Scholarly article on topic 'Neck Mass after Catheterization of a Neck Vein in a Child with Ventriculoperitoneal Shunt'

Neck Mass after Catheterization of a Neck Vein in a Child with Ventriculoperitoneal Shunt Academic research paper on "Clinical medicine"

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Academic research paper on topic "Neck Mass after Catheterization of a Neck Vein in a Child with Ventriculoperitoneal Shunt"

Pediatric Neurosurgery

Case Report

Pediatr Neurosurg 2004;40:182-185 DOI: 10.1159/000081936

Received: March 9, 2004 Accepted after revision: April 29, 2004

Neck Mass after Catheterization of a Neck Vein in a Child with Ventriculoperitoneal Shunt

Ki Hong Cho Soo Han Yoon SeHyukKim Yong Sam Shin Young Hwan Ahn Kyung Gi Cho

Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea

Key Words

Hydrocephalus • Postoperative complication • Pseudocyst • Cerebrospinal fluid leakage

Abstract

There have been many reports on various mechanical complications after shunt operations in children with hydrocephalus such as catheter fracture, obstruction, disconnection, dislocation and so on. However, there are no previous reports regarding subcutaneous mass formation due to cerebrospinal fluid (CSF) pseudocyst from direct puncture injury. The authors report with a review of the literature a case of a child with ventriculoperitoneal shunt who developed a neck mass after catheterization of the neck vein. The authors also advocate that percutaneous procedures in the vicinity of shunts be avoided whenever possible to prevent the possibility of CSF leakage resulting in pseudocyst formation.

Copyright © 2004 S. KargerAG, Basel

Introduction

There have been many reports on various mechanical complications after shunt operations in children with hydrocephalus, such as catheter fracture, obstruction, dis-

connection, dislocation [1-7]. Most of these complications were accompanied by localized or diffuse pseudo-cyst formation usually in the subcutaneous space with the least tissue pressure along the shunt tube and resulted from leakage of cerebrospinal fluid (CSF) [8]. There are also numerous reports regarding pseudocyst formation from shunt fractures and disconnections. However, there has been no report describing a subcutaneous CSF pseu-docyst from direct puncture injury. We report with a review of the literature a child with a ventriculoperitoneal shunt who developed a neck mass after catheterization of the neck vein.

Case Report

A 10-year-old boy presented with a 10 x 4 cm, long, slightly tender, movable, compressible, cyst-like subcutaneous mass on the left anterolateral neck (fig. 1). He had a history of congenital hydrocepha-lus and had been treated with a ventriculoperitoneal shunt via the frontal route a few months after birth. He had been healthy with good appetite and activity until several percutaneous punctures for intravenous catheterization on the anterior neck were performed that failed 1 year ago. After the punctures, a subcutaneous mass along the shunt catheter on the neck was found; it was a small finger-like size and enlarged progressively until 3 months ago. It did not increase in size thereafter, but the boy began to lose appetite with intermittent vomiting, and was also accompanied by easy fatigability and poor activity. Plain X-rays of the skull, neck, and abdomen showed no

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Soo Han Yoon, Department of Neurosurgery, Ajou University School of Medicine Yongtong-Gu, Wonchon-Dong, San No. 5 Suwon (Korea)

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Fig. 1. Preoperative picture shows a long Fig. 2. A, B CT scans show a long low-density mass from the first

soft tender subcutaneous mass along the cervical vertebra to the upper chest along the shunt tube without con-

shunt tube of the left neck. trast enhancement. C Three-dimensional image reconstructed from

the analytic computer program (VoxelPlus™): red color is the shunt tube and yellow color is the pseudocyst of the neck.

Fig. 3. Radioisotope shuntogram shows partially obstructed distal shunt tube and leaking from a portion of the tube in the neck resulting in a CSF pseudocyst. A Radioactivity of the distal catheter and neck mass was visualized 2 min after injection. B Relative radioactivity of the neck mass increased progressively until 5 min and radioactivity flowed slowly down to the distal tube around the umbilicus (UC). C Pumping of the reservoir resulted in diffusion of a small amount of radioactivity into the abdominal space. D Isotope scan after 4 h showed no more radioactivity in the distal catheter.

Fig. 4. The left tube shows a small opening resulting from a needle puncture of the neck and the right tube is the distal end of the shunt, showing obstructive opaque material on all slits.

evidence of shunt disconnection, and sufficient length of the intraabdominal shunt. Computed tomography scans of the brain and neck showed a water-like low-density mass along the shunt tube from the anterior chest up to the skull base (fig. 2A, B). There was some thickening and bead-like degeneration change of the neck and head portion of the shunt catheter, which was demonstrated in the three-dimensional computer analysis program Voxelpuls™, MEVISYS (fig. 2C). Radioisotope shuntogram showed good ventricular reflux upon injection of isotope into the reservoir, but with poor distal tube radioactivity. Radioactivity of the distal catheter and neck mass was visualized 2 min after injection (fig. 3A). Relative radioactivity of the neck mass increased progressively until 5 min, when radioactivity flowed slowly down to the distal tube around the umbilicus; but there was no more downward flow and no dispersion into the abdominal space even when standing (fig. 3B). Pumping of the reservoir resulted in diffusion of a small amount of radioactivity shortly into the abdominal space (fig. 3C). Isotope scan after 4 h showed no more radioactivity in the distal catheter but some radioactivity remained in the neck mass, ventricle, and reservoir (fig. 3D). We tentatively diagnosed the problem as a shunt malfunction with a pseudocyst of CSF leaking from the needle puncture to the shunt catheter in the neck, combined with degeneration of the shunt catheter in the neck and scalp.

We opened the old incision in the scalp above the reservoir, exposing the reservoir and distal catheter. The distal catheter was disconnected from the reservoir and removed. A small tunnel-like space along the distal tube was observed. Accumulated CSF in the neck was drained out through the subcutaneous tunnel-like space upon compression of the neck mass. We performed a new incision on the abdomen and constructed a new subcutaneous tunnel from the scalp reservoir down to the abdomen and inserted a distal catheter. The neck mass completely disappeared after the operation, and the patient was discharged and followed up for 2 months without any further problems.

Postoperative evaluation of the removed distal catheter revealed a small punctured opening on the catheter 16 cm distal from the reservoir, and partial obstruction of distal slits with amorphous connective tissue-like material (fig. 4).

case of a pseudocyst due to CSF leakage from a punctured shunt catheter.

Obstruction of the distal catheter tip is reported in 75% of distal catheter failure, which consists of 12-34% of all shunt catheter obstructions [3, 5-7]. Cozzens and Chandler [3] reported that obstructions occur more frequently in the slit end of the distal catheter compared to the open end. They also reported that no more obstructions developed after cutting the distal slit tip converting it to an open end, or replacing the slit tip distal catheter with an open-ended tube on revision. The slit end may be seen as an open end partially obstructed with debris or cells after a prolonged period. This implies that the open end could function longer than the slit end.

Gilkes et al. [8] reported pseudocyst formation in the subcutaneous tissue or in the abdominal space after shunt malfunction. The patient in this case also had a subcutaneous pseudocyst due to CSF leakage from a punctured opening of the distal catheter on the left neck, which was facilitated by the partial obstruction of the distal slit end. We could not find the exact puncture site on plain X-ray, CT, or radioisotope shuntogram, but we suspected CSF leakage from the shunt system of the head or neck portion on the radioisotope shuntogram. We were able to better understand the three-dimensional location of the pseudo-cyst in the shunt catheter, and other related anatomical structures of the head and neck with program-assisted three-dimensional reconstructions of routine CT images. We might be able to find the exact site from program-assisted three-dimensional analyses if we reconstructed many three-dimensional CT scan images less than 1 mm in thickness.

Discussion

Mechanical complications after shunt catheter include obstruction, fracture, disconnection, and migration. Among them, shunt obstruction is the most frequent cause of revision, followed by fracture and disconnection [6]. Shunt fracture consists of accidental fracture, and spontaneous fatigue fracture with calcification and degeneration. Spontaneous fatigue degeneration fracture is reported in 4.5-13.6% as a cause of shunt revision [6, 9]. Accidental fractures have also been reported from various injuries, such as seat belt injury, car-window injury, and after correction of spinal deformity [10-12]. There have been no reports to date found in Medline and Pubmed searches of punctured shunt catheters with resultant pseudocyst from CSF leakage. This might be the first reported

Conclusion

The authors report with a review of the literature a child with ventriculoperitoneal shunt who developed a neck mass after catheterization of the neck vein, which was later confirmed to be a pseudocyst due to CSF leakage from a punctured opening of the distal catheter with partial obstruction of the distal end slit.

Pediatr Neurosurg 2004;40:182-185

Cho/Yoon/Kim/Shin/Ahn/Cho

References

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Copyright: S. Karger AG, Basel 2004. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.

Copyright: S. Karger AG, Basel 2004. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.