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CASE REPORT |
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| Ahead of print
publication |
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Complete intraventricular migration of ventriculoperitoneal shunt: A case report and review of literature
Lavlesh Rathore, Debabrata Sahana, Sanjeev Kumar, Pravin R Borde, Amit K Jain, Rajiv K Sahu
Department of Neurosurgery, DKS Post Graduate Institute and Research Centre, Raipur, Chhattisgarh, India
| Date of Submission | 27-Oct-2020 |
| Date of Acceptance | 11-Feb-2021 |
| Date of Web Publication | 11-Oct-2021 |
Correspondence Address:
Lavlesh Rathore,
Department of Neurosurgery, DKS Post Graduate Institute and Research Centre, DKS Bhawan, Raipur, Chhattisgarh.
India
 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
| Introduction | |  |
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 | | |
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 | | |
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 | | |
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 | | |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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