Intrathoracic migration of subduroperitoneal shunt

Case contributed by Dr Liam Coulthard

Presentation

Initial presentation. 10 week old male with one month history of increasing head circumference, tense fontanelle, poor feeding. Linear bruising to arms and legs.

Patient Data

Age: 12 months
Gender: Male

Initial CT head

CT

Axial non-contrast CT brain demonstrating large bilateral chronic subdural collections causing sulcal effacement. Bilataral frontal hypodensities likely representing old contusions. Features consistent with previous traumatic head injury.

The subdural collections were initially tapped twice through the anterior fontanelle. Persistence of the right sided collection prompted insertion of a right subduroperitoneal shunt.

Post operative CT head

CT

Axial non-contrast CT brain post insertion of right frontal subduroperitoneal shunt. Interval reduction in bilateral subdural collections. Significant ventriculomegaly and loss of subarachnoid space suggesting hydrocephalus. Ventricular system remains patent, no evidence of obstructional cause.

The child went on to undergo placement of a left parietal ventriculoperitoneal shunt for hydrocephalus.

Shunt Series

X-ray

Post operative shunt series. Right subduroperitoneal and left ventriculoperitoneal shunt evidence on skull projections. Both distal catheters appear to be in adequate position and pass below the diaphragm on abdominal Xray.

Overall findings during admission were suggestive of non-accidental injury. The child was discharged to foster care with a left ventriculoperitoneal shunt and right subduroperitoneal shunt in situ.

The child represented age 12 months with a 3 day history of lethargy and associated vomiting. Episodes of sinus bradycardia were noted on ECG.

CT head on representation

CT

Subdural and ventricular catheters in adequate position. No ventriculomegaly. No evidence of subdural collection nor new hemorrhage.

Shunt series

X-ray

AP and lateral CXR demonstrating migration of the right subduroperitoneal shunt distal catheter into the thorax. Left ventriculoperitoneal distal catheter remains below the level of the diaphragm. 

Non-contrast axial CT of the thorax demonstrating transit of the right distal catheter into the thoracic cavity. The catheter passes subcutaneously over the clavicle before piercing pectorals major, traveling deep to the muscle and entering the pleural space beneath rectus abdominis. The intra thoracic catheter is looped adjacent to the right heart border.

The left ventriculoperitoneal shunt catheter can be traced subcutaneously over the thorax.

Attempted removal of subduroperitoneal shunt. Distal catheter was removed by gentle traction from site of attachment to Rickham's reservoir at the cranial end. The associated subdural catheter could not be removed intact, due to resistance to traction at the burrhole. The distal tip of the subdural catheter was cut and left in situ.

Skull Xray post removal of subduroperitoneal shunt

X-ray

AP and lateral skull projections demonstrating retained distal end of subdural catheter.

The patient represented two weeks post discharge with a fever and small pseudomeningocoele at the right frontal surgical site. A second inferior frontal burrhole was made to retrieve the distal catheter due to concerns over possible infection. Cultures remained negative and the child was discharged home.

Shunt series after removal of retained distal catheter

X-ray

Shunt series demonstrating left ventriculoperitoneal shunt in situ. Right subduroperitoneal shunt has been removed. An inferior frontal burrhole, used to retrieve the distal subdural catheter, is evident on the lateral skull radiograph.

The position of the left ventriculoperitoneal shunt remains unchanged. A right PICC line is seen with its tip at the cavoatrial junction.

Case Discussion

Subdural to peritoneal shunt is an accepted, but uncommon, treatment for persistent chronic subdural hematomas. Ventriculoperitoneal shunt catheters have been seen to migrate to various unusual locations, including the rectum, vagina and heart1,2. This is an unusual case of a subdural to peritoneal shunt catheter migrating to the thoracic cavity and causing cardiac arrhythmias. We suspect the course of the catheter when placed, either breached or came in contact with the pleura, allowing for erosion over time. The catheter may have been drawn into the thoracic cavity by negative pressure during respiration. It was removed by careful traction at the cranial end without incident.

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