Ventriculoperitoneal shunt complications: Difference between revisions
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***Needed to evaluate ventricular size | ***Needed to evaluate ventricular size | ||
***Very helpful to compare to previous study (many pts w/ shunts have abnormal baseline) | ***Very helpful to compare to previous study (many pts w/ shunts have abnormal baseline) | ||
***One third of patients with shunt malfunction will have normal head CT | |||
**If the baby has an open fontanelle, you may use US | **If the baby has an open fontanelle, you may use US | ||
Revision as of 23:13, 4 March 2016
Background
- Also called a cerebral sinus fluid (CSF), VP, or cerebral shunt
- Highest incidence of postoperative complications of any neurosurgical procedure
- Majority in the first 2 years (40% in the first year[1])
- May drain into peritoneal cavity or less commonly the R atrium, pleural cavity, ureter, GB
Clinical Features
- Develop over several days
- Adults
- Cephalgia, N/V, lethargy, ataxia, altered mental status
- Paralysis of upward gaze ("sunset eyes"), dilated pupils, CN palsies
- Infants
- Vomiting, irritability, bulging fontanelle
- Often very subtle: a caregiver-reported change in behavior predicts malfunction
Differential Diagnosis
Ventriculoperitoneal shunt problems
- Ventriculoperitoneal shunt obstruction
- Ventriculoperitoneal shunt overdrainage (Slit Ventricle Syndrome)
- Ventriculoperitoneal shunt infection
- Ventriculoperitoneal shunt mechanical failure
Loculation of Ventricles
- Separate, noncommunicating CSF accumulations may develop within a ventricle
- Shunt device unable to drain entire ventricular system -> incr ICP
Abdominal Complications
- Pseudocyst may form around the peritoneal catheter
- Can lead to occlusion and/or abdominal pain (depending on size)
Diagnosis
- Physical Exam
- Neither Sn nor Sp
- But decreased level of consciousness, erythema along shunt tract, buldging fontanel, n/v, irritability have PPV for shunt problem.
- Locate valve chamber
- Gently compress chamber and observe for refill
- Difficulty compressing chamber indicates distal flow obstruction
- Slow refill (>3s) indicates proximal obstruction
- Neither Sn nor Sp
- Imaging
- Shunt series
- AP and lateral skull, AP chest and abdomen
- Identifies kinking, migration, or disconnection
- CT
- Needed to evaluate ventricular size
- Very helpful to compare to previous study (many pts w/ shunts have abnormal baseline)
- One third of patients with shunt malfunction will have normal head CT
- If the baby has an open fontanelle, you may use US
- Shunt series
Management
- Assume shunt malfunction in pts w/ suggestive features regardless of findings on imaging
- Revisions are extremely common, low threshold to contact Neurosurgery
- Ventriculoperitoneal shunt drainage
See Also
References
- ↑ Drake JM, Kestle JRW, Tuli S. CSF shunts 50 years on past, present and future. Child’s Nerv Syst. 2000; 16:800–804.
Bober, Jacqueline, DO, FAAP, Rochlin, Jonathan, MD, Marneni, Shashidhar, MD. Ventriculoperitoneal Shunt Complications In Children: An Evidenced-Based Approach to Emergency Department Management. Pediatric Emergency medicine Practice. Vol 13, Num 2. Feb, 2016.