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Case Reports / Journal of Clinical Neuroscience 22 (2015) 402–404
Ventriculomammary shunt: An unusual ventriculoperitoneal shunt complication Nauman S. Chaudhry, Jeremiah N. Johnson, Jacques J. Morcos ⇑ University of Miami Miller School of Medicine, Department of Neurological Surgery, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
a r t i c l e
i n f o
Article history: Received 21 April 2014 Accepted 3 May 2014
Keywords: Breast Cerebrospinal fluid Cerebrospinal fluid effusion Equipment failure Shunt malfunction Ventriculoperitoneal shunt
a b s t r a c t Ventriculoperitoneal (VP) shunt malfunctions are common and can result in significant consequences for patients. Despite the prevalence of breast augmentation surgery and breast surgery for other pathologies, few breast related VP shunt complications have been reported. A 54-year-old woman with hydrocephalus post-subarachnoid hemorrhage returned 1 month after VP shunt placement complaining of painful unilateral breast enlargement. After investigation, it was determined that the distal VP shunt catheter had migrated from the peritoneal cavity into the breast and wrapped around her breast implant. The breast enlargement was the result of cerebrospinal fluid retention. We detail this unusual case and review all breast related VP shunt complications reported in the literature. To avoid breast related complications related to VP shunt procedures, it is important to illicit pre-procedural history regarding breast implants, evade indwelling implants during catheter tunneling and carefully securing the abdominal catheter to prevent retrograde catheter migration to the breast. Ó 2014 Elsevier Ltd. All rights reserved.
1. Background The ventriculoperitoneal (VP) shunt is a widely used treatment for hydrocephalus. Shunt malfunctions such as obstruction and disconnection are common; however, migration of the distal catheter out of the abdomen is less frequent. We report a unique case of distal VP shunt catheter migration out of the peritoneal cavity and into the breast. Although rare, surgeons should pay careful attention to catheter tunneling and securing the distal catheter at the abdominal wall, particularly in patients with breast implants, in order to avoid breast related VP shunt complications.
to the abdominal fascia and prevent re-herniation out the abdomen. Finally, an 18 gauge needle was placed into the breast medial to the saline implant and 400 cc of retained cerebrospinal fluid (CSF) was drained. Fluid analysis revealed no signs of infection and the cultures were negative. Post-operative radiographs confirmed the distal catheter was intact throughout its course in the chest and ended in the peritoneal cavity (Fig. 1F). The saline implant had not been perforated. The patient’s breast discomfort resolved and the cosmetic appearance of the breast returned to its usual size and appearance. At 2 week follow-up she remained asymptomatic.
3. Discussion 2. Clinical presentation A 54-year-old woman presented with Fisher Grade 3 aneurysmal subarachnoid hemorrhage and hydrocephalus (Fig. 1A). Her past medical history was significant for rheumatoid arthritis and saline implant breast augmentation 20 years prior. A right external ventricular drain (EVD) was placed and her ruptured anterior communicating artery aneurysm was coiled. After failing two EVD clamping trials, a left sided VP shunt was placed without complication. The patient did well clinically and was discharged. One month later, the patient returned to clinic complaining of left breast pain and swelling. Physical examination revealed an enlarged, firm, and tender left breast with no signs of infection or nipple discharge. A CT scan of the brain showed no ventriculomegaly. Shunt series radiographs revealed the proximal shunt catheter was in good position, but the distal VP shunt tubing was displaced from the abdomen and coiled inside the left breast, adjacent to the saline implant (Fig. 1B). A shunt revision was performed (Fig. 1C–E). Through a new incision the previous catheter was removed and a new distal catheter was tunneled in a more medial trajectory than the previous operation to avoid the breast. An encircling absorbable drain retention stitch was used to secure the new distal catheter ⇑ Corresponding author. Tel.: +1 305 243 4675; fax: +1 305 243 3337. E-mail address: [email protected] (J.J. Morcos).
Distal VP shunt catheters are known to migrate into unusual areas of the body, such as the lungs [1], heart [2], neck [3], and scrotum [4]. We report a case of distal VP shunt tubing migration from the peritoneal cavity to the previously operated left breast resulting in breast CSF pseudocyst and discomfort. A review of the literature found 21 previously reported cases of breast related VP shunt complications and 11 cases of distal catheter migration into the breast (Table 1). Including our patient, reported breast-related shunt complications comprise of 13.6% (3/ 22) shunt fractures and local leaks with breast pseudocyst [5–8], 9% (2/22) breast carcinoma invasion, 9% (2/22) breast implant perforation, 13.6% (3/22) retrograde CSF tracking from abdomen [10], and 50% (11/22) distal catheter migration into the breast [5,9]. The median age of diagnosis was 50 years (range: 13 to 88 years), and the mean time from surgery to presentation was 23.3 weeks (range: 1 week to 3 years). Ipsilateral breast swelling was the most common complaint (60%) and nipple CSF discharge, or ‘‘CSF galactorrhea,’’ was reported in six patients (27%) [10]. Ten of the 22 patients suffering breast related shunt complications had breast implants; nine had implants in place at the time of VP shunt placement, but two patients with a shunt had a complication after a breast augmentation procedure [9]. Of the 11 cases of catheter migration into the breast, eight of the patients also had breast implants and 91% (10/11) presented with breast CSF retention. The mechanism of catheter migration into the breast is unknown, but it is presumed to be the result of intra-abdominal
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Case Reports / Journal of Clinical Neuroscience 22 (2015) 402–404
Fig. 1. (A) Axial CT scan brain showing Fisher Grade 3 subarachnoid hemorrhage. (B) Pre-revision anteroposterior (AP) radiograph showing the shunt catheter coiled in the left breast. (C, D) Pre-revision intra-operative images showing the enlarged left breast pseudocyst. (E) Retrieval of shunt catheter from the breast via an infraclavicular incision. (F) AP radiograph 2 weeks post-revision showing shunt catheter in the left peritoneal cavity (This figure is available in colour at http://www.sciencedirect.com/). Table 1 Breast related ventriculoperitoneal shunt complications reported in the literature Author Present patient Maknojia and Caron, 2013 [12] Schrot et al., 2012 [17] Gulaldi et al., 2011 [8] Shafiee et al., 2011 [18] Chu et al., 2010 [5] Roka et al., 2010 [16] Lee et al., 2010 [22] Patel et al., 2010 [23] Mudo et al., 2009 [14] Dayananda et al., 2009 [7] Crawford and Friedman, 2008 [6] Lee et al., 2008 [24] Torres et al., 2008 [20] Iyer et al., 2006 [9] Spector et al. 2005 [19] Vimalachandran et al. 2003 [21] Kalra et al., 2002 [10] Lazarus et al., 1998 [11] Moron and Barrow, 1994 [13] Nakano et al., 1994 [15]
Breast implants?
Time
Breast findings
Catheter malfunction
Yes No Yes Yes No Yes No No Yes Yes No Yes No Yes Yes Yes No No No No No No
1m 1.5 m 1m – 12 m 2m 24 m – 2m 9m – 1m 1m 36 m 2.5 m 1.5 m – .25 m 1m .75 m .5 m 1.5 m
S, T, P N S, E, P T, P S, P S, P C C, E S, E S, N, P S, P S, P N S, P S, T, P S, P L, P N, P L, P L, P S, T, N, P N, P
Migration Migration Implant rupture and migration Unspecified leak Migration Migration Carcinoma obstruction Carcinoma obstruction Implant rupture and migration Migration Unspecified leak Fracture Retrograde CSF tracking from abdomen Migration Migration Migration Fracture Retrograde CSF tracking from abdomen Unspecified leak Thoracic catheter leak Migration Retrograde CSF tracking from abdomen
C = cancerous mass, CSF = cerebrospinal fluid, E = breast erythema, L = lump (
Case Reports / Journal of Clinical Neuroscience 22 (2015) 402–404
Ventriculomammary shunt: An unusual ventriculoperitoneal shunt complication Nauman S. Chaudhry, Jeremiah N. Johnson, Jacques J. Morcos ⇑ University of Miami Miller School of Medicine, Department of Neurological Surgery, 1095 NW 14th Terrace (D4-6), Miami, FL 33136, USA
a r t i c l e
i n f o
Article history: Received 21 April 2014 Accepted 3 May 2014
Keywords: Breast Cerebrospinal fluid Cerebrospinal fluid effusion Equipment failure Shunt malfunction Ventriculoperitoneal shunt
a b s t r a c t Ventriculoperitoneal (VP) shunt malfunctions are common and can result in significant consequences for patients. Despite the prevalence of breast augmentation surgery and breast surgery for other pathologies, few breast related VP shunt complications have been reported. A 54-year-old woman with hydrocephalus post-subarachnoid hemorrhage returned 1 month after VP shunt placement complaining of painful unilateral breast enlargement. After investigation, it was determined that the distal VP shunt catheter had migrated from the peritoneal cavity into the breast and wrapped around her breast implant. The breast enlargement was the result of cerebrospinal fluid retention. We detail this unusual case and review all breast related VP shunt complications reported in the literature. To avoid breast related complications related to VP shunt procedures, it is important to illicit pre-procedural history regarding breast implants, evade indwelling implants during catheter tunneling and carefully securing the abdominal catheter to prevent retrograde catheter migration to the breast. Ó 2014 Elsevier Ltd. All rights reserved.
1. Background The ventriculoperitoneal (VP) shunt is a widely used treatment for hydrocephalus. Shunt malfunctions such as obstruction and disconnection are common; however, migration of the distal catheter out of the abdomen is less frequent. We report a unique case of distal VP shunt catheter migration out of the peritoneal cavity and into the breast. Although rare, surgeons should pay careful attention to catheter tunneling and securing the distal catheter at the abdominal wall, particularly in patients with breast implants, in order to avoid breast related VP shunt complications.
to the abdominal fascia and prevent re-herniation out the abdomen. Finally, an 18 gauge needle was placed into the breast medial to the saline implant and 400 cc of retained cerebrospinal fluid (CSF) was drained. Fluid analysis revealed no signs of infection and the cultures were negative. Post-operative radiographs confirmed the distal catheter was intact throughout its course in the chest and ended in the peritoneal cavity (Fig. 1F). The saline implant had not been perforated. The patient’s breast discomfort resolved and the cosmetic appearance of the breast returned to its usual size and appearance. At 2 week follow-up she remained asymptomatic.
3. Discussion 2. Clinical presentation A 54-year-old woman presented with Fisher Grade 3 aneurysmal subarachnoid hemorrhage and hydrocephalus (Fig. 1A). Her past medical history was significant for rheumatoid arthritis and saline implant breast augmentation 20 years prior. A right external ventricular drain (EVD) was placed and her ruptured anterior communicating artery aneurysm was coiled. After failing two EVD clamping trials, a left sided VP shunt was placed without complication. The patient did well clinically and was discharged. One month later, the patient returned to clinic complaining of left breast pain and swelling. Physical examination revealed an enlarged, firm, and tender left breast with no signs of infection or nipple discharge. A CT scan of the brain showed no ventriculomegaly. Shunt series radiographs revealed the proximal shunt catheter was in good position, but the distal VP shunt tubing was displaced from the abdomen and coiled inside the left breast, adjacent to the saline implant (Fig. 1B). A shunt revision was performed (Fig. 1C–E). Through a new incision the previous catheter was removed and a new distal catheter was tunneled in a more medial trajectory than the previous operation to avoid the breast. An encircling absorbable drain retention stitch was used to secure the new distal catheter ⇑ Corresponding author. Tel.: +1 305 243 4675; fax: +1 305 243 3337. E-mail address: [email protected] (J.J. Morcos).
Distal VP shunt catheters are known to migrate into unusual areas of the body, such as the lungs [1], heart [2], neck [3], and scrotum [4]. We report a case of distal VP shunt tubing migration from the peritoneal cavity to the previously operated left breast resulting in breast CSF pseudocyst and discomfort. A review of the literature found 21 previously reported cases of breast related VP shunt complications and 11 cases of distal catheter migration into the breast (Table 1). Including our patient, reported breast-related shunt complications comprise of 13.6% (3/ 22) shunt fractures and local leaks with breast pseudocyst [5–8], 9% (2/22) breast carcinoma invasion, 9% (2/22) breast implant perforation, 13.6% (3/22) retrograde CSF tracking from abdomen [10], and 50% (11/22) distal catheter migration into the breast [5,9]. The median age of diagnosis was 50 years (range: 13 to 88 years), and the mean time from surgery to presentation was 23.3 weeks (range: 1 week to 3 years). Ipsilateral breast swelling was the most common complaint (60%) and nipple CSF discharge, or ‘‘CSF galactorrhea,’’ was reported in six patients (27%) [10]. Ten of the 22 patients suffering breast related shunt complications had breast implants; nine had implants in place at the time of VP shunt placement, but two patients with a shunt had a complication after a breast augmentation procedure [9]. Of the 11 cases of catheter migration into the breast, eight of the patients also had breast implants and 91% (10/11) presented with breast CSF retention. The mechanism of catheter migration into the breast is unknown, but it is presumed to be the result of intra-abdominal
403
Case Reports / Journal of Clinical Neuroscience 22 (2015) 402–404
Fig. 1. (A) Axial CT scan brain showing Fisher Grade 3 subarachnoid hemorrhage. (B) Pre-revision anteroposterior (AP) radiograph showing the shunt catheter coiled in the left breast. (C, D) Pre-revision intra-operative images showing the enlarged left breast pseudocyst. (E) Retrieval of shunt catheter from the breast via an infraclavicular incision. (F) AP radiograph 2 weeks post-revision showing shunt catheter in the left peritoneal cavity (This figure is available in colour at http://www.sciencedirect.com/). Table 1 Breast related ventriculoperitoneal shunt complications reported in the literature Author Present patient Maknojia and Caron, 2013 [12] Schrot et al., 2012 [17] Gulaldi et al., 2011 [8] Shafiee et al., 2011 [18] Chu et al., 2010 [5] Roka et al., 2010 [16] Lee et al., 2010 [22] Patel et al., 2010 [23] Mudo et al., 2009 [14] Dayananda et al., 2009 [7] Crawford and Friedman, 2008 [6] Lee et al., 2008 [24] Torres et al., 2008 [20] Iyer et al., 2006 [9] Spector et al. 2005 [19] Vimalachandran et al. 2003 [21] Kalra et al., 2002 [10] Lazarus et al., 1998 [11] Moron and Barrow, 1994 [13] Nakano et al., 1994 [15]
Breast implants?
Time
Breast findings
Catheter malfunction
Yes No Yes Yes No Yes No No Yes Yes No Yes No Yes Yes Yes No No No No No No
1m 1.5 m 1m – 12 m 2m 24 m – 2m 9m – 1m 1m 36 m 2.5 m 1.5 m – .25 m 1m .75 m .5 m 1.5 m
S, T, P N S, E, P T, P S, P S, P C C, E S, E S, N, P S, P S, P N S, P S, T, P S, P L, P N, P L, P L, P S, T, N, P N, P
Migration Migration Implant rupture and migration Unspecified leak Migration Migration Carcinoma obstruction Carcinoma obstruction Implant rupture and migration Migration Unspecified leak Fracture Retrograde CSF tracking from abdomen Migration Migration Migration Fracture Retrograde CSF tracking from abdomen Unspecified leak Thoracic catheter leak Migration Retrograde CSF tracking from abdomen
C = cancerous mass, CSF = cerebrospinal fluid, E = breast erythema, L = lump (
