- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Professor of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
- Neurosurgeon, Arad Hospital, Tehran University of Medical Sciences, Tehran, Iran
Neurosurgeon, Arad Hospital, Tehran University of Medical Sciences, Tehran, Iran
DOI:10.4103/2152-7806.152734Copyright: © 2015 Amirjamshidi A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Amirjamshidi A, Abbasioun K, Ghassemi B. Fractured inlet connecting tube of the flat bottom flushing device of a posterior fossa cystoperitoneal shunt. Surg Neurol Int 05-Mar-2015;6:36
How to cite this URL: Amirjamshidi A, Abbasioun K, Ghassemi B. Fractured inlet connecting tube of the flat bottom flushing device of a posterior fossa cystoperitoneal shunt. Surg Neurol Int 05-Mar-2015;6:36. Available from: http://sni.wpengine.com/surgicalint_articles/fractured-inlet-connecting-tube-of-the-flat-bottom-flushing-device-of-a-posterior-fossa-cystoperitoneal-shunt/
Background:There are well-known complications for shunt procedures. Shunt fracture or disconnection is the second most frequent cause of shunt malfunction in children. Shunt disconnection is not a common cause of shunt malfunction in the early period after installation, especially in the adulthood.
Case Description:Fracture of the proximal (inlet) connector of a flat-based shunt installed for decompression of a large posterior fossa arachnoid cyst in a 31-year-old female with signs of increased intracranial pressure led to recurrence of her symptoms 6 months after surgery.
Conclusion:Awareness of the possibility of fracture site in the junction of the inlet connector of flat bottom shunt systems is warranted and can be diagnosed by three-dimensional computed tomography (3D CT) imaging without performing shunt series study.
Keywords: Cystoperitoneal shunt, hydrocephalus, shunt malfunction, shunt revision
Placement of a ventriculo-peritoneal shunt (VPS) or cystoperitoneal shunt (CPS) is one of the most common surgeries for managing hydrocephalus and intracranial arachnoid cysts. There are well-known complications for this procedure and shunt fracture or disconnection is the second most frequent cause of shunt malfunction in children comprising up to 11% of the causes of shunt malfunction in the series with longer follow up periods.[
Fractures of the peritoneal catheter occur most commonly in the neck, the area where the tube is subject to any kind of mechanical stress.[
A 31-year-old female was admitted complaining of chronic headache, vertigo, and blurred vision for more than 6 months. She was married and had a 4-year-old child delivered by vaginal delivery. There was no history of head trauma, meningitis, or lumbar puncture. Neurological examination was normal except for bilateral moderate papilledema with limited visual field in all directions and decreased visual acuity to 0.7 on Snellen scaling system. Regular laboratory test and hormonal studies were all normal and she was not on any kind of medications except analgesics for headache. Magnetic resonance imaging (MRI) showed dilated supratentorial ventricular system with a dilated cisterna magna [
A medium pressure shunt with flat-based flushing device (Fuji System Corporation) was installed. With patient in supine position and head turned 45° to the left, a burr hole was placed in the right sub-occipital region. Tubing of the subcutaneous tissue for placement of the peritoneal tube was performed in standard manner. Dura was bluish and tight. The ventricular catheter was shortened to less than 4 cm and connected to the inlet connector of the flushing device before opening the dura. A small incision of the dura led to a gush of CSF and the shortened ventricular catheter was installed into the cyst cavity. The flushing device was fixed to the adjacent pericranium with four 40 silk sutures. The postoperative course was uneventful and her headache and vision improved remarkably the day after surgery. The device was palpable beneath the skin and could be flushed easily.
The magnetic resonance imaging (MRI) performed after 5 months showed remarkable decrease of the cyst volume, smaller ventricular system, and bilateral collection of thin layer-subdural fluid [
On exploring the shunt during the operation, the cyst catheter and the part of the connector, which was tied to it [
Complications of valve reservoirs or flushing devices are seldom reported as a cause of shunt malfunction.[
The typical presentation of a fractured shunt system is usually quite late. The most common location for a fracture is along the distal catheter segment, often near the clavicle or over the lower ribs.[
According to our review, collapse and intracranial migration of the valve reservoir, disconnection of the plastic dome from the metallic base of the reservoir, fracture in the soldered joint of the distal tube to the reservoir dome in an ‘Integral shunt,’ and fracture at the hardened plastic connecter lying within the unitized portion of the ventricular catheter of a Snap shunt (2 cases) are the similar complications reported in the literature.[
Accurate diagnosis of VPS malfunction is a challenging clinical task that most neurosurgeons face. A new shunt system has an expected survival time of approximately 73 months. The failure rate is reported to be 48% at 2 years and 59% at 4 years following placement.[
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