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CASE REPORT
Year : 2010  |  Volume : 58  |  Issue : 4  |  Page : 662-664

Unusual cause for ventriculoperitoneal shunt failure: Carcinoma breast compressing distal catheter


1 Neurological Surgery Unit, Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
2 General Surgery, Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal

Date of Acceptance01-Feb-2010
Date of Web Publication24-Aug-2010

Correspondence Address:
Yam B Roka
Neurosurgical Unit, Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.68704

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 » Abstract 

Insertion of a ventriculoperitoneal (VP) shunt is one of the most common surgical procedures in any neurosurgery unit worldwide. Distal catheter obstruction outside the peritoneum is a rare cause of shunt failure. We report the first case of distal obstruction in a 70-year old female by carcinoma breast engulfing the catheter and causing kinking. Intraoperatively, the catheter was intratumoral with no flow of cerebrospinal fluid distally. She underwent relocation of a new catheter to the opposite side of the abdomen and modified mastectomy with resolution of the hydrocephalus. The postoperative course has been uneventful.


Keywords: Carcinoma breast, hydrocephalus, shunt failure, ventriculoperitoneal shunt


How to cite this article:
Roka YB, Gupta R, Bajracharya A. Unusual cause for ventriculoperitoneal shunt failure: Carcinoma breast compressing distal catheter. Neurol India 2010;58:662-4

How to cite this URL:
Roka YB, Gupta R, Bajracharya A. Unusual cause for ventriculoperitoneal shunt failure: Carcinoma breast compressing distal catheter. Neurol India [serial online] 2010 [cited 2019 Sep 22];58:662-4. Available from: http://www.neurologyindia.com/text.asp?2010/58/4/662/68704



 » Introduction Top


Insertion of a ventriculoperitoneal (VP) shunt for various causes is one of the most common surgical procedures performed in any neurosurgical unit worldwide. Some of the common shunt related complications include obstruction of the ventricular or peritoneal end of the tube, infection, fracture, dislodgement and bowel perforation. [1],[2],[3] Distal catheter obstruction outside the peritoneum is a rare cause of shunt failure. The common causes for this obstruction are silicone allergy, valve collapse, dislodgement and intrathoracic penetration of the catheter. [1],[2],[3]


 » Case Report Top


A 70-year-old female was operated for normal pressure hydrocephalus in 2007 with no procedural complications. She had an uneventful follow-up until the present admission. She presented in July 2009 with history of episodic attacks of headache, altered sensorium and drowsiness. There was no history of trauma, fever, vomiting or seizure. On examination, she was conscious but confused with Glasgow Coma Scale score (GCS) of 14. Clinically the shunt valve was not compressible suggesting shunt malfunction. Further systemic examination revealed a six by eight cm right breast lump, with red surface, hard, mobile over the pectoral muscles and with the shunt tube passing right through the lump [Figure 1]. The shunt tube was fixed to the lump and prevented the latter's mobility. The family members now confessed that the breast lump had been present for six months before this admission and they had not seen a doctor for the same.
Figure 1 : Picture shows right breast lump with the proximal end of the VP shunt pulled subcutaneously (arrows)

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The chest X-ray surprisingly showed a calcified right breast mass with the distal VP shunt catheter passing through and pushed to the left. Computed tomography (CT) scan of head showed dilated ventricles with obvious hydrocephalus with the ventricular catheter in correct position [Figure 2]. Her serum electrolytes, blood sugar, renal and liver function test were normal and no coagulopathy. There were no enlarged axillary lymph nodes and the ultrasound of the abdomen was normal. Fine needle aspiration cytology showed the lump as carcinoma of breast.
Figure 2 : CT head shows gross hydrocephalus with normal placed intraventricular catheter

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She underwent right side modified radical mastectomy with division of the distal shunt tube in the neck and relocation to the left upper abdomen with a new tube. Intraoperatively, the shunt was seen traversing through the hard breast lump and could not be separated even by giving it moderate pull. On excision of the lump the shunt was in the center with a small angulation at one point distally [Figure 3]. There was no cerebrospinal fluid (CSF) flow distal to the lump but on transaction of the proximal end, there was CSF flow seen. The breast skin was primarily approximated except for a small defect which was covered by skin graft. There were no procedural complications and her GCS improved to 15 on the first postoperative day. She was discharged on the tenth day with no sequel. Histology showed tumor free margins with infiltrative type of ductal carcinoma. Follow-up for the last two months has been uneventful with no hydrocephalus on repeat scan and she has also been started on further chemotherapy.
Figure 3 : Cut breast lump shows the tumor surrounding the angulated intratumoral distal shunt tube

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 » Discussion Top


The common causes of failure of the VP shunt are blockage at the peritoneal or ventricular end, infection, dislodgement, migration, laparoscopic surgery and bowel perforation. [1],[2],[3],[4],[5],[6],[7],[8] Mechanical causes like knotting of the distal catheter, increased intraabdominal pressure secondary to constipation and silicone allergy leading to obstruction are uncommon and limited to case reports. [1],[2],[3],[4],[5],[6],[7],[8]

This case is probably the first to report breast lump causing mechanical obstruction of the distal catheter. Clinically the shunt valve was not compressible leading to distal obstruction as diagnosis but breast lump causing obstruction was the last cause one could expect. This case is also important because it highlights the social stigma attached in revealing malignancies in developing countries where diseases are not confessed. As exemplified by this case, routine superficial clinical examination would have led to missing the breast lump until the patient was in the operation theatre. Thus it is important to have a full physical examination done to rule out shunt failure by extra peritoneal mechanical causes and prevent intraoperative embarrassment.

 
 » References Top

1.Boch AL, Hermelin E, Sainte-Rose C, Sgouros S. Mechanical dysfunction of ventriculoperitoneal shunts caused by calcification of the silicone rubber catheter. J Neurosurg 1998;88:975-82.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Lundar T, Langmoen IA, Hovind KH. Shunt failure caused by valve collapse. J Neurol Neurosurg Psychiatry 1991;54:559-60.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Tsurushima H, Harakuni T, Saito A, Hyodo A, Yoshii Y. Shunt tube problems due to placement of valves on the chest wall--three case reports. Neurol Med Chir (Tokyo) 2000;40:342-4.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Chopra I, Gnanalingham K, Pal D, Peterson D. A knot in the catheter--an unusual cause of ventriculo-peritoneal shunt blockage. Acta Neurochir (Wien) 2004;146:1055-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Ghritlaharey RK, Budhwani KS, Shrivastava DK, Gupta G, Kushwaha AS, Chanchlani R, et al. Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: report of ten cases in children. Pediatr Surg Int 2007;23:575-80.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Powers CJ, George T, Fuchs HE. Constipation as a reversible cause of ventriculoperitoneal shunt failure. Report of two cases. J Neurosurg 2006;105:227-30.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Samdani AF, Storm PB, Kuchner EB, Garonzik IM, Sciubba D, Carson B. Ventriculoperitoneal shunt malfunction presenting with pleuritic chest pain. Pediatr Emerg Care 2005;21:261-3.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Baskin JJ, Vishteh AG, Wesche DE, Rekate HL, Carrion CA. Ventriculoperitoneal shunt failure as a complication of laparoscopic surgery. J Soc Laparoendosc 1998;2:177-80.  Back to cited text no. 8      


    Figures

  [Figure 1], [Figure 2], [Figure 3]

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