- Department of Surgery, General Hospital “Sava Surgery” Bulevar Zorana Djindjica, Serbia
- Ophthalmologic Clinic, Clinical Center Niš, Bulevar Zorana Djindjica 48, Serbia
- Center for Radiology, Clinical Center Niš, Bulevar Zorana Djindjica 48, Serbia
Milenkovic J. Zoran
Center for Radiology, Clinical Center Niš, Bulevar Zorana Djindjica 48, Serbia
DOI:10.4103/2152-7806.85982Copyright: © 2011 Zoran MJ. 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: Zoran MJ, Biljana SS, Ivana MP. Relocation of ventricular catheter trough ventriculostomy due to congenital unilateral hydrocephalus: Nine year follow-up. Surg Neurol Int 12-Oct-2011;2:141
How to cite this URL: Zoran MJ, Biljana SS, Ivana MP. Relocation of ventricular catheter trough ventriculostomy due to congenital unilateral hydrocephalus: Nine year follow-up. Surg Neurol Int 12-Oct-2011;2:141. Available from: http://sni.wpengine.com/surgicalint_articles/relocation-of-ventricular-catheter-trough-ventriculostomy-due-to-congenital-unilateral-hydrocephalus-nine-year-follow-up/
Background:Congenital unilateral hydrocephalus is an uncommon entity occurring almost exclusively in children. Atresia, stenosis, membranous occlusion and even functional obstruction of the foramen of Monro have been described to be the main cause of this type of hydrocephalus. There are two options available in the surgical management of unilateral hydrocephalus: one is the placement of shunt CSF diversion from the dilated ventricle and the other is fenestration of the occluded foramen of Monro or septum pellucidum by endoscopy or by stereotactic method. Migration of the ventriculoperitoneal (VP) shunt in or out of ventricles is not so uncommon, but the relocation of the ventricular tip of a catheter from the ventricle into the quadrigeminal cisterns and superior vermis in association with ventriculostomy is extremely rare. Spontaneous ventriculostomy is a rare event and results from spontaneous rupture of a ventricle into the subarachnoid space.
Case Description:A 5½-month-old baby with a right-sided congenital unilateral hydrocephalus underwent a VP shunt andhad experienced an uneventful outcome. Four years later on an MR imaging examination, the tip of the ventricular catheter passing through the medial wall of the ventricle and the quadrigeminal cistern was found to be situated in the superior vermis. During the follow-up period, there were no neurological difficulties. The cognitive and motor skill development corresponded well with the child's age. It transpired that the hydrocephalic ventricle reduced its size dramatically to normal.
Conclusion:We have described the extremely rare site of the relocation of the ventricular catheter after the treatment of the congenital unilateral hydrocephalus by VP shunting. Spontaneous ventriculostomy as a rare phenomenon may be the explanation of the relocation of the ventricular catheter.
Keywords: Congenital unilateral hydrocephalus, ventriculoperitoneal shunt, ventriculostomy
Migration of the ventriculoperitoneal (VP) shunt in or out of ventricles is not so uncommon, but the relocation of the ventricular tip of a catheter from the ventricle into the quadrigeminal cisterns and superior vermis in association with ventriculostomy is extremely rare and we have not been able to find any case in the currently available literature. We are presenting the case of an infant harboring a unilateral congenital hydrocephalus who was treated with a VP shunt. Almost 4 years later, the tip of the ventricular catheter, passing through the tiny ventricular wall, was found to be situated in the superior vermis. On the other hand, spontaneous ventriculostomy is a rare event and results from the spontaneous rupture of a ventricle into the subarachnoid space. Thereare only four reports regarding this phenomenon at the level of the lateral ventricle.[
A 5½ month-old infant was referred to a neurosurgeon for consultation due to congenital unilateral hydrocephalus detected on MR imaging investigation. From the discharge list of neonates issued by the Pediatric Clinic of the Clinical Center of Nis, Serbia, we were able to find out the course of the disease, outlined below. At 37 weeks of gestation, a boy weighing 3759 g, with an Apgar score of 9 at 1 min, was delivered after prolonged labor on 24th April 2002. Several ultrasound examinations had been performed during pregnancy and all were described as normal except for the last one that was done in the 37th week of gestation, which showed an enlargement of the right lateral ventricle compressing the left one and moving the interhemispheric fissure to the left. The third and forth ventricles were found to have a normal size. The second ultrasound done immediately after the delivery was identical. After birth, his head circumference was found to be 36 cm. The neonate was under thesupervision of a neonatologist and was transferred to the Pediatric clinic due to high fever with signs and symptoms of pneumonia. The infant spent more then 1½ months, being closely observed and treated by pediatrician and neurologist. The neurosurgeon suggested the operation, but the child's parents refused it, believing that the intervention would not bring any benefit. The child was discharged as a severely handicapped hydrocephalic baby with poor prognosis and was referred to pediatrician and neurologist in the outpatient clinic . For the next 4 months, the infant was followed up by them. The parents changed their opinion and the child was referred to the neurosurgeon for further treatment.
On admission, there were slight delays in cognitive and motor development. The neurological examination revealed an inconclusive left side weakness. The MR investigation showed a severe dilatation of the right ventricle, with the atrial diameter over 34 mm and evident midline shift to the left [
Coronal T1w image SE 540/14 (a) shows the severe dilatation of right lateral ventricle and consequent compression and loss of brain tissue in the right temporal and occipital region. Axial FLAIR T1 2200/35 (b) presents the enlargement of right atrium and occipital horn with reduced volume of periventricular and subcortical white matter. Parasagittal T1w image SE 550/20 (c) depicts the marked enlargement of the right lateral ventricle with prominent compression and lack of brain parenchyma volume, predominantly in the temporo-occipital region
(a, b) Coronal, axial and sagittal T1w SE 500/14 images show initial/incipient decompression (and decreased size) of the right lateral ventricle after shunting (right transparietal catheter in situ). Rim of brain parenchyma in the right temporo-occipital region is thicker, consequent to the mild increase of brain volume. Also, there is consequent mild atrial diverticulum and displacement of mediosagittal structures. Right frontal horn is slightly rounded, while the left lateral ventricle is completely decompressed
Spontaneous ventriculostomy is a rare event and results from a spontaneous rupture of a ventricle, generally at the level of the medial wall of the trigone or at the pineal recesses of the third ventricle into the subarachnoid space, but is usually seen in patients with chronic obstructive hydrocephalus. This rupture results in direct communication of the ventricular system with the subarachnoid space.[
Only two children with congenital unilateral hydrocephalus due to stenosis of the foramen of Monro had paraventricular diverticula and spontaneous ventriculostomy. Both patients had a cystic space in the quadrigeminal and supracerebellar cistern.[
The possibility of the overdrainage as a pathophysiological mechanism of the relocation of the catheter cannot be excluded. Overdrainage can occur normally with postural changes, REM sleep and straining. The gravity effect increases the differential pressure across the valve, keeping it open and allowing more CSF drainage. The effects of siphoning depend on multiple factors, occurring to a greater or lesser degree depending upon the type of valve implanted and present conditions. Ventricular overdrainage occurs when siphoning happens chronically and may in turn cause the brain to pull away from the inner surface of the skull, tearing the bridging scalp veins and causing associated bleeding and brain compression, debilitating headaches and slit ventricles and may also induce symptomatic orthostatic hypotension, subdural CSF collections, slit ventricle syndrome, craniosynostosis, loculation of the ventricles and so on. But we were not able to confirm any signs or symptoms related to overdrainage in our patient.
The clarification may lay in application of the NMT neurosciences’ gravity-compensating lumboperitoneal valve system with a ball-in-cone mechanism. This type of valve adds resistance when an individual stands through the weight of several stainless steel balls on a ball-in-cone mechanism. Flow is not restricted when an individual is lying down. Ball-in-cone valves are less prone to the effects of the aging of materials than are miter or slit valves, and they have been demonstrated to handle higher CSF protein levels. This advantage reduces the siphoning effects of the valve. The relocation of ventricular catheter is supposed to be followed by its occlusion which is usually followed by increasing ventricular size confirmed on CT scan or MR imaging. But there has not been increasing ventricular size in our case, in spite of the migration of the catheter outside of the ventricle. Moreover, the shrinkage of the ventricle had taken place during the following period. The communication between the right lateral ventricle and the supracerebellar cistern can be one of the reasonable contexts. This is the reason why we have postulated the option of existing ventriculostomy which enables direct communication of the right ventricle with subarachnoid cisterns, providing dynamic CSF circulation in the brain.
To our knowledge, this is the first report describing the migration of the ventricular tip of the catheter into the upper vermis through ventriculostomy.
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