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|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 622-623
Intrapleural migration of distal ventriculoperitoneal shunt catheter
Mohana Rao Patibandla, Roy W. R. Dudley, C Corbett Wilkinson
Department of Pediatric Neurosurgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
|Date of Web Publication||4-Aug-2015|
Mohana Rao Patibandla
Department of Pediatric Neurosurgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Patibandla MR, Dudley RW, Wilkinson C C. Intrapleural migration of distal ventriculoperitoneal shunt catheter. Neurol India 2015;63:622-3
Intrapleural migration of the distal catheter of a ventriculoperitoneal shunt (VPS) is a very rare complication. This occurred in a shunt that was placed by the senior two authors (RWRD, CCW) at Children's Hospital Colorado. It was successfully treated with a revision of the distal catheter.
A female neonate with a vein of Galen malformation presented with high-output heart failure and underwent two endovascular embolization procedures. She developed progressive hydrocephalus and a left frontal VPS was performed at the age of 5 months. There were no intra-or postoperative complications. The shunt was clinically and radiologically successful at controlling her hydrocephalus [Figure 1]a. Six months after shunt placement, she presented to the clinic with an asymptomatic swelling around her abdominal incision. On examination, the swelling was minimal, and the catheter was palpable underneath the abdominal skin; she exhibited no signs of elevated intracranial pressure. X-ray performed after her clinic appointment [Figure 1]b showed sufficient length of the catheter in her peritoneal cavity. It also showed a loop of the catheter in her chest. As she was doing well, with an apparently functioning shunt, it was decided to follow her clinically. She returned for routine MRI of her heart and brain several weeks later. The cardiac MRI showed an apparent pleural effusion with the catheter inside her chest. X-ray showed the entire distal end of the catheter coiled up inside her chest [Figure 1]c. In retrospect, X-ray performed immediately after shunt placement showed an unusual curvature of the thoracic portion of the distal catheter [Figure 1]b.
|Figure 1: (a) X - ray chest and abdomen performed immediately after initial shunt placement showing sufficient length of the catheter in the peritoneal space. Note the unusual curvature of the thoracic portion of the catheter; (b) X - ray abdomen performed 6 months after the initial shunt placement showing the gradual migration of the catheter into the chest; and, (c) X - ray chest and abdomen performed 4 weeks after the previous radiograph showing the complete migration of the catheter into the chest with an apparent pleural effusion.|
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The patient had been completely asymptomatic except for upper airway congestion and cough. However, since she was already anesthetized for the MRI, we decided to revise the distal catheter before she awoke. Upon palpation, prior to making an incision, we noted that the existing catheter passed superficial to the clavicle and entered the thoracic cavity between the third and fourth ribs. We aspirated 210 ml of intrapleural cerebrospinal fluid through the existing distal catheter before removing it. A completely new distal catheter was implanted from the valve to the peritoneal cavity. The patient recovered without any further event.
Very few cases of intrapleural migration of shunt catheters have been reported in the literature. ,, Intrapleural migration may be of two types, transdiaphragmatic  or supradiaphragmatic. ,, Transdiaphragmatic migration is mainly due to the erosion of the intraperitoneal tip of the catheter through the diaphragm or due to the presence of a congenital diaphragmatic hernia.  Supradiaphragmatic migration is caused by tunneling deep to the ribs and passing the catheter through the pleural space. This happened in our case. With each inspiration, the negative intrathoracic pressure will suck the catheter into the pleural space, which also happened in our case. Smaller children with intrapleural distal catheters will generally be symptomatic, as the pleural surface cannot absorb all the cerebrospinal fluid, but our child was either asymptomatic or minimally symptomatic despite the presence of a large amount of intrapleural fluid.
In our case, we are not sure whether we passed the metal tunneling tube for the catheter superiorly deep to the costal margin, through the pleura, and out between the fourth and fifth ribs; or, we passed the tunneling tube inferiorly below the ribs, through the pleura, and out deep to the costal margin. The direction in which we passed the tunneler was not recorded in our operative note. If we had passed the tunneler in an inferior-to-superior-direction (although we are usually extremely careful not to pass it deep to the costal margin or clavicle), this particular time, we were not careful enough. If we had passed the tunneler in a superior-to-inferior direction, we have something else to be extremely careful about - not to pass it between the ribs!
| » References|| |
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