Ventriculoperitoneal shunt complications: Difference between revisions
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*Highest incidence of postoperative complications of any neurosurgical procedure | *Highest incidence of postoperative complications of any neurosurgical procedure | ||
**Majority in the first 2 years (40% in the first year<ref>Drake JM, Kestle JRW, Tuli S. CSF shunts 50 years on past, present and future. Child’s Nerv Syst. 2000; 16:800–804. </ref>) | **Majority in the first 2 years (40% in the first year<ref>Drake JM, Kestle JRW, Tuli S. CSF shunts 50 years on past, present and future. Child’s Nerv Syst. 2000; 16:800–804. </ref>) | ||
*May drain into peritoneal cavity or less commonly the | *May drain into peritoneal cavity or less commonly the right atrium, pleural cavity, ureter, gallbladder | ||
[[File:vpvalve.png|thumb]] | [[File:vpvalve.png|thumb]] | ||
==Clinical Features== | ==Clinical Features== | ||
* | *Typically develop over several days | ||
* | ===Adults=== | ||
*[[headache|Cephalgia]], [[nausea and vomiting]], [[lethargy]], [[ataxia]], [[altered mental status]] | |||
*Paralysis of upward gaze ("sunset eyes"), dilated pupils, [[cranial nerve palsies]] | |||
* | |||
===Infants=== | |||
*[[nausea and vomiting (peds)|Vomiting]], irritability, [[bulging fontanelle]] | |||
**Often '''very subtle''': a caregiver-reported change in behavior predicts malfunction | **Often '''very subtle''': a caregiver-reported change in behavior predicts malfunction | ||
===Physical Exam=== | |||
*Neither sensitive nor specific | |||
*[[AMS|Decreased level of consciousness]], erythema along shunt tract, [[bulging fontanelle]], [[nausea/vomiting]], irritability should raise suspicion | |||
*Valve chamber abnormality | |||
**Gently compress chamber and observe for refill | |||
**Difficulty compressing chamber indicates distal flow obstruction | |||
**Slow refill (>3s) indicates proximal obstruction | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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**Can lead to occlusion and/or abdominal pain (depending on size) | **Can lead to occlusion and/or abdominal pain (depending on size) | ||
== | ==Evaluation== | ||
[[File:NormalVPshunt.jpg|thumb|Slit-like ventricles are expected to be seen on CT in a well-functioning shunt]] | |||
*CBC, Chem7, coags | *CBC, Chem7, coags | ||
*Blood cultures | *Blood cultures | ||
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***AP and lateral skull, AP chest and abdomen | ***AP and lateral skull, AP chest and abdomen | ||
***Identifies kinking, migration, or disconnection | ***Identifies kinking, migration, or disconnection | ||
**CT | **[[head CT|CT]] | ||
***Needed to evaluate ventricular size (if larger, concerning for elevated ICP) | ***Needed to evaluate ventricular size (if larger, concerning for elevated ICP) | ||
***Very helpful to compare to previous study (many | ***Very helpful to compare to previous study (many patients with shunts have abnormal baseline) | ||
***One-third of patients with shunt malfunction will have normal head CT{{Citation needed|reason=Reliable source needed|date=March 2016}} | ***One-third of patients with shunt malfunction will have normal head CT{{Citation needed|reason=Reliable source needed|date=March 2016}} | ||
** | **[[Ultrasound]] | ||
***If the baby has an open fontanelle, you may use US | ***If the baby has an open fontanelle, you may use US | ||
***Some literature for | ***Some literature for [[ultrasound]] of optic nerve diameter (if normal (3.3cm), lower chance of elevated ICP){{Citation needed|reason=Reliable source needed|date=March 2016}} | ||
==Management== | ==Management== | ||
*Assume shunt malfunction in | *Assume shunt malfunction in patients with suggestive features regardless of findings on imaging | ||
*Revisions are extremely common, low threshold to contact Neurosurgery | *Revisions are extremely common, low threshold to contact Neurosurgery | ||
*[[Ventriculoperitoneal shunt drainage]] | *[[Ventriculoperitoneal shunt drainage]] | ||
==Disposition== | |||
==See Also== | ==See Also== | ||
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<references/> | <references/> | ||
[[Category: | [[Category:Neurology]] | ||
Latest revision as of 02:59, 8 August 2021
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 right atrium, pleural cavity, ureter, gallbladder
Clinical Features
- Typically develop over several days
Adults
- Cephalgia, nausea and vomiting, lethargy, ataxia, altered mental status
- Paralysis of upward gaze ("sunset eyes"), dilated pupils, cranial nerve palsies
Infants
- Vomiting, irritability, bulging fontanelle
- Often very subtle: a caregiver-reported change in behavior predicts malfunction
Physical Exam
- Neither sensitive nor specific
- Decreased level of consciousness, erythema along shunt tract, bulging fontanelle, nausea/vomiting, irritability should raise suspicion
- Valve chamber abnormality
- Gently compress chamber and observe for refill
- Difficulty compressing chamber indicates distal flow obstruction
- Slow refill (>3s) indicates proximal obstruction
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 leading to increased ICP
Abdominal Complications
- Pseudocyst may form around the peritoneal catheter
- Can lead to occlusion and/or abdominal pain (depending on size)
Evaluation
- CBC, Chem7, coags
- Blood cultures
- Shunt tap if concerned for infection (this is usually done by or in consultation with neurosurgery)
- A normal lumbar puncture does not rule out ventriculitis (shunt infection)
- Imaging
- Shunt series
- AP and lateral skull, AP chest and abdomen
- Identifies kinking, migration, or disconnection
- CT
- Needed to evaluate ventricular size (if larger, concerning for elevated ICP)
- Very helpful to compare to previous study (many patients with shunts have abnormal baseline)
- One-third of patients with shunt malfunction will have normal head CT[citation needed]
- Ultrasound
- If the baby has an open fontanelle, you may use US
- Some literature for ultrasound of optic nerve diameter (if normal (3.3cm), lower chance of elevated ICP)[citation needed]
- Shunt series
Management
- Assume shunt malfunction in patients with suggestive features regardless of findings on imaging
- Revisions are extremely common, low threshold to contact Neurosurgery
- Ventriculoperitoneal shunt drainage
Disposition
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.