VP Shunt Complication

1. Ade Wijaya, MD – October 2020

2.  VP shunt is a common neurosurgical
procedure
 Complications are still high
 VP shunt failure rates have been estimated at
approximately 11–25% within the first year
after initial shunt placement
 Pediatrics > Adults
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

3.  Shunt infections
 Shunt obstruction
 Abdominal pseudocyst
 Bowel perforation
 Overdrainage and subdural hematoma
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

5.  2nd most common complication
 8-15 %
 In patients presenting with symptoms of
shunt malfunction, infection should always be
suspected since shunt infection is a serious
complication with a great potential for severe
morbidity and mortality
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

6.  Premature neonates
 Young age
 Post-operative CSF leak
 Glove holes during shunt handling
 African American race
 Public insurance
 Previous shunt infections
 Etiology of intraventricular hemorrhage
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

7. Early
• Inoculation during
shunt insertion
Late
• Peritonitis
• Abdominal
pseudocyst
• Bowel perforation
• Hematogenous
inoculation
M. Vinchon, M.P. Lemaitre, L. Vallee, P. Dhellemmes, Late shunt infection: in-cidence, pathogenesis, and therapeuric implications, Neuropediatrics 33
(2002)169–173.
C. Baird,D. O'connor, T. Pittman, Late shunt infections, Pediatr. Neurosurg. 31(1999) 269–27

8.  Clinical presentation:
- Shunt malfunctions (nausea, vomiting,
headache)
- Fever
 CSF analysis
 CSF culture
- Staph epidermidis
- Staph aureus
- Gram negative rods
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

9.  Removal of the infected hardware
 Initiation of intravenous antibiotic therapy
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

11.  Most common cause of shunt malfunction
 Most common site: proximal catheter
 Headache, lethargy, nausea and vomiting
 Diagnosis: CT scan and elevated opening
pressure in CSF tapping
 Treatment: VP shunt revision
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

13.  Rare complication
 1-4.5 %
 Late complication; after a year of procedure
 Collections of fluid that accumulate around
the tip of the distal catheter and are
surrounded by a wall of fibrous tissue lacking
an epithelium
 Cause: Inflammation and abdominal
adhesions, which may occur with shunt
infections and multiple abdominal surgeries
N. Rainov, Heidecke V. Schobess, W. Burkert, Abdominal CSF pseudocysts in pa-tients with ventriculoperitoneal shunts. Report of fourteen cases and review of theliterature, Acta
Neurochir. 127 (1–2) (1994) 73–78.
C.B. Dabdoub, C.F. Dabdoub, M. Chaves, J. Villarroel, J.L. Furrufino, A. Coimbra,B.M. Orlandi, Abdominal cerebrospinalfluid pseudocyst: a comparative analysisbetween and adults,
Childs Nerv. Syst. 30 (2014) 579–589.
C.M. Anderson,D.L. Sorrells, J.D. Kerby, Intra-abdominal pseudocysts as a com-plications of ventriculoperitoneal shunts, J. Am. Coll. Surg. 196 (2) (2003)297–300.
S. Ohba, Y. Kinoshita, M. Tsutsui, T. Nakagawa, K. Shimizu, T. Takahashi,H. Murakami, Formation of abdominal cerebrospinalfluid pseudocyst: case report,Neurol. Med. Chir. 52
(2012) 838–842

14. Clinical presentation
 Abdominal pain
 Palpable mass
Diagnosis
- Ultrasound
- Abdominal CT scan
Santos de Oliveira R, Barbosa A, Avalloni de Morares Villala de Andrade Vicente Y,and Machado HR. An alternative approach for management of abdominal cere-
brospinalfluid pseudocysts in children.
F. Aprarici-Robles, R. Molina-Fabrega, Abdominal cerebrospinalfluid pseudocyst: acomplication of ventriculoperitoneal shunts in adults, J. Med. Imaging
Radiat.Oncol. 52 (2008) 40–43
N. Rainov, Heidecke V. Schobess, W. Burkert, Abdominal CSF pseudocysts in pa-tients with ventriculoperitoneal shunts. Report of fourteen cases and review of
theliterature, Acta Neurochir. 127 (1–2) (1994) 73–78.
C.B. Dabdoub, C.F. Dabdoub, M. Chaves, J. Villarroel, J.L. Furrufino, A. Coimbra,B.M. Orlandi, Abdominal cerebrospinalfluid pseudocyst: a comparative
analysisbetween and adults, Childs Nerv. Syst. 30 (2014) 579–589

15.  Externalization of the shunt
 Sonographically-guided cyst aspiration
 pseudocyst recurrence to happen in 19.8% of
children and 24.2% of adults
 ventriculopleural and ventriculoatrial shunts
to prevent recurrence
N. Rainov, A. Schobess, V. Heidecke, W. Berkert, Abdominal CSF pseudocysts inpatients with ventriculoperitoneal shunts. Report of fourteen cases and review
ofthe literature, Acta Neurochir. 127 (1994) 73–78.
B.D. Coley, W.E. Shiels II, S. Elton, J.W. Murakami, M.J. Hogan, Sonographicallyguided aspiration of cerebrospinalfluid pseudocysts in children and
adolescents,AJR Am. J. Roentgenol. 183 (2004) 1507–1510.
R.B. Snow, M.H. Lavyne, R.A. Fraser, Colonic perforation by ventriculoperitonealshunts, Surg. Neurol. 25 (1986) 173–177.

17.  Rare
 0.1-0.7 %
 Protrusion of the tip of the distal catheter
through the anus
 Most common in children
 Treatment: replacement
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

19.  Incidence: 5-20 %
 May be due to the stretching of bridging veins as
the brain sinks away from the skull when the
pressure inside the ventricles drops after
shunting
 NPH and higher ICPs may be more sensitive to
increased CSF drainage and thusmore likely to
develop SDHs
 Management:
- Programmable shunt valves
- Spontaneous resolve
- drainage
Paff, M., Alexandru-Abrams, D., Muhonen, M., & Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.

20.  Shunt malfunction: common neurosurgical
complication of VP shunt
 Increase morbidity, mortality, and hospital
length of stay
 Early detection and proper management