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|Year : 2013 | Volume
| Issue : 1 | Page : 65-68
Subgaleo-peritoneal shunt: An effective and safer alternative to lumboperitoneal shunt in the management of persistent or recurrent iatrogenic cranial pseudomeningoceles
Narayanam Anantha Sai Kiran, Sumit Thakar, Dilip Mohan, Saritha Aryan, Arun Sadashiva Rao, Alangar S Hegde
Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
|Date of Submission||29-Nov-2012|
|Date of Decision||20-Jan-2013|
|Date of Acceptance||28-Jan-2013|
|Date of Web Publication||4-Mar-2013|
Narayanam Anantha Sai Kiran
Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Subgaleo-peritoneal (SP) shunting for pseudomeningoceles (PMCs) is an effective and safer alternative as compared to the lumboperitoneal (LP) shunt. SP shunting was done in six patients (14-60 years) with persistent or recurrent PMCs using the cranial (ventricular part) and the distal parts of a Chhabra shunt connected by a rigid connector without any intervening chamber or valve. Two patients had undergone a prior LP shunt that had failed. One patient was unsuitable for a LP shunt placement. The PMC subsided completely in all the patients following the SP shunt. In one patient, the shunt got displaced and required repositioning. None of the patients developed symptoms of over-drainage or any other complication. All patients were asymptomatic at a mean follow-up of 15 months. These results suggest that SP shunting is a safe, simple, and effective alternative to the traditional LP shunt in the management of persistent or recurrent cranial PMCs.
Keywords: Acquired Chiari malformation, lumboperitoneal shunt, pseudomeningocele, subgaleo peritoneal shunt, thecoperitoneal shunt
|How to cite this article:|
Kiran NS, Thakar S, Mohan D, Aryan S, Rao AS, Hegde AS. Subgaleo-peritoneal shunt: An effective and safer alternative to lumboperitoneal shunt in the management of persistent or recurrent iatrogenic cranial pseudomeningoceles. Neurol India 2013;61:65-8
|How to cite this URL:|
Kiran NS, Thakar S, Mohan D, Aryan S, Rao AS, Hegde AS. Subgaleo-peritoneal shunt: An effective and safer alternative to lumboperitoneal shunt in the management of persistent or recurrent iatrogenic cranial pseudomeningoceles. Neurol India [serial online] 2013 [cited 2020 Feb 28];61:65-8. Available from: http://www.neurologyindia.com/text.asp?2013/61/1/65/108014
| » Introduction|| |
A pseudomeningocele (PMC) is a cystic, extradural collection of cerebro spinal fluid (CSF) overlying a dural defect. , Various traumatic, congenital, and iatrogenic factors are implicated in the pathogenesis. Persistent/recurrent PMCs (PrPMCs) are commonly managed with either direct repair or lumboperitoneal (LP) shunt. ,,, We discuss subgaleo-peritoneal (SP) shunting as an effective and safer alternative to LP shunting for PrPMCs.
| » Case Report|| |
A retrospective study was conducted on 13 patients with PrPMCs that were managed at our institution over a 5-year period (2007-2011). The results of SP shunting were compared with other modalities of treatment (direct repair/LP shunting). "Persistent" PMCs were defined as ones that were constant or progressive despite conservative measures.
SP shunt-surgical technique
The shunt system used for SP shunting comprises of various components of the Chhabra shunt system (Surgiwear, Shahjahanpur, India), a commonly used shunt system in India. The cranial (SH002, Surgiwear) and distal ends (90 cms distal plain tube) of the system were connected by a rigid connector (SH003, Surgiwear) without any intervening chamber or valve. The cranial end of the shunt was placed in the PMC and connected to the distal part, which was placed in the peritoneal cavity. The shunt was anchored to the underlying periosteum at the level of the connector with 4-0 silk.
Re-exploratory excision of a recurrent foramen magnum meningioma [Figure 1]a in a 14-year-old boy was performed by a far lateral approach. Duraplasty was performed with an artificial dural patch (G patch, Surgiwear, Shahjahanpur, India). A watertight closure could not be achieved as the cerebellum was adherent densely to the dura due to the previous surgery. A tense PMC was noted on the third postoperative day, and this was followed by CSF leak from the wound [Figure 1]f , which did not respond to conservative measures. The child also had a concentric intradural extramedullary lesion occluding the subarachnoid space at T1-2 levels [Figure 1]b-e. With this lesion posing an anatomical block in the spinal CSF pathway, a lumbar subarachnoid drain was found to be ineffective. A magnetic resonance imaging (MRI) revealed normal sized ventricles, ruling out the role for a ventriculo-peritoneal (VP) shunt placement. Following a direct peritoneal shunt of the PMC [Figure 1]g and h, the CSF leak stopped and PMC resolved. Excision of the dorsal lesion was undertaken 3 months later. At the last follow- up 8 months after surgery, no recurrence of the PMC was noted.
|Figure 1: Patient 1 (a-e) MR images showing an anteriorly located foramen magnum lesion and an intradural extramedullary lesion (arrow) at D1-D2 level causing significant blockage of the subarachnoid space; (f) Postoperative MRI showing the PMC (arrow); (g) CT scan after direct peritoneal shunting of the PMC showing the tip of the cranial end in the PMC (arrow); (h) X-ray showing the shunt (arrow)|
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Of the 13 patients with PrPMCs included in this study, SP shunting was performed as the initial treatment in four patients, LP shunting in eight patients, and direct repair in one patient. Two patients developed transient symptoms of over drainage after LP shunting. LP shunt block and recurrence of the PMC was noted in two patients who were later successfully managed with SP shunting. The remaining patients managed by LP shunting/direct repair were asymptomatic at the final follow-up (Range: 1-27 months, mean: 12.6 months).
The operative procedures performed in six patients who underwent SP shunting are summarized in [Table 1]. The age of these patients ranged from 14 to 60 yrs (mean-38 yrs). One patient (Patient 1) was unsuitable for LP shunting. There was complete resolution of the PMC in all patients following the SP shunt [Figure 2]. One patient required repositioning and fixation of the displaced shunt. There was no shunt displacement or block in any of the other patients. None of the patients had symptoms of over-drainage. At follow-up, which ranged from 1-56 months (mean-15 months), all patients were asymptomatic.
|Table 1: Summary of patients who underwent subgaleo-peritoneal shunt for pseudomeningocele |
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|Figure 2: Patient 2 (a) Contrast axial (a) MRI showing a left falcotentorial meningioma; (b) Postoperative contrast axial MRI at the time of discharge showing gross total excision of the lesion with no PMC; (c) CT scan done 1 month after discharge showing a large PMC (solid black arrow); (d) CT scan after SP shunting showing complete resolution of the PMC. Shunt tip (broken black arrow) seen in the subgaleal space; (e) Clinical picture before SP shunting showing a large PMC; (f) Clinical picture after SP shunting showing complete resolution of the PMC|
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| » Discussion|| |
Commonly referred to as meningocele spurius, false cysts, or pseudocysts, PMCs are usually iatrogenic. A persistent dural defect resulting in a PMC may be related to underlying factors like a large dural defect, raised intracranial pressure (ICP), hydrocephalus, poor soft tissue cover, scar tissue, radiation, infection, and the usage of steroids.  In the case of smaller dural defects, the setting in of a ball valve mechanism may be an additional causative factor. 
Ventriculoperitoneal (VP) shunting is required in patients with PMCs associated with hydrocephalus. Majority of the cases of PrPMCs not associated with hydrocephalus or raised ICP can be successfully managed with conservative measures like elevation of head, lumbar drain, local tapping followed by compressive bandage (tap and wrap technique). , Rarely, the PMC persists despite these conservative measures. Direct dural repair and LP shunting are then the common modalities of treatment for PrPMCs. ,,, Though re-exploration and repair of the dural defect is effective in majority of these cases, recurrence of the PMC, even after water-tight dural closure, has been reported.  A water-tight closure may not be feasible when a synthetic dural patch is used, and in re-exploratory cases, where the underlying brain is densely adherent to the dura. Various materials like tissue glue, polyethylene hydrogel etc., used to achieve watertight dural closure are not effective in all the cases. 
Various complications like gravity related over-drainage, acquired Chiari malformation, acute subdural hematoma after minor trauma, chronic subdural hematoma, subarachnoid bleed, and radicular pain have been reported in association with LP shunts. ,,, Of the listed complications, acquired Chiari malformation is extremely common in children. Chumas et al.,  reported tonsillar herniation in as high as 70% of pediatric patients after LP shunts. Another disadvantage of the LP shunt is its high failure rate. ,
Andrew et al.,  and Epstein  described wound- peritoneal (WP) shunts in the management of intraoperative anterior dural lacerations during surgery for ossified posterior longitudinal ligament (OPLL). The present report of SP shunting is based on a similar concept. The SP shunt has several advantages over the LP shunt in the management of PMCs. Firstly, the placement of the SP shunt is safe and simple. Secondly, as it is completely outside the ventricular system and subarachnoid space, the possibility of complications like gravity-related over-drainage, acquired Chiari malformation and others does not arise. Thirdly, it facilitates complete drainage of the collected CSF and allows for easy adhesion of subgaleal surfaces and complete resolution of the PMC. Fourthly, blockage of the SP shunt system is unlikely due to the absence of a valve and chamber. Finally, the SP shunt is far safer than LP shunts in cases of posterior fossa PMCs with one-way communications, which can reportedly develop a life-threatening posterior fossa syndrome after lumbar drainage.  SP shunting is also effective in cases where the LP shunt fails, as seen in two of our cases.
SP shunting is a safe, simple, and effective alternative to LP shunting in the management of iatrogenic cranial PMCs. It has none of the drainage-related complications that the LP shunt is commonly associated with. SP shunt is preferable to LP shunt in the management of PMC in children as acquired Chiari malformation after LP shunt is extremely common in them. Additionally, the procedure is efficacious in cases of failure of LP shunt.
| » References|| |
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[Figure 1], [Figure 2]
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|[Pubmed] | [DOI]|