Sub-galeal coiling of the proximal and distal components of a ventriculo-peritoneal shunt. An unusual complication and proposed mechanism

A pediatric case of upward migration of distal shunt catheter followed by outward migration of ventricular catheter

INTRODUCTION

Catheter migration and coiling are rare complications of ventriculoperitoneal shunt (VPS).

CASE REPORT

A 4-month-old girl presented with poor feeding and vomiting. At presentation, the patient showed sunset phenomenon and tense fontanelles. Magnetic resonance imaging revealed tetraventricular dilation.

RESULTS

The patient underwent right VPS and was discharged on postoperative day (POD) 8. She visited hospital 33 days later, with considerable swelling in the right frontoparietal region. Radiography revealed upward VPS catheter migration and coiling. The patient underwent shunt revision and was discharged on POD 8. However, 12 days later, she returned to hospital with frequent vomiting. Neuroimaging revealed an outward migration of the ventricular catheter. The patient underwent shunt revision again, which was complicated by meningitis. After resolution of it, a left VPS was installed.

CONCLUSIONS

VPS catheters installed in loose pediatric connective tissues are influenced by many factors that may cause an unexpected catheter migration.

Traumatic Migration of a Shunt Valve Into the Cyst

Hardware migration is an unavoidable complication of intracranial shunt surgeries. Traumatic dislodgement of a valve into the skull occurred in a young boy with a cystoperitoneal shunt following a head injury. Shortly before admission, he fell off his wheelchair and hit his head on the floor. Medical treatment was initiated to manage the patient for traumatic intracranial hemorrhage, and he was subsequently discharged home. However, 2 weeks after discharge, computed tomography (CT) showed a migrating valve and associated meningitis. The CT scan showed that the shunt valve was deep in the temporal cyst. The dislodged shunt valve was left in situ because the parents did not want surgical intervention. The author demonstrates how this complication develops and suggests preventive measures through reviews on the migration of the shunt into the cranium.

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.

The Shunt Slippage: A Complication of Pumping Test

Surgery for the placement of a ventriculoperitoneal shunt incurs numerous procedure-related complications. Distal dislodgment of the device from the cranial insertion site after pumping of the shunt chamber has rarely occurred and it has not been evaluated to date. Herein, we report an interesting case of a 20-year-old man who underwent shunt revision for ventricular catheter migration after a manual pumping test. We reviewed previously reported cases related to such rare conditions and described a simple method of valve fixation for preventing disconnection and migration of the proximal shunt system.

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.

Upward Migration and Coiling of the Distal Catheter Toward the Valve Site

Hydrocephalus, which is caused by the accumulation of cerebrospinal fluid (CSF), is a common condition in children. It is known to be most likely treated by the insertion of a ventriculoperitoneal (VP) shunt. However, a VP shunt can lead to multiple complications. The upward migration of a VP shunt is considered rare.

A newborn male baby with a known case of Chiari malformation type 2 associated with myelomeningocele (MMC) and hydrocephalus had a VP shunt inserted for control of the hydrocephalus. He presented two months after the surgery with occipital swelling at the surgical site. Shunt series followed by Computerized tomography (CT) scan showed that the distal end of the catheter had migrated upward and coiled around the valve. Urgent revision of the VP shunt was performed.

Reabsorption of subgaleal fluid, increased abdominal pressure, repeated abdominal wall contraction, and repeated head motion of the child are the previously suggested theories of upward migration of distal catheter to the site of the valve. However, the combination of multiple theories can be the logical explanation, as they do not oppose each other.

Distal ventriculoperitoneal shunt catheter tightly coiled around the valve in the absence of a subgaleal cerebrospinal fluid collection: illustrative case

BACKGROUND

Among the known complications of ventriculoperitoneal (VP) shunts, subcutaneous or subgaleal migration of distal catheters is rare. Prior case reports have proposed several risk factors, including inadequate fixation of the shunt device, presence of a large subgaleal space filled with cerebrospinal fluid (CSF), and repetitive flexion/extension movement of the head producing a "windlass effect." Tight coiling of a distal catheter around the valve without a large subgaleal space has not been reported.

OBSERVATIONS

The patient was born prematurely and underwent VP shunt placement for posthemorrhagic ventricular dilatation at 3 months of age with reassuring postoperative imaging. At approximately 3 years of age, shunt radiography and head computed tomography unexpectedly showed excess tubing coiled extracranially around the shunt valve. The patient did not exhibit any clinical symptoms of shunt malfunction and underwent an uneventful revision of the VP shunt system. No CSF-filled subgaleal space was observed intraoperatively.

LESSONS

Distal catheter migration can occur without the clear presence of a subgaleal CSF collection and symptoms of acute hydrocephalus. Appropriate fixation of the shunt system using nonabsorbable stitches is recommended to prevent catheter migration caused by the windlass effect.

A shunt lost in the mists of time

Ventriculo peritoneal shunts offer promising results in the management of hydrocephalus. However, they are not without complications. Shunt migrations and extrusions have been reported plenty of times in the literature. Migration of both the proximal and distal catheter has been reported. However; entire shunt migrations are rare and can result in worsening of the clinical condition of the patient. We report a case of entire shunt migration in to the abdominal cavity which was diagnosed during her childhood 8 years after shunt surgery. The parents of the child were advised shunt removal and new shunt insertion but they did not agree to it and they lost follow-up. The patient attended neurosurgery outpatient clinic 24 years later for evaluation of traumatic brain injury, when this finding was incidentally detected. She remained asymptomatic for this condition during all these years. To our knowledge, such incidence of entire shunt migration being remaining asymptomatic for such a long duration has never been reported in the literature.

Spontaneous Coiling of Peritoneal Catheter-Uncommon Complication of Ventriculoperitoneal Shunt: Recognition and Management

Background

Coiling of peritoneal catheter is a rare complication associated with ventriculoperitoneal shunt procedures performed for the treatment of hydrocephalus. In most of the reported cases, coiling is associated with shunt migration resulting in shunt malfunction.

Case Description

Here, we report two cases where spontaneous coiling of peritoneal end was observed following insertion of shunt, one of which was also associated with pseudocyst formation, which was clinically silent. Interestingly, in both the patients, shunt system was intact. We describe the clinical features, management, and possible mechanism of this feature.

Conclusion

In asymptomatic coiling of the peritoneal catheter, the patient should be kept in close observation as these groups of patients may be vulnerable to malfunction, and timely intervention may save the patient from further abdominal and cranial complications. Patients presenting with shunt malfunction should get abdominal evaluation performed to look for silent pseudocyst formation over and above a cranial computed tomography and shunt series.

Retrograde migration and subcutaneous coiling of the peritoneal catheter of a ventriculoperitoneal shunt in a cat

Case summary Ventriculoperitoneal shunt placement is the most commonly utilised surgical treatment for hydrocephalus in human and veterinary patients. Migration of the peritoneal catheter is an uncommon but well-documented complication in people, usually occurring within the first 3 months postoperatively, although only a single feline case report exists. A ventriculoperitoneal shunt was placed in a domestic shorthair cat, aged 4 years and 10 months, following a diagnosis, with MRI, of unilateral, non-communicating hydrocephalus. Diarrhoea, increased vocalisation and pruritus were reported within the first 3 months postoperatively. A shunt-associated seroma developed, which was aspirated under ultrasound guidance. Within 3 days, the entire peritoneal catheter was subcutaneously coiled at the level of the seroma. The peritoneal catheter was replaced within the abdomen via a new subcutaneous tunnel. No further complications had occurred 24 months following revision surgery.

Relevance and novel information This is the second report describing peritoneal catheter migration in a cat. Repetitive head and neck movements during self-grooming, raised intra-abdominal pressure secondary to vocalisation and tenesmus, and negative pressure exerted during seroma aspiration may have contributed to ventriculoperitoneal shunt migration. Excessive loose skin and increased activity may further increase the risk of migration in cats. Diagnostic imaging should be offered prior to and following aspiration of shunt-associated swellings, and minimal negative pressure should be exerted. Attempts to reduce the frequency of postoperative self-grooming, prevention and prompt treatment of conditions predisposing to raised intra-abdominal pressure and moderate exercise restriction, particularly within the first 3 months, may help reduce the risk of peritoneal catheter migration.

Rare complication of ventriculoperitoneal shunt: Catheter protrusion to subcutaneous tissue - Case report

Background:

Ventriculoperitoneal (VP) shunt is a day-to-day procedure performed by a neurosurgeon. The most frequent associated complications are obstructive and infectious. Although rare, there are well-reported complications related to the poor positioning of the distal catheter, with perforation of organs and tissues. Still rarer are the complications related to the migration of this catheter.

Case Description:

We describe an atypical case of VP shunt postoperative by normal pressure hydrocephalus. After well-documented proper positioning of the distal catheter into the intraperitoneal cavity, it protruded into the subcutaneous space. Even on a new documented satisfactory abdominal tomography, this catheter migrated back again to the subcutaneous tissue.

Conclusion:

We did not find plausible explanation for this rare event.

A Subglandular Breast Cerebrospinal Fluid Pseudocyst Following Postsurgical Shunt Migration

Cerebrospinal fluid (CSF) drainage catheters have been associated with numerous complications in various anatomic locations, because of migration, infection, and obstruction. However, breast-related CSF shunt complications tend to occur infrequently or have seldom been reported in the empirical literature. Therefore, a case is presented detailing a breast pseudocyst caused by migration and subsequent coiling of a ventriculoperitoneal shunt in the right breast pocket. To the best of the authors’ knowledge, this is the first case that has been reported in the peer-reviewed literature of a pseudocyst resulting from a CSF drainage catheter coiling around the breast implant post pancreaticoduodenectomy. Moreover, this case highlights the importance of cross-disciplinary procedural awareness, particularly in regards to breast, ventriculoperitoneal shunt, and pancreatic procedures.

Ventriculo-peritoneal shunt malfunction due to complete migration and subgaleal coiling of the proximal and distal catheters

Ventriculo-peritoneal (VP) shunt malfunction due to proximal and distal catheter migration has been rarely reported in the literature. Shunt migration has been proposed to occur as a result of a combination of various mechanisms, including the windlass effect, retained memory of the shunt tubing, inadequate shunt fixation, and increased intra-abdominal pressures. We describe a rare case of a 6-week-old child who presented in our department with VP shunt malfunction due to complete proximal migration and coiling of the peritoneal and ventricular VP shunt catheters within a subgaleal pocket at the left occipital area.

Upward migration of a peritoneal catheter following ventriculoperitoneal shunt

We present an unusual case of peritoneal catheter migration following a ventriculoperitoneal shunt operation. A 7-month-old infant, who had suffered from intraventricular hemorrhage at birth, was shunted for progressive hydrocephalus. The peritoneal catheter, connected to an 'ultra small, low pressure valve system' (Strata®; PS Medical,Gola, CA, USA) at the subgaleal space, was placed into the peritoneal cavity about 30 cm in length. The patient returned to our hospital due to scalp swelling 21 days after the surgery. Simple X-ray images revealed total upward migration and coiling of the peritoneal catheter around the valve. Possible mechanisms leading to proximal upward migration of a peritoneal catheter are discussed.

Urinary bladder perforation, intra-corporeal knotting, and per-urethral extrusion of ventriculoperitoneal shunt in a single patient: case report and review of literature

BACKGROUND

Ventriculoperitoneal shunt (VPS) surgery is the most common procedure performed for the treatment of hydrocephalus. Erosive bladder perforation by a peritoneal catheter is an extremely rare complication of VPS. Only ten cases involving the normal (non-augmented) urinary bladder have been reported so far.

CASE

We report a case of erosive bladder perforation, intra-corporeal knot formation, and perurethral extrusion of the distal end of VPS. This is the second only case report so far in the world literature showing triad of uncommon VPS complications in a single patient.

CONCLUSION

Prompt management could avoid further complications. Patient's parents should be aware about this rare complication, so that they can seek timely medical help.

Ventriculoperitoneal shunt migration and coiling: A report of two cases

Migration of the proximal and distal catheters of the ventriculoperitoneal shunt is a very rare event. Here, we report two infants with hydrocephalus and ventriculoperitoneal shunt who presented later with shunt coiling and migration. The first infant was admitted with scalp swelling around proximal incision 3 months after shunt insertion and migration and coiling of both ventricular and peritoneal catheters occurred under the scalp at that point. The second patient was referred 1 month after shunting with tense fontanel and vomiting. New brain imaging confirmed the whole shunt inside both lateral ventricles. The possible mechanisms causing this very uncommon complication and the management are explained.

Subgaleal coiling of the proximal and distal components of a ventriculoperitoneal shunt

Migration is a rare complication of venticuloperitoneal shunts and is thought to be associated with the "memory" of the plastic tubing and the windlass effect of neck flexion and extension. The purpose of this case report is to detail a very rare case of complete distal to proximal shunt migration.

Spontaneous knot formation in the peritoneal catheter: a rare cause of ventriculoperitoneal shunt malfunction

Ventriculoperitoneal shunt malfunction is a relatively common problem encountered in shunted hydrocephalic patients and is attributed most frequently to mechanical obstruction of the ventricular catheter. We present the case of a rare cause of mechanical obstruction of the peritoneal catheter due to the spontaneous formation of a knot just underneath the abdominal wound. This occurred 1 year after shunt implantation and is thought to have been caused by a combination of plastic material memory and bowel peristaltic movements. This case brings for discussion the role of radiographic investigation of the shunt system in children who present with suspected shunt obstruction. Radiographic investigation is warranted in children who have unusual shunt arrangements (e.g., Y-connectors and multiple catheters) in order to exclude disconnections or those who develop shunt problems years after implantation, to exclude material fracture in the neck or migration of any kind. In shunt systems which have been implanted for shorter time periods, the need for radiographs is less apparent. Some surgeons proclaim that when clinical circumstances fall outside the realms of obvious possible proximal obstruction, radiographic evaluation of the shunt system should be considered.

Coiling and migration of peritoneal catheter into the breast: a very rare complication of ventriculoperitoneal shunt

Upward migration of distal catheter of a ventriculoperitoneal shunt with coiling is very rare. Pseudocyst and galactorrhea are known breast-related complications. Here, we report a 13-year-old girl, known case of myelomeningocele and shunted hydrocephalus, who presented with right breast pseudocyst due to distal tube migration and coiling of the catheter. Plain radiography was not diagnostic because of severe levoscoliosis, but chest computed tomography scan was confirmatory of shunt coiling lateral to the breast. The possible mechanisms causing this uncommon complication are described.

Subgaleal migration of the distal catheter of a ventriculoperitoneal shunt

Proximal migration of the distal end of a ventriculoperitoneal shunt has been observed much more rarely than other numerous shunt-related complications. Subgaleal migration of the peritoneal end is one of the samples. In the preset report we have discussed a case of subgaleal migration of the peritoneal end detected as a result of the examinations performed for shunt dysfunction. There was ventricular dilatation on CT scan of the brain. X-ray examinations confirmed proper ventricular catheter and shunt valve placement but a complete migration of distal (peritoneal) catheter into the subgaleal space. Then the patient's shunt was revised. When our case and the literature were examined, we observed that this complication was frequently encountered during the first postoperative months, in the pediatric ages and in patients with advanced hydrocephalus. Besides, we have detected that the peritoneal catheters had tendency to migration into the subgaleal tissues similar to pre-insertion forms of the preoperatively original packages.

The utility of the plain radiograph "shunt series" in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients

BACKGROUND

To our knowledge, the sensitivity of plain radiography, known as the shunt series, in diagnosing an etiology of ventriculoperitoneal (VP) shunt malfunction in children has not been previously investigated.

OBJECTIVE

To determine the accuracy of plain radiography in diagnosing VP shunt failure in children in whom shunt malfunction is clinically suspected.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 238 children who had undergone plain radiographic examination for evaluation of clinically suspected VP shunt failure over a 5-year period. The results were compared with those of CT, MRI, and nuclear cisternography.

RESULTS

Just 6.72% of patients demonstrated plain radiographic signs of shunt failure. Of patients with normal plain radiographs, 43% demonstrated shunt abnormalities on CT, MRI or cisternography. Statistical analysis indicated that no more than 10.46% (P < 0.05) of plain radiographs showed signs of failure and that the sensitivity of plain radiography for the detection of VP shunt failure is no higher than 31%. Furthermore, there was poor agreement between the results of plain radiography and those of CT, MRI and cisternography.

CONCLUSION

Children with clinically suspected VP shunt failure should proceed directly to cross-sectional or nuclear imaging, as plain radiographic examinations have low sensitivity and significant false-negative rates for detecting shunt abnormalities in all-comers. Use of the shunt series should be limited to patients who specifically have suspected mechanical causes of shunt failure.

Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review

INTRODUCTION

The decision-making process when we compare endoscopic third ventriculostomy (ETV) with shunts as surgical options for the treatment of hydrocephalus in infants is conditioned by the incidence of specific and shared complications of the two surgical procedures.

REVIEW

Our literature review shows that the advantages of ETV in terms of complications are almost all related to two factors: (a) the avoidance of a foreign body implantation and (b) the establishment of a 'physiological' cerebrospinal fluid (CSF) circulation. Both these kinds of achievements are particularly important in infants because of the relative high rate of some intraoperative (i.e. abdominal) and late (secondary craniosynostosis, slit-ventricle syndrome) shunt complications in this specific subset of patients. On the other side, the main factor which is claimed against ETV is the relatively high risk of immediate mortality and neurological complications. Clinical manifestations of neurological structure damage seem to be more frequent in infants, probably due to the more relevant effect of parenchymal and vascular damage in this age group; however, both the immediate mortality and neurological damage risk of ETV procedures should be weighted against the long-term mortality and the late neurological damage which is not infrequently described as a consequence of shunt malfunction and proximal shunt revision procedures. Infections are possible in both ETV and extrathecal CSF procedures, especially in infants. However, the incidence of infective complications is significantly lower in case of ETV (1-5% vs 1-20%). Moreover, different from shunting procedures, infections in children with third ventriculostomy have a more benign course, being generally controlled by antibiotic treatment alone.

Subgaleal migration of a ventriculoperitoneal shunt

Blockage of a ventriculoperitoneal (VP) shunt is very common. Here, we describe an unusual case of shunt blockage in an infant. He was shunted for hydrocephalus associated with a Dandy-Walker malformation diagnosed at birth. At surgery, the entire VP shunt was found to have migrated into the subgaleal space, which clinically presented as shunt obstruction. We suggest techniques to avoid this rare, but preventable, complication of shunt surgery.

Retrograde migration of ventriculoperitoneal shunt to the neck. Case report

We report a patient, given a ventriculoperitoneal shunt at the neonatal period, who presented with a painless subcutaneous mass on his neck. Plain radiographs of the cervical region showed that the swelling was made up by a migrated and coiled peritoneal catheter. We briefly discuss the proposed mechanism for this complication and suggest that this occurrence must be taken into account at the time of evaluating a patient with shunt malfunction.

Proximal migration of a lumboperitoneal unishunt system

Proximal migration of a lumboperitoneal (LP) shunt is a rare complication associated with unishunt systems. We report three cases with a hypothesis that raised intra-abdominal pressure may be a factor responsible for the proximal migration of a LP unishunt. A rare case of proximal migration of LP shunt into the quadrigeminal cistern is also reported.

Radionuclide shuntogram demonstrating migration of distal ventriculoperitoneal shunt tubing out of the peritoneal cavity

An 81-year-old man with a history of ventriculoperitoneal (V-P) shunt placement for symptomatic normal pressure hydrocephalus presented with recurrence of confusion and gait disturbance. Radionuclide cisternography demonstrated loculation of In-111 DTPA in the abdominal wall. A soft tissue mass palpated at the location of tracer accumulation was confirmed to be extraperitoneal pooling of fluid at the site of coiling of the distal shunt tip. After surgical revision, with repositioning of the distal tube in the peritoneal cavity, the patient's symptoms promptly improved. When symptoms of hydrocephalus recur after successful V-P shunt placement, shunt malfunction should be suspected and evaluation for mechanical failure pursued. Catheter migration should be recognized as a correctable cause of shunt malfunction.