An Unusual Iatrogenic Cerebrospinal Fluid Leakage from Ventriculoperitoneal Shunt

An Unusual Iatrogenic Cerebrospinal Fluid Leakage from Ventriculoperitoneal Shunt Hsin-Yi Wang 1, Wan-Yu Lin 1,2 1 Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan 2 Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan A case of renal insufficiency received Hickman catheter insertion for hemodialysis suffered from fever and continuous discharge after then. Local infection at the insertion site of the Hickman catheter was less favored due to the insertion site is absent in local redness, swelling or pus formation and the discharge is large in amount and clear in character. Taking his history into consideration, leakage of the ventriculoperitoneal (VP) shunt that inserted previously was suspected instead and the VP shunt patency scan proved it. Key words: ventriculoperitoneal shunt, CSF leakage, Hickman catheter, hemodialysis Ann Nucl Med Sci 2010;23:59-63 Introduction The ventriculoperitoneal (VP) shunt is a surgery to relieve the symptoms and signs caused by excess cerebrospinal fluid (CSF) in the ventricle by draining the extra fluid to the other part of the body, most commonly the peritoneum. However, the symptoms may recur due to malfunction of the shunt. The VP shunt patency scan is a simple, minimal invasive examination to evaluate the function of the shunt. Here we presented a less common indication for the Received 11/30/2009; accepted 12/8/2009. For correspondence and reprints contact: Wan-Yu Lin, M.D., Department of Nuclear Medicine, Taichung Veterans General Hospital. 160 Section 3, Chung- Gung Road, Taichung 407, Taiwan. Tel: (886)4-23741349, Fax: (886)4-23741348, E-mail:wylin@vghtc.gov.tw VP shunt patency scan. Case Report This 78-year-old male patient was a case of hypertension without regular medical control and hypothyroidism. Fifteen years ago, he received VP shunt insertion due to hydrocephalus developed after traumatic intracranial hemorrhage. Due to the continuous exacerbation of the renal insufficiency, he received hemodialysis via Hickman catheter in right subclavian vein in January, 2009. However, fever and continuous discharge from the insertion site of the Hickman catheter developed after then. Under the suspicion of Hickman catheter infection, he was transferred from local clinic to our hospital for further evaluation. Local infection was less favored due to the insertion site was absent in local redness, swelling or pus formation and the discharge was large in amount and clear in character. Instead, taking his history into consideration, CSF leakage was suspected. VP shunt patency scan (Figure 1) was arranged for confirmation. The radiotracer was shown in the ventricle via the ventricular catheter soon after being administered to the subcutaneous reservoir of the VP shunt. The radioactivity was shown in the peritoneal catheter since the 15-min image. However, no significant radioactivity was passage to the abdomen after then. An unusual radioactivity accumulation was demonstrated in the right upper chest, where the Hickman catheter inserted, since the 15-min image with gradually increased intensity. On the 80-min image, the radioactive region at the right chest was lung-shaped. To exclude the possibility of intrapleural allocation of the CSF drainage shunt or intrapleural leakage, the gauze covered at right chest wall in order to collect the leakage was removed from the patient s chest before the

Wang HY et al Figure 1. Serial anterior images of head (A, C, E, G), chest (B, H) and abdomen (D,F) on 5, 15, 30 and 80 min showed increased radioactivity in the (A) lateral ventricle on the 5-min image, (D) peritoneal catheter on the 15-min image but not in the abdomen throughout this study. (F, H). An unusual radioactivity accumulation is demonstrated in the right upper chest, where the Hickman catheter inserted, since the 15-min image (C) and turned in to lung-shaped on the 80-min image (G, H, arrow). The intensity, size and shape of the radio-active gauze (I) covered at right chest wall were identical to that in the right chest region. acquisition of image. The intensity, size and shape of the radioactive gauze were identical to that in the right chest region. The absence of radioactivity in the peritoneum and the absence of blood component in the radioactive gauze both excluded the blood origin of the radioactivity since the 99m Tc-DTPA was resorbed quickly by peritoneum into the blood stream. The radioactive leakage from where the Hickman catheter inserted was proved VP-shunt-originated. Under the impression of VP shunt leakage, the VP shunt was replaced by external ventricular drainage (EVD). However, the fever persisted. The culture of the CSF obtained at surgery as well as the blood sampling both yielded Staphylococcus aureus. After the endotracheal intubation due to septic shock, this patient was transferred for intensive care. However, the condition was downhilled gradually after several episodes of nosocomial septisemia. He was discharged on impending death on March 27, 2009. Ann Nucl Med Sci 2010;23:59-63 Vol. 23 No. 1 March 2010 60

Iatrogenic CSF leakage Discussion Hickman catheters are a kind of central venous catheters, which are made of barium impregnated silicone rubber [1]. After placing the catheter through a subcutaneous tunnel, the catheter can be inserted to a central vein. At the exit site, it has a Dacron cuff, which is implanted in the subcutaneous tissue to avoid infection [2]. Hickman catheters are used for hemodialysis mostly and also can be used for plasmaphoresis and long-term venous access. The subclavian catheterization is a widely used insertion route and techniques. There are many complications associated with this technique, such as pneumothorax, hemothorax, arterial puncture, perforation of the great vessels and myocardium, catheterization of the aorta and cardiac tamponade [3-6]. The standard device used to treat hydrocephalus is CSF drainage, which could be ventriculojugular, ventriculoatrial, ventriculopleural, lumboperitoneal and the ventriculoperitoneal shunt [7], which is the most widely-used procedure. The proximal catheter (ventricular catheter) of the ventriculoperitoneal shunt is placed into the cerebral ventricle and a distal catheter (peritoneal catheter) is placed in the peritoneal cavity. There is a one-way valve between this two ends to prevent reflux of cerebral spinal fluid into ventricles [8]. This procedure is associated with various complications, such as obstruction, infection, disconnection, breaking, and kinking of the tube. Other uncommon complications include pseudocyst, mesenteric pseudotumor, metastasis of cerebral tumors via the shunt, and protrusion of the distal catheter through the scrotum or vagina [9-11]. The VP shunt patency scan is usually arranged in cases who undergo ventriculoperitoneal shunt due to hydrocephalus under the suspicion of obstruction of the shunt due to recurred symptom and signs of NPH (dementia, incontinence, unsteady gait) or increased intracranial pressure (nausea, vomiting, headache, seizure, irritable, blurred vision). In normal-functioned shunts, quick passage of the radiotracer via the peritoneal catheter to the peritoneal cavity is noted soon after intra-reservoir injection. The presence of the radiotracer in the ventricle could be noted only in cases with two-way shunt, in which the direction of CSF flow between ventricle and the subcutaneous reservoir could be either ventricle to reservoir or vice versa). Non-visualization of the radioactivity in the peritoneum is a typical sign of obstruction of the peritoneal shunt. Knotting or kinking of the peritoneal catheter could also present as absence of radiotracer in the peritoneum. However, the presence of radioactivity in the peritoneum is not necessarily equivalent to a functional shunt. The delayed radiotracer passage to the peritoneum may be secondary to improper pressure setting of the valve of VP shunt, increased intra-peritoneal pressure (such as usage of a corset or during periods of constipation) [12]. In addition, the distribution and absorption of the radioactive tracer in the peritoneum also play a role in evaluating the function of a shunt. Fibrous adhesion or encasement around the distal end of the peritoneal catheter could cause improper dissemination and poor absorption of the CSF, as well as the radiotracer, in the peritoneum, which resulted in prolonged loculation of radioactivity at the vicinity of the distal end of the peritoneal catheter. Chronic irritation of the peritoneum or subclinical peritonitis could also decrease the resorption of CSF through the peritoneum [13]. Unusual radiotracer passage had been reported to the bowel wall, abdominal wall, scrotal wall, pelvic organs and the gallbladder [11,14-17] due to catheter tip perforation. In addition to evaluating the mechanical and functional obstruction of the shunt, the VP shunt patency scan is also helpful in cases with suspected leakage of CSF, such as discontinuity of connection of the catheter. Abnormal pooling of radiotracer at somewhere out of the VP shunt is the typical pattern of leakage, which could be due to traumatic or iatrogenic. In this patient, the watery excretion from the insertion site developed right after catheterization of Hickman at right chest. A lung-shaped region of intensely increased radioactivity was demonstrated at right chest after radiotracer administration via the intra-reservoir injection. This lung-shaped region could be due to CSF drainage or leakage to the pleura space or the gauze covered at right chest wall in order to collect the leakage fluid. For further differentiation, the image was acquired again after the gauze was removed. There is no more lung-shaped radioactive region at right chest region and the removed gauze is intensely radioactive, which both suggest that the leakage fluid is CSF-originated. Another possible origin of the radioactivity may come from the blood since the 99m Tc-DTPA 2010;23:59-63 2010 3 23 1 61

Wang HY et al is resorbed quickly by peritoneum into the blood stream. This is less likely since there is no radioactivity in the peritoneum and no blood component in the radioactive gauze. All of the above proved that the VP shunt patency scan successfully proved that the watery discharge is originated from CSF. The leakage of CSF from VP shunt is thought secondary to iatrogenic trauma by Hickman insertion since the symptom of watery discharge developed right after this procedure. Conclusion The CSF leakage, an unusual complication resulted from iatrogenic trauma of VP shunt by Hickman insertion, could be detected easily by the simple, minimal invasive VP shunt patency scan, which is often used to evaluate the function of the shunt. Alert of symptom and signs by clinician and correct interpretation of images by nuclear medicine physician are necessary to obtain an accurate diagnosis. References 1. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;136:602-606. 2. Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-875. 3. Bernard RW, Stahl WM, Chase RM Jr. Subclavian vein catheterizations: a prospective study. II. Infectious complications. Ann Surg 1971;173:191-200. 4. Bernard RW, Stahl WM. Subclavian vein catheterizations: a prospective study. I. Non-infectious complications. Ann Surg 1971;173:184-190. 5. Dunbar RD, Mitchell R, Lavine M. Aberrant locations of central venous catheters. Lancet 1981;1:711-715. 6. Conces DJ Jr, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293-295. 7. McKusick KA, Malmud LS, Kordela PA, Wagner HN Jr. Radionuclide cisternography: normal values for nasal secretion of intrathecally injected 111 In-DTPA. J Nucl Med 1973;14:933-934. 8. Adeloye A. Protrusion of ventriculo peritoneal shunt through the anus: report of two cases. East Afr Med J 1997;74:337-339. 9. Digray NC, Thappa DR, Arora M, Mengi Y, Goswamy HL. Silent bowel perforation and transanal prolapse of a ventriculoperitoneal shunt. Pediatr Surg Int 2000;16:94-95. 10. Ashpole R, Boulton R, Holmes AE. A case of asymptomatic passage per-rectum of a fractured redundant peritoneal catheter from a ventriculo-peritoneal shunt. Eur J Pediatr Surg 1995;5:280-281. 11. Agha FP, Amendola MA, Shirazi KK, Amendola BE, Chandler WF.. Unusual abdominal complications of ventriculo-peritoneal shunts. Radiology 1983;146:323-326. 12. Drake JM, da-silva MC, Rutka JT. Functional obstruction of an antisiphon device by raised tissue capsule pressure. Neurosurgery 1993;32:137-139. 13. Altman J, James AE Jr. Ventriculo-venous cerebrospinal fluid shunts. Roentgenologic analysis. Am J Roentgenol Radium Ther Nucl Med 1971;112:237-250. 14. Fischer EG, Shillito J Jr. Large abdominal cysts: a complication of peritoneal shunts. Report of three cases. J Neurosurg 1969;31:441-444. 15. Eschelman DJ, Lee VW. Lesser sac cerebrospinal fluid collection. An unusual complication of a ventriculoperitoneal shunt. Clin Nucl Med 1990;15:415-417. 16. Grosfeld JL, Cooney DR, Smith J, Campbell RL. Intraabdominal complications following ventriculoperitoneal shunt procedures. Pediatrics 1974;54:791-796. 17. Goldfine SL, Turetz F, Beck AR, Eiger M. Cerebrospinal fluid intraperitoneal cyst: an unusual abdominal mass. AJR Am J Roentgenol 1978;130:568-569. Ann Nucl Med Sci 2010;23:59-63 Vol. 23 No. 1 March 2010 62

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