Abdominal cerebrospinal fluid (CSF) pseudocyst presented with inferior vena caval obstruction and hydronephrosis

A rare case of inferior vena cava occlusion secondary to abdominal pseudocyst associated with ventriculoperitoneal shunt-case report and review of literature

BACKGROUND AND IMPORTANCE

Abdominal pseudocyst (APC) is an uncommon but well-recognised complication of ventriculo-peritoneal (VP) shunt. Diagnosis is based on clinical features of shunt malfunction, including headaches, vomiting and drowsiness, and abdominal swelling. APCs can grow to large sizes resulting in compression of abdominal viscera; however, inferior vena cava (IVC) compression is extremely rare, and only one other case associated with VP shunt had been reported.

CLINICAL PRESENTATION

We report a case of a 12-year-old girl with a background of open myelomeningocoele repair, kyphoscoliosis and right-sided VP shunt in situ who presented with bilateral lower limb swelling and abdominal distension. She exhibited no features of raised intracranial pressure but had bilateral pitting oedema up to the groin. Abdominal ultrasound and CT scan showed a massive septated pseudocyst (20 × 18 × 8 cm) compressing the IVC. The APC was drained, and the shunt was externalised, with conversion to a ventriculo-atrial (VA) shunt 1 week later after cultures of the cystic fluid, cerebrospinal fluid and shunt tube came back sterile. The patient remained well with no recurrence of the abdominal fluid and no VA shunt complication at 36-month follow-up.

CONCLUSION

This patient had specific risk factors for development of a massive APC and the subsequent IVC compression, including prior surgeries, spinal deformity, abnormal abdominal anatomy and poor abdominal muscle tone and sensation. Early recognition of this complication and prompt alleviation of the mass effect of IVC compression can prevent long-term neurological and vascular sequalae.

Abdominal pseudocysts, an unusual complication of ventriculoperitoneal shunt systems: Literature systematic review

Since the first report in 1954, abdominal pseudocysts have been recognized as a particularly uncommon complication of ventriculoperitoneal shunts of CSF, so their etiology, diagnosis, and therapeutic management remain very controversial. Our objective is to offer a critical and updated systematic review of those controversial points, using a thorough search and review of the most relevant literature available. The clinical presentation of pseudocysts is normally through non-specific abdominal symptoms. The most validated etiology consists on the existence of a concomitant infection of the CSF shunt system, and so, treatment needs of antibiotherapy and total or partial substitution of the system. However, the pseudocyst itself doesn't need an active treatment, except for some specific cases. This management, algorithmically presented in the present work, achieves a lower recurrence rate than other options, but this one is still important, and is also associated with other complications of those shunts related with several other factors which need to be taken in account.

Abdominal Cerebrospinal Fluid Pseudocyst Diagnosed with Point-of-care Ultrasound

Abdominal pseudocysts are rare complications of ventriculoperitoneal (VP) shunts characterized by accumulations of cerebrospinal fluid surrounded by fibrous layers in the intra-abdominal cavity or abdominal wall. We present a woman with bilateral VP shunts who presented with right-sided abdominal distension, pain, and tenderness and who was found to have an abdominal pseudocyst on point-of-care ultrasound and computed tomography. Given the potential to develop a secondary infection or VP shunt malfunction, it is important for emergency providers to consider intra-abdominal complications of VP shunts, including rare ones such as abdominal pseudocysts, in these patients who present with vague abdominal complaints.

Intraperitoneal cerebrospinal fluid pseudocyst with ventriculoperitoneal shunt

Ventriculoperitoneal (VP) shunting is mostly used in the treatment of hydrocephalus and many complications have been reported with this method. Abdominal Pseudocyst (APC) are relatively uncommon but important complications in patients with VP shunts. We herein report the case of a 9-year-old boy with VP shunt who presented with abdominal distension, abdominal pain, malaise, and decrease of appetite. Abdominal pelvic computed tomography confirmed a diagnosis of APC. Laparotomy was done and VP shunt was placed into the other side of peritoneal cavity again. Also here, etiology, presentation, diagnosis, and treatment of APC were reviewed.

Severe hydronephrosis caused by an infected intra-abdominal fluid collection in a patient with a ventriculoperitoneal shunt

CASE

The authors report a case of a 10-year-old boy with myelodysplasia and shunted hydrocephalus who developed acute severe hydronephrosis presumed secondary to a large abdominal cerebrospinal fluid (CSF) collection.

METHOD

The patient had recently begun having trouble catheterizing his Monti channel, and had been diagnosed and treated for an Escherichia Coli urinary tract infection. He presented with abdominal pain, and an abdominal CT demonstrated severe hydronephrosis and a large abdominal fluid collection presumed to be a CSFoma. The shunt was externalized, and fluid consistent with CSF was removed by aspiration of the shunt catheter at the time of surgery and by interventional radiology placement of a pigtail drain into the remaining fluid collection. Endoscopic evaluation of the Monti channel revealed evidence of healed perforation. A suprapubic catheter was placed and the Monti channel remained catheterized. The shunt was eventually converted to a ventriculoatrial shunt. A postoperative renal ultrasound later demonstrated marked improvement in the hydronephrosis and mild caliectasis. The suprapubic catheter and the indwelling Monti catheter were removed. The patient resumed catheterization of the Monti channel.

RESULT

Follow-up ultrasounds have shown stable, mild hydronephrosis, consistent with the patient's baseline.

CONCLUSIONS

Practitioners should have a high index of suspicion for potential shunt contamination and CSFoma development in patients with Monti channels and a history of difficult catheterization.

Abdominal cerebrospinal fluid pseudocyst: a comparative analysis between children and adults

PURPOSE

Abdominal cerebrospinal fluid (CSF) pseudocyst is a rare but important complication in patients with ventriculoperitoneal shunt (VPS). In addition to presenting our experience, we performed a comparative analysis between children and adults with this entity. To the author's knowledge, there are no studies in which this condition has been compared.

METHODS

The PubMed database was searched for all relevant reports published from 1954 to 2012. The differences were statistically compared, especially regarding clinical investigations, etiology of the hydrocephalus, shunt revision, CSF infection, treatment, and recurrence. Chi-square test or Fisher's exact test was used to find associations among the variables.

RESULTS

Compiled from literature, we found 393 cases of abdominal pseudocyst: 295 children, including our cases, and 55 adults, with age not informed in 43 cases. In children, 33 % of the patients have a positive culture on presentation, with higher incidence in children younger than 10 years. In contrast, only 15 % among adults were positive CSF culture. In total, 287 abdominal pseudocyst cases who underwent shunt revision have been reported; 78.4 % of children and 62.2 % of adults. The main occurrence of this complication according to the etiology of hydrocephalus in children was different from adults. The recurrence of pseudocyst occurred in 19.8 and 24.2 % of children and adults, respectively.

CONCLUSIONS

The differences between children and adults might represent distinct trends on the etiology and treatment of this entity. Hence, additional well-designed cohort studies will be necessary to strengthen our findings.

Abdominal cerebrospinal fluid pseudocyst occurring 21 years after ventriculoperitoneal shunt placement: a case report

Background

Ventriculoperitoneal shunt (VPS) placement is an established procedure for the treatment of hydrocephalus of diverse etiologies in children and adults. Abdominal cerebrospinal fluid pseudocyst, which is potentially life threatening, is a rare complication and usually occurs during childhood. However, with increasing longevity following successful treatment, it can also occur in adults.

Case presentation

Here we describe a 22-year-old man who was admitted to our hospital because of diffuse abdominal distention. A VPS was placed 21 years earlier to treat hydrocephalus secondary to spina bifida. Abdominal computed tomography (CT) revealed a homogeneous low-density fluid collection adjacent to the VPS catheter tip, causing stomach obstruction. Thus a peritoneal pseudocyst around VPS was suspected and emergency laparotomy was performed. The large mass was localized in the left upper abdomen between the stomach and mesentery of the transverse colon, exactly at the omental bursa. The cystic mass was opened and 1500 ml of clear fluid was drained; the distal end of the VPS was repositioned outside the mass. Thus, an abdominal cerebrospinal fluid pseudocyst as a complication of VPS was diagnosed.

Conclusion

Gastroenterological surgeons should be aware of this possible complication, and this complication should be considered during differential diagnosis of an acute abdomen complaint.