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CASE REPORT
Ahead of print publication
 

Complete intraventricular migration of ventriculoperitoneal shunt: A case report and review of literature


 Department of Neurosurgery, DKS Post Graduate Institute and Research Centre, Raipur, Chhattisgarh, India

Date of Submission27-Oct-2020
Date of Acceptance11-Feb-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Lavlesh Rathore,
Department of Neurosurgery, DKS Post Graduate Institute and Research Centre, DKS Bhawan, Raipur, Chhattisgarh.
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_287_20

 

   Abstract 

Ventriculoperitoneal shunt (VP shunt) is a commonly performed surgery for hydrocephalus, and like for any other surgery, complications are an inseparable part of this surgery as well. Here, we present a rare complication of VP shunt in a six-month-old child where complete shunt assembly had migrated into the lateral ventricle. Endoscopic retrieval of the migrated shunt with simultaneously endoscopic third ventriculostomy was performed. Operative steps for the procedure have been described. A detailed literature review of the migrated intraventricular shunt and its possible pathogenesis has been discussed.


Keywords: Endoscopic retrieval, migrated intraventricular shunt, pathogenesis, VP shunt complications



How to cite this URL:
Rathore L, Sahana D, Kumar S, Borde PR, Jain AK, Sahu RK. Complete intraventricular migration of ventriculoperitoneal shunt: A case report and review of literature. J Pediatr Neurosci [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=327905





   Introduction Top


Complications are an inseparable part of shunt surgery. Migration of the shunt system into the peritoneal cavity has been reported, but intraventricular migration of the whole shunt system is rare.[1] The literature has proposed various procedure-related technical points and mechanisms as causes. Here, we report such a case in a six-month-old child along with a concise review.


   Case Description Top


A three-month-old male underwent VP shunt for aqueductal stenosis, with a Chhabra “Slit N Spring” medium pressure shunt through a right occipital burr hole. The signs and symptoms of raised ICP were resolved postoperatively.

Three months later, the child presented with progressive macrocephaly and downgazing eyes (Sunset Sign). His anterior fontanel was tense, and the shunt system was not palpable. X-ray skull showed the entire shunt system inside the cranium [Figure 1]A and B. Computed tomography confirmed proximal intraventricular migration of the entire shunt system along with gross hydrocephalus and a thin cortical mantle [Figure 1]C. Endoscopic ventricular inspection showed a roomy ventricle with the entire shunt system within it. The septum pellucidum was incomplete, and the ventricular and peritoneal ends were embedded into the ependyma [Figure 2]A and B. There was a knot at the distal end of the catheter. The connection between the ventricular end, shunt chamber, and peritoneal ends was intact [Figure 2]C. The buried ventricular end was gently pulled away from the ependymal with grasping forceps [Figure 3]A. The tip of the ventricular end was grasped along its axis, and the endoscope along with the catheter was brought out till the shunt chamber was delivered out of the cortex [Figure 3]B. At this point, the endoscope was re-inserted to enable the delivery of the rest of the shunt system under vision, and to avoid injury to the ependymal vessels and choroid plexuses [Figure 3]C. Finally, third ventriculostomy was done. Inspection of the retrieved shunt system revealed a knot formation at the peritoneal end. The shunt chamber was compressible with a patent distal end [Figure 3]D. Postop scan showed a reduction in the size of ventricles. There were no untoward events till the last follow-up at five months [Figure 3]E.
Figure 1: (A) X-ray skull AP view showing whole shunt assembly intracranially. (B) X-ray chest–abdomen showing an absent shunt tube along the track. (C) Axial computed tomography of a brain coiled shunt tube within the lateral ventricle

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Figure 2: (A) The ventricular end was embedded in a lateral ventricular ependymal wall (pointed with a broken arrow). (B) The abdominal end was buried in the occipital horn, and a slit on the abdominal catheter end can be seen (pointed with a broken arrow). (C) Shunt connector tied with a silk suture can be seen (pointed with a broken arrow)

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Figure 3: (A) Ventricular end of the shunt was held with grasping forceps. (B) Ventricular end of the shunt was removed out of the cranium with a ventriculoscope and grasping forceps. (C) After passing out of the chamber, a ventriculoscope was reinserted. (D) A knot in the distal catheter end can be seen (pointed with a broken arrow). (E) Postoperative computed tomography of the brain showing a clear lateral ventricle with reduced size of the ventricle

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   Discussion Top


Migrated shunts have been discovered from subcutaneous space,[2],[3] subgaleal space,[4] subdural space, intraparenchymally, and inside the ventricles.[5],[6],[7] Ventricular migration of the shunt system is reported in 0.1% to 0.4%, whereas complete intraventricular migration is rarely reported. Our literature search through popular databases identified 14 such cases, 12 of whom were infants [Table 1].[1],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] Infants with congenital hydrocephalus have wide open fontanelle, with CSF pressures close to atmospheric pressure. A relatively higher intra-abdominal pressure creates a pressure gradient in the cranial direction. A sudden drop in intracranial pressure after shunt surgery further accentuates this gradient and produces a suction effect, pulling the shunt cranially. In congenital hydrocephalus, grossly dilated ventricles may accommodate the whole shunt system.[11] Poor neck control in infants with excessive neck movement may create a “windlass effect” facilitating upward migration of the peritoneal end.[15]
Table 1: Review of literature for intraventricular migration of complete shunt system

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Raimondi et al. suggested a one-piece shunt system to reduce shunt migration compared with a three-piece shunt system,[16] but other studies have labeled it as a cause of migration, due to a lack of reservoir. Eljamel et al. suggested using a reservoir between the proximal and distal catheter to prevent migration.[17] However, these complications are also seen with the Chhabra Shunt system, which has a reservoir.[1],[8],[10],[12],[14] The cylindrical shape of the reservoir in the Chhabra system has been pointed out as the reason for easy passage through the dural defect. The catheter memory due to packaging may promote re-coiling of the shunt within the ventricle. The present case has both of these findings.

Most of proximal shunt migration has occurred within three to four months of shunt surgery,[1],[6],[7],[8],[9],[11],[13],[14] which may be due to a less well-formed fibrous tract around the shunt assembly allowing movement. Some studies have found pseudo-meningocoele at the operative site.[1],[8],[9],[10],[11],[18] It facilitates cranial shunt migration by providing a fluid medium proximally with less frictional resistance than at the distal region with a fibrous tract. The pulsatile flow in the surrounding fluid medium of pseudo-meningocele may also allow micromovement of the catheter.

Large burr hole, wide dural opening, and improper anchoring of the shunt to pericranium might be responsible for proximal migration.[1] Anchoring of ventricular and abdominal ends has been advocated as a solution. However, Eljamel et al. reported complete intraventricular migration of a one-piece shunt even after fixation of the device fixation with a “lock-clip” and “slip-clip” device. The parieto-occipital burr hole with a relatively straight course of tunneling may also be responsible for shunt migration.[9] Children with poor nutritional status have lesser subcutaneous fat and seem to be at increased risk of shunt movement.[15]

Management of such an intraventricular shunt includes either leaving the shunt in situ and close follow-up, for asymptomatic cases; or its removal via craniotomy or endoscopically. A nonfunctioning shunt inside the ventricle is a potential source of infection[19] and, whenever possible, merits removal. Endoscopy provides a safe means of retrieval under vision and allows performance of CSF diversion via ventriculostomy in the same sitting. There are three successful reports of endoscopic retrieval in the literature, along with the revision of the shunt.[1],[7],[18] To the best of the author’s knowledge, this case may be the first, in which endoscopic third ventriculostomy was done in the same sitting as shunt retrieval.


   Conclusions Top


Complete migration of the entire shunt system is a rare complication and mostly occurs in infants with gross hydrocephalus. Its pathogenesis is multifactorial with large ventricles, open fontanelles, shunt with cylindrical reservoirs, improper anchoring techniques, and pseudo-meningocele formation. Endoscopy not only provides a safe means of retrieval under vision but may also provide a chance to perform a third ventriculostomy in the same sitting.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Acharya R, Bhutani A, Saxena H, Madan VS. Complete migration of ventriculoperitoneal shunt into the ventricle. Neurol Sci 2002;23:75-7.  Back to cited text no. 1
    
2.
Pang D, Wilberger JE Jr. Upward migration of peritoneal tubing. Surg Neurol 1980;14:363-4.  Back to cited text no. 2
    
3.
Agarwal A, Kakani A. Shunt malfunction due to proximal migration and subcutaneous coiling of a peritoneal catheter. J Neurosci Rural Pract 2010;1:120-1.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Pikis S, Cohen JE, Shoshan Y, Benifla M. Ventriculo-peritoneal shunt malfunction due to complete migration and subgaleal coiling of the proximal and distal catheters. J Clin Neurosci 2015;22:224-6.  Back to cited text no. 4
    
5.
Mori K, Yamashita J, Handa H. “Missing tube” of peritoneal shunt: Migration of the whole system into ventricle. Surg Neurol 1975;4:57-9.  Back to cited text no. 5
    
6.
Abou El Nasr H. Modified method for prophylaxis against unishunt system complications with presentation of total intraventricular migration of unisystem ventriculoperitoneal shunt. Child’s Nerv Syst [Internet]. 1988;4:116-8. https://doi.org/10.1007/BF00271393  Back to cited text no. 6
    
7.
Gupta PK, Dev EJ, Lad SD. Total migration of a ventriculo-peritoneal shunt into the ventricles. Br J Neurosurg 1999;13:73-4.  Back to cited text no. 7
    
8.
Sharma RK, Bansal M, Agrawal M, Gupta A, Sinha VD. Complete intracranial migration of a ventriculoperitoneal shunt: Rare complication of a common procedure. Neurol India 2015;63:106-7.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Young HA, Robb PJ, Hardy DG. Complete migration of ventriculoperitoneal shunt into the ventricle: report of two cases. Neurosurgery 1983;12:469-71.  Back to cited text no. 9
    
10.
Sharma S, Gupta DK. Intraventricular migration of an entire VP shunt. Indian Pediatr 2005;42:187-8.  Back to cited text no. 10
    
11.
Nadkarni TD, Menon RK, Dange NN, Desai KI, Goel A. Cranial migration of complete ventriculo-peritoneal shunt assembly. J Clin Neurosci 2007;14:92-4.  Back to cited text no. 11
    
12.
Parihar V, Yadav YR, Pandey N, Sharma D. A rare case of complete intraventricular migration of ventriculo-peritoneal shunt. Journal of Pediatric Neurology 2009;7:419-21.  Back to cited text no. 12
    
13.
Agarwal A, Kakani A. Total migration of a ventriculo-peritoneal shunt catheter into the ventricles. J Pediatr Neurosci 2011;6:88-9.  Back to cited text no. 13
  [Full text]  
14.
Malhotra A, Malhotra M. Ventricular migration of shunt: Chhabra shunt complication. Int Surg J 2015;2:706-9.  Back to cited text no. 14
    
15.
Scott M, Wycis HT, Murtagh F, Reyes V. Observations on ventricular and lumbar subarachnoid peritoneal shunts in hydrocephalus in infants. J Neurosurg 1955;12:165-75.  Back to cited text no. 15
    
16.
Raimondi AJ, Robinson JS, Kuwawura K. Complications of ventriculo-peritoneal shunting and a critical comparison of the three-piece and one-piece systems. Childs Brain 1977;3:321-42.  Back to cited text no. 16
    
17.
Eljamel MS, Sharif S, Pidgeon CN. Total intraventricular migration of unisystem ventriculo-peritoneal shunt. Acta Neurochir (Wien) 1995;136:217-8.  Back to cited text no. 17
    
18.
Naik V, Phalak M, Chandra PS. Total intracranial shunt migration. J Neurosci Rural Pract 2013;4:95-6.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Vajramani GV, Jones G, Bayston R, Gray WP. Persistent and intractable ventriculitis due to retained ventricular catheters. Br J Neurosurg 2005;19:496-501.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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