Management of acute hydrocephalus due to pregnancy with ventriculoperitoneal shunt

Abstract

IntroductionThe ventriculoperitoneal (VP) shunt is an effective andmainstay of treatment for hydrocephalus. Although VPshunt reduces the morbidity and mortality of hydrocepha-lus considerably, it often malfunctions due to complica-tions such as obstruction, breakage, migration and infection[1, 2]. In pregnant women, shunt malfunction occurs due toincreasing abdominal pressure associated with enlargementof the uterus and other organs [3]. We present a case inwhich the patient presented an acute VP shunt malfunctionin the third trimester of pregnancy, and the externaldrainage of cerebrospinal fluid (CSF) management relievedher symptoms, so that she was able to successfully deliver ahealthy infant vaginally.Case reportAn 18-year-old female, who was at 30 weeks of gestation,was admitted to our emergency room due to acute distur-bance of consciousness. A computed tomography (CT)scan showed dilation of the ventricles (Fig. 1d).Previously, about 2 years ago, the patient had a pro-gressive visual impairment. Magnetic resonance images(MRIs) of the head indicated obstructive hydrocephalusdue to the rupture of an epidermoid cyst in the fourthventricle (Fig. 1b). Since the content of the epidermoidcyst had flowed to all ventricles and total resection of thecyst was impossible (Fig. 1a), a ventriculoperitoneal (VP)shunt was placed in the right lateral ventricle. Her visionreturned back to normal with rare headaches. A CT scanafter the procedure confirmed the relief of hydrocephalus(Fig. 1c).In the emergency room, the patient was not able to openher eyes spontaneously and showed flexion to pain with noverbal response (Glasgow Coma Scale, GCS 5 E1V1M3).A quick but systematic evaluation was made by bothneurosurgeons and obstetricians. The shunt catheter was inthe right lateral ventricle. The pressure of the shunt valvewas high, but the flexibility was good. The heart rate of thefetus was around 140 beats per minute. The reason for theVP shunt malfunction was due to increased intra-abdominalpressure because of the pregnancy. An external drainage inthe left ventricles was done immediately under generalanesthesia.After the procedure, approximately 60 ml of clear CSFwas drained per day and the CSF analyses were normal.The patient’s neurological condition was graduallyimproved (GCS8 E1V1M6) with a better flowing ventriclesystem that was confirmed by the CT scan (Fig. 1d). Twodays after the external drainage, premature rupture of themembrane was detected and vaginal delivery was per-formed successfully without epidural analgesia but underclose surveillance by neurosurgeons and obstetricians. Theinfant was healthy with an Apgar score of ten. The externaldrainage catheter was removed 2 days later on the condi-tion that VP shunt reverted functioning, confirmed byanother CT scan (Fig. 1f). The patient was discharged18 days after surgery.