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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 50  |  Issue : 4  |  Page : 142-144

Cranial migration of ventriculoperitoneal shunt


1 Department of Paediatric Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
2 Department of Radiodiagnosis, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

Date of Submission16-Jul-2016
Date of Decision14-Sep-2016
Date of Acceptance06-Jan-2017
Date of Web Publication19-Jul-2017

Correspondence Address:
Rahul Gupta
202 A, A3 Block, Kamal Apartment-2, Banipark, Jaipur - 302 006, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_45_17

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  Abstract 

We report a rare case of an 11-month male infant with cranial migration of ventriculoperitoneal (VP) shunt assembly. The shunt chamber was lying inside the ventricles. At the time of shunt revision, outsized burr hole and wide dural opening were observed. The ventricular migrated chamber of VP shunt was first retrieved from the ventricle followed by the removal of whole shunt assembly. A new VP shunt was placed on the other side with the chamber firmly anchored to the pericranium. The diagnosis was timely done and prevented complete shunt migration into the ventricles. We attribute factors such as outsized burr hole, wide dural opening, and poor anchoring of the straight connector of shunt chamber to periosteum because of poor tissue preservation (redo operation). Repeated flushing of the shunt chamber by cranial direction pressing on it by the mother might be a contributing factor for loosening of anchor sutures and cranial migration. Patients undergoing VP shunt procedure must be under regular follow-up for early recognition of this potential complication. Cranial migration of VP shunt is usually not a fatal complication.

Keywords: Cranial, hydrocephalus, intraventricular, migration, ventriculoperitoneal shunt


How to cite this article:
Mathur P, Gupta R, Mehra S, Chaturvedi P, Gupta PK, Shukla R. Cranial migration of ventriculoperitoneal shunt. Formos J Surg 2017;50:142-4

How to cite this URL:
Mathur P, Gupta R, Mehra S, Chaturvedi P, Gupta PK, Shukla R. Cranial migration of ventriculoperitoneal shunt. Formos J Surg [serial online] 2017 [cited 2017 Nov 22];50:142-4. Available from: http://www.e-fjs.org/text.asp?2017/50/4/142/211084




  Introduction Top


Ventriculoperitoneal (VP) shunt is a common procedure performed for treating hydrocephalus.[1],[2] We report a case of an 11-month male infant with abnormal cranial migration of VP shunt assembly. The shunt chamber was lying inside the ventricles. Cranial migration of VP shunt into the ventricle is a rare complication with <60 cases of isolated intraventricular catheter migration and approximately 25 cases of complete assembly migrating into the ventricles but very few reported cases of shunt chamber lying inside the ventricles.[3],[4] The probable mechanisms and preventive measures to avoid the occurrence of such a rare complication are discussed along with brief review of literature.


  Case Report Top


An 11-month male infant presented to pediatric surgical emergency department with enlargement of the head and decreased oral intake for 1 week. Previously, the patient had undergone medium pressure VP shunt (Chhabra shunt) surgery twice due to congenital hydrocephalus. The patient was born by vaginal delivery. The head size of the patient at birth was 38 cm with ventricular-hemispheric ratio of 0.6 on ultrasonography (USG) of the brain. Computed tomography brain scans suggested aqueductal stenosis. The condition was not known antenatally. The antenatal period was uneventful, and antenatal USG was not performed.

The child was first operated at the age of 3 weeks and later at 8 months because of shunt blockage. He was doing apparently well after the second surgery. However, his head increased in size again. Clinical examination revealed enlarged head with nonpulsatile and bulging anterior fontanel, engorged scalp veins, and presence of sunset sign. A bulge presented at the site of previous parietal burr hole on the right side [Figure 1]. Shunt chamber could not be palpated throughout the entire course of shunt. On further enquiring, the mother acknowledged that as per the advice from their clinician, she was repeatedly flushing and pressing the chamber cranially to check for shunt malfunction.
Figure 1: Photograph (left) showing enlarged head size, bulging anterior fontanelle, engorged scalp veins, and bulge at the site of previous parietal burr hole on the right side. Peroperative / intraoperative image (right) showing migrated shunt chamber of ventriculoperitoneal shunt being retrieved from the ventricle

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Skull X-ray (anterior–posterior and lateral view) clearly suggested an abnormal cranial migration of VP shunt assembly with shunt chamber lying inside the cranium [Figure 2]. USG suggested severe hydrocephalus with shunt chamber lying inside the ventricles. Laboratory investigations revealed white blood cells total count of 12,500 mm 3 and hemoglobin 9.2 g/dl, with normal renal and liver functions. Shunt revision was performed. Outsized burr hole, wide dural opening, large free subgaleal space, loosened and opened anchor sutures, and a poor local tissue condition for anchoring of the straight connector of shunt chamber were observed. The ventricular migrated shunt chamber of VP shunt was first retrieved followed by the whole shunt assembly [Figure 1]. New VP shunt was placed on the left side with the chamber firmly anchored to the pericranium. The child improved clinically and was doing well.
Figure 2: Skull radiographs (anterior–posterior and lateral view) showing ventricular end of ventriculoperitoneal shunt with chamber (yellow arrow) lying inside the cranium; site of burr hole (red arrow), original site of shunt chamber (white arrow), and skull bone (green arrow). Thoracoabdominal radiograph showing intact shunt assembly (inset image)

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  Discussion Top


VP shunt introduced in 1908 is one of the most common neurosurgical procedures performed for patients with hydrocephalus.[1],[2] VP shunt complications include shunt infection, over drainage, and shunt obstruction/malfunction. Peritoneal complications involve pseudocyst formation, bowel perforation, and protrusion (umbilicus and anus). Other shunt complications are disconnection and migration.[1],[2] Cranial and ventricular migrations are rare complications as the present reported case.[3],[4],[5],[6],[7],[8],[9],[10] A retrospective review of institutional records from January 2014 to December 2015 revealed a total of 321 patients undergoing VP shunt operations. No similar incidence was seen over the past 2 years.

There are three main causes of proximal (intracranial) shunt migration: (1) Positive abdominal pressure with respect to the intracranial pressure and the windlass effect.[5],[6],[7] (2) The shunt system with a small cylindrical chamber or a valveless system not properly secured to prevent its migration.[8] (3) Large burr hole, wide dural opening, and large ventricle with thin cerebral mantle.[5],[9],[10]

We attribute the following factors responsible for cranial migration of VP shunt observed in our case: outsized burr hole, wide dural opening, and cylindrical chamber (reservoir) of Chhabra shunt. The failure of anchoring of shunt chamber connector was due to poor local tissue preservation for redo surgery.[4],[9] Another possible cause was the repeated flushing and pressing the chamber cranially by the mother that might further loosen the anchor sutures.[4]

Reported surgical techniques to prevent intracranial shunt migration include appropriate size burr hole, small dural incision, and using shunt system incorporating a flushing chamber.[4],[5],[8],[10] A shunt system with straight tubing or attached with a cylindrical flushing chamber may facilitate migration.[4],[5],[8],[10] The most important technique to prevent intracranial migration is to suture the straight connector of shunt chamber to periosteum. In shunt revision, the neighboring periosteum may be destroyed and hence contributes to shunt migration.[4],[9] The repeated pressing and flushing of the shunt chamber by the infant's mother may further weaken the anchor sutures, and facilitate cranial migration should be avoided.[4]

Enlargement of the head again after the second operation led to the referral and diagnosis of partial intraventricular migration of VP shunt. Thus, total migration of VP shunt into lateral ventricles as reported in literature was prevented. The treatment of cranial migration of VP shunt into the ventricles is removal of the migrated shunt tube and replacement with a new VP shunt preferably on the contralateral side with the chamber firmly fixed to the pericranium.[10] In case of complete cranial migration of VP shunt into the ventricles, removal is performed either by endoscopy (preferably) or by craniotomy.[4],[10] The tip of migrated shunt is usually adherent to choroid plexus and should be carefully removed by taking care to free the adhesions as it may lead to fatal hemorrhage.[4],[10]

In conclusion, cranial migration of VP shunt into the ventricle is a rare complication. Proper fixation of the straight connector of shunt chamber to periosteum, creation of appropriate size burr hole, small dural incision, and using shunt system incorporating a flushing chamber are preventive measures. Practice of repeated pressing of the chamber should be avoided. Patients undergoing VP shunt procedure must be under regular follow-up for early recognition of this potential complication. Cranial migration of VP shunt is usually not a fatal complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name 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.
Lifshutz JI, Johnson WD. History of hydrocephalus and its treatments. Neurosurg Focus 2001;11:E1.  Back to cited text no. 1
    
2.
Ghritlaharey RK, Budhwani KS, Shrivastava DK, Srivastava J. Ventriculoperitoneal shunt complications needing shunt revision in children: A review of 5 years of experience with 48 revisions. Afr J Paediatr Surg 2012;9:32-9.  Back to cited text no. 2
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3.
Herbowski L, Szydłowska R, Rudnicki J, Harat A, Sagan L. Fluoroscopy neuro-guided endoscopic removal of a lost ventricular catheter in hydrocephalic girl with staphylococcal shunt infection. Open J Mod Neurosurg 2012;2:50-3.  Back to cited text no. 3
    
4.
Malhotra A, Malhotra M. Ventricular migration of shunt: Chhabra shunt complication. Int Surg J 2015;2:706-9.  Back to cited text no. 4
    
5.
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. 5
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6.
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. 6
    
7.
Garijo JA, Pecourt JC, de la Resurrección M. Migration of ventriculo-peritoneal shunt into lateral ventricle of an adult. Surg Neurol 1979;11:399-400.  Back to cited text no. 7
    
8.
Ergungor MF. Migration of an entire one-piece ventriculoperitoneal shunt into the ventricle. Turk Neurosurg 1989;1:47-8.  Back to cited text no. 8
    
9.
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. 9
    
10.
Naik V, Phalak M, Chandra PS. Total intracranial shunt migration. J Neurosci Rural Pract 2013;4:95-6.  Back to cited text no. 10
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