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Intraparenchymal pericatheter cyst following disconnection of ventriculoperitoneal shunt system
S Balasubramaniam, DK Tyagi, HV Sawant
Department of Neurosurgery, TN Medical College and BYL Nair Hospital, Mumbai Central, Mumbai, Maharashtra, India
Correspondence Address:
S Balasubramaniam
Department of Neurosurgery, TN Medical College and BYL Nair Hospital, Mumbai Central, Mumbai, Maharashtra
India
Abstract
Ventriculoperitoneal (VP) shunt is one of the most commonly performed procedures in neurosurgery, but it is also the procedure, which is most prone to complications. Spread of cerebrospinal fluid (CSF) into the brain parenchyma is a rare complication of VP shunt and can take the form of CSF edema or a porencephalic cyst. We describe a case of a 1½-year-old child who presented to us with seizures. Computed tomography scan revealed pericatheter porencephalic cyst. Surgical exploration revealed a disconnected VP shunt system. Patient was neurologically observed after shunt extraction. He was seizure free and radiological follow-up showed resolution of cyst. Ours is the first case to document the presence of pericatheter cyst following complete disconnection of shunt system. Though shunt revision is the accepted treatment modality, careful neurological observation can be done after shunt removal especially in asymptomatic cases with compensated hydrocephalus.
How to cite this article:
Balasubramaniam S, Tyagi D K, Sawant H V. Intraparenchymal pericatheter cyst following disconnection of ventriculoperitoneal shunt system.J Postgrad Med 2013;59:232-234
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How to cite this URL:
Balasubramaniam S, Tyagi D K, Sawant H V. Intraparenchymal pericatheter cyst following disconnection of ventriculoperitoneal shunt system. J Postgrad Med [serial online] 2013 [cited 2023 Sep 24 ];59:232-234
Available from: https://www.jpgmonline.com/text.asp?2013/59/3/232/118048 |
Full Text
Introduction
Ventriculoperitoneal (VP) shunt is one of the most commonly performed procedures in Neurosurgery, but it is also the procedure with the biggest list of post-operative complications. [1],[2] Long-term follow-up of operated cases of VP shunt have reported complications in up to 30% of cases of which infection and obstruction are the most common. [3] The spread of Cerebrospinal fluid (CSF) into the brain parenchyma is a rare complication of VP shunt and can take the form of CSF edema or a porencephalic cyst. Pericatheter cysts have previously been reported in cases of shunt obstruction, however, ours is the first to report it in a case of complete disconnection of the shunt system.
Case Report
A 1½-year-old male child presented to us with generalized tonic clonic (GTC) seizures. Patient had a previous history of been operated for meningomyelocele at the age of 18 days. Following surgery, the head circumference was noted to be progressively increasing. Computed tomography (CT) of Brain showed gross hydrocephalus [Figure 1]. VP shunt was carried out at the age of 3 months. Following shunt procedure patient developed meningitis. Revision VP shunt was performed 20 days after the first surgery. Patient was apparently alright for the next year following, which he started, having GTC's. A small subgaleal swelling too appeared just below the incision site [Figure 2]. Neurological examination revealed mild mental retardation with borderline social maturity, but no motor or sensory deficit. Local examination showed discontinuity in the shunt catheter. Repeat CT scan showed a periventricular porencephalic cyst around the shunt catheter [Figure 3].{Figure 1}{Figure 2}{Figure 3}
Decision to operatively explore the shunt system was taken. Previous incision site was opened. There was a gush of CSF after opening the skin. The ventricular tip of shunt was found to be disconnected from the distal system [Figure 4]. CSF was allowed to drain to decompress the cyst. The entire shunt system was then removed and we decided to neurologically observe the patient for signs of raised intracranial tension. Patient's wound healed well, the swelling subsided with compression dressing and the seizures abated. Patient was discharged and a delayed CT was performed at 1 month follow-up which showed significant resolution of the cyst [Figure 5].{Figure 4}{Figure 5}
Discussion
VP shunt is regarded as the standard treatment for hydrocephalus. Though, infection and obstruction of the VP shunt are the commonest complications, pericatheter cysts have been described as a rare complication. [2],[3] Literature search (done on 28-Sept-2012) showed 4 reported cases of pericatheter porencephalic cyst in previously operated cases of meningomyelocele [4],[5],[6],[7] [Table 1]. All the cases had evidence of shunt block and improved with shunt revision. In our case, the shunt was completely disconnected and did not need revision also.{Table 1}
Two mechanisms have been postulated in the occurrence of pericatheter cysts. First is the "direct infusion edema model" wherein due to obstruction of shunt, CSF leaks into the surrounding white matter at the site of penetration of the ventricular catheter. [7],[8] Disconnection of the shunt system would have caused shunt obstruction in our case. The second probable mechanism is leakage of CSF from the ventricles into the parenchyma through the patent perforations lying outside the ventricle. Pediatric population is more prone to develop these cysts due to two reasons. Firstly, the brain parenchyma of pediatric patients is soft and yielding. Secondly, young patients develop ventricular tautness after shunt installation more frequently. [7]
Chiba et al. in their review noted that pericather cysts are an early post-operative complication of shunt surgery (develops within 6 weeks of operation). [8] However, Rim et al. have found that duration between surgery and cyst identification ranged from 1 month to 4 years. [3] Hence, we feel that the pericatheter cyst might have developed in the early post-operative period, but became symptomatic only after a year. The shunt catheter might have acted as an epileptic focus leading to presentation as seizures. Pericatheter cysts may also present as focal neurological deficits such as hemiparesis, sensory disturbances, visual deterioration etc., depending on site of cyst formation. [1],[2]
Shunt revision is advisable in cases of shunt obstruction. Most of the cases in literature who had focal neurological deficits following cyst formation needed removal of existing shunt followed by revision. [1],[2],[3],[4],[6],[7] Other modalities include, cortisectomy with cyst aspiration, marsupialization or cystoperitoneal shunt. [1] These modalities may be needed only in recurrent cysts. In some cases of over-drainage with slit ventricle, an anti-siphon device is advisable. [7] Sinha et al. reported two cases of pericather cysts following VP shunt insertion, which were totally asymptomatic. Following removal of shunt they were serially followed with imaging, which showed regression of cyst size. [5] Our patient too did not need shunt revision and improved with shunt removal and neurological observation. However, a longer close follow-up (clinical and radiological) is warranted to rule out the necessity of a repeat shunt procedure at a later date.
Considering the frequency of VP shunt procedures, pericatheter cyst formation is a very rare complication. These cysts can present late and awareness on the part of the surgeon is needed to recognize this pathology. All cases of shunt disconnection should be evaluated for development of this condition. Though, shunt revision is the accepted treatment modality, careful neurological observation can be carried out after shunt removal especially in asymptomatic cases with compensated hydrocephalus.
References
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