 72-year-old male who presented with subarachnoid haemorrhage with hydrocephalus and underwent a VP shunt, following which the patient had early intraventricular haemorrhage (eIVH) with an unfortunate outcome. Here, we propose pathophysiology and risk factors for eIVH.

Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review

Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.

Intraparenchymal hemorrhage after serial ventricular reservoir taps in neonates with hydrocephalus and association with neurodevelopmental outcome at 2 years of age

OBJECTIVE

Decompressing the ventricles with a temporary device is often the initial neurosurgical intervention for preterm infants with hydrocephalus. The authors observed a subgroup of infants who developed intraparenchymal hemorrhage (IPH) after serial ventricular reservoir taps and sought to describe the characteristics of IPH and its association with neurodevelopmental outcome.

METHODS

In this multicenter, case-control study, for each neonate with periventricular and/or subcortical IPH, a gestational age-matched control with reservoir who did not develop IPH was selected. Digital cranial ultrasound (cUS) scans and term-equivalent age (TEA)-MRI (TEA-MRI) studies were assessed. Ventricular measurements were recorded prior to and 3 days and 7 days after reservoir insertion. Changes in ventricular volumes were calculated. Neurodevelopmental outcome was assessed at 2 years corrected age using standardized tests.

RESULTS

Eighteen infants with IPH (mean gestational age 30.0 ± 4.3 weeks) and 18 matched controls were included. Reduction of the ventricular volumes relative to occipitofrontal head circumference after 7 days of reservoir taps was greater in infants with IPH (mean difference -0.19 [95% CI -0.37 to -0.004], p = 0.04). Cognitive and motor Z-scores were similar in infants with and those without IPH (mean difference 0.42 [95% CI -0.17 to 1.01] and 0.58 [95% CI -0.03 to 1.2]; p = 0.2 and 0.06, respectively). Multifocal IPH was negatively associated with cognitive score (coefficient -0.51 [95% CI -0.88 to -0.14], p = 0.009) and ventriculoperitoneal shunt with motor score (coefficient -0.50 [95% CI -1.6 to -0.14], p = 0.02) after adjusting for age at the time of assessment.

CONCLUSIONS

This study reports for the first time that IPH can occur after a rapid reduction of the ventricular volume during the 1st week after the initiation of serial reservoir taps in neonates with hydrocephalus. Further studies on the use of cUS to guide the amount of cerebrospinal fluid removal are warranted.

Delayed Intracerebral Hemorrhage after Placement of a Ventriculoperitoneal Shunt in a Case of Hydrocephalus: A Rare Case Report and Review of Literature

Ventriculoperitoneal (VP) shunt is a frequently performed operation to achieve cerebrospinal fluid (CSF) diversion but is associated with many complications. Postoperative delayed intracerebral hemorrhage is a kind of rare but catastrophic complication of a VP shunt which questions the survival of a seemingly recovered patient. Here, we present one such case where the patient presented to casualty in altered sensorium and with a history of vomiting. On examination, the Glasgow Coma Scale (GCS) score was E2V1M3; pupils were middilated but reactive. Computerized tomography of the brain showed ventriculomegaly and hydrocephalus, and an emergency VP shunt was done. There was an initial phase of good recovery followed by sudden loss consciousness, vomiting, and a fall in the GCS scores on postoperative day 7. Computed tomography showed an intracerebral hematoma along the shunt track and an intraventricular bleed. The presumed cause for this occurrence is a deranged coagulation profile.

Delayed Intraventricular Hemorrhage following a Ventriculoperitoneal Shunt Placement: Exploring the Surgical Anatomy of a Rare Complication

Ventriculoperitoneal shunt (VPS) placement is one of the commoner neurosurgical procedures worldwide. The purpose of this article is to report a case of delayed intraventricular hemorrhage (IVH) following a VPS and to review the literature regarding anatomic factors that could potentially explain this rare complication. A 78-year-old man with normal pressure hydrocephalus, who underwent an uneventful right VPS placement, suffered from a catastrophic isolated IVH five days later. The reported cases of delayed intracerebral hemorrhage (ICH) following VPS are rare and those with IVH are even rarer. Potential factors of surgical anatomy that could cause delayed ICH/IVH following a VPS procedure include erosion of vasculature by catheter cannulation, multiple attempts at perforation, puncture of the choroid plexus, improper placement of the tubing within the brain parenchyma, VPS system revision, venous infarction, vascular malformations, head trauma, and brain tumors. Other causes include generalized convulsion, VPS system malfunction, increased intracranial or blood pressure, sudden intracranial hypotension, and bleeding disorders. According to the current literature, our case is the first reported delayed isolated IVH after a VPS placement so far. Neurosurgeons should be aware of the delayed ICH/IVH as a rare, potentially fatal complication of VPS, as well as of its risk factors.

Delayed Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt: A Retrospective Study

BACKGROUND

Postoperative delayed intracerebral hemorrhage (DICH) secondary to ventriculoperitoneal (VP) shunt is a rare but severe event. The present study aimed to investigate the incidence and risk factors related to DICH after placement of the VP shunt.

METHODS

The clinical data from 532 patients with VP shunt were collected retrospectively. All clinical variables were examined by univariate analysis, and a binary logistic regression analysis was performed to identify the risk factors related to DICH.

RESULTS

DICH occurred in 20 patients, from 3 to 10 days after placement of the VP shunt. Univariate analysis showed significant differences between the patients with DICH and without DICH with respect to age, history of hypertension, history of craniotomy, and features of the first computed tomography (CT) scans after placement of the VP shunt (all P < 0.05). The binary logistic regression analysis showed that age, history of craniotomy, and features of first CT scans after placement of the VP shunt were independent risk factors for DICH (all P < 0.05). The prognosis for patients with DICH was consistent with the hematoma volume and the neurologic status at the time of hospital admission (all P < 0.05).

CONCLUSIONS

DICH is a rare and potentially severe complication secondary to VP shunt, and a repeat of cranial CT scans after placement of the VP shunt is recommended. Advanced age, craniotomy history, and brain edema around the catheter on the first cranial CT scan after placement of the VP shunt served as independent risk factors for DICH. The patients with DICH with poor neurologic status at the time of hospital admission or large hematoma volume were associated with poor outcome.

Symptomatic Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt in Adults without Bleeding Tendency

BACKGROUND

Ventriculoperitoneal shunt (VPS) is a common procedure in daily neurosurgical practice. According to some reports, the rate of intracerebral hemorrhage secondary to VPS in patients with no bleeding tendency can be 43.1%; however, symptomatic intracerebral hemorrhage (SICH) secondary to VPS is rare with only sporadic cases reported in adults. To further elucidate the characteristics, mechanism, management, and prognosis of SICH secondary to VPS, we performed a retrospective study in our institution and a systematic review of the literature.

METHODS

A retrospective review of the medical records of patients admitted for VPS was performed. We also performed a systematic PubMed search of published studies.

RESULTS

Of 5 patients identified at our institution, 3 experienced a favorable recovery. Including our case series, there were 16 (8 female) patients. The time interval from the termination of VPS procedure to SICH was 4 hours to 15 days. All but 1 patient experienced intracerebral hemorrhage adjacent to cannulation. Of 11 patients in whom a Glasgow Outcome Scale score could be obtained, the score was 5 in 4 patients, 4 in 1 patient, 3 in 1 patient, and 1 in 5 patients.

CONCLUSIONS

SICH is a rare complication after VPS in adults without bleeding tendency. The mechanism is obscure, management is challenging, and prognosis is dismal. Future prospective study is anticipated.

Delayed Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt: A Case Report and Literature Review

The ventriculoperitoneal (VP) shunt is a routine procedure for cerebrospinal fluid (CSF) diversion, and is associated with many complications. A delayed hemorrhage after the VP shunt surgery, however, is quite rare. In this study, we report a case involving late-onset hemorrhage. The 67-year-old male patient with a history of head trauma and brain surgery underwent a VP shunt placement for hydrocephalus. The surgery course was uneventful and no bleeding was revealed in the first computed tomographic (CT) scan after the procedure. However, a massive intraparenchymal and intraventricular hemorrhage occurred 8 h following adjustment of the valve system on the 8th day after surgery.Erosion of the vasculature by catheter cannulation and a sudden reduction of CSF pressure after downregulation of the valve could be one of the possible causes of the intracerebral hemorrhage (ICH).

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 intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Case report and literature review

We present another case of delayed intracerebral hemorrhage after a ventriculoperitoneal (VP) shunting procedure. In this case, a right occipital intraparenchymal hematoma and associated intraventricular hemorrhage occurred six days after the operation for hydrocephalus secondary to subarachnoid hemorrhage in a 64 year old woman. It is a rare complication of VP shunting, with few cases reported previously in the literature. The presumed mechanism is the erosion of a cerebral blood vessel secondary to a close contact with the ventricular catheter; bleeding disorder, vascular malformation, head trauma or brain tumor were excluded in this patient.

Low incidence of delayed intracerebral hemorrhage secondary to ventriculoperitoneal shunt insertion

OBJECT

Bleeding into the brain parenchyma or ventricles is an infrequently reported complication in adults who undergo insertion of a ventriculoperitoneal (VP) shunt. The purpose of this study was to establish the incidence of delayed intracerebral hemorrhage secondary to ventricular cannulation during shunting procedures.

METHODS

Over a 24-year period, in a series of 125 adult patients with hydrocephalus, postoperative computerized tomography scans were obtained in every case within 48 hours of shunt surgery performed by the same neurosurgeon. The rate of delayed intracerebral hematoma or intraventricular hemorrhage after VP shunt placement was documented by routine neuroradiological follow up to be 4%.

CONCLUSIONS

In adult patients with no coagulopathy or occult vascular lesions, the rate of bleeding after VP shunt insertion may be low if the procedure is uncomplicated by multiple attempts at perforation, puncture of the choroid plexus, or improper placement of the tubing within the parenchyma of the brain.