Migration of the peritoneal tip of a ventriculoperitoneal catheter causing shunt malfunction

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This 6-year-old boy presented with a short history of headache, nausea, and vomiting. He was born prematurely at 24.5 weeks of gestational age and suffered an intraventricular hemorrhage causing hydrocephalus. A ventriculosubgaleal shunt was inserted 4.5 months later, which was converted after 1 month to a ventriculoperitoneal shunt with a medium-pressure valve. The peritoneal catheter was placed using a trocar; no purse-string suture was placed around the opening. An intraoperative lateral radiograph of the abdomen confirmed intraperitoneal placement of the catheter. The shunt was revised twice at the upper end. The last revision had been 3 years prior to presentation, when the valve was changed to an Orbis Sigma valve (Integra NeuroSciences; Sophia Antipolis, France). Upon admission to our institution, the boy was lethargic but otherwise normal neurologically. A computed tomography scan of his head showed no change in ventricular size (Fig. 1), and radiographs of the shunt were nondiagnostic. The patient’s neurological condition subsequently deteriorated, necessitating a shunt revision. During the surgery, the ventricular end was found to be working, but the peritoneal catheter was blocked. When the abdominal wound was opened, the shunt was found to be tracking back along the shunt track. The peritoneal end was removed and a new catheter was inserted via a new abdominal opening into the peritoneum. The patient recovered, and his symptoms resolved immediately. On reviewing the radiographs of the shunt retrospectively, they were found to show the backtracking of the shunt clearly (Fig. 2 upper). Radiographs of the shunt obtained 1 year previously had shown normal findings (Fig. 2 lower). Retrograde migration of a shunt in the same track is rare; one case of its occurrence in a 1-year-old patient has been previously reported. 1 In that case it was hypothesized to be due to a combination of excess catheter, a small peritoneal cavity, and an opening in the peritoneum that was not in a purse-string configuration around the catheter. The mechanism of the migration in our case remains unclear, but a lateral radiograph would have indicated clearly that the shunt catheter was extraperitoneal. 1