Downstream Dislocation of a Ventriculo-Atrial Shunt Catheter

Excerpt

A 46-year-old woman was transferred to our clinic via ambulance from a nearby airport. The patient reportedly hit the back of her head against the bathroom wall during turbulences on an inbound flight. Afterward, she complained about holocephalic headaches and demonstrated bilateral abducens nerve palsy. The remainder of the physical examination was unremarkable. In the past, she had undergone multiple cerebral shunt operations due to a posttraumatic hydrocephalus stemming from a motor vehicle accident as a child (Figure 1). Anamnestic details were sparse, but from the initial head computed tomography (CT) we could surmise that she had previously been implanted with a ventricular shunt in the left ventricle as well as an infratentorial shunt, which was inserted into a suboccipital midline trepanation. Dorsal to the cerebellum, there was a persistent cerebrospinal fluid buildup, which the suboccipital catheter appeared to drain. Both catheters then joined together in a y-connection at the right side of the skull and continued downward. At first, it remained unclear whether the catheter drained into the atrium or the peritoneal cavity. An initial X-ray of the chest and abdomen suggested an intact ventriculo-peritoneal shunt system, but the patient stated that after shunt revision the drainage was into the right atrium. Subsequently, the diagnostics were expanded by a CT scan of the neck and chest. It was revealed that there was a breakage of the tubing in the nuchal area, dorsal and right to C2/C3. The distal shunt catheter was found to be dislocated into the pulmonary artery and extended into the subsegmental pulmonary arteries on both sides (Figs. 2, 3, white arrows). The patient’s electrocardiogram demonstrated frequent ventricular extrasystoles, but no certain connection to the dislocated catheter could be established. The distal end of the catheter could subsequently be retrieved by transfemoral arterial catheterization using a grapple hook device (Fig. 4). During hospitalization, the abducens nerve palsies remained unchanged and the headaches responded to medication, but the intracranial pressure measured by tapping into the cranial shunt reservoir progressively increased (4th hospital day 25 cmH₂O, 5th day 25 cmH₂O, 6th day 45 cmH₂O) and lastly drowsiness developed. Subsequently, the patient underwent urgent shunt revision, after which she directly regained consciousness. Some residual limitation of abduction was observed, but the patient reported subjective improvement of double vision at discharge on day 25. She was subsequently lost to follow-up.

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