Letters to Editor

However, tracking of blood upto the lower border of C3 and absence of blood in front of the transverse ligament suggests the subdural location of haemorrhage. An extradural hematoma would dissect inferiorly upto the attachment of the membrana tectoria to the C2 body but no further downward.[1] This is because the posterior [inner] layer of the clival dura is continuous with the spinal dura, while the anterior [periosteal] layer is continuous with the upward extension of the posterior longitudinal ligament, that is, the tectorial membrane. All posttraumatic cases were young,[5] while nontraumatic cases were elderly. Rarity of the condition defies establishment of proper management protocols. All the reported cases of retroclival SDHs, except one, had been successfully management by conservative means and surgery is considered only in patients with progressive neurological deficits.[1,5] In conclusion, retroclival SDHs are rare and it could be posttraumatic or spontaneous due to abnormal coagulation. This is a difficult area to approach surgically. However, most cases can probably be managed conservatively as the clot decompresses into the spinal subdural space. Surgery has a role only if there is life‑threatening compression of posterior fossa structures. Awareness of this pathology and establishing the diagnosis early on CT scan will help in monitoring such patients for neurological deterioration and institution of appropriate management strategies.

7. 8.

Guilloton L, Godon P, Drouet A, Guerard S, Aczel F, Ribot C. Retroclival hematoma in a patient taking oral anticoagulants. Rev Neurol (Paris) 2000;156:392‑4. van Rijn RR, Flach HZ, Tanghe HL. Spontaneous retroclival subdural hematoma. JBR‑BTR 2003;86:174‑5. Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121951

Received: 12-08-2013 Review completed: 18-08-2013 Accepted: 25‑08‑2013

Intrathoracic migration of ventriculoperitoneal shunt through the Morgagni’s hernia in case with Down syndrome: A rare shunt complication

Department of Neurosurgery and Radiology, National Neurosciences Centre, Peerless Hospital, Kolkata, West Bengal, India. E‑mail: [email protected]

Sir, In the patients with Down syndrome, diaphragmatic anomalies are seen frequently. Migration of ventriculoperitoneal (VP) shunt inside the thorax is quite rare and it can cause serious complications.[1] We present a rare case with Down syndrome who presented with respiratory distress due to migration of VP shunt catheter into the thorax through Morgagni’s hernia.

1. Casey D, Chaudhary BR, Leach PA, Herwadkar A, Karabatsou K. Traumatic clival subdural hematoma in an adult. J Neurosurg 2009;110:1238‑41. 2. Mohamed AH, Rodrigues JC, Bradley MD, Nelson RJ. Retroclival subdural hematoma secondary to pituitary apoplexy. Br J Neurosurg 2013;19:267‑70. 3. Ayberk G, Ozveren MF, Aslan S, Yaman ME, Yaman O, Kayaci S, et al. Suabarachnoid, subdural and interdural spaces at the clival region: An anatomical study. Turk Neurosurg 2011;21:372‑7. 4. Ahn ES, Smith ER. Acute clival and spinal subdural hematoma with spontaneous resolution: Clinical and radiographic correlation in support of a proposed pathophysiological mechanism. Case report. J Neurosurg 2005;103:175‑9. 5. Sridhar K, Venkateshwara PG, Ramakrishnaiah S, Iyer V. Posttraumatic retroclival acute subdural hematoma: Report of two cases and review of literature. Neurol India 2010;58:945‑8. 6. Catala‑Antunez I, de Quintana‑Schmidt C, Clavel‑Laria P, Montes‑Graciano G, Molet‑Teixido J. Abducens nerve palsy due to postraumatic retroclival and spinal subdural hematoma: Case Report and literature review. Neurocirugia 2011;22:337‑41.

A 5‑month‑old female has been evaluated for fever, diarrhea, cough, and respiratory distress. She is a diagnosed case of Down syndrome (trisomy 21) and was operated for myelomeningocele and hydrocephalus during the neonatal period and VP shunt was applied. On examination, she was in serious respiratory distress and intestinal sounds were heard on left side chest. Chest X‑ray and computed tomography showed diaphragmatic hernia and the migration of the shunt catheter into the thorax were observed [Figures 1 and 2]. Chest X‑ray done 24 h after the myelomeningocele and VP shunt surgery was reevaluated and no significant pathology was seen regarding the diaphragmatic hernia [Figure 3]. The patient was operated along with the pediatric surgeons and the peritoneal shunt catheter inside the thorax and the intestines were retracted into the abdomen. It was observed that the shunt was functioning. The Morgagni’s hernia defect which was approximately 5 × 3 cm wide was repaired by primarily

Prasad Krishnan, Rajaraman Kartikueyan, Siddhartha Roy Chowdhury, Sayan Das1 1

References

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Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

Letters to Editor

sutures. The patient was discharged with functioning VP shunt and improved respiratory distress. Despite the high prevalence of Down syndrome, the occurrence of myelomeningocele is rarely documented. Abnormal folate metabolism and genetic polymorphism of the folate pathway in Down syndrome and neural tube defect has been documented.[2] However, this association needs to be studied in a larger patient sample.

Figure 1: Chest X‑ray showing diaphragmatic hernia and migration of the shunt in to the thorax

Morgagni’s hernia is found in approximately 20% of cases with Down syndrome.[3] In our patient a significant diaphragm hernia was not noted in the chest X‑ray done 24 h after the initial surgery in the neonatal period. New defect and/or enlargement of small defects may occur in the diaphragm over a time period possibly related to the intra‑abdominal pressure secondary to VP shunt CSF drainage. Our patient suggests that patient with Down syndrome with VP shunt should be followed up closely. During surgery, one should be careful about the relationship of intra‑abdominal structures and shunt catheter with the intrathoracic tissues. Pulling the peritoneal catheter back in an uncontrolled way can cause organ injuries because of the associated adhesions.[4]

Hakan Çakin, Metin Kaplan, Sait Öztürk, Ahmet Kazez1 Departments of Neurosurgery and 1Pediartic Surgery, Fırat University, Elazig, Turkiye E‑mail: [email protected]

References Figure 2: Computed tomography of the chest showing migration of peritoneal shunt catheter and the intestines in to the thorax through Morgagni’s defect of diaphragm

1. Taub E, Lavyne MH. Thoracic complications of ventriculoperitoneal shunts: Case report and review of the literature. Neurosurgery 1994;34:181‑4. 2. Al‑Gazali LI, Padmanabhan R, Melnyk S, Yi P, Pogribny IP, Pogribna M, et al. Abnormal folate metabolism and genetic polymorphism of the folate pathway in a child with Down sydrome and neural tube defect. Am J Med Genet 2001;103:128‑32. 3. Picard E, Ben Nun A, Fisher D, Schwartz S, Goldberg M, Goldberg S. Morgagni hernia mimiking pneumonia in Down sydrome. J Pediatr Surg 2007;42:1608‑11. 4. Kaplan M, Özel SK, Akgün B, Kazez A, Kaplan S. Hepatic pseudocyst as a result of ventriculoperitoneal shunts: Case report and review of the literature. Pediatr Neurosurg 2007;43:501‑3. Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121952

Figure 3: Chest X‑ray taken 24 h after the myelomeningocele and VP shunt surgery showing no significant pathology in the diaphragm

Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

Received: 18‑08‑2013 Review completed: 31‑08‑2013 Accepted: 21‑10‑2013

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Intrathoracic migration of ventriculoperitoneal shunt through the Morgagni's hernia in case with Down syndrome: a rare shunt complication.

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