CASE REPORT Open Access Subgaleal coiling of the proximal and … · 2017. 8. 29. · 3. Fewel ME,...
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CASE REPORT Open Access Subgaleal coiling of the proximal and distal components of a ventriculoperitoneal shunt Brian T Kloss 1* , David M Hart 2 and LaLainia Secreti 1 Abstract Migration is a rare complication of venticuloperitoneal shunts and is thought to be associated with the “memory” of the plastic tubing and the windlass effect of neck flexion and extension. The purpose of this case report is to detail a very rare case of complete distal to proximal shunt migration. Case Report An 11-month-old female with a history of multilocu- lated, complex intracranial cysts with shunt-dependent hydrocephalus and seizure disorder presented to the emergency department with a 2-day history of lethargy, sleepiness, nausea and vomiting. The patient was 3 days status post insertion of a left ventriculoperitoneal shunt insertion. Vital signs were stable, and physical exam revealed a large subgaleal mass at the left occipital area. (Figures 1 and 2) Skull films (Figures 3 and 4) and head CT (Figures 5 and 6) revealed that the shunt catheter was located completely outside the cranium and con- tained within it a 3.4 × 5.1 × 4.0-cm subgaleal fluid- filled pocket. The child was taken back to the OR, and a new shunt catheter was placed without complication. The child has since been doing well. Significant proximal shunt migration is an extremely rare complication that has only been reported in the lit- erature on six occasions [1-5], with the full migration of the distal and proximal aspects of the shunt catheter into a subgaleal pocket reported only twice [2,4]. The proposed mechanism for the migration of the catheter involves the “ windlass ” effect combined with the retained “memory” of the shunt tubing [2]. The flexion and extension of the child’s neck in the days following the surgery combined with the “memory” of the plastic tubing were the likely culprits causing the shunt migration. * Correspondence: [email protected] 1 SUNY Upstate Medical University, Syracuse, NY Full list of author information is available at the end of the article Figure 1 Side Photograph Showing Coiled Shunt. Figure 2 Top Photograph Showing Coiled Shunt. Kloss et al. International Journal of Emergency Medicine 2012, 5:15 http://www.intjem.com/content/5/1/15 © 2012 Kloss et al; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transcript of CASE REPORT Open Access Subgaleal coiling of the proximal and … · 2017. 8. 29. · 3. Fewel ME,...
CASE REPORT Open Access
Subgaleal coiling of the proximal and distalcomponents of a ventriculoperitoneal shuntBrian T Kloss1*, David M Hart2 and LaLainia Secreti1
Abstract
Migration is a rare complication of venticuloperitoneal shunts and is thought to be associated with the “memory”of the plastic tubing and the windlass effect of neck flexion and extension. The purpose of this case report is todetail a very rare case of complete distal to proximal shunt migration.
Case ReportAn 11-month-old female with a history of multilocu-lated, complex intracranial cysts with shunt-dependenthydrocephalus and seizure disorder presented to theemergency department with a 2-day history of lethargy,sleepiness, nausea and vomiting. The patient was 3 daysstatus post insertion of a left ventriculoperitoneal shuntinsertion. Vital signs were stable, and physical examrevealed a large subgaleal mass at the left occipital area.(Figures 1 and 2) Skull films (Figures 3 and 4) and headCT (Figures 5 and 6) revealed that the shunt catheterwas located completely outside the cranium and con-tained within it a 3.4 × 5.1 × 4.0-cm subgaleal fluid-filled pocket. The child was taken back to the OR, and anew shunt catheter was placed without complication.The child has since been doing well.Significant proximal shunt migration is an extremely
rare complication that has only been reported in the lit-erature on six occasions [1-5], with the full migration ofthe distal and proximal aspects of the shunt catheterinto a subgaleal pocket reported only twice [2,4]. Theproposed mechanism for the migration of the catheterinvolves the “windlass” effect combined with theretained “memory” of the shunt tubing [2]. The flexionand extension of the child’s neck in the days followingthe surgery combined with the “memory” of the plastictubing were the likely culprits causing the shuntmigration.
* Correspondence: [email protected] Upstate Medical University, Syracuse, NYFull list of author information is available at the end of the article
Figure 1 Side Photograph Showing Coiled Shunt.
Figure 2 Top Photograph Showing Coiled Shunt.
Kloss et al. International Journal of Emergency Medicine 2012, 5:15http://www.intjem.com/content/5/1/15
© 2012 Kloss et al; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons AttributionLicense (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work is properly cited.
Author details1SUNY Upstate Medical University, Syracuse, NY 2University of RochesterMedical Center, Rochester, NY
Authors’ contributionsBK oversaw and edited the case report and the organization of the imagesas published. DH researched the current literature and wrote the body ofthe paper. LS oversaw patient care in the ED and obtained verbal andwritten consent for publication. All authors read and approved the finalmanuscript.
Competing interestsThe authors declare that they have no competing interests.
Received: 15 November 2010 Accepted: 16 March 2012Published: 16 March 2012
References1. Cheng JY, Lo WC, Liang HH, Kun IH: Migration of ventriculoperitoneal
shunt into the stomach, presenting with gastric bleeding. Acta Neurochir(Wien) 2007, 149(12):1269-70.
2. Dominguez CJ, Tvagi A, Hall G, Timothy J, Chumas PD: Sub-galeal coilingof the proximal and distal components of a ventriculo-peritoneal shunt.An unusual complication and proposed mechanism. Childs Nerv Syst2000, 16(8):493-5.
3. Fewel ME, Garton HJ: Migration of distal ventriculoperitoneal shuntcatheter into the heart. Case report and review of the literature. JNeurosurg 2004, 100(2 Suppl Pediatrics):206-11.
4. Heim RC, Kaufman BA, Park TS: Complete migration of peritoneal shunttubing to scalp. Childs Nerv Syst 1994, 10(6):399-400.
Figure 3 AP Skull Showing Coiled Shunt.
Figure 4 Lateral Skull Showing Coiled Shunt.
Figure 5 Cross Section CT Showing Coiled Shunt.
Figure 6 Cross Section CT Showing Coiled Shunt andHydrocephalus.
Kloss et al. International Journal of Emergency Medicine 2012, 5:15http://www.intjem.com/content/5/1/15
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5. Kim KJ, Wang KC, Cho BK: Proximal migration and cutaneous coiling of aperitoneal catheter: report of two cases. Childs Nerv Syst 1995,11(7):428-31.
doi:10.1186/1865-1380-5-15Cite this article as: Kloss et al.: Subgaleal coiling of the proximal anddistal components of a ventriculoperitoneal shunt. International Journalof Emergency Medicine 2012 5:15.
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