A CASE OF OSA IN A PATIENT WITH A VENTRICULO-PERITONEAL SHUNT: A REAL HEADACHE

Abstract

SESSION TITLE: Medical Student/Resident Sleep Disorders Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The patient is a 65 year old female who presented to the pulmonology clinic for management of her Obstuctive Sleep Apnea Syndrome (OSAS). She had been diagnosed with OSAS in early 2017 after a sleep study at an external facility and had been prescribed a Continuous Positive Airway Pressure (CPAP) Machine fitted with an oro-nasal mask. She had not been able to use the CPAP due to recurrent headaches and nasal congestion associated with use. CASE PRESENTATION: The patient was diagnosed with pseudotumo- cerebri after a motor vehicle accident in 2004. A right-sided ventricular shunt catheter (VP shunt) was placed in 2005. Her nausea, dizziness and frequent headaches subsequently resolved. In the interim she had been following up with her neurosurgeon and primary care physician on a regular basis and remained symptom free. She had a past medical history of mild intermittent asthma, pulmonary artery hypertension and hypertension which were well controlled with medical management. Five months after starting to use the CPAP machine she presented to her neurosurgeon with symptoms of dizziness, headaches and gait instability. Visit records were obtained with the patients consent and it was noted the neurological exam at the time was unremarkable and opthalmoscopic inspection did not show any evidence of papilledema. The Ventriculo-Peritoneal (VP) shunt was interrogated at the time and found to be functioning optimally. She was referred for a Computed Tomography (CT) scan of the head and a shunt study. CT head after showed the right frontal shunt catheter in position with a decrease in volume of the right lateral ventricle, there was no evidence of hemorrhage, hydrocephalus or extra-axial fluid. The shunt study showed no evidence of kinking or obstruction in the catheter along its course from the right lateral aspect of the cranium, over the right neck and right hemithorax up to the left abdomen overlying the left sacroiliac joint. The concurrent initiation of her symptoms with starting CPAP machine use warranted enquiry. The patient visited the pulmonology clinic 4 months later. In the interim she had stopped using the CPAP machine and her headaches, dizziness and gait instability had resolved, albeit her OSAS was uncontrolled. DISCUSSION: In view of the unremarkable CT of the head and normal shunt study the patients symptoms were attributed to external compression of the VP shunt by the securing straps of the oro-nasal attachment for the CPAP machine. This periodic occlusion could lead to an intermittent intracranial hypertension, which manifests as dizziness and gait instability with headaches. The intermittent nature of the obstruction resulted in the absence of ventriculomegaly on CT and the normal shunt study. CONCLUSIONS: The patient was fitted with a Dental appliance(Mandibular advancement device/ tongue retaining mouthpiece) for management of her OSAS and her symptoms resolved. Reference #1: Chee, B. N. H., Jalil, M. F. A., & Bulluss, K. J. (2016). Spontaneous pneumocephalus from nasal continuous positive airway pressure in a patient with ventriculo-peritoneal shunt. Journal of Clinical Neuroscience, 34, 215–217. doi: 10.1016/j.jocn.2016.05.040 Reference #2: Salem-Memou, S., Vallee, B., Jacquesson, T., Jouanneau, E., & Berhouma, M. (2016). Pathogenesis of Delayed Tension Intraventricular Pneumocephalus in Shunted Patient: Possible Role of Nocturnal Positive Pressure Ventilation. World Neurosurgery, 85. doi: 10.1016/j.wneu.2015.09.001 Reference #3: Jones, R., Davis, E. M., & Coleman, J. (2016). Pneumocephalus Secondary to CPAP in Setting of Remote Craniofacial Trauma. Chest, 150(4). doi: 10.1016/j.chest.2016.08.276 DISCLOSURES: No relevant relationships by Matthew Castillo, source=Web Response No relevant relationships by Abhishek Chakraborti, source=Web Response No relevant relationships by Erum Zahid, source=Web Response