Indian Pediatrics - Editorial

Letters to the Editor

Indian Pediatrics 2003; 40:911-912

Massive CSF Varicosity as a Presenting Feature of VP Shunt Disconnection

A 10-year-old male child had a ventriculoperitoneal (VP) shunt surgery done at the age of 5 months. He was asymptomatic till 3 months when he started getting inter-mittent headache and vomiting. In addition he had a progressively increasing tortuous swelling over the right anterior lower chest and abdominal wall. The swelling became tense on coughing and straining. On local examination, there was a large tense cystic swelling in the subcutaneous region over the right lower chest and the hypochondrium (Fig. 1). It was serpentine in appearance due to the marked tortuosity. It was nonfluctuant, nontender, bosselated and brilliantly translucent. The overlying skin was normal. There was clinical evidence of shunt malfunction. Neurological examination showed that he was dull in sensorium but was oriented. Fundus examina-tion revealed bilateral papilledema. There was no motor or sensory deficit. Computerized tomography (CT) of the brain showed dilated lateral ventricles suggestive of shunt malfunction. The ventricular catheter was seen in situ. Plain lateral radiography showed the disconnected shunt tube in the neck.

Fig. 1. Photograph showing massive cerebrospinal varicosity over the right lower chest and abdominal wall.

The patient underwent a left ventri-culoperitoneal shunt. The right-sided shunt assembly was removed. Following the procedure, the patient was symptom free. The subcutaneous swelling became soft and the tortuosity remarkably lessened over the next 24 hours. At follow-up after three months, there was complete resolution of the cerebrospinal fluid varicosity over the right lower chest and abdominal wall.

Shunt tube disconnection has been well described in literature as a cause of shunt malfunction. The likelihood of shunt disconnection is higher in occipitally placed shunts and if the connection is more distal from the ventricle(1). High tension is sometimes caused in the shunt tube between the two anchor point viz., head and chest wall due to movement of the neck or growth and may induce such dislocation and disconnection of the shunt tube(2). The use of an extended length peritoneal shunt catheter may prevent shunt disconnection(3).

The markedly tortuous cerebrospinal fluid collection over the lower chest and abdominal wall presenting 10 years following right ventriculoperitoneal shunt insertion is rather unusual and interesting.

D.P. Mazumdar,
A. Goel,
Department of Neurosurgery,
Seth G.S. Medical College and King
Edward Memorial Hospital
Mumbai, India.

References

1. Aldrich EF, Harmann P. Disconnection as a cause of ventriculoperitoneal shunt mal-function in multicomponent shunt systems. Pediatr Neurosurg 1990; 16: 309-311.

2. Tsurushima H, Harakuni T, Saito A, Hyodo A, Yoshii Y. Shunt tube problems due to place-ment of valves on the chest wall–three case reports. Neurol Med Chir 2000; 40: 342-344.

3. Couldwell WT, LeMay DR, McComb JG. Experience with use of extended length peritoneal shunt catheters. J Neurosurg 1996; 85: 425-427.