PLEURAL EFFUSION FOLLOWING VENTRICULO-PLEURAL SHUNT PLACEMENT

Abstract

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Ventriculo-pleural shunts (VPLS), is an alternative management of hydrocephalus, where excess cerebrospinal fluid is drained to the pleural cavity. Imbalances between production and absorption of CSF will lead to the accumulation and development of pleural effusion. We describe a case of a pleural effusion related to a VPLS. CASE PRESENTATION: A 42 year old female with CSF leak managed by VPLS, previous STEMI with stent placement, and asthma, presented with retrosternal, right chest discomfort and dyspnea. Dyspnea began four months prior, and a right-sided thoracentesis had been performed two weeks earlier. Her pulmonologist previously noted small chronic pleural effusions insufficient for thoracentesis. From her previous thoracentesis, cultures were negative and cytology showed chronic inflammation. Cell profile, LDH, and protein were not tested. Subsequent thoracentesis yielded 165 WBC, <2000 RBC, 25 neutrophils, 39 lymphocytes. Cultures were negative and cytology showed acute and chronic inflammation. The fluid was transudative with an LDH of 109 U/L and a protein of 1.6 g/dL. She underwent a revision of her shunt to the peritoneal cavity. DISCUSSION: Extra-cranial shunts are used to divert CSF into an extracerebral compartment to relieve symptoms associated with hydrocephalus. The most widely used locations for shunt placement are the peritoneum and atrium. VPLS is an alternative when a peritoneal or atrial shunt is not suitable. This could be due to adhesions, infection, thrombosis or obliteration.(1) VPLS has a 7% complication rate and includes obstruction (functional or structural), pleural effusion, and pneumothorax.(2) The most common are pleural effusions; typically occurring within the first year of placement. Pleural fluid reabsorption by parietal lymphatics is estimated to be around 0.15 ml/k/h. This can increase as a response to increased pleural fluid filtration. Pleural effusions occur when filtration exceeds the maximum pleural lymph flow, typically 30 ml/kg/h.(3) The pleural fluid analysis shows a transudative effusion resembling CSF, but exudative effusions may also occur in chronic inflammation. Mild cases may resolve without intervention. Symptomatic cases with moderate or recurrent effusions may require thoracentesis, chest tube insertion, and occasionally shunt revisions (4). CONCLUSIONS: The pleural cavity is an alternative to peritoneal and atrial shunts for drainage of CSF in the treatment of refractory hydrocephalus. Pleural effusion is the most common complication typically occurring within the first year. While mild cases are self-limited, moderate or recurrent effusions will require intervention such as thoracentesis, chest tube insertion or possibly shunt revision. Reference #1: Ransohoff J. Ventriculopleural anastomosis in treatment of midline obstructed masses. J Neurosurg. 1954;11:295–301 Reference #2: Donald P. Megison & Edward C. Benzel (1988) Ventriculo-pleural Shunting for Adult Hydrocephalus, British Journal of Neurosurgery, 2:4, 503-505, DOI: 10.3109/02688698809029605 Reference #3: Miserocchi, G. “Physiology and Pathophysiology of Pleural Fluid Turnover.” European Respiratory Journal, vol. 10, no. 1, 1997, pp. 219–225., DOI:10.1183/09031936.97.10010219. DISCLOSURES: No relevant relationships by Sarah Cheyney, source=Web Response No relevant relationships by Gurjot Garcha, source=Web Response No relevant relationships by Ahmed Khan, source=Web Response No relevant relationships by Albert Magh, source=Web Response No relevant relationships by Crystal Verdick, source=Web Response