AUTHOR(S): Lee, Joung H., M.D.; Malik, Jacek, M.D.; Park, T. S., M.D. Department of Neurosurgery, University of Virginia Health Sciences Center (JHL, JM), Charlottesville, Virginia, and Department of Neurosurgery, St. Louis Children's Hospital and Washington University School of Medicine (TSP), St. Louis, Missouri Neurosurgery 30; 249-251, 1992 ABSTRACT: A technique to divert cerebrospinal fluid into the right atrium via the transverse sinus is described. This has proven effective when the peritoneum becomes unavailable as the primary receptor site for cerebrospinal fluid drainage. KEY WORDS: Cerebrospinal fluid; Hydrocephalus; Transverse sinus; Ventriculoatrial shunt INTRODUCTION Over the years, hydrocephalus has been treated by shunting the cerebrospinal fluid (CSF) into virtually every body cavity, duct, and venous structure including the sagittal sinus and the atrium (1,6,12-15,17, 19) . More recently, the peritoneum has become the primary receptor site for CSF drainage (14,16). Occasionally, this preferred receptor site becomes unavailable for various reasons (e.g., development of adhesions, infections, and pseudocysts). When such complications occur in the pediatric population, the secondary receptor site is commonly the right atrium via the internal jugular or common facial vein. We treated a patient with a tracheostomy and compromised pulmonary function who developed a severe intra-abdominal abscess, which required us to search for an alternative CSF receptor site. Because of this tenuous pulmonary status, the pleural cavity was excluded as a potential receptor site. Moreover, a standard ventriculoatrial (VA) shunt via the internal jugular or common facial vein could not be performed because of the close proximity of the required neck incision to the tracheostomy site. In this patient, the CSF was shunted successfully into the right atrium via the transverse sinus. Subsequently, the same technique was applied successfully in two other patients who had similar complications with ventriculoperitoneal (VP) shunts. As this procedure has not been described previously, we report the surgical technique that offers an alternative route for the placement of a VA shunt. CASE REPORT The patient was a 14-year-old boy who had an arachnoid cyst of the posterior fossa, enlarged lateral and 4th ventricles, and syringomyelia/syringobulbia. He had undergone a resection of an arachnoid cyst of the posterior fossa and the placement of a VP shunt at

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the age of 1 year with multiple subsequent shunt revisions. At the age of 3.5 years, he required posterior fossa decompression. Two months after this procedure, he underwent a separate 4th ventricleperitoneal shunt for decompression of the 4th ventricle. One month later, he also underwent a myelotomy and fenestration of the syringomyelia. His neurological condition subsequently remained stable for approximately 6 months, and then he had a series of shunt complications that became a major management problem, eventually leading to the placement of a VA shunt via the transverse sinus. His shunt complications were as follows. The patient's 4th ventricle-peritoneal shunt malfunctioned, and he underwent a fenestration of the 4th ventricle and the placement of a posterior fossa cysto-subarachnoid shunt. Six weeks later, the shunt malfunctioned, requiring the placement of a cystoperitoneal shunt. During the next month, his VP shunt repeatedly malfunctioned, and four shunt revisions were required. In addition, as the patient could not be weaned from the ventilator, he required a tracheostomy. Five weeks later, the VP shunt again obstructed secondary to the formation of an intraperitoneal abscess, at which time both the VP and cystoperitoneal shunts were externalized. Ten days later, the placement of a VA shunt via the transverse sinus with a Y-connection to the cyst catheter was performed (Figs. 1 and 2). SURGICAL TECHNIQUE A technique for placing a VA shunt via the right transverse sinus is illustrated in Fig. 3. A vertical skin incision is made 1 cm posterior to the right mastoid process. The asterion is identified, and a burr hole is made at the asterion, exposing the underlying transverse sinus. This burr hole then is enlarged to expose adequately the junction of the transverse sinus and the sigmoid sinus. A very small dural incision, measuring 1 to 2 mm in length, is made on the transverse sinus, just large enough to pass a cardiac catheter. A cardiac catheter filled with normal saline is inserted rapidly into the transverse sinus and advanced under fluoroscopic guidance. Bleeding, if it occurs, is controlled readily with Gelfoam (Upjohn, Kalamazoo, MI). The catheter tip is positioned in the right atrium. The proximal end of the cardiac catheter is clamped. If a VP shunt is already in place, at this point, the old shunt incision is reopened to expose the underlying shunt reservoir and the valve. The existing shunt is disconnected between the valve and the peritoneal catheter. The peritoneal catheter then is removed completely. The valve remains connected to the ventricular catheter, and spontaneous CSF outflow is confirmed. Then, a subcutaneous tunnel is made between the incision overlying the mastoid process and the right posterior parietal incision. The newly placed Pudenz (Pudenz-Schulte, Goleta, CA) cardiac catheter then is connected to the valve. DISCUSSION Thus far, we have placed a VA shunt via the transverse sinus in three patients. The second and

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Neurosurgery 1992-98 February 1992, Volume 30, Number 2 249 Ventriculoatrial Shunt via the Transverse Sinus: Technical Note Technical Note

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atrial shunts, the development of cardiac complications, pulmonary emboli, and cor pulmonale are potential risks associated with this particular procedure (4,5,7,10,14,18). Because of the location of the point of entry into the venous system, this procedure does not allow the use of an antisiphon device or a siphon control device. Also, the previous use of the cervical veins for central line placement prohibits the use of this technique. Finally, revisions of the VA shunt via the transverse sinus may be difficult to perform. SUMMARY A technique is described to divert the CSF into the right atrium via the transverse sinus when the peritoneum becomes unavailable as the primary receptor site for CSF drainage. This procedure can be performed expeditiously with minimal surgical trauma and blood loss. In selected patients in whom no other site is available, this technique may offer a useful alternative for the insertion of a VA shunt. Received for publication, June 13, 1991; accepted, August 20, 1991. Reprint requests: T. S. Park, M.D., Department of Neurosurgery, St. Louis Children's Hospital, 400 S. Kingshighway Blvd., St. Louis, MO 63110. REFERENCES: (1-19) 1.

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Balasubramaniam C, DuBois JJ, Laurent JP, Pokorny WJ, Harberg FJ, Cheek WR: Ventriculoatrial shunting via the azygos vein. Child Nerv Syst 6:205-207, 1990. Becker DP, Jane JA, Nulsen FE: Investigation of sagittal sinus for venous shunt in hydrocephalus. Surg Forum 16:440-442, 1965. Chaudhary MY, Sachdev VP, Cho SH, Weitzner I, Puljic S, Huang YP: Dural arteriovenous malformation of the major venous sinuses: An acquired lesion. AJNR 3:13-19, 1982. Emery JL, Hilton HB: Lung and heart complications of the treatment of hydrocephalus by ventriculoauriculostomy. Surgery 50:309-314, 1961. Forrest DM, Cooper DGW: Complications of ventriculo-atrial shunts. J Neurosurg 29:506512, 1968. Hash CJ, Shenkin HA, Crowder L: Ventricle to sagittal sinus shunt for hydrocephalus. Neurosurgery 4:394-400, 1979. Hoffman HJ: Comment on Balasubramaniam C: Ventriculoatrial shunting via the azygos vein. Child Nerv Syst 6:205-207, 1990. Houser OW, Campbell JK, Campbell RJ, Sundt TM: Arteriovenous malformation affecting the transverse dural venous sinus-An acquired lesion. Mayo Clin Proc 54:651661, 1979. Kaplan HA, Browder A, Browder J: Narrow and atretic transverse dural sinuses: Clinical significance. Ann Otol Rhinol Laryngol

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third patients both had developed multiple complications from VP shunts, including shunt infections and intra-abdominal pseudocysts. At the present, all three VA shunts are functioning, with a mean follow-up time of 48 months. No shunt complications were encountered in these patients. Before utilizing this technique, we had performed ventriculo-transverse sinus shunts in four patients, with the distal tip of the catheter placed in either the proximal internal jugular vein or the distal sigmoid sinus; however, all four shunts became obstructed within 2 months after their placement. The risk of the development of thrombosis around the catheter leading to obstruction seems to be a function of the ratio between the catheter diameter and the diameter of the receptor sites (e.g., the internal jugular vein, the sigmoid sinus, and the atrium (2). When this ratio is relatively large (i.e., the catheter tip is placed in the internal jugular vein or the sigmoid sinus), shunt obstruction invariably results; however, when the ratio is made very small, by placing the catheter tip in the atrium, the risk of thrombosis-induced shunt obstruction becomes low. The major advantage of this procedure is that it can be used in patients in whom the peritoneum is unavailable as a CSF receptor site and the traditional route of shunting into the atrium via the common facial or internal jugular vein is difficult because of a tracheostomy. Some neurosurgeons prefer to use the pleural cavity as the next alternative before resorting to the atrium (7); however, in patients requiring a tracheostomy for acute pulmonary instability, the potential use of the pleural cavity may be excluded. When performing this procedure, it should be kept in mind that, in 2.6% of anatomical specimens, a portion of or the entire transverse sinus was reported to be absent (9). In addition, in 3.1%, a markedly narrowed segment of one or the other transverse sinus was observed (9). Therefore, although we had not performed preoperative arteriograms in our patients, this may be considered to avoid the risk of shunting into a single dominant transverse sinus. An alternative to angiography would be either a regular magnetic resonance imaging study, a magnetic resonance angiogram, or possibly a contrastenhanced computed tomographic scan to determine the integrity of the transverse and sigmoid sinuses. The transverse sinuses are unequal in size in about 25%, with the right sinus usually larger than the left (11) . For this reason, the right-sided shunt is preferred whenever possible. No shunt complication was encountered in our patients; however, thrombosis of the transverse sinus and its tributaries is a significant potential complication. Although the exact risk of acquired dural arteriovenous malformations is unknown, these vascular lesions are hypothesized to be preceded by thrombosis of the involved dural sinus (3,8). Therefore, thrombosis in the transverse sinus may, theoretically, later lead to the development of a dural arteriovenous malformation. Excessive bleeding is another potential complication. Blood loss was minimized in our patients by the use of Gelfoam and a small dural incision over the transverse sinus. As with standard

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82:351-354, 1973. Noonan JA, Ehmke DA: Complications of ventriculovenous shunts for control of hydrocephalus. N Engl J Med 269:70-74, 1963. Osborn AG: Introduction to Cerebral Angiography. Philadelphia, Harper & Row, 1980, p 333. Overton MC, Kirksey TD, Snodgrass SR, Nelson WJ, Derrick JR: Direct atrial and vena caval shunting: Procedures for hydrocephalus. Surg Gyn Obs 124:819-825, 1965. Pudenz RH: Experimental and clinical observations on the shunting of cerebrospinal fluid into the circulatory system. Clin Neurosurg 6:98-115, 1958. Pudenz RH: The surgical treatment of hydrocephalus--A historical review. Surg Neurol 15:15-26, 1981. Pudenz RH, Russell FE, Hurd AH, Shelden CH: Ventriculo-auriculostomy. A technique for shunting cerebrospinal fluid into the right auricle. Preliminary report. J Neurosurg 14:171-179, 1957. Rekate HL: Treatment of hydrocephalus, in McLaurin RL, Schut L, Venes JL (eds): Pediatric Neurosurgery, Surgery of the Developing Nervous System. Philadelphia, Saunders, 1989, ed 2, pp 200-218. Sharkey PC: Ventriculo-sagittal sinus shunt. J Neurosurg 22:362-367, 1965. Strenger L: Complications of ventriculovenous shunts. J Neurosurg 20:219224, 1963. Wen HL: Ventriculo-superior sagittal sinus shunt for hydrocephalus. Surg Neurol 17:432434, 1982.

COMMENT I have several problems with this technique. First, I do not feel the heart is a good second option to the peritoneal cavity. The complications of atrial shunts are so severe (pulmonary and renal) that they have become my last option. Second, to risk sinus thrombosis for easier access to the jugular vein is also unacceptable. I would suspect that revision of this system also would be more difficult. The pleural cavity would be my first choice after the peritoneum. This is an interesting and controversial paper. The drawings and photographs are good, and the paper is well written. David G. McLone Chicago, Illinois

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10.

Figure 2. Postoperative anteroposterior chest x-ray. The tip of the cardiac catheter (arrow) is placed adequately in the atrium.

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Figure 1. Postoperative lateral skull x-ray. A, small craniectomy over the junction of the transverse sinus and the sigmoid sinus. B, cyst catheter draining the arachnoid cyst of the posterior fossa. C, a Yconnector joining the ventricular CSF drainage with the drainage of the posterior fossa arachnoid cyst. D, cardiac catheter in the sigmoid sinus.

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Figure 3. Illustration summarizing the technique of a VA shunt placement via the transverse sinus. The transverse sinus is exposed through a burr hole placed over the asterion. Through a small dural incision, a cardiac catheter is positioned in the right atrium under fluoroscopic guidance.

Ventriculoatrial shunt via the transverse sinus: technical note.

A technique to divert cerebrospinal fluid into the right atrium via the transverse sinus is described. This has proven effective when the peritoneum b...
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