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internus muscle fibrosis.[2] A combination of detailed history, a thorough physical examination, imaging techniques, and neurophysiological tests will aid in an accurate diagnosis. The symptoms may be refractory, and a step-by-step, individualized approach is necessary in each case.
Mehmet Besir Turkmen, Figen Kocyigit1, Ali Kocyigit2 Department of Physical Medicine and Rehabilitation, Norobilim Medical Center, Denizli, 1School of Physical Therapy and Rehabilitation, 2Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey E-mail: [email protected]
“Chabbra shunt” was inserted. After 3 months, the patient presented in an altered sensorium with decreased oral intake. The upper and lower ends of the shunt were reexplored, found to be functioning well, and left, in situ. On examination, the head was disproportionately enlarged with a bulging and tense anterior fontanel, engorged scalp veins, and the sunset sign. There was a small pulsatile swelling at the parietal burr hole site. The abdominal scar was puckered. The shunt catheter was not palpable anywhere across the chest wall. A guarded lumbar puncture revealed a normal cerebrospinal fluid (CSF) picture. The shunt catheter was not visible on a plain chest and abdominal radiographs. X-ray skull [Figure 1] and computed tomography (CT) of the head
References 1.
2.
Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 2008;27:306-10. Insola A, Granata G, Padua L. Alcock canal syndrome due to obturator muscle fibrosis. Muscle Nerve 2010;42:431-2.
Access this article online Website:
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www.neurologyindia.com DOI: 10.4103/0028-3886.152671
Figure 1: X-ray skull showing completely migrated and coiled intracranial shunt
PMID: xxxxx
Complete intracranial migration of a ventriculoperitoneal shunt: Rare complication of a common procedure Sir, Clinicians managing patients undergoing a ventriculoperitoneal shunt procedure must be aware of its possible complications and their early recognition. Here, we report a rare case of complete intracranial migration of a ventriculoperitoneal shunt, a potentially fatal complication. A 6-month-old female child presented with gradual enlargement of head and decreased oral intake. The child had a previous history of low birth weight and an occipital encephalocele (she was operated for the later condition). The patient developed hydrocephalus in the post-operative period for which a medium-pressure ventriculoperitoneal 106
Figure 2: Non-contrast CT Head showing the coiled intracranial shunt with hydrocephalus
Neurology India / January 2015 / Volume 63 / Issue 1
[Downloaded free from http://www.neurologyindia.com on Thursday, March 05, 2015, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
[Figure 2] showed the entire shunt catheter lying inside the cranium, confirming the upward migration. The CT head also showed gross hydrocephalus, with a thin cortical mantle. Endoscopy-assisted removal of the migrated shunt with placement of a new shunt on the opposite side was planned. Under general anesthesia, a zero degree, rigid endoscope was introduced through the Kocher’s point inside the ventricle where the coiled and migrated shunt was seen. The tip of the shunt was found adherent to the choroid plexus. Attempts at separation of the adherent shunt resulted in mild intraventricular bleeding. In spite of constant saline irrigation and bipolar coagulation, the bleeding did not stop. Finally, the procedure was abandoned. An external ventricular drain (EVD) was placed inside the ventricular cavity. In the post-operative period, the child continued to be dull but the anterior fontanel remained lax. There was blood-tinged CSF emerging from the EVD. In spite of our best efforts, the child expired after 24 hours. The ventriculoperitoneal shunt procedure is a deceptively simple operation with a wide range of complications. Mechanical shunt failure is the most common complication. Complete intracranial migration of the ventriculo-peritoneal shunt is extremely rare [1] with a reported incidence of 0.1–0.4% of all shunt procedures. [2,3] On reviewing the database in PubMed and Google Scholar, we found only nine reported cases of total intracranial shunt migration. The factors that may be responsible for the migration of the shunt are malnourishment (less subcutaneous tissue for anchorage), anemia, sepsis, and a thin cortical mantle.[4] Excessive neck movements producing a windlass effect coupled with a large potential subgaleal space created for chamber positioning, dilated ventricles with negative suctioning pressure, or a positive intra-abdominal pressure may be responsible for the migration. [5] The technical factors include a large burr hole, larger dural opening, re-exploration leading to poor local tissue availability for anchorage, and an improper shunt securing. [6] The “Chabbra” shunt, having a cylindrical chamber can easily pass into the cranium.[7] Shunt migration may be prevented by taking precautions during the procedure, especially in high-risk patients. If the shunt has recently migrated proximally and is not considered adherent to the choroid plexus, the decision to remove it may be taken. In case of any suspicion of adherence of the shunt tubing to the choroid plexus or the ventricular ependyma, the shunt should be left in situ. Optimum creation of the subgaleal space for the shunt chamber, a smaller burr hole, a smaller dural opening, and proper anchorage of the chamber to the pericranium, are some of the measures that may be useful in obviating this complication.[8]
Rakesh Kumar Sharma, Mayank Bansal, Manish Agrawal, Ashok Gupta, Virendra deo Sinha Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India E-mail: [email protected]
References 1.
2. 3.
4.
5. 6. 7.
8.
Ghritlaharey RK, Budhwani KS, Shrivastava DK, Gupta G, Kushwaha AS, Chanchlani R, et al. Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: Report of ten cases in children. Pediatr Surg Int 2007;23:575-80. Acharya R, Bhutani A, Saxena H, Madan VS. Complete migration of ventriculoperitoneal shunt into the ventricle. Neurol Sci 2002;23:75-7. Nadkarni TD, Menon RK, Dange NN, Desai KI, Goel A. Cranial migration of complete ventriculoperitoneal shunt assembly. J Clin Neurosci 2007;14:92-4. Oluwole KE, Abiodun AA. Complete intraventricular migration of a ventriculo-peritoneal shunt-A case report and brief literature review. Afr J Neurol Sci 2007;26:69-74. Agarwal A, Kakani A. Total migration of a ventriculo-peritoneal shunt catheter into the ventricles. J Pediatr Neurosci 2004;6:88-9. Ali MN, Atif SM, Khan S. Intracranial migration of a ventriculoperitoneal shunt. J Coll Physicians Surg Pak 2008;18:382-3. Choudhury AR. Avoidable factors that contribute to the complications of ventriculoperitoneal shunt in childhood hydrocephalus. Childs Nerv Syst 1990;6:346-9. Naik V, Phalak M, Chandra PS. Total intracranial shunt migration. J Neurosci Rural Pract 2013;4:95-6. Access this article online
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www.neurologyindia.com DOI: 10.4103/0028-3886.152673 PMID: xxxxx
Intractable yawning caused by foramen magnum meningioma in a patient with neurofibromatosis type 2 Sir, Yawning is a stereotyped event seen in all vertebrates. Neural networks in the brainstem, autonomic nervous system, hypothalamus, and limbic system may be involved in the physiology of yawning. Tumor-related yawning has rarely been reported.[1,2] We present a rare case of a patient with a meningioma at foramen magnum who presented with intractable yawning. After total removal of the tumor, the recurrent yawning resolved completely.
Neurology India / January 2015 / Volume 63 / Issue 1
107
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
internus muscle fibrosis.[2] A combination of detailed history, a thorough physical examination, imaging techniques, and neurophysiological tests will aid in an accurate diagnosis. The symptoms may be refractory, and a step-by-step, individualized approach is necessary in each case.
Mehmet Besir Turkmen, Figen Kocyigit1, Ali Kocyigit2 Department of Physical Medicine and Rehabilitation, Norobilim Medical Center, Denizli, 1School of Physical Therapy and Rehabilitation, 2Department of Radiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey E-mail: [email protected]
“Chabbra shunt” was inserted. After 3 months, the patient presented in an altered sensorium with decreased oral intake. The upper and lower ends of the shunt were reexplored, found to be functioning well, and left, in situ. On examination, the head was disproportionately enlarged with a bulging and tense anterior fontanel, engorged scalp veins, and the sunset sign. There was a small pulsatile swelling at the parietal burr hole site. The abdominal scar was puckered. The shunt catheter was not palpable anywhere across the chest wall. A guarded lumbar puncture revealed a normal cerebrospinal fluid (CSF) picture. The shunt catheter was not visible on a plain chest and abdominal radiographs. X-ray skull [Figure 1] and computed tomography (CT) of the head
References 1.
2.
Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn 2008;27:306-10. Insola A, Granata G, Padua L. Alcock canal syndrome due to obturator muscle fibrosis. Muscle Nerve 2010;42:431-2.
Access this article online Website:
Quick Response Code
www.neurologyindia.com DOI: 10.4103/0028-3886.152671
Figure 1: X-ray skull showing completely migrated and coiled intracranial shunt
PMID: xxxxx
Complete intracranial migration of a ventriculoperitoneal shunt: Rare complication of a common procedure Sir, Clinicians managing patients undergoing a ventriculoperitoneal shunt procedure must be aware of its possible complications and their early recognition. Here, we report a rare case of complete intracranial migration of a ventriculoperitoneal shunt, a potentially fatal complication. A 6-month-old female child presented with gradual enlargement of head and decreased oral intake. The child had a previous history of low birth weight and an occipital encephalocele (she was operated for the later condition). The patient developed hydrocephalus in the post-operative period for which a medium-pressure ventriculoperitoneal 106
Figure 2: Non-contrast CT Head showing the coiled intracranial shunt with hydrocephalus
Neurology India / January 2015 / Volume 63 / Issue 1
[Downloaded free from http://www.neurologyindia.com on Thursday, March 05, 2015, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
[Figure 2] showed the entire shunt catheter lying inside the cranium, confirming the upward migration. The CT head also showed gross hydrocephalus, with a thin cortical mantle. Endoscopy-assisted removal of the migrated shunt with placement of a new shunt on the opposite side was planned. Under general anesthesia, a zero degree, rigid endoscope was introduced through the Kocher’s point inside the ventricle where the coiled and migrated shunt was seen. The tip of the shunt was found adherent to the choroid plexus. Attempts at separation of the adherent shunt resulted in mild intraventricular bleeding. In spite of constant saline irrigation and bipolar coagulation, the bleeding did not stop. Finally, the procedure was abandoned. An external ventricular drain (EVD) was placed inside the ventricular cavity. In the post-operative period, the child continued to be dull but the anterior fontanel remained lax. There was blood-tinged CSF emerging from the EVD. In spite of our best efforts, the child expired after 24 hours. The ventriculoperitoneal shunt procedure is a deceptively simple operation with a wide range of complications. Mechanical shunt failure is the most common complication. Complete intracranial migration of the ventriculo-peritoneal shunt is extremely rare [1] with a reported incidence of 0.1–0.4% of all shunt procedures. [2,3] On reviewing the database in PubMed and Google Scholar, we found only nine reported cases of total intracranial shunt migration. The factors that may be responsible for the migration of the shunt are malnourishment (less subcutaneous tissue for anchorage), anemia, sepsis, and a thin cortical mantle.[4] Excessive neck movements producing a windlass effect coupled with a large potential subgaleal space created for chamber positioning, dilated ventricles with negative suctioning pressure, or a positive intra-abdominal pressure may be responsible for the migration. [5] The technical factors include a large burr hole, larger dural opening, re-exploration leading to poor local tissue availability for anchorage, and an improper shunt securing. [6] The “Chabbra” shunt, having a cylindrical chamber can easily pass into the cranium.[7] Shunt migration may be prevented by taking precautions during the procedure, especially in high-risk patients. If the shunt has recently migrated proximally and is not considered adherent to the choroid plexus, the decision to remove it may be taken. In case of any suspicion of adherence of the shunt tubing to the choroid plexus or the ventricular ependyma, the shunt should be left in situ. Optimum creation of the subgaleal space for the shunt chamber, a smaller burr hole, a smaller dural opening, and proper anchorage of the chamber to the pericranium, are some of the measures that may be useful in obviating this complication.[8]
Rakesh Kumar Sharma, Mayank Bansal, Manish Agrawal, Ashok Gupta, Virendra deo Sinha Department of Neurosurgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India E-mail: [email protected]
References 1.
2. 3.
4.
5. 6. 7.
8.
Ghritlaharey RK, Budhwani KS, Shrivastava DK, Gupta G, Kushwaha AS, Chanchlani R, et al. Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: Report of ten cases in children. Pediatr Surg Int 2007;23:575-80. Acharya R, Bhutani A, Saxena H, Madan VS. Complete migration of ventriculoperitoneal shunt into the ventricle. Neurol Sci 2002;23:75-7. Nadkarni TD, Menon RK, Dange NN, Desai KI, Goel A. Cranial migration of complete ventriculoperitoneal shunt assembly. J Clin Neurosci 2007;14:92-4. Oluwole KE, Abiodun AA. Complete intraventricular migration of a ventriculo-peritoneal shunt-A case report and brief literature review. Afr J Neurol Sci 2007;26:69-74. Agarwal A, Kakani A. Total migration of a ventriculo-peritoneal shunt catheter into the ventricles. J Pediatr Neurosci 2004;6:88-9. Ali MN, Atif SM, Khan S. Intracranial migration of a ventriculoperitoneal shunt. J Coll Physicians Surg Pak 2008;18:382-3. Choudhury AR. Avoidable factors that contribute to the complications of ventriculoperitoneal shunt in childhood hydrocephalus. Childs Nerv Syst 1990;6:346-9. Naik V, Phalak M, Chandra PS. Total intracranial shunt migration. J Neurosci Rural Pract 2013;4:95-6. Access this article online
Website:
Quick Response Code
www.neurologyindia.com DOI: 10.4103/0028-3886.152673 PMID: xxxxx
Intractable yawning caused by foramen magnum meningioma in a patient with neurofibromatosis type 2 Sir, Yawning is a stereotyped event seen in all vertebrates. Neural networks in the brainstem, autonomic nervous system, hypothalamus, and limbic system may be involved in the physiology of yawning. Tumor-related yawning has rarely been reported.[1,2] We present a rare case of a patient with a meningioma at foramen magnum who presented with intractable yawning. After total removal of the tumor, the recurrent yawning resolved completely.
Neurology India / January 2015 / Volume 63 / Issue 1
107
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
