Ventriculopleural Shunts Research Articles

Comparing ventriculoatrial and ventriculopleural shunts in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study.

When the peritoneal cavity cannot serve as the distal shunt terminus, nonperitoneal shunts, typically terminating in the atrium or pleural space, are used. The comparative effectiveness of these two terminus options has not been evaluated. The authors directly compared shunt survival and complication rates for ventriculoatrial (VA) and ventriculopleural (VPl) shunts in a pediatric cohort. The Hydrocephalus Clinical Research Network Core Data Project was used to identify children ≤ 18 years of age who underwent either VA or VPl shunt insertion. The primary outcome was time to shunt failure. Secondary outcomes included distal site complications and frequency of shunt failure at 6, 12, and 24 months. The search criteria yielded 416 children from 14 centers with either a VA (n = 318) or VPl (n = 98) shunt, including those converted from ventriculoperitoneal shunts. Children with VA shunts had a lower median age at insertion (6.1 years vs 12.4 years, p < 0.001). Among those children with VA shunts, a hydrocephalus etiology of intraventricular hemorrhage (IVH) secondary to prematurity comprised a higher proportion (47.0% vs 31.2%) and myelomeningocele comprised a lower proportion (17.8% vs 27.3%) (p = 0.024) compared with those with VPl shunts. At 24 months, there was a higher cumulative number of revisions for VA shunts (48.6% vs 38.9%, p = 0.038). When stratified by patient age at shunt insertion, VA shunts in children < 6 years had the lowest shunt survival rate (p < 0.001, log-rank test). After controlling for age and etiology, multivariable analysis did not find that shunt type (VA vs VPl) was predictive of time to shunt failure. No differences were found in the cumulative frequency of complications (VA 6.0% vs VPl 9.2%, p = 0.257), but there was a higher rate of pneumothorax in the VPl cohort (3.1% vs 0%, p = 0.013). Shunt survival was similar between VA and VPl shunts, although VA shunts are used more often, particularly in younger patients. Children < 6 years with VA shunts appeared to have the shortest shunt survival, which may be a result of the VA group having more cases of IVH secondary to prematurity; however, when age and etiology were included in a multivariable model, shunt location (atrium vs pleural space) was not associated with time to failure. The baseline differences between children treated with a VA versus a VPl shunt likely explain current practice patterns.

Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children’s Hospital

BackgroundAt Red Cross War Memorial Children’s Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures.MethodA single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion.ResultsTwenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3–14.9) and 5.3 years (0.5–13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2–28) versus 4.5 (2–17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0–67) and 5 months (0–118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group.ConclusionOur findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.

Ventriculopleural Shunt Following Failed Ventriculoperitoneal Shunt in Children: Two Case Reports

Abstract There have been no reports of ventriculopleural (VPL) shunt in children younger than four years of age in the last 24 years. The pleural space is an alternative to the peritoneum for shunting cerebrospinal fluid (CSF) in cases where the latter cannot be used due to infection or other complications. Though there have been case series published reporting the use of VPL shunts, the anesthetic management has not been described in detail. We describe the management of two pediatric patients aged three and six years old who successfully underwent VPL shunt after failure of ventriculoperitoneal (VP) shunt.

An Overview of Hydrocephalus and Shunts Used in The Clinical Management of Hydrocephalus

Hydrocephalus is a complex neurological condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. The clinical management of hydrocephalus often involves the surgical placement of a shunt system to divert CSF and restore normal fluid dynamics. This article provides a comprehensive overview of hydrocephalus, its etiology, clinical presentation, and various types of shunts used in its management. The outline of this report encompasses the principles of shunt surgery, indications for shunt placement and primary types of shunts used in the clinical management of hydrocephalus, including ventriculoperitoneal (VP), ventriculoatrial (VA), ventriculopleural (VPL), lumboperitoneal (LP) and ventriculo-subgaleal (VS) shunts. Additionally, some non-conventional shunts such as ventriculo-osseous, ventriculo renal, ventriculo gall bladder, intraventricular (Aqueductal stents) and long-tunnelled external ventricular drains are also discussed. The distinct features of each shunt type, its associated advantages, limitations and complications are also outlined together with a comparison between pressure vs flow regulated valves. An understanding of the different shunt types and their specific characteristics is essential for clinicians to make informed decisions in tailoring treatment to individual patients. This review offers a comprehensive understanding of shunt characteristics which we believe will empower clinicians to make informed decisions tailored to individual patients, ensuring effective CSF diversion and long-term management of hydrocephalus.

Ventriculopleural shunt outcomes for pediatric hydrocephalus: a single-institution experience.

The aim of this study is to analyze rates of ventriculopleural (VPL) shunt failure and complications among patients with pediatric hydrocephalus, and to analyze which factors may predict early (< 1year) or late (> 1year) VPL shunt failure in this sample. A retrospective chart review was conducted of all consecutive VPL shunt placements from 2000 to 2019 at our institution. Data was collected on patient characteristics, shunt history, and shunt type. Primary endpoints include rates of VPL shunt survival and rates of symptomatic pleural effusion. The Kaplan-Meier method was used to calculate shunt survival, and Fisher's exact test and t-test were used to compare differences between categorical variables and means, respectively (p < 0.05). Thirty-one patients with pediatric hydrocephalus underwent VPL shunt placement (mean age 14.2years). Of the 27 patients with long-term follow-up (mean 46months), VPL shunt revision was required in 19, seven of which were due to pleural effusion. Overall shunt survival rates at 1, 3, 5, and 7years were 76%, 62%, 55%, and 46%, respectively. Mean duration of shunt survival was 26.74months. Overall pleural effusion rate was 26%. No patient-specific factors, including shunt valve type, were significantly associated with shunt survival, risk of early revision, or risk of pleural effusion. Our results are comparable to those reported in the literature and represent one of the largest case series on the topic. VPL shunts are a viable second-line option when ventriculoperitoneal (VP) shunt placement is not possible or desirable, though there are high rates of shunt revision and pleural effusion.

Ventriculopleural shunts in a pediatric population: a review of 170 consecutive patients.

The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population. All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children's Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site. A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient. VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt's terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.

A Brief Review of Ventriculoatrial and Ventriculopleural Shunts.

Alternate approaches such as ventriculoatrial (VA) or ventriculopleural (VPL) procedures still have a place in the surgical armamentarium for patients with recurrent ventriculoperitoneal (VP) shunt failures related to defective absorption, infections, or frequent malfunctions. We reviewed the literature and our experience with these techniques, and offered suggestions for safely performing these operations. Historical perspectives were also included to facilitate an improved understanding of the technical developments. Our findings and the available medical literature suggest VA and VPL options are safe and effective alternatives for managing the complex patient with hydrocephalus. Potential issues and complications were discussed along the technical advances for a safer operation. The VA and VPL options should be considered for patients with recurrent VP shunt issues. They are safe and effective options for managing complex hydrocephalus patients.

PLEURAL EFFUSION FOLLOWING VENTRICULO-PLEURAL SHUNT PLACEMENT

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

Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus.

Ventriculoatrial (VA) and ventriculopleural (VPL) shunts are used as alternatives when CSF diversion to the peritoneal compartment with a ventriculoperitoneal (VP) shunt is not possible. The objective of this study is to compare directly the shunt survival and complications for both procedures in this setting in children. A retrospective analysis of 54 consecutive patients who underwent VA (36) or VPL (18) shunt insertion between January 2002 and December 2017 was conducted. The overall mean follow-up was 4.1 (SD 4.3) years, 2.8 (SD 4.1) for VPL and 4.7 (SD 4.4) for VA shunts, respectively (p = 0.11). Twenty-four (66.7%) patients in the VA group and 9 (50.0%) in the VPL group underwent shunt revision (p = 0.236); mean number of revisions was 2.2 (SD 3.0) and 0.94 (SD 1.4) in the VA and VPL groups (p = 0.079). Median time to failure was 8.5 (IQr 78, range 0-176) months for VA and 5.50 (IQr 36, range 0-60) for VPL shunts (log rank (Mantel-Cox) 0.832). Shunt survival at 3, 6, 12 and 30months was 60.6, 51.5, 36.4 and 27.3%, respectively, for VA and 56.3, 43.8, 37.5 and 37.5% for VPL shunts (log rank (Mantel-Cox) test value 0.727). The infection rate was 13.8% for VA and 5.6% for VPL shunts (p = 0.358). Four patients with VPL shunts (22.2%) developed pleural effusions. Fourteen deaths (25.9%) were recorded during follow-up, 8 (22.2%) in the VA and 6 (33.3%) in the VPL group (p= 0.380); two of the deaths in the VA group were shunt-related. This study demonstrates that the outcomes of VA and VPL shunts, when used as second-line surgical treatment in paediatric hydrocephalus, were similar, as were the revision, infection and survival rates. The shorter longevity of these shunts compared with the general shunted population may reflect the complex nature of these children.

Case series of ventriculopleural shunts in adults: a single-center experience.

OBJECTIVE The peritoneal cavity is widely used as the destination of choice for cerebrospinal fluid shunts. Various alternative sites have been used, particularly in the presence of certain contraindications. The pleural cavity has been used; however, a paucity of evidence details ventriculopleural (VPL) shunt survival, complication, and revision rates in adults. The aim of this study was to present a single center's experience with VPL shunts, identifying complication, revision, and survival rates. METHODS A single-center, retrospective case series analysis was conducted for VPL shunt insertions and revisions over a period of 5 years. Demographic as well as clinical data were collected. Ventriculopleural shunt survival was assessed using Kaplan-Meier curves and the log rank (Cox-Mantel) test. RESULTS Twenty-two VPL shunts were inserted in 19 patients. Median survival of the VPL shunts was 14 months. Pathological indication for the VPL shunt did not significantly affect survival. A total of 10 complications was observed: 2 infections, 2 cases of overdrainage, 2 obstructions, 1 distal catheter retraction, 2 symptomatic pleural effusions, and 1 asymptomatic pleural effusion. CONCLUSIONS Ventriculopleural shunting is a safe and viable second-line procedure for cases in which ventriculoperitoneal shunts are unsuitable. While VPL shunts have a high revision rate, their complication rate is comparable to that of VP shunts. Ventriculopleural shunt survival can be improved by careful patient selection and the implementation of a combination of valves with antisiphon devices.

Ventriculo-gallbladder shunt: An alternative for the treatment of hydrocephalus

Abstract Background In the management of hydrocephalus, the ventriculo-gallbladder shunt is justified in situations where the ventriculo-peritoneal shunt is not useful due to peritoneal involvement and/or when the ventriculo-auricular and ventriculo-pleural shunts are contraindicated. Clinical case A 27 year-old female with hydrocephalus at birth, managed with ventricle-peritoneal shunt, modified 3 times throughout her life due to repeated infections and other different reasons. She was admitted due to colitis caused by Clostridium difficile , presenting concomitant signs of intracranial hypertension and neurological impairment. This led to a review and change of the ventriculo-peritoneal shunt system, with distal dysfunction due to peritoneal thickening. Atrial and pleural shunts were not indicated because the risk of infection. As an alternative, it was decided to place the distal end of the catheter in the gallbladder. The patient recovered her neurological functions after the surgery. Conclusions Drainage alternatives may be needed in 5% of patients with valvular shunt dysfunction. The ventriculo-gallbladder is a good and viable option because it has an absorptive capacity of 1500 cc liquid daily, besides being an excellent drainage through the bile duct. The abdominal surgery is easy to perform, and it is an alternative option in the failure of the ventriculo-peritoneal shunt.

CSF Hydrothorax as a Late Complication of Ventriculoatrial Shunt Catheter Displacement.

A 21-year-old man was admitted to our emergency department with chest pain and progressively increasing dyspnoea commencing 1 week previously. His self-history revealed that he had received a ventriculo-atrial shunt at the age of 2 weeks due to congenital hydrocephalus (Figure 1a). At physical examination, no breathing sounds were heard on the right side. Neurological examination was normal. Total blood counts and C-reactive protein (CRP) were within normal limits. Chest X-ray showed right-sided hydrothorax and a catheter tip at the right thoracic apex (Figure 1b). The patient was transferred to the neurosurgery department. A consultation was held with the thoracic department. Thoracentesis was performed 3 times in 1 week, but the hydrothorax still persisted (Figure 1c). Subsequent removal of the ventriculo-atrial shunt catheter with disconnection on the scalp was performed. The distal tip of the catheter was left in the vessel. Symptoms improved rapidly. Chest X-ray revealed resolution of pleural effusion and re-expansion of the right lung (Figure 1d, e). Recovery was uneventful and no further thoracentesis or new shunt catheter were required. The patient was discharged 7 days later in good condition. The patient has remained in good clinical condition at the 2-year follow-up, and hydrocephalus has been arrested. FIG. 1. a-e. The patient’s cranial computed tomography (CT) shows the ventricular shunt catheter at the right lateral ventricle (a); Chest X-ray shows right sided hydrothorax (b); Chest X-ray after thoracentesis shows persisting hydrothorax (c); Chest X-ray ... We suggest that the shunt catheter may migrate from the intravascular space to the thoracic cavity through the area of entry into the internal jugular vein near the brachiocephalic trunk as a result of age-related upward pull. This was suggested by the catheter position in the right thoracic apex. The absence of bleeding into the thoracic cavity while the catheter tip was being exvasated may be attributed to the process having occurred over an extended period. The vessel wall was therefore repaired during this long period. Complications of ventriculoperitoneal or ventriculo-atrial shunts commonly occur due to obstruction, disconnection or infection (1–3). There are some reports of hydrothorax as a complication of ventriculoperitoneal (V-P) shunting (4). Taub et al. (5) classified V-P shunt thoracic complications into three types: 1) intrathoracic trauma during shunt replacement, 2) peritoneal catheter migration into the thoracic cavity, and 3) pleural effusion with cerebrospinal fluid (CSF) ascites. The peritoneal catheter may migrate into the thoracic cavity in either a supradiaphragmatic or transdiaphragmatic manner. In supradiaphragmatic migration, the peritoneal catheter is accidentally inserted into and out of the pleural cavity during the tunnelling procedure, especially at the supraclavicular fossa, which is the most dangerous area (6, 7). In transdiaphragmatic migration, the peritoneal catheter is gradually pulled into the thoracic cavity due to the negative pressure effect of inspiration. Increased intra-abdominal pressure due to peritoneal malabsorption also facilitates this process (5). The peritoneal catheter may migrate from a pre-existing hiatus into the diaphragm or may perforate it. Congenital hiatuses or weak points in the diaphragm are areas where the peritoneal catheter tip may pass into the thoracic cavity. Local inflammation around the peritoneal catheter tip may also facilitate the passage of the shunt tip through the diaphragm (4, 6). Hydrothorax may sometimes occur in association with CSF ascites. Peritoneal malabsorption leads to excessive CSF collection in the peritoneal cavity. CSF may pass through the thoracic cavity via congenital hiatuses (foramen Bochdalek or foramen of Morgagni) with increased intra-abdominal pressure (6). Ventriculo-pleural shunts have only been used infrequently for hydrocephalus. CSF hydrothorax is also one of the serious thoracic complications of ventriculo-pleural shunts (8). In particular, the long-term results are less satisfactory for ventriculo-pleural shunts, because shunt obstruction or pleural effusions are most frequently developed in 3 years (8). The late hydrothorax complicating the ventriculo-pleural shunts can be explained by two hypotheses: (a) Decreased CSF absorption in the pleural space as a result of impaired pleural absorptive capacity secondary to pleural damage due to prior infection and/or chronic exposure to CSF and (b) over-drainage of CSF into the pleural space (8, 9). The present case behaved as a ventriculo-pleural shunt due to prolonged drainage of CSF into the pleural space from the right thoracic apex. The possible mechanisms of hydrothorax formation in our patient with ventriculo-atrial shunts are the same as those in ventriculo-pleural shunt. To the best of our knowledge, this is the first reported case of CSF hydrothorax as a late complication of ventriculo-atrial shunt catheter displacement. We therefore wish to report this unique complication of ventriculo-atrial shunt.

The Genesis of Low Pressure Hydrocephalus

Low pressure hydrocephalus (LPH) is an uncommon entity. Recognition of this treatable condition is important when clinicians are faced with the paradox of symptomatic hydrocephalus despite low intracranial pressures (ICP). Its etiology remains enigmatic. We identified patients with LPH from the prospective, inpatient neuro-intensive care database over a 4-year period (2006-2010). Nine patients with LPH were identified over a 4-year period. The time from diagnosis of the initial neurosurgical condition to development of LPH varied from 7days to 5years. The sub-zero drainage method of Pang and Altschuler was successful in all cases. LPH was accompanied by transependymal edema in five patients despite low ICP. Four patients developed LPH during their initial admission for intracranial bleeding. As patients entered the LPH state, the ICP remained in a normal range yet daily CSF output from the external ventricular drain was reduced. When LPH patients were drained at sub-zero levels, daily CSF output exceeded baseline values for several days and then receded to baseline. Long-term management was achieved with low pressure shunt systems: six programmable shunts; one valveless ventriculoperitoneal shunt; two ventriculopleural shunts. Conditions most commonly associated with LPH are: subarachnoid hemorrhage, chronic hydrocephalus, brain tumors, and chronic CNS infections. Low pressure hydrocephalus is a challenging diagnosis. The genesis of LPH was associated with a drop in EVD output, symptomatic ventriculomegaly, and a remarkable absence of intracranial hypertension. When LPH was treated with the sub-zero method, a 'diuresis' of CSF ensued. These observations support a Darcy's flux of brain interstitial fluid due to altered brain poroelastance; in simpler terms, a boggy brain state.

Tension Hydrothorax in a Pediatric Patient with a Ventriculopleural Shunt

Ventriculopleural shunts have been utilized in the management of hydrocephalus since the early 1900s. Shunt malfunctions can lead to fluid accumulation in the pleural space and a tension hydrothorax can develop. Improved diagnostic and therapeutic resources have led to an increasing number of ventriculopleural shunts being utilized in patients with symptomatic hydrocephalus. Emergency physicians are being called upon more frequently to diagnose and help manage many of the critical complications that can arise with ventricular shunts. Very little literature exists concerning the evaluation and treatment of patients with a suspected tension hydrothorax secondary to a ventriculopleural shunt malfunction. If left unrecognized and untreated, tension pneumothoraces can progress and result in hemodynamic decompensation and cardiopulmonary arrest. Patient survival depends on early diagnosis and prompt fluid drainage in this clinically challenging scenario. This is the first article in the emergency medicine literature to describe the presentation and management of a pediatric patient who presents to the Emergency Department with a rare diagnosis of a tension hydrothorax secondary to a defective ventriculopleural shunt. The increasing number of ventriculopleural shunts being utilized requires emergency physicians to become familiar with the life-threatening complications that can be associated with these types of shunts. Correctly identifying this complication and initiating immediate treatment can lead to improved patient outcomes.

The Role of a Vascular Access Surgeon in Ventriculo-Venous Shunts in Difficult Hydrocephalus

Cerebrospinal fluid (CSF) diversion into the right atrium or peritoneal cavity is the mainstay of treatment for normotensive hydrocephalus. Unfortunately multiple shunt failures can lead to patients returning for repeat interventions, leaving drainage options limited. We present a case series of five patients requiring venous access for shunt placement. Using the St Georges technique of axillary vein dissection, a suitable vein draining into the axillary vein was found and a shunt inserted under direct vision into the vein. Four females and one male were retrospectively followed up from first venous shunt employment in February 2003 to May 2008. Of the 34 revised shunts performed (ventriculo-peritoneal, ventriculo-pleural or ventriculo-venous) in the group, 13 procedures included the use of the axillary vein for CSF diversion. All shunts had a cumulative primary and secondary patency of 50% and 80% at 1 yr, respectively. There was no significant difference in the primary or secondary patency between the three types. We have presented a series of 35 primary and secondary shunts in five patients with hydrocephalus. All patients had exhausted all CSF diversion options prior to the use of the axillary vein. With comparable survival of the axillary shunts with ventriculo-pleural and peritoneal shunts, we therefore present a favorable outcome in the use of the axillary vein for CSF diversion.

Duropleural Fistula Revealed by Neurological Manifestations: An Unusual Cause of Pleural Effusion

Symptomatic pleural collection of cerebrospinal fluid is a rare but accepted complication in hydrocephalic paediatric patients treated with ventriculopleural shunts. Few cases have been described in adults, usually as complication of trauma, tumours or spinal surgery, particularly post-laminectomy. It should be considered in the differential diagnosis of pleural effusion after neurosurgical procedures involving the spine. We describe two patients with large cerebrospinal fluid collections in the pleural cavity caused by postoperative duropleural fistula, who presented with neurological symptoms, cerebrospinal fluid pressure headache and meningitis.

Acute-recurrent subcutaneous emphysema after ventriculopleural shunt placement

Ventriculopleural shunts are one of the alternatives to ventriculoperitoneal shunts for draining cerebrospinal fluid. They are used in patients who have failed multiple ventriculoperitoneal shunts because of peritonitis, loculated ascites, or pseudocyst formation, or those who are not optimal candidates for vascular shunts. A case of acute recurrent subcutaneous emphysema around the incision of a ventriculopleural shunt is presented.

The Ventriculo-Gallbladder Shunt in the Treatment of Refractory Hydrocephalus: A Review of the Current Literature

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) -shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.

Routine imaging in patients with ventriculopleural shunts: lessons learned from a case of tension hydrothorax

Routine imaging in patients with ventriculopleural shunts: lessons learned from a case of tension hydrothorax

Fibrothorax in adulthood caused by a cerebrospinal fluid shunt in the treatment of hydrocephalus

Ventriculopleural shunts have been used as an alternative to ventriculoperitoneal shunts in the treatment of hydrocephalus. Although recurrent pleural effusion is a known complication of this procedure, severe fibrothorax requiring decortication has been described only once, in a case involving a child. The authors report a case of a severe fibrothorax with an entrapped lung presenting in an adult patient.