- Neurosurgery Division, Department of Surgery, Udayana University, Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Indonesia
Correspondence Address:
Christopher Lauren, Neurosurgery Division, Department of Surgery, Udayana University, Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Indonesia.
DOI:10.25259/SNI_754_2024
Copyright: © 2025 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Anak Agung Ngurah Agung Harawikrama Adityawarma, Christopher Lauren, Angky Saputra, Joshua Sutikno, Made Gemma Daniswara Maliawan, Tjokorda Gde Bagus Mahadewa. Ventriculoperitoneal shunt-associated giant intraperitoneal cerebrospinal fluid pseudocysts: A case report and literature review. 24-Jan-2025;16:19
How to cite this URL: Anak Agung Ngurah Agung Harawikrama Adityawarma, Christopher Lauren, Angky Saputra, Joshua Sutikno, Made Gemma Daniswara Maliawan, Tjokorda Gde Bagus Mahadewa. Ventriculoperitoneal shunt-associated giant intraperitoneal cerebrospinal fluid pseudocysts: A case report and literature review. 24-Jan-2025;16:19. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=13348
Abstract
Background: Ventriculoperitoneal (VP) shunt placement, a common treatment for hydrocephalus, can lead to various complications, including the formation of cerebrospinal fluid (CSF) pseudocysts within the peritoneal cavity. Although rare, occurring in 1–4.5% of cases, these pseudocysts pose significant clinical challenges due to their potential recurrence and the complexity of their management. The optimal management strategy depends on individual patient factors and the presence of infection.
Case Description: A 24-year-old woman presented with decreased consciousness, worsening headaches, and progressive abdominal enlargement. Imaging revealed a giant intraperitoneal cystic lesion, initially suspected to be a malignant ovarian cyst, but later identified as a CSF pseudocyst associated with the distal tip of a VP shunt placed 9 years earlier. The patient underwent urgent shunt revision, converting to a ventriculoatrial shunt. Postoperatively, her neurological status improved, and the abdominal mass resolved completely within 3 weeks. Follow-up over 1 year confirmed the absence of recurrence or neurological deficits.
Conclusion: VP shunt-associated intraperitoneal CSF pseudocysts, while rare, can develop long after shunt placement and present significant diagnostic and management challenges. Early recognition and appropriate surgical intervention are crucial to prevent complications. This case underscores the importance of individualized treatment approaches and diligent follow-up to ensure favorable outcomes, even in complex cases.
Keywords: Cerebrospinal fluid, Cyst, Neurosurgical procedures, Ventriculoperitoneal shunt
INTRODUCTION
Ventriculoperitoneal (VP) shunt placement can lead to various complications, including shunt obstruction, tip migration, infection, and issues with cerebrospinal fluid (CSF) drainage.[
Among these, the formation of a CSF pseudocyst within the peritoneal cavity is a rare but serious complication, occurring in 1–4.5% of cases with a recurrence rate of up to 19.8%.[
In this report, we present the case of a 24-year-old woman diagnosed with a VP shunt-associated giant intraperitoneal CSF pseudocyst. We will detail the patient’s medical history, diagnostic findings, management, postoperative care, and outcomes, followed by a discussion of this case in the context of existing literature.
CASE PRESENTATION
A 24-year-old woman presented to the emergency department with a complaint of decreased consciousness that had begun one day earlier. Previously, the patient had been fully alert, but she had suddenly become difficult to awaken in the morning and was disoriented when spoken to. She had been experiencing headaches for the past month, with the pain worsening over the previous week. In addition, the patient reported gradual abdominal enlargement over the past year, which had developed slowly and without pain. A week prior, she had undergone an abdominal computed tomography (CT) scan, which revealed a cystic lesion measuring approximately 23.9 × 18.6 × 28.9 cm, with solid components along the edges and minimal septations, extending from the pelvic cavity to the abdominal cavity [
On initial examination, the patient’s Glasgow coma scale (GCS) score was Eye 3, Verbal 4, and Motor 6. Bilateral papilledema was observed, but there were no meningeal signs, neck stiffness, or other neurological abnormalities. A head CT scan revealed acute hydrocephalus, with the proximal tip of the shunt located in the third ventricle [
Figure 2:
Non-contrast head computed tomography (CT) scans before and after shunt revision. (a and b) Pre-revision CT scans show the proximal shunt tip within the third ventricle in the (a) axial and (b) coronal views. (c) Post-revision CT scan shows the shunt catheter correctly positioned in the frontal horn of the right lateral ventricle.
The patient underwent a shunt system replacement with the insertion of a ventriculoatrial shunt on the same day. Cultures from the distal shunt tip showed no bacterial growth. On the 1st postoperative day, the patient’s condition improved, and she regained full consciousness with a GCS score of 15 without any additional neurological deficits. The patient was monitored in the hospital for 5 days, and a follow-up CT scan confirmed proper positioning of the proximal shunt tip in the anterior horn of the right lateral ventricle [
DISCUSSION
VP shunt placement is a common neurosurgical procedure used to treat hydrocephalus by diverting CSF from the ventricles to the peritoneal cavity. Although VP shunt procedures are generally safe and straightforward, complications such as shunt obstruction, shunt tip migration, infection, and under or over-drainage can occur. CSF pseudocyst formation is a rare complication, occurring in only 1–4.5% of cases, with a recurrence rate of up to 19.8%.[
While the pathophysiology of pseudocyst formation is not fully understood, several factors, including CSF protein levels, peritoneal adhesions from previous abdominal surgeries, repeated shunt revisions, and alterations in CSF absorption due to peritoneal inflammatory reactions, may contribute to this complication in both pediatric and adult patients.[
Pseudocysts are more commonly observed in children, with only 30 reported cases in adults.[
Intraperitoneal pseudocysts can be detected through imaging modalities such as ultrasound and CT scan. These studies typically show a well-defined intraperitoneal fluid collection without septations, with the distal shunt tip located within or near the pseudocyst.[
Management of abdominal pseudocysts can vary. Surgical intervention with cyst evacuation and repositioning of the shunt catheter within the peritoneal cavity has a success rate of 70% and is the primary treatment option, especially in non-infectious cases. Other therapeutic options, such as external ventricular drainage, laparotomy, laparoscopy-assisted fluid drainage, and CT-guided needle aspiration with or without surgical evacuation, have also been reported in some cases. Ultrasound-guided aspiration may be performed to relieve acute symptoms while awaiting elective shunt revision. In cases of recurrent pseudocysts or shunt malfunction, as observed in our case, converting the shunt to a ventriculoatrial or ventriculopleural system may be a viable treatment option. If recurrent pseudocysts or shunt malfunctions occur, it may indicate that the peritoneal cavity is no longer a suitable long-term option for shunt placement, and shunt diversion to an alternative location should be considered.[
CONCLUSION
VP shunt-associated intraperitoneal CSF pseudocysts are rare but significant complications that can occur years after shunt placement. Factors such as elevated CSF protein levels, peritoneal adhesions, and inflammatory reactions to shunt materials contribute to their development. Accurate diagnosis is critical to avoid treatment delays. Management should be individualized, with alternative shunt systems considered in cases of recurrent pseudocysts or malfunction. This case demonstrates that, with appropriate intervention and follow-up, favorable outcomes are achievable without recurrence or neurological deficits.
Ethical approval:
The Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship:
Nil.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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