Presentation
Shortness of breath and incidental fluid collection in the caudal chest on a CT abdomen/pelvis acquired for unrelated reasons.
Patient Data
A shunt traverses the right side of the neck and anterior chest wall and enters the chest cavity at the interspace between the 5th and 6th ribs. It loops and the tip terminates in a large, loculated pleural fluid collection in the upper and mid right hemithorax. Additionally, there is a small volume of right free pleural fluid. An abdominal portion of previous ventriculoperitoneal shunt tubing is present.
Extensive pleural calcifications bilaterally are compatible with chronic asbestos related pleural disease. Round atelectasis bilaterally with comet-tail appearance and adjacent to thickened pleura is also present, as is a moderate hiatal hernia.
Case Discussion
Cerebral shunts remove cerebrospinal fluid in the context of hydrocephalus. Ventriculopleural shunts direct cerebrospinal fluid to the pleura and are less common than ventriculoperitoneal shunts 1. Asymptomatic pleural effusion is a common sequela of ventriculopleural shunts (from 5-20%) 2,3. However, a symptomatic pleural effusion is considered rare and thought to be due to either a high flow of shunt drainage or decreased absorptive ability of the pleura 1. In the case of decreased absorption, this can be due to inflammation from long-standing cerebrospinal fluid exposure or from infection 1. The loculated fluid in this case is of simple attenuation and favoured to represent transudate. The presence of previous, disconnected ventriculoperitoneal shunt tubing in this case added a degree of uncertainty that was resolved by reviewing the past history.
Case courtesy of Dr. William Dawson MD FRCPC.
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