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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
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.
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It’s All About The Anatomy!
Ventriculoperitoneal Shunts
VP Shunt Basics
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
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
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/
Ventriculoperitoneal Shunts
Normal VP Shunt Series
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
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
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
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
Ventriculoperitoneal Shunts
Complications and Diagnostic Imaging
Common Shunt Complications
Primary Shunt Dysfunction
• Slit Ventricle Syndrome
• Catheter Migration
• Shunt Fracture
• Shunt Disconnection
• Shunt Infection
• Shunt Obstruction
Secondary Complications
• Pleural effusion
• Bowel Obstruction
• Intra-Abdominal CSF Pseudocyst
• Ascites Collection
• Intracranial Hemorrhage
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?
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
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.
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
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.
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
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
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
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?
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
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.
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
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?
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.
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.
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
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?
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.
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
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?
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
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?
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
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?
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
Test Your Knowledge!
Cases From Carolinas Medical Center
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?
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
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?
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
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
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
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?
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
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
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
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?
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
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
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
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?
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.
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?
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.
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?
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
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
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
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
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
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?
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
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
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
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
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
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?
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
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
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
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
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
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.
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
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
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?
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
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
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
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!
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.
Thank You!

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Implanted Devices - VP Shunts: EMGuidewire's Radiology Reading Room

  • 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.
  • 3. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Imaging Presentations And Much More!
  • 4. It’s All About The Anatomy!
  • 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
  • 15. Common Shunt Complications Primary Shunt Dysfunction • Slit Ventricle Syndrome • Catheter Migration • Shunt Fracture • Shunt Disconnection • Shunt Infection • Shunt Obstruction Secondary Complications • Pleural effusion • Bowel Obstruction • Intra-Abdominal CSF Pseudocyst • Ascites Collection • Intracranial Hemorrhage
  • 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
  • 41. Test Your Knowledge! Cases From Carolinas Medical Center
  • 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.