Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters

Reducing radiation exposure and costs: CT body scout views with an enhanced protocol versus conventional radiography after shunt surgery

OBJECTIVE

Ventriculoperitoneal shunt implantation has become standard treatment for cerebrospinal fluid diversion, besides endoscopic third ventriculostomy for certain indications. Postoperative X-ray radiography series of skull, chest and abdomen combined with cranial CT are obtained routinely in many institutions to document the shunt position and valve settings in adult patients. Measures to reduce postoperative radiation exposure are needed, however, there is only limited experience with such efforts. Here, we aim to compare routine postoperative cranial CT plus conventional radiography series (retrospective arm) with cranial CT and body scout views only (prospective arm) concerning both diagnostic quality and radiation exposure.

PATIENTS AND METHODS

After introduction of an enhanced CT imaging protocol, routine skull and abdomen radiography was no longer obtained after VP shunt surgery. The image studies of 25 patients with routine postoperative cranial CT and conventional radiography (retrospective arm of study) were then compared to 25 patients with postoperative cranial CT and CT body scout views (prospective arm of study). Patient demographics such as age, sex and primary diagnosis were collected. The image quality of conventional radiographic images and computed tomography scout views images were independently analyzed by one neurosurgeon and one neuroradiologist.

RESULTS

There were no differences in quality assessments according to three different factors determined by two independent investigators for both groups. There was a statistically significant difference, however, between the conventional radiography series group and the CT body scout view imaging group with regard to radiation exposure. The effective dose estimation calculation yielded a difference of 0.05 mSv (two-tailed t-test, p = 0.044) in favor of CT body scout view imaging. Furthermore, the new enhanced protocol resulted in a reduction of cost and the use of human resources.

CONCLUSION

CT body scout view imaging provides sufficient imaging quality to determine shunt positioning and valve settings. With regard to radiation exposure and costs, we suggest that conventional postoperative shunt series may be abandoned.

Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children's Hospital

BACKGROUND

At Red Cross War Memorial Children's Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures.

METHOD

A single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion.

RESULTS

Twenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3-14.9) and 5.3 years (0.5-13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2-28) versus 4.5 (2-17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0-67) and 5 months (0-118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group.

CONCLUSION

Our findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.

Iatrogenic Cerebrospinal Fluid Breast Augmentation: Rare Complication of Ventriculoperitoneal Shunts and Management Strategies

BACKGROUND

Ventriculoperitoneal shunt is one of the most common neurosurgical procedures in the treatment of hydrocephalus. There are reports of migration of the distal catheter to the breast pocket where cerebrospinal fluid then collects and can develop into a pseudocyst. There exist case reports in the literature of patients with prior breast augmentation who present with distal catheter migration from the peritoneal space into the breast tissue. We present a case series of 3 patients with preexisting breast augmentation who returned with unilateral breast enlargement after ventriculoperitoneal shunt. In all 3 patients, the distal catheter migrated out of the peritoneal space and was found to be coiled around the breast prosthesis. Additionally, we offer recommendations for managing these complications and a review of the literature.

METHODS

We performed a systematic review without meta-analysis of studies involving management of shunt migration in the setting of preexisting breast implants. We present a case series of 3 patients whom we treated with breast cerebrospinal pseudocyst after migration of the distal catheter into the breast tissue.

RESULTS

A total of 17 studies, dating from 2002 to 2022, met our inclusion and exclusion criteria and were selected for full review. Catheter migration occurred between 2 weeks and 9 months of initial shunt placement. All patients presented with unilateral breast enlargement and cerebrospinal fluid pseudocyst formation. All patients underwent revision shunt surgery. Surgical treatment strategies used included reimplantation of the distal catheter into the pleural space or ipsilateral or contralateral peritoneal space or complete removal of the entire shunt system.

CONCLUSIONS

Breast-related ventriculoperitoneal shunt complication is a rare entity that is increasingly seen as more patients receive breast augmentation. Breast-related shunt complications most commonly present with cerebrospinal fluid pseudocyst formation in the breast. It is important for neurosurgeons to be aware of an underlying breast implant before placing a ventriculoperitoneal shunt. For patients who have migration of the distal catheter into the breast, a protocol for managing these situations should be followed to ensure no shunt infection and avoidance of future catheter migration complications with subsequent shunt revisions.

Cerebrospinal fluid shunt infections in children

Cerebrospinal fluid (CSF) shunts are commonly used for the long-term management of hydrocephalus in children. Shunt infection remains a common complication, occurring in about 5%-15% of CSF shunts. This narrative review summarises key evidence from recent literature on the epidemiology, pathogenesis, clinical presentation, diagnosis, management, outcomes and prevention of CSF shunt infections in children. The majority of shunt infections occur due to contamination at the time of surgery, with coagulase-negative staphylococci and Staphylococcus aureus being the most common infecting organisms. Clinical presentations of shunt infection can be varied and difficult to recognise. CSF cultures are the primary test used for diagnosis. Other CSF and blood parameters may aid in diagnosis but lack sensitivity and specificity. Core aspects of management of shunt infections include systemic antimicrobial therapy and surgical removal of the shunt. However, many specific treatment recommendations are limited by a lack of robust evidence from large studies or controlled trials. Shunt infections may result in long hospital stays, worsening hydrocephalus, neurological sequelae and other complications, as well as death. Therefore, reducing the incidence of infection and optimising management are high priorities. Antibiotic prophylaxis at the time of shunt placement, improved surgical protocols and antibiotic-impregnated shunts are key strategies to prevent shunt infections. Nevertheless, further work is needed to identify additional strategies to prevent complications and improve outcomes.

Appendicitis and Peritonitis in Children with a Ventriculo-Peritoneal Shunt

The purpose of this study was to outline the management of patients with appendicitis and ventriculoperitoneal shunt (VPS) in the largest pediatric surgery department in Germany. Patients with VPS presenting with an acute abdomen between 2012 and 2022 at a tertiary-care pediatric facility were the subject of a retrospective descriptive analysis. Patients were divided into two groups based on their diagnoses: group A (appendicitis) and group B (primary peritonitis). Medical records were analyzed to look at the diagnostics, operative approach, complications, peritoneal and liquor culture, and antibiotic treatment. A total of seventeen patients were examined: seven patients in group A and ten individuals in group B. In the present study patients in group A typically presented younger, sicker, and with more neurological symptoms than those in group B. All patients with appendicitis had their VPS exteriorized, and a new shunt system into the peritoneum was reimplanted 20 days later. Surgery should be aggressively administered to patients who present with an acute abdomen and a VPS. Change of the whole shunt system is suggested. Shunt infection and dysfunction should be ruled out in patients with abdominal symptoms, and surgical care should be started with a low threshold.

MRI as a one-stop destination for evaluation of CSF shunt malfunction

Background

Despite the high-frequency rate of cerebrospinal fluid shunt malfunction, radiological evaluation of CSF shunts has remained deficient, focusing mainly on demonstrating secondary signs of shunt failure rather than evaluating the shunt tube itself. We aimed to study the utility of different MR pulse sequences in evaluating the cranial and abdominal ends of CSF shunts in order to identify the potential cause of shunt failure and its impact on patient management.

Results

Twenty-five patients (18 males, 7 females, median age 2.5 years, IQR 0.75–15) were enrolled in the study, having 28 ventriculo-peritoneal shunts and single ventriculo-gallbladder shunt. The catheter lumen and fine intraventricular septae were only demonstrated in 3D-DRIVE sequences (p < 0.001). Except for three patients (having cranial end-related complications), all patients with cranial and/or abdominal end-related complications received surgery (p < 0.001, positive likelihood and negative likelihood ratios = 7.27, 0.3, respectively, sensitivity = 0.7 and specificity = 0.9). MRI findings (luminal occlusion, disconnection, CSF collection, or migration) were consistent with operative data. There is no significant difference between patients who underwent surgery and those with conservative management, or symptomatic and asymptomatic patients in terms of the prevalence of ventricular dilatation or white matter signal abnormality. The results of the abdomino-pelvic fat-suppressed T2-WI showed excellent agreement with ultrasound findings (Cohen’s Kappa 0.9). Quantitative PC could give insights into CSF dynamics, which depend on the site and cause of shunt malfunction.

Conclusions

MRI could be a one-stop destination for evaluating patients with suspected non-acute shunt malfunction. It was found to have clinical relevance in terms of accurately locating the exact site and possible cause of shunt-related complications.

Huge subcutaneous extraperitoneal pseudocyst after migration of the ventriculoperitoneal shunt catheter

The formation of an intraperitoneal pseudocyst as a complication of ventriculoperitoneal shunts is well known. However, the formation of a pseudocyst at the subcutaneous extraperitoneal abdominal space is unusual and likely secondary to the migration of the peritoneal catheter. We present a 53-year-old male who had placement of a ventriculoperitoneal shunt for hydrocephalus secondary to a vestibular schwannoma. Five months later, he presented with an enormously distended abdomen. Investigations showed the peritoneal catheter in the extraperitoneal space within a large right lower quadrant abdominal wall pseudocyst. The patient was taken to the operating theatre, and the shunt was externalised at the original abdominal incision. Approximately 3 L of cerebrospinal fluid were aspirated from the distal peritoneal catheter. After negative cultures, a new peritoneal catheter was placed intraperitoneally at the contralateral lower abdominal quadrant. The contralateral quadrant was utilised to prevent fluid accumulation into the old extraperitoneal cavity.

Thoracic abscess due to unusual migration of a ventriculoperitoneal shunt and literature review

Background:

Thoracic complications of ventriculoperitoneal (VP) cerebrospinal fluid shunting are rare and the diagnosis is difficult without neurological impairment.

Case Description:

We report a case of a 36-year-old woman who had a VP shunt in the right side when she was 13 years for a posterior fossa ependymoma and hydrocephalus. 23 years after surgery, she developed acute yellowfish cough and sputum, and the computed tomography scan found an intrathoracic cyst. She had a thoracotomy for the cyst and during surgery, we found the peritoneal catheter of the VP shunt, with a collected abscess in the left side. The patient was treated for the abscess and the VP shunt was removed. We also review the literature cases of thoracic complications after VP shunts.

Conclusion:

Thoracic abscess due to VP shunt migration is extremely rare and could happen after a long time delay VP shunt surgery.

Development and implementation of an ultralow-dose CT protocol for the assessment of cerebrospinal shunts in adult hydrocephalus

Background

Cerebrospinal fluid shunts in the treatment of hydrocephalus, although associated with clinical benefit, have a high failure rate with repeat computed tomography (CT) imaging resulting in a substantial cumulative radiation dose. Therefore, we sought to develop a whole-body ultralow-dose (ULD) CT protocol for the investigation of shunt malfunction and compare it with the reference standard, plain radiographic shunt series (PRSS).

Methods

Following ethical approval, using an anthropomorphic phantom and a human cadaveric ventriculoperitoneal shunt model, a whole-body ULD-CT protocol incorporating two iterative reconstruction (IR) algorithms, pure IR and hybrid IR, including 60% filtered back projection and 40% IR was evaluated in 18 adult patients post new shunt implantation or where shunt malfunction was suspected. Effective dose (ED) and image quality were analysed.

Results

ULD-CT permitted a 36% radiation dose reduction (median ED 0.16 mSv, range 0.07–0.17, versus 0.25 mSv (0.06–1.69 mSv) for PRSS (p = 0.002). Shunt visualisation in the thoracoabdominal cavities was improved with ULD-CT with pure IR (p = 0.004 and p = 0.031, respectively) and, in contrast to PRSS, permitted visualisation of the entire shunt course (p < 0.001), the distal shunt entry point and location of the shunt tip in all cases. For shunt complications, ULD-CT had a perfect specificity. False positives (3/22, 13.6%) were observed with PRSS.

Conclusions

At a significantly reduced radiation dose, whole body ULD-CT with pure IR demonstrated diagnostic superiority over PRSS in the evaluation of cerebrospinal fluid shunt malfunction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41747-021-00222-4.

Treatment Strategies of Complications of Breast Implants Associated With Ventriculoperitoneal Shunts: A Case Report and Review of the Literature

ABSTRACT

Breast augmentation is among the most commonly performed cosmetic procedures in the United States. As these patients age or develop comorbidities, surgeons across many other disciplines will inevitably encounter these patients in their own practices. Consequently, surgeons must be aware of the potential interactions between breast implants and devices commonly used in their fields. This case, the second of its kind encountered by our own department, describes a woman who suffered one such interaction: migration and coiling of a ventriculoperitoneal shunt around her breast implant. A systematic review was conducted to characterize breast-related ventriculoperitoneal shunt complications reported in the literature and generate an algorithm for management of the most commonly reported scenarios. Recognition of potential complications will aid surgeons in appropriate operative planning and prevention of these adverse events.

Management of Hydrocephalus in Children: Anatomic Imaging Appearances of CSF Shunts and Their Complications

OBJECTIVE. This article addresses the management of hydrocephalus and the CSF shunts used to treat this entity. CONCLUSION. CSF shunts have a high failure rate. Imaging plays a pivotal role in assessing CSF shunt failure and determining the need for surgical revision. An in-depth knowledge of CSF shunt components, their failure modes, and the corresponding findings on anatomic imaging studies is necessary to ensure timely diagnosis and prevent permanent neurologic damage.

Inguinal Extrusion of a Ventriculoperitoneal Shunt

BACKGROUND

Complications of ventriculoperitoneal (VP) shunts include migration into various anatomic compartments and even extrusion through tissue layers.

CASE DESCRIPTION

A 31-year-old female patient with a VP shunt presented with distal shunt tubing extruding through the skin at the level of the inguinal ligament. Shunt hardware was removed, and cultures grew Dermacoccus. The patient was treated with broad-spectrum antibiotics and underwent placement of a lumboperitoneal shunt.

CONCLUSIONS

Dermacoccus is a gram-positive skin organism with rare human pathogenicity and not previously known to cause shunt infections.

Shunt-Bronchial Fistula with Coughing Up and Swallowing of Cerebrospinal Fluid: Rare Complication of Ventriculopleural Shunt

BACKGROUND

Erosion of the distal catheter into lung parenchyma is an extremely rare complication of ventriculopleural shunt placement.

CASE DESCRIPTION

We report a 51-year-old woman with a history of parasagittal meningioma invading the sagittal sinus who presented with recurrent pneumonia after placement of a ventriculopleural shunt. A nuclear study revealed accumulation of radiotracer material sequentially in the right hemithorax, trachea, mainstem bronchi, stomach, and bowel. The ventriculopleural shunt had eroded into the patient's lung parenchyma, with the effect of cerebrospinal fluid draining into the respiratory system and then being coughed up and swallowed into the gastrointestinal system.

CONCLUSION

Surgeons should be aware of the potential complication of a ventriculopleural shunt eroding through the lung parenchyma to cause a shunt-bronchial fistula with persistent coughing and recurrent pneumonias. Shuntogram nuclear imaging may be useful in the diagnosis of the complication.

Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs

Thousands of patients with hydrocephalus are treated successfully with ventriculoperitoneal shunts. Ventriculoperitoneal shunts are known to have high malfunction rates, most of which are owing to mechanical causes. When shunt malfunction is suspected, shunt series are often performed to evaluate the mechanical causes of malfunction. These initial radiographs have proven critical in guiding subsequent management. This article is designed to review the various causes of shunt malfunction that can be diagnosed with radiographs.

Imaging of the pediatric peritoneum, mesentery and omentum

The normal peritoneal structures, including the mesenteries and the omenta, are only a few cell layers thick and are visible on imaging based upon the tissues (e.g., fat) and structures (e.g., blood vessels and lymph nodes) contained within them. These structures become more visible and change in appearance when involved by pathological processes. In this pictorial essay, we discuss the normal anatomy of the various abdominopelvic peritoneal structures and illustrate numerous developmental and acquired diagnoses that involve these structures in the pediatric and young adult population.