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The ventriculopleural shunt procedure for hydrocephalus
418
The Journal o[ P E D I A T R I C S
The ventriculopleural shunt procedure for hydrocephalus Case report of an unusual complication
Laibe A. Kessler, M.D., e and Wilhelm Z. Stern, M.D. NEW
YORK,
N.
Y.
A c E R E S R O S P I N A L fluid shunting tube which passes from one of the lateral cerebral ventricles to the pleural cavity has been described by Ransohoff a and has been used for the relief of hydrocephalus for the past eight years, particularly at the Neurological Institute of New YorkY The problems and complications encountered thus far have been those common to other shunting techniques. This case, however, presents a most unusual complication: the development of a fistula between a bronchiole and the shunt tube, resulting in a spontaneous and continuous replacement of cerebrospinal fluid by air. The case report will deal specifically only with the complication under discussion. A 28-year-old, left-handed male was admitted in stupor to Montefiore Hospital, New York City, on June 25, 1959. Three months previously, he was treated elsewhere for acute meningitis, from which he had recovered, except for a mild right hemiparesis. Six days prior to this admission, he began From the Divisions o/Neurosurgery and Diagnostic Radiology, Montefiore Hospital, New York. ~'Address, 3600 Forbes Avenue, Pittsburgh 13, Pa.
having severe headaches, nausea, vomiting, and lethargy progressing to stupor. Findings on physical examination included a moderate degree of papilledema, mild right hemiparesis, and right sixth nerve palsy. An air study demonstrated generalized enlargement of the ventricles, absence of air over the convexity, and marked obliteration of the basal cisterns (Fig. 1). The diagnosis was established as hydrocephalus due to arachnoiditis. A ventriculopleural shunt, with latex tubing, was performed and the patient recovered, except for the mild right hemiparesis which was present on admission. In February, 1960, he was readmitted for replacement of the pleural end of the tube which had become dislodged. Within one week, he returned to work as an engineer. On April 7, 1960, he was admitted for the third time with the complaint of severe headache of one week's duration, increased by coughing, straining, or head motion. Significantly, for the entire six weeks since revision of the tube, he reported an irritating and constant desire to cough. X-rays of the skull (Figs. 2 and 3) showed air in the ventricular system. The diagnosis was a bronehoventricular fistula.
Volume 60 Number 3
Ventriculopleural shunt [or hydrocephalus
The patient was taken to the operating room and, under general endotracheal anesthesia, the tube was withdrawn from its position in the left hemithorax and reinserted in the opposite pleural cavity. This was done with the patient in the face-down position and, when he was positioned, a free flow of spinal fluid was seen to trickle from the endotracheal tube. This reinforced the certainty of the preoperative diagnosis. The postoperative course was uneventful and after ten days the patient returned to work. He was doing well when examined one year later. (Fig. 4). DISCUSSION The ventriculopleural shunting procedure for the relief of hydrocephalus has proved very satisfactory, particularly in adults and in instances of obliteration of the subarachnoid spaces. The procedure, technically, is
Fig. 1. Initial ventriculogram in June, 1959, showing a moderate hydrocephalus with symmetrical ventricular dilatation, attributed to araehnoiditis.
Fig. 2. Film of skull, April, 1960, showing air in the ventricular system. The tip of the shunting tube is seen in the anterior horn of the left lateral ventricle. This surprising, spontaneous appearance of air suggested the presence of a bronchoventricufar fistula.
4 19
not difficult, requiring simply the insertion of a small rubber catheter or other tube of choice into a lateral ventricle through a parietooccipital burr hole. The tube is passed subcutaneously to the posterior chest wall to the level of the third or fourth thoracic vertebra. Through a small thoracotomy incision, it is inserted into the pleural space. There is, however, a high frequency of obstruction of the tube, revision being necessary one or more times in about 50 per cent of cases of infantile hydrocephalus, a It should be noted that this revision is accomplished easily with negligible morbidity or discomfort. If the patency of the tube or the cerebral condition remains in doubt, it is a simple matter to inject the tube and obtain air studies of the ventricular system. Other bypassing techniques present differing obstacles: For instance, the Torkildsen procedure and third ventriculostomy are not
420
Kessler and Stern
March 1962
Fig. 4. Follow-up film a year later (April, 1961) after transplantation of the tube into the right pleural cavity. The shunt is functioning adequately.
Fig. 3. The pleural end of the shunting tube is seen in situ in the left upper hemithorax.
applicable when the subarachnoid spaces are obliterated; also, both require craniotomy. Shunts into the cardiovascular system can produce intravascular thrombosis and subject the patient to the possibility of septicemia. 4 Furthermore, they render a subsequent air study dangerous if the bypass is functioning (air embolism). Intracerebral h e m a t o m a is a problem c o m m o n to all types of shunting procedures. The complication described in this case report represents the only type peculiar to this technique and the first to occur in over 100 known cases. It was easily treated. T h e fistula closed readily after the tube was transposed to the opposite pleural cavity. I n retrospect, it is likely that this complication was caused by replacement of the pleural end of the tube (second admission) into the same pleural cavity from which it had first become dislodged instead of using the other side. Since this area undoubtedly had developed pleural adhesions, free movement of the tube was prevented and the irri-
tation at one point on the lung surface resulted in erosion of the bronchiole and formation of a bronchoventricular fistula. SUMMARY
A brief review of the simple ventriculopleural bypassing technique for the treatment of hydrocephalus is given and an unusual complication is reported.
REFERENCES
1. Ransohoff, J.: Ventriculo-pleuraI Anastomosis: In treatment of obstructing Neoplasms, J. Neurosurg. 11: 295, 1954. 2. Ransohoff, J., Shulman, K , and Fishman, R.: Hydrocephalus, a Review of Et'ology and Treatment, J. PEDlnT. 56: 339, 1960. 3. Ransohoff, J.: Persona] communication. 4. Anderson, F. M.: Ventriculo-auriculostomy in Treatment of Hydrocephalus, J-. Neurosurg. 16: 551, 1959.
The Journal o[ P E D I A T R I C S
The ventriculopleural shunt procedure for hydrocephalus Case report of an unusual complication
Laibe A. Kessler, M.D., e and Wilhelm Z. Stern, M.D. NEW
YORK,
N.
Y.
A c E R E S R O S P I N A L fluid shunting tube which passes from one of the lateral cerebral ventricles to the pleural cavity has been described by Ransohoff a and has been used for the relief of hydrocephalus for the past eight years, particularly at the Neurological Institute of New YorkY The problems and complications encountered thus far have been those common to other shunting techniques. This case, however, presents a most unusual complication: the development of a fistula between a bronchiole and the shunt tube, resulting in a spontaneous and continuous replacement of cerebrospinal fluid by air. The case report will deal specifically only with the complication under discussion. A 28-year-old, left-handed male was admitted in stupor to Montefiore Hospital, New York City, on June 25, 1959. Three months previously, he was treated elsewhere for acute meningitis, from which he had recovered, except for a mild right hemiparesis. Six days prior to this admission, he began From the Divisions o/Neurosurgery and Diagnostic Radiology, Montefiore Hospital, New York. ~'Address, 3600 Forbes Avenue, Pittsburgh 13, Pa.
having severe headaches, nausea, vomiting, and lethargy progressing to stupor. Findings on physical examination included a moderate degree of papilledema, mild right hemiparesis, and right sixth nerve palsy. An air study demonstrated generalized enlargement of the ventricles, absence of air over the convexity, and marked obliteration of the basal cisterns (Fig. 1). The diagnosis was established as hydrocephalus due to arachnoiditis. A ventriculopleural shunt, with latex tubing, was performed and the patient recovered, except for the mild right hemiparesis which was present on admission. In February, 1960, he was readmitted for replacement of the pleural end of the tube which had become dislodged. Within one week, he returned to work as an engineer. On April 7, 1960, he was admitted for the third time with the complaint of severe headache of one week's duration, increased by coughing, straining, or head motion. Significantly, for the entire six weeks since revision of the tube, he reported an irritating and constant desire to cough. X-rays of the skull (Figs. 2 and 3) showed air in the ventricular system. The diagnosis was a bronehoventricular fistula.
Volume 60 Number 3
Ventriculopleural shunt [or hydrocephalus
The patient was taken to the operating room and, under general endotracheal anesthesia, the tube was withdrawn from its position in the left hemithorax and reinserted in the opposite pleural cavity. This was done with the patient in the face-down position and, when he was positioned, a free flow of spinal fluid was seen to trickle from the endotracheal tube. This reinforced the certainty of the preoperative diagnosis. The postoperative course was uneventful and after ten days the patient returned to work. He was doing well when examined one year later. (Fig. 4). DISCUSSION The ventriculopleural shunting procedure for the relief of hydrocephalus has proved very satisfactory, particularly in adults and in instances of obliteration of the subarachnoid spaces. The procedure, technically, is
Fig. 1. Initial ventriculogram in June, 1959, showing a moderate hydrocephalus with symmetrical ventricular dilatation, attributed to araehnoiditis.
Fig. 2. Film of skull, April, 1960, showing air in the ventricular system. The tip of the shunting tube is seen in the anterior horn of the left lateral ventricle. This surprising, spontaneous appearance of air suggested the presence of a bronchoventricufar fistula.
4 19
not difficult, requiring simply the insertion of a small rubber catheter or other tube of choice into a lateral ventricle through a parietooccipital burr hole. The tube is passed subcutaneously to the posterior chest wall to the level of the third or fourth thoracic vertebra. Through a small thoracotomy incision, it is inserted into the pleural space. There is, however, a high frequency of obstruction of the tube, revision being necessary one or more times in about 50 per cent of cases of infantile hydrocephalus, a It should be noted that this revision is accomplished easily with negligible morbidity or discomfort. If the patency of the tube or the cerebral condition remains in doubt, it is a simple matter to inject the tube and obtain air studies of the ventricular system. Other bypassing techniques present differing obstacles: For instance, the Torkildsen procedure and third ventriculostomy are not
420
Kessler and Stern
March 1962
Fig. 4. Follow-up film a year later (April, 1961) after transplantation of the tube into the right pleural cavity. The shunt is functioning adequately.
Fig. 3. The pleural end of the shunting tube is seen in situ in the left upper hemithorax.
applicable when the subarachnoid spaces are obliterated; also, both require craniotomy. Shunts into the cardiovascular system can produce intravascular thrombosis and subject the patient to the possibility of septicemia. 4 Furthermore, they render a subsequent air study dangerous if the bypass is functioning (air embolism). Intracerebral h e m a t o m a is a problem c o m m o n to all types of shunting procedures. The complication described in this case report represents the only type peculiar to this technique and the first to occur in over 100 known cases. It was easily treated. T h e fistula closed readily after the tube was transposed to the opposite pleural cavity. I n retrospect, it is likely that this complication was caused by replacement of the pleural end of the tube (second admission) into the same pleural cavity from which it had first become dislodged instead of using the other side. Since this area undoubtedly had developed pleural adhesions, free movement of the tube was prevented and the irri-
tation at one point on the lung surface resulted in erosion of the bronchiole and formation of a bronchoventricular fistula. SUMMARY
A brief review of the simple ventriculopleural bypassing technique for the treatment of hydrocephalus is given and an unusual complication is reported.
REFERENCES
1. Ransohoff, J.: Ventriculo-pleuraI Anastomosis: In treatment of obstructing Neoplasms, J. Neurosurg. 11: 295, 1954. 2. Ransohoff, J., Shulman, K , and Fishman, R.: Hydrocephalus, a Review of Et'ology and Treatment, J. PEDlnT. 56: 339, 1960. 3. Ransohoff, J.: Persona] communication. 4. Anderson, F. M.: Ventriculo-auriculostomy in Treatment of Hydrocephalus, J-. Neurosurg. 16: 551, 1959.