Abstract
Background
Ventriculoatrial shunt (VA) insertion is one of the possible surgical procedures to treat hydrocephalus. However, it is also associated with several complications such as obstruction and shunt infection as well as life-threatening complications like intraatrial thrombus or thrombosis on the distal catheter. In this case report, we share a rare case of a patient with a VA shunt, who was admitted to our hospital with a stroke.
Case description
A 56-year-old female patient with suspected acute stroke was admitted to the stroke unit. CT and MRI scans showed multiple cerebral infarctions in both hemispheres. The transesophageal echocardiography (TEE) showed at the tip of the VA shunt catheter, which was implanted about 30 years ago due to aqueduct stenosis, also a thrombotic formation as the reason of stroke. Interestingly, the tip of the catheter was not in the right atrium as expected, but in the left atrium. Further evaluation showed a patent foramen ovale (PFO), through which the catheter migrated from the right to the left side. At first, conservative treatment with anticoagulation was started with the aim to dissolve the thrombotic formation; however, a control TEE showed an unchanged mass at the catheter tip. Therefore, a ventriculoperitoneal shunt was implanted and the proximal shunt catheter was removed with an additional closure of the PFO by our heart surgeons. Postoperatively, the patient was discharged 10 days later in good condition to a rehabilitation center.
Conclusions
Thromboembolic events due to a PFO are rare but possible life-threatening complication after VA shunt insertion. Therefore, preoperative cardiac diagnostic might be clinically relevant prior to a VA shunt implantation to avoid such complications.
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References
Alcázar L, Alfaro R, Tamarit M, Gómez-Angulo JC, Ortega JM, Aragonés P, Jerez P, Salazar F, del Pozo JM (2007) Delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Case report and literature review. Neurocirugia (Astur) 18(2):128–133
Clark DJ, Chakraborty A, Roebuck DJ, Thompson DNP (2016) Ultrasound guided placement of the distal catheter in paediatric ventriculoatrial shunts-an appraisal of efficacy and complications. Childs Nerv Syst 32(7):1219–1225
Czosnyka ZH, Sinha R, Morgan JAD, Wawrzynski JR, Price SJ, Garnett M, Pickard JD, Czosnyka M (2016) Shunt testing in vivo: observational study of problems with ventricular catheter. Acta Neurochir Suppl 122:353–356
Evangelos D, Dimitrios G, Georgios S, Nikolaos E, Filippos P, Marios T (2017) Percutaneous placement of the peripheral catheter to the subclavian vein for a VA shunt. Pan Afr Med J 27:42
Hagen PT, Scholz DG, Edwards WD (1984) Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 59(1):17–20
Heidenreich P (2017) Are drug eluting stents worth triple therapy? J Am Heart Assoc. https://doi.org/10.1161/JAHA.117.006983
Illingworth RD, Logue V, Symon L, Uemura K (1971) The ventriculocaval shunt in the treatment of adult hydrocephalus. Results and complications in 101 patients. J Neurosurg 35(6):681–685
Keucher TR, Mealey J (1979) Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 50(2):179–186
Lam CH, Villemure JG (1997) Comparison between ventriculoatrial and ventriculoperitoneal shunting in the adult population. Br J Neurosurg 11(1):43–48
Levine GN, Bates ER, Bittl JA et al (2016) 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice guidelines: an update of the. Circulation 134(10):e123–e155
Little JR, Rhoton AL, Mellinger JF (1972) Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children. Mayo Clin Proc 47(6):396–401
Lo Presti A, Rogers JM, Assaad NNA, Rodriguez ML, Stoodley MA, Morgan MK (2018) De novo brain arteriovenous malformation after tumor resection: case report and literature review. Acta Neurochir 160(11):2191–2197
Lundar T, Langmoen IA, Hovind KH (1991) Fatal cardiopulmonary complications in children treated with ventriculoatrial shunts. Childs Nerv Syst 7(4):215–217
McGovern RA, Kelly KM, Chan AK, Morrissey NJ, McKhann GM (2014) Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus? J Neurosurg 120(6):1458–1464
Park YK, Yi H-J, Choi K-S, Lee Y-J, Chun H-J, Kwon SM, Kim D-W (2018) Predicting factors for shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Acta Neurochir. https://doi.org/10.1007/s00701-018-3560-6
Pillai A, Mathew G, Nachimuthu S, Kalavampara SV (2017) Ventriculo-ureteral shunt insertion using percutaneous nephrostomy: a novel minimally invasive option in a patient with chronic hydrocephalus complicated by multiple distal ventriculoperitoneal shunt failures. J Neurosurg:1–5
Qian Z, Gao L, Wang K, Pandey S (2017) Delayed catheter-related intracranial hemorrhage after a ventriculoperitoneal or ventriculoatrial shunt in hydrocephalus. World Neurosurg 107:846–851
Tonn P, Gilsbach JM, Kreitschmann-Andermahr I, Franke A, Blindt R (2005) A rare but life-threatening complication of ventriculo-atrial shunt. Acta Neurochir 147(12):1303–1304
Yurtseven T, Erşahin Y, Kitiş O, Mutluer S (2005) Thrombosis and thrombophilebitis of the internal jugular vein as a very rare complication of the ventriculoatrial shunt. Clin Neurol Neurosurg 107(2):144–146
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Kilinç, F., Won, SY., Spyrantis, A. et al. Thromboembolic infarction caused by an unknown patent foramen ovale 30 years after VA shunt insertion: a case report and review of the literature. Acta Neurochir 161, 1381–1384 (2019). https://doi.org/10.1007/s00701-019-03946-w
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DOI: https://doi.org/10.1007/s00701-019-03946-w