The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Ventriculoperitoneal Shunts and their Complications and is brought to you by Brandon Friedman, MD, Kelsey Patterson, and L. Erin Miller MD. It is has special guest editor: Scott Wait, MD
This network meta-analysis compared clinical outcomes of 5 coronary bifurcation PCI techniques based on 21 randomized trials including 5,711 patients. The techniques were provisional stenting, T/TAP stenting, crush, culotte, and double-kissing crush (DK-crush). When all techniques were considered, DK-crush was associated with fewer major adverse cardiovascular events (MACE), driven by lower rates of repeat revascularization, with no differences among techniques for death, myocardial infarction, or stent thrombosis. In non-left main bifurcations specifically, DK-crush reduced MACE compared to provisional stenting. No differences in MACE were found among provisional stenting, culotte,
A New Electrocardiographic Marker of Sudden Death in Brugada Syndrome The S-W...Marina Mercurio
This study analyzed electrocardiographic (ECG) data from 347 patients with Brugada syndrome to identify markers that predict risk of ventricular fibrillation or sudden cardiac death. During follow-up, 32 patients (9.2%) experienced ventricular fibrillation or sudden cardiac death. The presence of a wide and/or large S-wave in lead I of the ECG was found to be a powerful predictor of these life-threatening arrhythmias. Electroanatomic mapping in 12 patients found conduction delays in the right ventricular outflow tract, particularly in those with an S-wave in lead I. The duration of the S-wave in lead I over 40 ms was an independent predictor of ventricular fibrillation or
This lecture proves an overview of assessing the thyrod nodule upon presentation. The use of imaging, including nuclear medicine, PET, CT/MR and Ultrasound is discussed.
There is more detail on ultrasound evaluation with particular emphasis on ACR TIRADS
These slides have been selected from an "ask the expert" session that Dr Amit Pawa gave at the Dublin Convention Centre on 13th September 2018 for the ESRA (European Society of Regional Anaesthesia) 2018 annual meeting. These slides are shared to anyone with the link - please only practice techniques described if you are suitably trained to do so. Many thanks
The presentation gives an Overview of ROSS operation and delves in to depth in 3 key areas as follows:
1. Our experience
2. Special situations
3. RVOT Reconstruction with xenografts
This document summarizes two studies on percutaneous left ventricular assist devices (LVADs) and coronary artery fistulas.
The first study investigated the ability of a percutaneous LVAD to deliver blood to the systemic circulation during cardiac arrest in pigs. The LVAD maintained blood flow and preferentially perfused vital organs like the brain. Intensified fluid loading further improved LVAD performance.
The second study evaluated the microvascular effects of ultrasound contrast (Definity) in hamsters with conditions like ischemia-reperfusion, diabetes, and sepsis. Inflammatory responses were higher in diabetes with ischemia and sepsis groups, independent of contrast use. Contrast did not alter hemodynamics or reology.
Tips and tricks to site and maintain nerve cathetersAmit Pawa
This lecture was given on Friday 13th September 2019 at the annual congress of the European Society of Regional Anaesthesia in Bilbao and Spain. The talk was also contributed to by the Twitter Community. Strategies and techniques to site, secure and maintain perineural nerve catheters is discussed
This network meta-analysis compared clinical outcomes of 5 coronary bifurcation PCI techniques based on 21 randomized trials including 5,711 patients. The techniques were provisional stenting, T/TAP stenting, crush, culotte, and double-kissing crush (DK-crush). When all techniques were considered, DK-crush was associated with fewer major adverse cardiovascular events (MACE), driven by lower rates of repeat revascularization, with no differences among techniques for death, myocardial infarction, or stent thrombosis. In non-left main bifurcations specifically, DK-crush reduced MACE compared to provisional stenting. No differences in MACE were found among provisional stenting, culotte,
A New Electrocardiographic Marker of Sudden Death in Brugada Syndrome The S-W...Marina Mercurio
This study analyzed electrocardiographic (ECG) data from 347 patients with Brugada syndrome to identify markers that predict risk of ventricular fibrillation or sudden cardiac death. During follow-up, 32 patients (9.2%) experienced ventricular fibrillation or sudden cardiac death. The presence of a wide and/or large S-wave in lead I of the ECG was found to be a powerful predictor of these life-threatening arrhythmias. Electroanatomic mapping in 12 patients found conduction delays in the right ventricular outflow tract, particularly in those with an S-wave in lead I. The duration of the S-wave in lead I over 40 ms was an independent predictor of ventricular fibrillation or
This lecture proves an overview of assessing the thyrod nodule upon presentation. The use of imaging, including nuclear medicine, PET, CT/MR and Ultrasound is discussed.
There is more detail on ultrasound evaluation with particular emphasis on ACR TIRADS
These slides have been selected from an "ask the expert" session that Dr Amit Pawa gave at the Dublin Convention Centre on 13th September 2018 for the ESRA (European Society of Regional Anaesthesia) 2018 annual meeting. These slides are shared to anyone with the link - please only practice techniques described if you are suitably trained to do so. Many thanks
The presentation gives an Overview of ROSS operation and delves in to depth in 3 key areas as follows:
1. Our experience
2. Special situations
3. RVOT Reconstruction with xenografts
This document summarizes two studies on percutaneous left ventricular assist devices (LVADs) and coronary artery fistulas.
The first study investigated the ability of a percutaneous LVAD to deliver blood to the systemic circulation during cardiac arrest in pigs. The LVAD maintained blood flow and preferentially perfused vital organs like the brain. Intensified fluid loading further improved LVAD performance.
The second study evaluated the microvascular effects of ultrasound contrast (Definity) in hamsters with conditions like ischemia-reperfusion, diabetes, and sepsis. Inflammatory responses were higher in diabetes with ischemia and sepsis groups, independent of contrast use. Contrast did not alter hemodynamics or reology.
Tips and tricks to site and maintain nerve cathetersAmit Pawa
This lecture was given on Friday 13th September 2019 at the annual congress of the European Society of Regional Anaesthesia in Bilbao and Spain. The talk was also contributed to by the Twitter Community. Strategies and techniques to site, secure and maintain perineural nerve catheters is discussed
Endeavor IV-A Randomized Comparison of a Zotarolimus-Eluting Stent Endeavor...MedicineAndFamily
- Endeavor IV was a randomized trial comparing the zotarolimus-eluting Endeavor stent to the paclitaxel-eluting Taxus stent.
- The primary endpoint was target vessel failure at 9 months, with a pre-specified non-inferiority margin of 3.8%.
- 1,548 patients at 80 sites in the US were randomized 1:1 to receive either the Endeavor or Taxus stent. Follow-up was planned through 5 years.
By: Joseph Zygmunt, Jr., RVT, RPhS
Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
This document summarizes several studies presented at the 2006 Transcatheter Cardiovascular Therapeutics (TCT) Conference related to drug-eluting stents (DES). It discusses proposed definitions for stent thrombosis from the Academic Research Consortium. It summarizes findings from the DEScover Registry on outcomes of DES vs bare-metal stents. It also summarizes results from the PREMIER and REWARDS registries related to discontinuing thienopyridine therapy after DES and outcomes of the Cypher vs Taxus DES.
This article presents a case study of an 8-year-old girl who experienced a right middle cerebral artery stroke after a medical procedure. Imaging revealed a right supraclinoid internal carotid artery occlusion, likely caused by perioperative carotid compression or dissection. Follow-up imaging 20 months later showed that the right carotid canal, which houses the internal carotid artery, had decreased in size to about half that of the left carotid canal. This observation suggests that while carotid canal asymmetry is often congenital, an acquired internal carotid artery lesion can also result in decreased size of the corresponding carotid canal over time. Therefore, the size of the carotid canal alone cannot be used to determine whether an internal carotid artery occlusion is congenital or acquired.
This document provides guidelines for the diagnosis and management of aortic disease from the 2022 ACC/AHA writing committee. Some of the key points discussed include:
- Multidisciplinary aortic team care is recommended to optimize outcomes for patients with aortic disease.
- Imaging of the aorta should follow standardized approaches and measurements.
- Thresholds for surgical intervention in thoracic aortic aneurysms have been lowered to 5.0 cm at experienced centers.
- Endovascular techniques are increasingly used for thoracic aortic aneurysms and dissections when anatomy allows.
- Screening of relatives is recommended for patients with thoracic aortic aneurysms or dissections.
This document contains abstracts from presentations at the 29th Annual Northeast Regional Scientific Meeting. The abstracts describe several studies involving nuclear imaging techniques:
1. A study evaluating the reproducibility of quantitative measurements from FDG PET and gallium scans in distinguishing between interstitial nephritis and acute tubular necrosis in rats. It found the measurements to be highly reproducible.
2. A case report describing how SPECT/CT imaging with indium-111 labeled white blood cells revealed unsuspected pulmonary septic emboli in a patient with infected hemodialysis access.
3. A case report where bone SPECT/CT identified an acute pelvic fracture that was missed on other imaging in a patient
This study used medical imaging and computational modeling to analyze blood flow patterns in a patient with an aortic dissection. Computational fluid dynamics (CFD) models of the patient's aorta were created using CT and MRI imaging data. Simulations were performed to: 1) Compare flow patterns in the dissected aorta to a healthy aorta model; 2) Estimate the increased workload on the heart from the dissection; and 3) Analyze the impact of secondary tears in the dissection flap on flow. The results provide insights into complex hemodynamics in dissections that may help predict patient outcomes.
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
This document discusses endovascular thrombolytic therapy for acute deep vein thrombosis (DVT). It provides background on the quality of life issues for DVT patients, including long term complications like post-thrombotic syndrome (PTS). It reviews evidence that immediate clot removal may help prevent PTS by preserving venous valves and function. The document outlines the ATTRACT trial, a large multicenter randomized controlled trial testing whether catheter-directed thrombolysis (CDT) plus standard therapy is more effective than standard therapy alone for reducing PTS in patients with acute proximal DVT. It lists the primary and secondary outcomes that will be assessed to determine if CDT is safer, improves quality of life, and is cost-
1) Stereotactic arrhythmia radioablation (STAR) is a non-invasive technique using SBRT to treat refractory ventricular tachycardia (VT).
2) The first human case was reported in 2015 where a single fraction of 33Gy targeted to the scar substrate significantly reduced the VT burden.
3) Target delineation involves multimodality cardiac imaging including CT, MRI, nuclear imaging and electroanatomical mapping to identify and track the scar substrate through the cardiac cycle.
Cardiovascular Pathophysiology In the Setting of Spinal Cord InjuryInsideScientific
Dr. Christopher West shares his research that investigates the cardiovascular and autonomic changes that occur following spinal cord injury as well as the efficacy of neuro-therapeutic interventions.
Dr. West’s group uses small and large in vivo animal models to understand how the circuitry that controls the cardiovascular system changes following injury and what the downstream impact of these changes are for heart and blood vessel function. They also use these models to test the efficacy of novel therapies in the both the acute and chronic setting following injury. In the clinical and athletic spinal cord injury population, his group has conducted a number of mechanistic and applied studies to, 1) improve the understanding of how best to hemodynamically manage acutely injured patients, and 2) enhance the capacity of the cardiovascular system to enable an improved exercise response.
This webinar introduces the major cardiovascular changes that have been characterized following spinal cord injury in animal models and the clinical population. Chris shares some exciting results from recent studies in which his group has tested the efficacy of novel therapies to improve cardiovascular function. Finally, he provides his outlook for the future of the field.
Innovations in Percutaneous Intervention, 1977-2007. Slides created by Simon H. Stertzer, MD, FACC, FAHA, Professor Emeritus, Stanford University School of Medicine.
This document summarizes several studies that examined anatomical variations in the branches of the external carotid artery. The results of the studies found variations in the origin and course of arteries such as the superior thyroid artery, lingual artery, and facial artery. One study also reported an unusual case where the superior thyroid arteries were absent and the superior laryngeal arteries arose directly from the external carotid arteries.
Ultrasound basics for Nephrologists.pptxJAFAR ALSAID
This document provides an overview of ultrasound basics for nephrologists. It discusses ultrasound physics, how to perform and interpret a renal ultrasound exam, and recognizes some abnormalities. The document aims to establish ultrasound as a useful examination tool for nephrologists and provides several case examples of using ultrasound to determine the cause of renal disease or kidney abnormalities.
This document provides a pictorial review of ultrasound images to illustrate benign and malignant features of thyroid nodules according to the U1-U5 classification system of the British Thyroid Association. It begins with an overview of normal thyroid ultrasound appearance and anatomy as a baseline for comparison. The majority of the document then features ultrasound images paired with descriptions of thyroid nodules demonstrating benign characteristics, such as a halo sign, microcystic/spongiform appearance, peripheral egg shell calcification, or peripheral vascularity, which correspond to a U2 classification. The aim is to help radiologists and clinicians recognize sonographic patterns to determine whether fine needle aspiration is necessary.
Manuscript editing service | Primary and secondary data | Neurogenic ShockPubrica
Pubrica writers have worked with numerous journals in medical and scientific subjects. We work with scientists and researchers across the globe to write novel manuscripts that explain finding in a clear and cohesive structure. We provide prepublication services, including editing, proofreading, rewriting, and translation services for your manuscript.
Read more @ https://pubrica.com/insights/sample-work/management-of-neurogenic-shock-outside-of-the-hospital/
This document summarizes information about aortic graft infections, including:
1. The incidence of aortic graft infections is between 0.8-6% and they have high mortality rates of 25-40% and 5-year survival rates of less than 50%.
2. Diagnosis involves imaging like CT, MRI, PET scans and lab tests. CT is often the gold standard but MRI is better at differentiating fluid/inflammation from hematoma/fibrosis. Staphylococcus species are the most common causes.
3. Treatment options include extra-anatomic bypass grafting, in-situ replacement with prosthetic grafts using antimicrobials like rifampin, arterial allog
This chapter discusses the history and development of coronary angiography. It began with Claude Bernard performing the first cardiac catheterization on a horse in 1844. Werner Forssmann performed the first human cardiac catheterization in 1929. Further advances like those of Sones and others improved imaging quality. Andreas Grüntzig introduced balloon angioplasty in 1977, launching the field of interventional cardiology. The chapter describes the views needed to visualize coronary arteries without overlap, including the right and left anterior oblique planes and cranial and caudal projections. It also provides example images of views used to examine the left anterior descending artery, left circumflex artery, and right coronary artery.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: May CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Spontaneous Pneumothorax
• Esophageal Stent
• Iatrogenic Pneumothorax
• Pleural Effusion
• Shoulder Dislocation
• Proximal Humeral Fracture
• Aspiration Event
• Subcutaneous Emphysema
• Metastatic Germ Cell Cancer
• ARDS
• Right Lower Lobe Pneumonia
• Mediastinal Mass
Sternal Fractures & Dislocations - EMGuidewire Radiology Reading RoomSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Sternal Fractures and Dislocations and is brought to you by Carrie Bissell, MD, Aaron Fox, MD, Kendrick Lim, MD, Stephanie Jensen, MD, and Olivia Rice, MD. It is has special guest editor: Sean Dieffenbaugher, MD and Laurence Kempton, MD
Diaphragmatic Injuries - Radiology Reading RoomSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Kylee Brooks, MD, Parker Hambright, MD, Alexis Holland, MD, and William Lorenz, MD. It is has special guest editor: Kyle Cunningham, MD
More Related Content
Similar to Implanted Devices - VP Shunts: EMGuidewire's Radiology Reading Room
Endeavor IV-A Randomized Comparison of a Zotarolimus-Eluting Stent Endeavor...MedicineAndFamily
- Endeavor IV was a randomized trial comparing the zotarolimus-eluting Endeavor stent to the paclitaxel-eluting Taxus stent.
- The primary endpoint was target vessel failure at 9 months, with a pre-specified non-inferiority margin of 3.8%.
- 1,548 patients at 80 sites in the US were randomized 1:1 to receive either the Endeavor or Taxus stent. Follow-up was planned through 5 years.
By: Joseph Zygmunt, Jr., RVT, RPhS
Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
This document summarizes several studies presented at the 2006 Transcatheter Cardiovascular Therapeutics (TCT) Conference related to drug-eluting stents (DES). It discusses proposed definitions for stent thrombosis from the Academic Research Consortium. It summarizes findings from the DEScover Registry on outcomes of DES vs bare-metal stents. It also summarizes results from the PREMIER and REWARDS registries related to discontinuing thienopyridine therapy after DES and outcomes of the Cypher vs Taxus DES.
This article presents a case study of an 8-year-old girl who experienced a right middle cerebral artery stroke after a medical procedure. Imaging revealed a right supraclinoid internal carotid artery occlusion, likely caused by perioperative carotid compression or dissection. Follow-up imaging 20 months later showed that the right carotid canal, which houses the internal carotid artery, had decreased in size to about half that of the left carotid canal. This observation suggests that while carotid canal asymmetry is often congenital, an acquired internal carotid artery lesion can also result in decreased size of the corresponding carotid canal over time. Therefore, the size of the carotid canal alone cannot be used to determine whether an internal carotid artery occlusion is congenital or acquired.
This document provides guidelines for the diagnosis and management of aortic disease from the 2022 ACC/AHA writing committee. Some of the key points discussed include:
- Multidisciplinary aortic team care is recommended to optimize outcomes for patients with aortic disease.
- Imaging of the aorta should follow standardized approaches and measurements.
- Thresholds for surgical intervention in thoracic aortic aneurysms have been lowered to 5.0 cm at experienced centers.
- Endovascular techniques are increasingly used for thoracic aortic aneurysms and dissections when anatomy allows.
- Screening of relatives is recommended for patients with thoracic aortic aneurysms or dissections.
This document contains abstracts from presentations at the 29th Annual Northeast Regional Scientific Meeting. The abstracts describe several studies involving nuclear imaging techniques:
1. A study evaluating the reproducibility of quantitative measurements from FDG PET and gallium scans in distinguishing between interstitial nephritis and acute tubular necrosis in rats. It found the measurements to be highly reproducible.
2. A case report describing how SPECT/CT imaging with indium-111 labeled white blood cells revealed unsuspected pulmonary septic emboli in a patient with infected hemodialysis access.
3. A case report where bone SPECT/CT identified an acute pelvic fracture that was missed on other imaging in a patient
This study used medical imaging and computational modeling to analyze blood flow patterns in a patient with an aortic dissection. Computational fluid dynamics (CFD) models of the patient's aorta were created using CT and MRI imaging data. Simulations were performed to: 1) Compare flow patterns in the dissected aorta to a healthy aorta model; 2) Estimate the increased workload on the heart from the dissection; and 3) Analyze the impact of secondary tears in the dissection flap on flow. The results provide insights into complex hemodynamics in dissections that may help predict patient outcomes.
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
This document discusses endovascular thrombolytic therapy for acute deep vein thrombosis (DVT). It provides background on the quality of life issues for DVT patients, including long term complications like post-thrombotic syndrome (PTS). It reviews evidence that immediate clot removal may help prevent PTS by preserving venous valves and function. The document outlines the ATTRACT trial, a large multicenter randomized controlled trial testing whether catheter-directed thrombolysis (CDT) plus standard therapy is more effective than standard therapy alone for reducing PTS in patients with acute proximal DVT. It lists the primary and secondary outcomes that will be assessed to determine if CDT is safer, improves quality of life, and is cost-
1) Stereotactic arrhythmia radioablation (STAR) is a non-invasive technique using SBRT to treat refractory ventricular tachycardia (VT).
2) The first human case was reported in 2015 where a single fraction of 33Gy targeted to the scar substrate significantly reduced the VT burden.
3) Target delineation involves multimodality cardiac imaging including CT, MRI, nuclear imaging and electroanatomical mapping to identify and track the scar substrate through the cardiac cycle.
Cardiovascular Pathophysiology In the Setting of Spinal Cord InjuryInsideScientific
Dr. Christopher West shares his research that investigates the cardiovascular and autonomic changes that occur following spinal cord injury as well as the efficacy of neuro-therapeutic interventions.
Dr. West’s group uses small and large in vivo animal models to understand how the circuitry that controls the cardiovascular system changes following injury and what the downstream impact of these changes are for heart and blood vessel function. They also use these models to test the efficacy of novel therapies in the both the acute and chronic setting following injury. In the clinical and athletic spinal cord injury population, his group has conducted a number of mechanistic and applied studies to, 1) improve the understanding of how best to hemodynamically manage acutely injured patients, and 2) enhance the capacity of the cardiovascular system to enable an improved exercise response.
This webinar introduces the major cardiovascular changes that have been characterized following spinal cord injury in animal models and the clinical population. Chris shares some exciting results from recent studies in which his group has tested the efficacy of novel therapies to improve cardiovascular function. Finally, he provides his outlook for the future of the field.
Innovations in Percutaneous Intervention, 1977-2007. Slides created by Simon H. Stertzer, MD, FACC, FAHA, Professor Emeritus, Stanford University School of Medicine.
This document summarizes several studies that examined anatomical variations in the branches of the external carotid artery. The results of the studies found variations in the origin and course of arteries such as the superior thyroid artery, lingual artery, and facial artery. One study also reported an unusual case where the superior thyroid arteries were absent and the superior laryngeal arteries arose directly from the external carotid arteries.
Ultrasound basics for Nephrologists.pptxJAFAR ALSAID
This document provides an overview of ultrasound basics for nephrologists. It discusses ultrasound physics, how to perform and interpret a renal ultrasound exam, and recognizes some abnormalities. The document aims to establish ultrasound as a useful examination tool for nephrologists and provides several case examples of using ultrasound to determine the cause of renal disease or kidney abnormalities.
This document provides a pictorial review of ultrasound images to illustrate benign and malignant features of thyroid nodules according to the U1-U5 classification system of the British Thyroid Association. It begins with an overview of normal thyroid ultrasound appearance and anatomy as a baseline for comparison. The majority of the document then features ultrasound images paired with descriptions of thyroid nodules demonstrating benign characteristics, such as a halo sign, microcystic/spongiform appearance, peripheral egg shell calcification, or peripheral vascularity, which correspond to a U2 classification. The aim is to help radiologists and clinicians recognize sonographic patterns to determine whether fine needle aspiration is necessary.
Manuscript editing service | Primary and secondary data | Neurogenic ShockPubrica
Pubrica writers have worked with numerous journals in medical and scientific subjects. We work with scientists and researchers across the globe to write novel manuscripts that explain finding in a clear and cohesive structure. We provide prepublication services, including editing, proofreading, rewriting, and translation services for your manuscript.
Read more @ https://pubrica.com/insights/sample-work/management-of-neurogenic-shock-outside-of-the-hospital/
This document summarizes information about aortic graft infections, including:
1. The incidence of aortic graft infections is between 0.8-6% and they have high mortality rates of 25-40% and 5-year survival rates of less than 50%.
2. Diagnosis involves imaging like CT, MRI, PET scans and lab tests. CT is often the gold standard but MRI is better at differentiating fluid/inflammation from hematoma/fibrosis. Staphylococcus species are the most common causes.
3. Treatment options include extra-anatomic bypass grafting, in-situ replacement with prosthetic grafts using antimicrobials like rifampin, arterial allog
This chapter discusses the history and development of coronary angiography. It began with Claude Bernard performing the first cardiac catheterization on a horse in 1844. Werner Forssmann performed the first human cardiac catheterization in 1929. Further advances like those of Sones and others improved imaging quality. Andreas Grüntzig introduced balloon angioplasty in 1977, launching the field of interventional cardiology. The chapter describes the views needed to visualize coronary arteries without overlap, including the right and left anterior oblique planes and cranial and caudal projections. It also provides example images of views used to examine the left anterior descending artery, left circumflex artery, and right coronary artery.
Drs. Milam and Thomas's CMC X-Ray Mastery Project: May CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Spontaneous Pneumothorax
• Esophageal Stent
• Iatrogenic Pneumothorax
• Pleural Effusion
• Shoulder Dislocation
• Proximal Humeral Fracture
• Aspiration Event
• Subcutaneous Emphysema
• Metastatic Germ Cell Cancer
• ARDS
• Right Lower Lobe Pneumonia
• Mediastinal Mass
Similar to Implanted Devices - VP Shunts: EMGuidewire's Radiology Reading Room (20)
Sternal Fractures & Dislocations - EMGuidewire Radiology Reading RoomSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Sternal Fractures and Dislocations and is brought to you by Carrie Bissell, MD, Aaron Fox, MD, Kendrick Lim, MD, Stephanie Jensen, MD, and Olivia Rice, MD. It is has special guest editor: Sean Dieffenbaugher, MD and Laurence Kempton, MD
Diaphragmatic Injuries - Radiology Reading RoomSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Kylee Brooks, MD, Parker Hambright, MD, Alexis Holland, MD, and William Lorenz, MD. It is has special guest editor: Kyle Cunningham, MD
Acute Chest Syndrome - EMGuidewire's Radiology Reading RoomSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Acute Chest Syndrome and is brought to you by Angela Pikus, MD, Mark Baumgarten, MD, Andres Gil Bustamante, and Ahmed Mashal, MD. As always, Michael Gibbs, MD serves as the projects editor.
Adult Orthopedic Imaging Series: Presentation #2 Native Hip DislocationsSean M. Fox
Drs. Carrie Bissell, Aaron Fox, and Kendrick Lim are Emergency Medicine Residents at Carolinas Medical Center and are interested in emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine and Dr. Laurence Kempton, an Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides that focus on Adult Orthopedic cases. This set will cover:
- Hip Dislocations
Neuroimaging Mastery Project: Presentation #5 Subdural HematomasSean M. Fox
Drs. Faith Meyers, Madison Watts and Steven Perry are Emergency Medicine Residents at Carolinas Medical Center who are interested in medical education. Dr. Rebecca DeCarlo, MD is a Neurosurgical resident at Carolinas Medical Center. Along with the guidance of Dr. Michael Gibbs (Chair of Emergency Medicine), Dr. Jonathan Clemente (Chief of the Department of Radiology and Neuroradiology specialist), Dr. Christa Swisher (Neurocritcal Care Intensivist), and Dr. Scott Wait (Chief of Pediatric Neurosurgery) they aim to help educate us on Neuroimaging. In this presentation they will address Subdural Hematomas. Follow along with the EMGuideWire.com team as they post the CMC Neuroimaging Case Studies.
- Subdural Hematomas
Neuroimaging Mastery Project Presentation #4: Acute Epidural HematomasSean M. Fox
Drs. Faith Meyers, Madison Watts and Steven Perry are Emergency Medicine Residents at Carolinas Medical Center who are interested in medical education. Along with the guidance of Dr. Michael Gibbs (Chair of Emergency Medicine), Dr. Jonathan Clemente (Chief of the Department of Radiology and Neuroradiology specialist), Dr. Christa Swisher (Neurocritcal Care Intensivist), and Dr. Scott Wait (Chief of Pediatric Neurosurgery) they aim to help educate us on Neuroimaging. In this presentation they will address Atraumatic Neurosurgical Intracranial Infections. Follow along with the EMGuideWire.com team as they post the CMC Neuroimaging Case Studies.
- Acute Epidural Hematomas
Pediatric Orthopedic Imaging Case Studies #7 Pediatric Elbow FracturesSean M. Fox
The document provides an overview of commonly encountered pediatric elbow injuries seen in the emergency department setting. It reviews the anatomy and imaging evaluation of pediatric elbow fractures including the supracondylar humerus, radial neck, lateral condyle, and medial epicondyle fractures. Specific radiographic findings that help identify subtle fractures are discussed. Challenges in pediatric elbow imaging related to ossification centers are also covered. The goal is to help emergency physicians accurately diagnose pediatric elbow fractures on radiographs.
Adult Orthopedic Imaging Mastery Project - Pelvic Ring FracturesSean M. Fox
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1. Imaging Of Medical Devices
Ventriculoperitoneal Shunts
Brandon Friedman, MD1, Kelsey Patterson2, L. Erin Miller, MD3
Carolinas Medical Center & Levine Children’s Hospital
Department of Emergency Medicine1; Charlotte Neurosurgery & Spine3;
NYU School of Global Public Health & Wagner Graduate School of Public Service2
Scott Wait, MD, Faculty Editor, Charlotte Neurosurgery & Spine
Michael Gibbs, MD1, Imaging Mastery Project Lead Editor
Medical Device Imaging Mastery Project
Presentation #5
2. Disclosures
This ongoing imaging interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
The goal is to promote widespread mastery of imaging interpretation.
There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.
6. Introduction – Ventriculoperitoneal Shunts
Definition:
A cerebral shunt drains excess cerebrospinal
fluid (CSF) in the setting of an outflow
obstruction or decreased reabsorption
Shunt Components:
1. Proximal ventricular catheter drains CSF
2. Reservoir (optional) for tapping
3. One-way valve to regulate pressure and
flow, and prevent reversal of flow.
4. Distal catheter to deposit fluid into the
peritoneum, pleural space or atrium
Reservoir
One-Way Valve
7. Common Indications and Contraindications
Non-Communicating (Obstructive) Hydrocephalus Communicating* (Non-Obstructive) Hydrocephalus
Congenital aqueductal stenosis Idiopathic intracranial hypertension
Atresia of the Foramen of Monroe Normal pressure hydrocephalus
Skull base anomalies Post-hemorrhagic
Intracranial tumors Post-infectious (meningitis; ventriculitis)
Arachnoid cysts Choroid plexus papilloma/carcinoma (↑ secretion)
Chiari malformation
Dandy-Walker malformation
Cerebellar infarction (space-occupying) *Note that there is considerable overlap in the categorizations of these etiologies as
Communicating vs Non-Communicating; these lists serve as a general framework
Absolute Contraindications: (1) Infection over the entry site, (2) CSF infection, (3) allergy to catheter components
Relative Contraindications: (1) Impaired coagulation, (2) high CSF protein, (3) presence of CSF blood
*All hydrocephalus is obstructive somewhere in the system, communicating is an old term used to indicate that it is distal to the ventricular system
8. VP Shunt Imaging Modalities
Shunt Series (Plain Film Imaging)
• Frontal head (a), lateral head (b), AP chest (c), and (d)
AP abdomen
• Obtain in all cases of suspected shunt dysfunction
• Evaluate for shunt damage, shunt kinking, catheter
migration, or fluid collections (e.g., pleural effusion)
Computed Tomography
• Obtained in almost all adults
• CT head to evaluate for ventricular abnormalities (e.g.,
ventriculomegaly, slit ventricle syndrome) or
intracranial hemorrhage/infection
• CT chest/abdomen/pelvis to evaluate for fluid
collections, bowel obstruction, or visceral injury
(rarely needed)
Magnetic Resonance Imaging
• Rapid sequence MRI in pediatric patients, in place of a
CT head, to spare radiation exposure
• Consider if high suspicion for intracranial infection
Fowler JB, De Jesus O, Mesfin FB. Ventriculoperitoneal Shunt. [Updated 2023
Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459351/
10. Normal VP Shunt Series
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org
(Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-77252
11. Normal VP Shunt Series
Proximal Catheter
Reservoir
Reservoir
One-Way
Valve
One-Way
Valve
Proximal Catheter
Distal
Catheter
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org
(Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-77252
Distal
Catheter
12. Normal VP Shunt Series
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-77252
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-77252
13. Normal VP Shunt Series
Distal Catheter
Distal Catheter
Tip of Distal
Catheter
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-77252
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-77252
16. Shunt Complication #1
Coley, Brian & Kosnik, Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in
Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009.
What do you notice
about the distal
catheter in this
portion of the
abdominal x-ray?
17. Shunt Obstruction
Coley, Brian & Kosnik, Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in
Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009.
Abou-Al-Shaar H, Mallela AN, Algattas HN, Rogers R, Friedlander RM.
Ventriculoperitoneal Shunt Failure Due to Distal Peritoneal Catheter
Kinking. Am J Case Rep. 2022 Apr 5;23:e935077. doi:
10.12659/AJCR.935077. PMID: 35379769; PMCID: PMC8994830.
Kinking of the end of the
drainage catheter (left)
can cause obstruction of
the shunt tubing and
prevent the drainage of
CSF. This may result in
ventriculomegaly as a
result of the shunt’s
failure to drain
appropriately (right).
Kinking Of The
Distal Catheter,
Causing Obstruction
Tip Of The
Distal Catheter
Unilateral Ventriculomegaly
Secondary To Shunt Obstruction
18. Shunt Complication #2
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain
Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
What do you notice
about the tubing from
these two catheters?
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain
Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
19. Shunt Fracture
These images
demonstrate fractures
of both the proximal
(left) and distal (right)
shunt tubing,
respectively. This
results in inadequate
drainage of CSF and
can also be associated
with recurrent
hydrocephalus or
ventriculomegaly.
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain
Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
Fractured
Distal Shunt
Tubing
Coiling Of
Distal Tubing
In The Pelvis
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain
Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
Fractured Proximal
Shunt Tubing
20. Shunt Complication #3
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal
Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018
Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID:
28830622.
What do you notice
about this patient’s
shunt? Remember the
four components that
make up the shunt and
where they typically
reside in relation to
one another.
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal
Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol.
2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29.
PMID: 28830622.
21. Shunt Disconnection
All Images: Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt
Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
These images demonstrate disconnection of the distal portion of the shunt
tubing from the proximal components of the shunt. A 3D reconstruction of
the skull and shunt components is seen in the image to the far right.
Disconnected Distal
Shunt Tubing
Proximal
Catheter
22. Shunt Complication #4
What do you notice
about these MRI
images? Why might
they be asymmetrical?
Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article,
Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127
Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article,
Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127
23. Unilateral Slit Ventricle
These MRI images
demonstrate unilateral Slit
Ventricle, which results
from over-drainage of the
CSF; the proximal shunt
catheter can be visualized
extending from the skull to
the right lateral ventricle.
Slit ventricle cannot be
diagnosed with plain-film
imaging but can be seen on
CT or MRI.
Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article,
Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127
Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article,
Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127
Collapse Of The Right Lateral
Ventricle From Over-Drainage
Proximal Drainage Catheter
Collapse Of The Right Lateral
Ventricle From Over-Drainage
24. Shunt Complication #5
Chivate R, [Shunt Complication #5]. Case study, Radiopaedia.org (Accessed on 04
Jun 2023) https://doi.org/10.53347/rID-24964
Coley, Brian & Kosnik, Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts
in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009.
This complication is typically diagnosed with CSF studies,
laboratory evaluation, and clinical presentation. But
what abnormalities do you see in these images that can
help clarify the presenting diagnosis?
25. Shunt Infection
Chivate R, Ventriculitis. Case study, Radiopaedia.org (Accessed on 04 Jun 2023)
https://doi.org/10.53347/rID-24964
Coley, Brian & Kosnik, Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts
in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009.
Infections associated with VP shunts can occur at any point along the device’s
path. Here we see evidence of an intra-abdominal infection on CT (left) and
ventriculitis on MRI (right). One must have a high index of suspicion for shunt
infections for any patient with a shunt, presenting with infectious symptoms.
Shunt infection cannot be diagnosed with plain-film imaging.
Bowel Wall Thickening
Distal Catheter Tip
Intra-Abdominal Fluid Collection;
Suggestive Of Infection
Hyper-Intense Signal
Outlining The Ventricles;
Suggestive Of Ventriculitis
26. Shunt Complication #6
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs.
Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
What do you notice
about the positioning
of the distal portions of
the catheters? Could
this have implications
on their function?
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal
Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol.
2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29.
PMID: 28830622.
27. Catheter Migration
Both catheters show to
continuity in the tubing but
have migrated. The image to
the left demonstrates coiling
of the distal catheter in the
scrotum, which hinders its
ability to properly drain fluid.
The image to the right
demonstrates a case where
the catheter eroded through
the vaginal wall and has
migrated into the vaginal
canal. Both cases required
surgical revision.
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs.
Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
Coiling Of
Distal Tubing
In The Scrotum
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal
Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol.
2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29.
PMID: 28830622.
Perforation Of Shunt
Tubing Into The
Vaginal Canal
28. Shunt Complication #7
Zhao J, Chen Y, Yang K, Hu X. A case of repeated [Shunt Complication #7] secondary to ventriculoperitoneal shunt. Inter-discip Neurosurg. 2015;02(01):48–50.
What is the differential for the findings of these images?
Can this complication be sub-categorized any further?
29. Intracranial Hemorrhage
Zhao J, Chen Y, Yang K, Hu X. A case of repeated intracerebral hemorrhages secondary to ventriculoperitoneal shunt. Inter-discip Neurosurg. 2015;02(01):48–50.
Intraparenchymal
Hemorrhage
Intraventricular
Hemorrhage
Proximal Catheter
Proximal Catheter
Here we see two types of intracranial hemorrhage, intraparenchymal and intraventricular.
Subarachnoid and subdural hemorrhages can also occur but are not visualized in these images.
30. Shunt Complication #8
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt
Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-
323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
What subtle finding do
you notice in this
patient’s catheter?
Why do we obtain
plain film imaging in
orthogonal planes?
Bates P, Rajderkar D. Common and Uncommon Causes
of Ventriculoperitoneal Shunt Malfunction Diagnosed
on Plain Radiographs. Curr Probl Diagn Radiol. 2018
Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006.
Epub 2017 Jul 29. PMID: 28830622.
31. Shunt Fracture
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt
Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-
323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
This case demonstrates
another example of a
fracture of the shunt tubing.
Note that the fracture is not
visible on the AP view but is
seen in the lateral view. This
demonstrates the
importance of obtaining x-
rays in orthogonal planes.
Bates P, Rajderkar D. Common and Uncommon Causes
of Ventriculoperitoneal Shunt Malfunction Diagnosed
on Plain Radiographs. Curr Probl Diagn Radiol. 2018
Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006.
Epub 2017 Jul 29. PMID: 28830622.
Fractured Distal
Shunt Tubing
Shunt Fracture Not
Visible On AP View
Calcified Region Of
The Shunt Tubing
That May have
Caused Tethering
That Predisposed To
Shunt Fracture
32. Shunt Complication #9
Rahalkar, M. (2017). Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A
Pictorial Essay. Indian Journal of Neurosurgery. 07. 10.1055/s-0037-1599786.
What’s abnormal
about this plain film
image of the chest
and abdomen in a
patient with
abdominal pain and
distension? Does
the bowel gas
pattern give you any
clue as to what
might be going on?
33. Ascites Accumulation
CT imaging demonstrates large-
volume accumulation of ascites
fluid. The bowel gas pattern on
the x-ray image shows that the
bowel has been displaced
secondary to the presence of fluid.
The image also shows hypo-
inflated lungs, which is likely
secondary to the ascites. This
complication results from the
body’s inability to fully absorb the
CSF, once it’s drained into the
abdomen. While CT or ultrasound
imaging would be required to
confirm the diagnosis, the x-ray
gives us clues that can help raise
suspicion for ascites and prompt
further imaging.
Ascites
Distal Catheter
Distal
Catheter Tip
Bowel Gas
Paucity Of Bowel Gas
Hypo-Inflated
Lungs
Rahalkar, M. (2017). Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A Pictorial Essay. Indian Journal of Neurosurgery. 07. 10.1055/s-0037-1599786.
34. Shunt Complication #10
Bacon JL, Sithamparanathan S. A rare cause of [Shunt Complication #10]. Respir Med CME 2011;4:124–5.
10.1016/j.rmedc.2011.01.002
What’s abnormal
about this plain
film? Remember
our standardized
approach to reading
chest x-rays.
Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum
35. Shunt Complication #11
Radswiki T, Bell D, Deng F, et al. [Shunt Complication #11]. Reference article, Radiopaedia.org
(Accessed on 09 Jun 2023) https://doi.org/10.53347/rID-11105
What’s abnormal
about this AP view of
the abdomen? Does
the bowel gas pattern
give you any clues to
the diagnosis? Does
this look similar to a
previously-discussed
complication?
36. Intra-Abdominal CSF Pseudocyst
While the plain film appears
similar to the previous case
of ascites accumulation, the
CT image demonstrates a
well-defined region of CSF
accumulation, consistent
with a pseudocyst. In this
case, a CT of the abdomen
is necessary to distinguish a
pseudocyst from ascites.
Radswiki T, Bell D, Deng F, et al. Peritoneal CSF pseudocyst.
Reference article, Radiopaedia.org (Accessed on 09 Jun 2023)
https://doi.org/10.53347/rID-11105
Distal
Catheter Tip
CSF
Pseudocyst
Radswiki T, Bell D, Deng F, et al. Peritoneal CSF pseudocyst. Reference article, Radiopaedia.org
(Accessed on 09 Jun 2023) https://doi.org/10.53347/rID-11105
Paucity Of
Bowel Gas
Distal
Catheter Tip
37. Shunt Complication #12
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal
Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol.
2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29.
PMID: 28830622.
What are we most
concerned about with
this AP view of the
abdomen? What
classic imaging
findings are present
that would help make
this diagnosis?
38. Small Bowel Obstruction
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal
Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol.
2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29.
PMID: 28830622.
Both the plain film and
CT images demonstrate
distended loops of
bowel and air-fluid
levels, suggestive of a
small bowel
obstruction. Further, on
the CT image, a
whirlpool sign is
visualized, indicative of
a small bowel volvulus.
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt
Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018
Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID:
28830622.
Whirlpool Sign
Distended Loops
Of Bowel
Air-Fluid
Levels
39. Shunt Complication #13
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr
Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
What do you notice
about this AP view of
the skull? Is there a
finding that hints at a
diagnosis without a
CT or MRI?
40. Intracranial Hemorrhage
Bates P, Rajderkar D. Common and Uncommon Causes of
Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr
Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi:
10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
Here we have a rare
case, where we can see
calcifications on the
plain film images, which
represent calcified
subdural hemorrhages!
A CT or MRI would
confirm the findings of a
chronic subdural bleed
Calcifications Within A
Subdural Hemorrhage
Calcifications Within A
Subdural Hemorrhage
42. Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches and vomiting
Is there anything abnormal about the shunt tubing in these views?
43. Disconnected
Distal Catheter
Disconnected
Distal Catheter
Valve Valve
Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches and vomiting
The AP and lateral skull views show two intact proximal catheters, but
show disconnection of the distal shunt tubing from the valve
44. Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches and vomiting
Is there anything abnormal about the shunt tubing in these views?
45. The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen
Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches and vomiting
46. Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches and vomiting
What do you notice between the patient’s old comparison head CT and the one obtained on this presentation?
Comparison CT CT on Presentation
47. There appears to be significant ventriculomegaly secondary to the inability to drain CSF from the disruption of the
distal catheter. The patient’s ventriculomegaly and symptoms resolved with surgical reattachment of the catheter.
Ventriculomegaly
Proximal Catheter
Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches and vomiting
Proximal Catheter
Comparison CT CT on Presentation
48. Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for morning headaches and lightheadedness
The skull and chest views of the shunt series are unremarkable. What do you notice
about the position of the distal catheter on the two-view plain film of the abdomen?
49. On the lateral view, the catheter appears to overly the abdomen. However, on the AP view, the distal end of the
catheter appears to terminate laterally to the abdominal wall. A CT scan was obtained to evaluate further.
Distal Catheter Tip
Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for morning headaches and lightheadedness
Distal Catheter Tip
50. The tip of the distal catheter is in view in all three planes of this CT abdomen, what do you notice about its position?
Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for morning headaches and lightheadedness
51. Distal Catheter Tip
Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for morning headaches and lightheadedness
The catheter is shown to terminate in the subcutaneous space, preventing outflow of CSF into the peritoneal cavity.
This can happen spontaneously especially in patients with a pannus. The patient was taken to the OR for distal
catheter revision and her symptoms subsequently resolved.
Distal Catheter Tip
Distal Catheter Tip
52. Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and
ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura
Is there anything abnormal about the shunt tubing in these views?
53. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the right atrium.
Valve
Distal Catheter Tip
Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and
ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura
54. Comparison CT CT on Presentation
What do you notice between the patient’s old comparison head CT and the one obtained on this presentation?
Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and
ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura
55. There appears to be significant ventriculomegaly secondary to the inability to drain CSF. Surgical evaluation identified
an obstruction to flow of the proximal catheter, which was corrected. The patient’s symptoms subsequently resolved.
Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and
ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura
Comparison CT CT on Presentation
Ventriculomegaly
Proximal Catheter
Proximal Catheter
56. Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for routine annual shunt evaluation
Is there anything abnormal about the shunt tubing in these views?
57. Disconnected
Distal Catheter
Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for routine annual shunt evaluation
Disconnected
Distal Catheter
Here we see both a disconnection of the distal shunt tubing from the valve, as
well as a fractured distal catheter overlying the right anterior chest.
58. Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for routine annual shunt evaluation
Is there anything abnormal about the shunt tubing in these views?
59. Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for routine annual shunt evaluation
The shunt tubing appears to be intact and in an appropriate location on the two views of the
abdomen. The patient underwent replacement of the distal catheter, without complications.
60. Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by
bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting
Is there anything abnormal about the shunt tubing in these views?
61. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the neck.
Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by
bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting
62. Is there anything abnormal about the shunt tubing in these views?
Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by
bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting
63. Tracheostomy
Tube
The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen
Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by
bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting
64. Comparison CT CT on Presentation
What do you notice between the patient’s old comparison head CT and the one obtained on this presentation?
Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by
bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting
65. Chronic
Subdural
Hematoma
Mass Effect On
Ventricles
Comparison CT CT on Presentation
Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by
bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting
The new CT image shows enlargement of the patient’s subacute bilateral subdural hematomas. The patient
underwent surgical evacuation of the bilateral hemorrhages, with resolution of his intractable vomiting.
Chronic
Subdural
Hematoma
66. Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement,
presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating
Is there anything abnormal about the shunt tubing in these views?
67. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the neck.
Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement,
presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating
68. Is there anything abnormal about the shunt tubing in these views?
Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement,
presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating
69. The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen.
Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement,
presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating
70. Comparison
CT
What do you notice about
the ventricles when
comparing the patient’s old
CT to the one obtained on
presentation?
Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement,
presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating
CT On
Presentation
71. The CT demonstrates a
decreased size of the lateral
ventricles consistent with
Overshunting that results
from over-drainage of CSF.
This fits with the clinical
picture of headaches that
improved when recumbent.
The patient’s shunt was
modified to slow the
drainage of CSF, and her
symptoms resolved.
Slit-Like Lateral
Ventricle
Decompression Of
The Lateral Ventricles
Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement,
presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating
CT On
Presentation
Comparison
CT
72. Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes
Is there anything abnormal about the shunt tubing in these views?
73. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the neck.
Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes
74. Is there anything abnormal about the shunt tubing in these views?
Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes
75. The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen
Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes
76. This patient presented with the CT on the left and underwent operative intervention. What
do you notice as differences between the presentation CT and the post-surgical CT?
CT on Presentation Post-operative CT
Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes
77. The CT on the left shows hydrocephalus and the patient was found to have a proximal shunt disconnection (not seen on
imaging). The post-operative CT shows improvement of the hydrocephalus and a replacement catheter in a new position.
Old Proximal
Catheter Bilateral
Hydrocephalus
Improved
Ventricular Size
Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes
CT on Presentation Post-operative CT
New Proximal
Catheter
78. Case 8: 47-year-old female with grade 3 astrocytoma and craniectomy and pseudomeningocele and VP shunt
placement, presents to the Emergency Department cranial soft tissue mass, hypertension, and vomiting
Comparison CT CT on Presentation
What do you notice between the patient’s old comparison head CT and the one obtained on this
presentation? The patient’s plain-film shunt series showed an intact shunt in an appropriate position.
79. The patient has a pseudomeningocele that was noted on the prior CT. But the repeat scan appears to show enlargement of the
communicating extracranial fluid collection. The patient underwent operative evaluation and was found to have a malfunctioning valve.
Enlarging Extracranial
Fluid Collection
Proximal
Catheter Tip
Comparison CT CT on Presentation
Pseudomeningocele
Case 8: 47-year-old female with grade 3 astrocytoma and craniectomy and pseudomeningocele and VP shunt
placement, presents to the Emergency Department cranial soft tissue mass, hypertension, and vomiting
80. Here we see the coronal view demonstrating the increased size of the extracranial fluid collection with some
worsening midline shift. The fluid collection improved with replacement of the malfunctioning valve.
Comparison CT CT on Presentation
Pseudomeningocele
Enlarging Extracranial
Fluid Collection
Case 8: 47-year-old female with grade 3 astrocytoma and craniectomy and pseudomeningocele and VP shunt
placement, presents to the Emergency Department cranial soft tissue mass, hypertension, and vomiting
81. Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department with headaches, nausea, and
dizziness
Is there anything abnormal about the shunt tubing in these views?
82. The proximal shunt tubing appears to be intact and in an appropriate place, but
we cannot identify any distal tubing in these plain-film images of the skull.
Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department with headaches, nausea, and
dizziness
83. Is there anything abnormal about the shunt tubing in these views?
Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department with headaches, nausea, and
dizziness
84. The distal shunt is not visible on the chest x-ray, but is noted to be coiled in the pelvis, consistent with disconnection of
the distal shunt from the proximal tubing. The patient underwent successful distal shunt replacement.
Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt
placement, presents to the Emergency Department with headaches, nausea, and
dizziness
85. If You Have Interesting Cases Demonstrating Ventriculoperitoneal Shunts We
Invite You To Send A Set Of Digital PDF Images And A Brief Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!
86. Selected Embedded References:
Abou-Al-Shaar H, Mallela AN, Algattas HN, Rogers R, Friedlander RM. Ventriculoperitoneal Shunt Failure Due to Distal Peritoneal Catheter
Kinking. Am J Case Rep. 2022 Apr 5;23:e935077. doi: 10.12659/AJCR.935077. PMID: 35379769; PMCID: PMC8994830.
Bacon JL, Sithamparanathan S. A rare cause of [Shunt Complication #10]. Respir Med CME 2011;4:124–5. 10.1016/j.rmedc.2011.01.002.
Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl
Diagn Radiol. 2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.
Chivate R, Ventriculitis. Case study, Radiopaedia.org (Accessed on 04 Jun 2023) https://doi.org/10.53347/rID-24964.
Coley, Brian & Kosnik, Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in Children. Seminars in ultrasound, CT, and MR.
27. 152-60. 10.1053/j.sult.2006.01.009.
Fowler JB, De Jesus O, Mesfin FB. Ventriculoperitoneal Shunt. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459351/.
Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252.
Radswiki T, Bell D, Deng F, et al. Peritoneal CSF pseudocyst. Reference article, Radiopaedia.org (Accessed on 09 Jun 2023)
https://doi.org/10.53347/rID-11105
Rahalkar, M.. (2017). Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A Pictorial Essay. Indian Journal of Neurosurgery. 07.
10.1055/s-0037-1599786.
Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article, Radiopaedia.org (Accessed on 31 May 2023)
https://doi.org/10.53347/rID-26127.
Zhao J, Chen Y, Yang K, Hu X. A case of repeated intracerebral hemorrhages secondary to ventriculoperitoneal shunt. Inter-discip Neurosurg.
2015;02(01):48–50.