Ventriculoperitoneal shunt abdominal complications

Ventriculoperitoneal shunt abdominal complications

Abdominal complications include peritonitisascites, bowel and abdominal wall perforation, and inguinal hernias.

Abdominal complications are reported in 5–47 % of ventriculoperitoneal shunt cases 1) 2).

Ascites

Abdominal pseudocyst

Bowel perforation

Hydrocele

Shunt extrusion

Shunt migration

CSF leaks

Viscous perforations

Protrusion of the catheter from the anus

Spontaneous knotting of the peritoneal catheter is a rare complication of the VP shunt 3).

Peritoneal catheter knot formation

Liver abscess

Pyogenic liver abscess in Taiwan is most commonly due to Klebsiella pneumoniae infection in diabetic patients, and less frequently due to biliary tract infections. Liver abscess caused by ventriculoperitoneal (VP) shunt is very rare. We report a case of liver abscess caused by methicillin-resistant Staphylococcus aureus (MRSA), which developed as a complication of an infected VP shunt. A 53-year-old woman, who had shad a VP shunt implanted 3 months previously for hydrocephalus due to intracranial hemorrhage, presented with fever off and on, drowsiness and seizure attacks for 1 week. Computed tomography (CT) of the brain showed only mild right-sided hydrocephalus, and was negative for intracranial hemorrhage and intracranial mass. Analysis of cerebrospinal fluid showed significant pleocytosis and hypoglycorrhachia. CT scan of the abdomen disclosed a huge abscess in the right lobe of the liver. Cultures of both the cerebrospinal fluid and aspirated liver abscess isolated MRSA. The patient was treated with intraventricular and intravenous vancomycin, intravenous teicoplanin and oral rifampicin, followed by oral chloramphenicol and rifampicin. Percutaneous drainage of the liver abscess and externalization of the VP shunt were performed. The liver abscess had resolved almost completely on ultrasonography after 2 weeks of therapy. Liver abscess in patients with a VP shunt should be considered a possible abdominal complication of the VP shunt, and may be caused by unusual pathogens. Diagnosis requires CT scan and direct aspiration and culture of the liver abscess. Treatment requires management of both the liver abscess and the infected shunt 4).

Liver pseudocyst

The formation of a liver pseudocyst is a rare occurrence, and its mechanisms are still largely unknown.

Mallereau et al. reported the case of a 69-year-old woman with a ventriculoperitoneal shunt, inserted for the management of hydrocephalus after aneurysmal subarachnoid hemorrhage, presenting to the Accident and Emergency for acute cholecystitis. Besides confirming the diagnosis, an ultrasound investigation revealed the presence of a hepatic cyst. Conservative treatment with antibiotics and non-steroidal anti-inflammatory drugs was performed with favorable outcomes and resorption of the cyst. Interestingly the patient kept on presenting several similar episodes managed well by non-steroidal anti-inflammatory drugs alone, each of them associated with transient symptoms and signs of ventriculoperitoneal shunt malfunction. Computerized Tomography brain and lumbar puncture were normal, whereas the CT abdomen showed the ventriculoperitoneal shunt distal catheter passing through the hepatic cyst. Given the ventriculoperitoneal shunt malfunction, in the context of an infective/inflammatory process, a conversion of the ventriculoperitoneal shunt into a ventriculoatrial shunt was carried out with a successful clinical outcome.

Based on current literature they propose a clinical and radiological classification of such pseudocysts related to ventriculoperitoneal shunt. Clinical presentation, diagnostic findings, and management options are proposed for each type: purely infective, spurious (infective/inflammatory), and purely inflammatory. In the absence of system infection, a simple replacement of the distal catheter seems to be the best solution 5).

References

1)

Chung J, Yu J, Joo HK, Se JN, Kim M. Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature. American Journal of Roentgenology. 2009;193(5):1311–1317.
2)

Murtagh FR, Quencer RM, Poole CA. Extracranial complications of cerebrospinal fluid shunt function in childhood hydrocephalus. American Journal of Roentgenology. 1980;135(4):763–766.
3)

Borcek AO, Civi S, Golen M, Emmez H, Baykaner MK. An unusual ventriculoperitoneal shunt complication: spontaneous knot formation. Turkish Neurosurgery. 2012;22(2):261–264.
4)

Shen MC, Lee SS, Chen YS, Yen MY, Liu YC. Liver abscess caused by an infected ventriculoperitoneal shunt. J Formos Med Assoc. 2003 Feb;102(2):113-6. PubMed PMID: 12709741.
5)

Mallereau CH, Ganau M, Todeschi J, Addeo PF, Moliere S, Chibbaro S. Relapsing-Remitting Hepatic Pseudo-Cyst: a great simulator of malfunctioning ventriculoperitoneal shunt. Case report and proposal of a new classification. Neurochirurgie. 2020 Oct 10:S0028-3770(20)30399-4. doi: 10.1016/j.neuchi.2020.08.001. Epub ahead of print. PMID: 33049283.

Chronic subdural hematoma surgery complications

Chronic subdural hematoma surgery complications

The most frequent complication after chronic subdural hematoma (CSDH) is chronic subdural hematoma recurrence requiring reoperation. Although several definitions of recurrence have been proposed 1) one of the most consensual definitions of recurrence is the association between new clinical symptoms and hematoma revealed by CT scans. Thus, one can wonder whether a systematic CT scan is necessary after CSDH evacuation for a patient without symptoms.

Common postoperative complications include acute epidural and/or subdural bleeding, tension pneumocephalusintracranial hematomas and ischemic cerebral infarction.

Failure of the brain to re-expand, pneumocephalus, incomplete evacuation, and recurrence of the fluid collection are the most frequently.

Recurrence

see Chronic subdural hematoma recurrence.

Seizures

Seizures (including intractable status epilepticus).

Intracerebral hemorrhage

Intracerebral hemorrhage (ICH): occurs in 0.7–5%. Very devastating in this setting: one–third of these patients die and one third are severely disabled

Brain herniation

Chronic subdural hematoma (CSDH) with brain herniation signs is rarely seen in the emergent department. As such, there are few cumulative data to analyze such cases.

Failure of postoperative cerebral reexpansion

A wide variation in postoperative drainage volumes is observed during treatment of chronic subdural hematoma (CSDH) with twist-drill or burr-hole craniostomy and closed-system drainage.

The postoperative drainage volumes varied greatly because of differences in the outer membrane permeability of CSDH, and such variation seems to be related to the findings on the CT scans obtained preoperatively. Patients with CSDH in whom there is less postoperative drainage than expected should be carefully observed, with special attention paid to the possibility of recurrence 2).

Patients with high subdural pressure showed the most rapid brain expansion and clinical improvement during the first 2 days. Nevertheless, a computerized tomography (CT) scan performed on the 10th day after surgery demonstrated persisting subdural fluid in 78% of cases. After 40 days, the CT scan was normal in 27 of the 32 patients. There was no mortality and no significant morbidity. A study suggests that well developed subdural neomembranes are the crucial factors for cerebral reexpansion, a phenomenon that takes at least 10 to 20 days. However, blood vessel dysfunction and impairment of cerebral blood flow may participate in delay of brain reexpansion. It may be argued that additional surgical procedures, such as repeated tapping of the subdural fluid, craniotomy, and membranectomy or even craniectomy, should not be evaluated earlier than 20 days after the initial surgical procedure unless the patient has deteriorated markedly 3).

Postoperative pneumocephalus

see Tension pneumocephalus after chronic subdural hematoma evacuation.

Remote cerebellar hemorrhage (RCH)

see Remote cerebellar hemorrhage.

Epidural hematoma

After chronic subdural hematoma evacuation surgery, the development of epidural hematoma is a very rare entity.

Akpinar et al. report the case of a 41-year-old man with an epidural hematoma complication after chronic subdural hematoma evacuation. Under general anesthesia, the patient underwent a large craniotomy with closed system drainage performed to treat the chronic subdural hematoma. After chronic subdural hematoma evacuation, there was epidural leakage on the following day.

Although trauma is the most common risk factor in young CSDH patients, some other predisposing factors may exist. Intracranial hypotension can cause EDH. Craniotomy and drainage surgery can usually resolve the problem. Because of rapid dynamic intracranial changes, epidural leakages can occur. A large craniotomy flap and silicone drainage in the operation area are key safety points for neurosurgeons and hydration is essential 4).

Intracranial subdural empyema

A case of intracranial subdural empyema following chronic subdural hematoma drainage 5).

Skin depression

see Skin depression after chronic subdural hematoma surgery.

Oculomotor nerve palsy

see Oculomotor nerve palsy in chronic subdural hematoma.

Pseudohypoxic brain swelling

Pseudohypoxic brain swelling (PHBS) is a rare and potentially fatal complication that may occur in patients following uneventful brain surgery. Fan presented a case of PHBS after chronic subdural hematoma surgery that developed after drilling and drainage. Neuroimaging findings, pathogenic factors, and therapy are also discussed 6).

References

1)

A. Chiari, K. Hocking, E. Broughton, C. Turner, T. Santarius, P. Hutchinson, A. Kolias, Core outcomes and common data elements in chronic subdural hematoma: a systematic review of the literature focused on reported outcomes, J.Neurotrauma 33 (2016) 1212–1219, https://doi.org/10.1089/neu.2015.3983.
2)

Kwon TH, Park YK, Lim DJ, Cho TH, Chung YG, Chung HS, Suh JK. Chronic subdural hematoma: evaluation of the clinical significance of postoperative drainage volume. J Neurosurg. 2000 Nov;93(5):796-9. PubMed PMID: 11059660.
3)

Markwalder TM, Steinsiepe KF, Rohner M, Reichenbach W, Markwalder H. The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage. J Neurosurg. 1981 Sep;55(3):390-6. PubMed PMID: 7264730.
4)

Akpinar A, Ucler N, Erdogan U, Yucetas CS. Epidural Hematoma Complication after Rapid Chronic Subdural Hematoma Evacuation: A Case Report. Am J Case Rep. 2015 Jul 6;16:430-433. PubMed PMID: 26147957.
5)

Ovalioglu AO, Aydin OA. A case of subdural empyema following chronic subdural hematoma drainage. Neurol India. 2013 Mar-Apr;61(2):207-9. doi: 10.4103/0028-3886.111165. PubMed PMID: 23644343.
6)

Fan Q. Pseudohypoxic Brain Swelling after Drilling and Drainage for Chronic Subdural Hematoma. J Neurol Surg A Cent Eur Neurosurg. 2020 Oct 13. doi: 10.1055/s-0040-1712500. Epub ahead of print. PMID: 33049793.

Idiopathic normal pressure hydrocephalus treatment complications

Idiopathic normal pressure hydrocephalus treatment complications

The rate of complications or readmission within 30 d of ventricular shunting for NPH is 25.15%. Preoperative comorbidities of myocardial infarction within 1 yr, cerebrovascular disease, and moderate/severe renal disease are independent risk factors for poor outcomes 1) 2).


The goal is to avoid serious complications, such as subdural effusion or subdural hematomaAdjustable pressure valves offer the advantage of being able to lower the pressure setting incrementally until symptoms improve and to raise the pressure setting if low-pressure symptoms or complications emerge. The introduction of adjustable valves has dramatically lowered the need for shunt revisions, and most complications can be handled by changing the shunt setting. Severe complications, such as subdural hematoma with mass effect, shunt infection, and shunt obstruction, typically require neurosurgical intervention. Adjustable shunts can be used to safely manage patients with Idiopathic normal pressure hydrocephalus who need chronic anticoagulation 3).

Subdural collections, shunt malfunction, and postoperative seizures constituted the most frequent complications 4).

see Shunt overdrainage in idiopathic normal pressure hydrocephalus.

The objectives of Larsson et al., from the Umeå University, in Sweden were to establish the frequencies of epilepsyheadache, and abdominal pain and determine their impact on patient quality of life (QOL), in long-term follow-up after shunt surgery for INPH.

One hundred seventy-six shunt-treated patients with Idiopathic normal pressure hydrocephalus (INPH) (mean age 74 years) and 368 age- and sex-matched controls from the population were included. The mean follow-up time after surgery was 21 months (range 6-45 months). Each participant answered a questionnaire regarding present frequency and severity of headache and abdominal pain. Confirmed diagnoses of epilepsy and all prescriptions for antiepileptic drugs (AEDs) before and after shunt surgery for INPH were gathered from national registries. Equivalent presurgical and postsurgical time periods were constructed for the controls based on the date of surgery (the division date for controls is referred to as virtual surgery). All registry data covered a mean period of 6 years (range 3-8 years) before surgery/virtual surgery and 4 years (range 2-6 years) after surgery/virtual surgery. Provoked epileptic seizures were excluded. Patient QOL was assessed with the EuroQoL 5-dimension 5-level instrument.

Epilepsy was more common in shunt-treated patients with INPH than in controls (4.5% vs 1.1%, respectively; p = 0.023), as was treatment with AEDs (14.8% vs 7.3%, respectively; p = 0.010). No difference was found between the populations before surgery/virtual surgery (epilepsy, 2.3% [INPH] vs 1.1% [control], p = 0.280; AED treatment, 8.5% [INPH] vs 5.4% [control], p = 0.235). New-onset epilepsy and new AED treatment after surgery/virtual surgery were more common in INPH (epilepsy, 2.3% [INPH] vs 0.0% [control], p = 0.011; AED, 8.5% [INPH] vs 3.3% [control], p = 0.015). At follow-up, more patients with INPH than controls experienced headache several times per month or more often (36.1% vs 11.6%, respectively; p < 0.001). Patients with INPH and unilateral headache had more right-sided headaches than controls (p = 0.038). Postural headache was experienced by 16% (n = 27 of 169) of the patients with INPH. Twenty percent (n = 35) of the patients with INPH had persistent abdominal pain. Headache was not correlated to lower QOL. The study was underpowered to draw conclusions regarding QOL in patients with INPH who had epilepsy and abdominal pain, but the finding of no net difference in mean QOL indicates that no correlation between them existed.

Epilepsy, headache, and abdominal pain are common in long-term follow-up in patients after shunt surgery for INPH and are more common among patients with INPH than in the general population. All adverse events, including mild and moderate ones, should be considered during postoperative follow-ups and in the development of new methods for shunt placement 5).

References

1)

Nadel JL, Wilkinson DA, Linzey JR, Maher CO, Kotagal V, Heth JA. Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis. Neurosurgery. 2020 Jun 1;86(6):843-850. doi: 10.1093/neuros/nyz299. PMID: 31420654.
2)

D’Antona L, Thompson SD, Thorne L, Watkins LD, Toma AK. Letter: Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis. Neurosurgery. 2020 Sep 28:nyaa386. doi: 10.1093/neuros/nyaa386. Epub ahead of print. PMID: 32985659.
3)

Goodwin CR, Kharkar S, Wang P, Pujari S, Rigamonti D, Williams MA. Evaluation and treatment of patients with suspected normal pressure hydrocephalus on long-term warfarin anticoagulation therapy. Neurosurgery. 2007 Mar;60(3):497-501; discussion 502. PubMed PMID: 17327794.
4)

Black PM. Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg. 1980 Mar;52(3):371-7. PubMed PMID: 7359191.
5)

Larsson J, Israelsson H, Eklund A, Malm J. Epilepsy, headache, and abdominal pain after shunt surgery for idiopathic normal pressure hydrocephalus: the INPH-CRasH study. J Neurosurg. 2018 Jun;128(6):1674-1683. doi: 10.3171/2017.3.JNS162453. Epub 2017 Sep 8. PubMed PMID: 28885121.
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