- Email: [email protected]
Ventriculomammary shunt: An unusual ventriculoperitoneal shunt complication
402
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 (<20% of breast affected), m = month(s), N = cerebrospinal fluid nipple discharge, P = cerebrospinal fluid pseudocyst, S = breast swelling, T = breast tenderness, TB = tuberculosis, – = not stated or not applicable.
pressure elevations (such as cough, strain, exercise) exerting a positive force on the abdominal catheter. In the setting of a less than optimal multilayer abdominal closure or inadequate anchoring of the peritoneal catheter, the catheter can be pushed retrograde from the abdomen into a potential space in the breast. In the specific case of a pre-pectoral breast implant, we speculate that the presence of a fibrotic capsule around the implant may exert a tethering proximal pulling effect of the tubing and provide a potential space for migration.
4. Conclusion This case report represents a cautionary tale. In five of the 10 patients with implants and breast related VP shunt complications, the physician was unaware that the patient had breast implants prior to surgery [6,9]; therefore, obtaining a pre-operative history of breast augmentation is important to avoid breast implant related complications. In patients with known implants, tunneling should be performed carefully to avoid implant perforation, and
404
Case Reports / Journal of Clinical Neuroscience 22 (2015) 404–406
the distal shunt catheter should be secured meticulously to avoid retrograde catheter migration. Finally, female patients with and without breast implants should be advised of potential breast related complications that can occur with VP shunts, including the hazards of future breast augmentation procedures. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Sahin S, Shaaban AF, Iskandar BJ. Recurrent pneumonia caused by transdiaphragmatic erosion of a ventriculoperitoneal shunt into the lung. Case report. J Neurosurg 2007;107:156–8. [2] Frazier JL, Wang PP, Patel SH, et al. Unusual migration of the distal catheter of a ventriculoperitoneal shunt into the heart: case report. Neurosurgery 2002;51: 819–22 [discussion 822]. [3] de Carvalho RW, Pereira CU, Santos EA, et al. Retrograde migration of a ventriculoperitoneal shunt to the neck after dental treatment. J Dent Child (Chic) 2013;80:47–9. [4] Mohammadi A, Hedayatiasl A, Ghasemi-Rad M. Scrotal migration of a ventriculoperitoneal shunt: a case report and review of literature. Med Ultrason 2012;14:158–60. [5] Chu YT, Chuang HC, Lee HC, et al. A ventriculoperitoneal shunt catheter wrapped around a right mammary prosthesis forming a pseudocyst. J Clin Neurosci 2010;17:801–3. [6] Crawford MH, Friedman JD. Cerebrospinal fluid leak after immediate tissue expander breast reconstruction in a patient with Dandy–Walker syndrome. Plast Reconstr Surg 2008;121:347e–8e. [7] Dayananda L, Karthik GA, Santhosh Kumar DG. Case report: CSF pseudocyst in the breast. Indian J Radiol Imaging 2009;19:291–2. [8] Gulaldi NC, Aras O, Gordon LL, et al. Ventriculoperitoneal shunt leakage into a breast implant demonstrated by radionuclide cisternography. Clin Nucl Med 2011;36:1127–8.
[9] Iyer HP, Jacob LP, Chaudhry NA. Breast cerebrospinal fluid pseudocyst. Plast Reconstr Surg 2006;118:87e–9e. [10] Kalra N, Mani NB, Jain M, et al. Cerebrospinal fluid pseudocyst of the breast. Australas Radiol 2002;46:76–9. [11] Lazarus E, Nebres M, Spencer P, et al. Iatrogenic breast mass associated with a malfunctioning ventriculoperitoneal shunt in a patient with neurosarcoidosis. AJR Am J Roentgenol 1998;171:529–30. [12] Maknojia A, Caron JL. Proximal subcutaneous migration of the distal end of a ventriculoperitoneal shunt presenting with recurrent cerebrospinal fluid galactorrhea. J Neurosurg 2013. [13] Moron MA, Barrow DL. Cerebrospinal fluid galactorrhea after ventriculopleural shunting: case report. Surg Neurol 1994;42:227–30. [14] Mudo ML, Amantea AV, Joaquim AF, et al. Distal migration of ventriculoperitoneal shunting catheter under silicon breast implant. Arq Neuropsiquiatr 2009;67:697–8. [15] Nakano A, Tani E, Sato M, et al. Cerebrospinal fluid leakage from the nipple after ventriculoperitoneal shunt: case report. Surg Neurol 1994;42:224–6. [16] Roka YB, Gupta R, Bajracharya A. Unusual cause for ventriculoperitoneal shunt failure: carcinoma breast compressing distal catheter. Neurol India 2010;58:662–4. [17] Schrot RJ, Ramos-Boudreau C, Boggan JE. Breast-related CSF shunt complications: literature review with illustrative case. Breast J 2012;18: 479–83. [18] Shafiee S, Nejat F, Raouf SM, et al. Coiling and migration of peritoneal catheter into the breast: a very rare complication of ventriculoperitoneal shunt. Childs Nerv Syst 2011;27:1499–501. [19] Spector JA, Culliford AT, Post NH, et al. An unusual case of cerebrospinal fluid pseudocyst in a previously augmented breast. Ann Plast Surg 2005;54:85–7. [20] Torres AN, Barraguer EL, Salvador Sanz JF, et al. Late complication of a ventriculoperitoneal shunt in a patient with mammary prosthesis. J Plast Reconstr Aesthet Surg 2008;61:212–4. [21] Vimalachandran D, Martin L, Lafi M, et al. Cerebrospinal fluid pseudocyst of the breast. Breast 2003;12:215–6. [22] Lee D, Cutler B, Roberts S, et al. Multi-centric breast cancer involving a ventriculoperitoneal shunt. Breast J 2010;16:653–5. [23] Patel KB, Wong MS, Whetzel TP, et al. Breast cerebrospinal fluid after ventriculoperitoneal shunt placement. Plast Reconstr Surg 2010;126:261e–2e. [24] Lee SC, Chen JF, Tu PH, et al. Cerebrospinal fluid galactorrhea: a rare complication of ventriculoperitoneal shunting. J Clin Neurosci 2008;15: 698–700.
http://dx.doi.org/10.1016/j.jocn.2014.05.026
Thoracic spinal cord intramedullary aspergillus invasion and abscess Addason F. McCaslin, Rishi R. Lall ⇑, Albert P. Wong, Rohan R. Lall, Patrick A. Sugrue, Tyler R. Koski Northwestern University Feinberg School of Medicine, Department of Neurological Surgery, NMH/Arkes Family Pavilion Suite 2210, 676 N Saint Clair Street, Chicago, IL 60611, USA
a r t i c l e
i n f o
Article history: Received 21 February 2014 Accepted 21 April 2014
Keywords: Abscess Central nervous system vasculitis Fungi Intramedullary aspergilloma Neuroaspergillosis Precursor cell lymphoblastic leukemialymphoma
a b s t r a c t Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most commonly in immunocompromised individuals. There have been multiple previous reports of aspergillus vertebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lymphoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12–L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Invasive central nervous system (CNS) aspergillosis is a rare form of fungal infection that may arise in immunocompromised ⇑ Corresponding author. Tel.: +1 312 695 6200; fax: +1 312 695 0225. E-mail address: [email protected] (R.R. Lall).
patients [1–3]. Intracranial disease occurs most commonly and is rapidly fatal without treatment [1]. Spinal aspergillosis is more indolent, but far rarer and typically develops from contiguous vertebral osteomyelitis or systemic infection [3]. Reports in the literature have catalogued multiple patients with epidural or intradural extramedullary abscesses, but never with intramedullary involvement [2,3]. Here we describe to our knowledge the first
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 (<20% of breast affected), m = month(s), N = cerebrospinal fluid nipple discharge, P = cerebrospinal fluid pseudocyst, S = breast swelling, T = breast tenderness, TB = tuberculosis, – = not stated or not applicable.
pressure elevations (such as cough, strain, exercise) exerting a positive force on the abdominal catheter. In the setting of a less than optimal multilayer abdominal closure or inadequate anchoring of the peritoneal catheter, the catheter can be pushed retrograde from the abdomen into a potential space in the breast. In the specific case of a pre-pectoral breast implant, we speculate that the presence of a fibrotic capsule around the implant may exert a tethering proximal pulling effect of the tubing and provide a potential space for migration.
4. Conclusion This case report represents a cautionary tale. In five of the 10 patients with implants and breast related VP shunt complications, the physician was unaware that the patient had breast implants prior to surgery [6,9]; therefore, obtaining a pre-operative history of breast augmentation is important to avoid breast implant related complications. In patients with known implants, tunneling should be performed carefully to avoid implant perforation, and
404
Case Reports / Journal of Clinical Neuroscience 22 (2015) 404–406
the distal shunt catheter should be secured meticulously to avoid retrograde catheter migration. Finally, female patients with and without breast implants should be advised of potential breast related complications that can occur with VP shunts, including the hazards of future breast augmentation procedures. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Sahin S, Shaaban AF, Iskandar BJ. Recurrent pneumonia caused by transdiaphragmatic erosion of a ventriculoperitoneal shunt into the lung. Case report. J Neurosurg 2007;107:156–8. [2] Frazier JL, Wang PP, Patel SH, et al. Unusual migration of the distal catheter of a ventriculoperitoneal shunt into the heart: case report. Neurosurgery 2002;51: 819–22 [discussion 822]. [3] de Carvalho RW, Pereira CU, Santos EA, et al. Retrograde migration of a ventriculoperitoneal shunt to the neck after dental treatment. J Dent Child (Chic) 2013;80:47–9. [4] Mohammadi A, Hedayatiasl A, Ghasemi-Rad M. Scrotal migration of a ventriculoperitoneal shunt: a case report and review of literature. Med Ultrason 2012;14:158–60. [5] Chu YT, Chuang HC, Lee HC, et al. A ventriculoperitoneal shunt catheter wrapped around a right mammary prosthesis forming a pseudocyst. J Clin Neurosci 2010;17:801–3. [6] Crawford MH, Friedman JD. Cerebrospinal fluid leak after immediate tissue expander breast reconstruction in a patient with Dandy–Walker syndrome. Plast Reconstr Surg 2008;121:347e–8e. [7] Dayananda L, Karthik GA, Santhosh Kumar DG. Case report: CSF pseudocyst in the breast. Indian J Radiol Imaging 2009;19:291–2. [8] Gulaldi NC, Aras O, Gordon LL, et al. Ventriculoperitoneal shunt leakage into a breast implant demonstrated by radionuclide cisternography. Clin Nucl Med 2011;36:1127–8.
[9] Iyer HP, Jacob LP, Chaudhry NA. Breast cerebrospinal fluid pseudocyst. Plast Reconstr Surg 2006;118:87e–9e. [10] Kalra N, Mani NB, Jain M, et al. Cerebrospinal fluid pseudocyst of the breast. Australas Radiol 2002;46:76–9. [11] Lazarus E, Nebres M, Spencer P, et al. Iatrogenic breast mass associated with a malfunctioning ventriculoperitoneal shunt in a patient with neurosarcoidosis. AJR Am J Roentgenol 1998;171:529–30. [12] Maknojia A, Caron JL. Proximal subcutaneous migration of the distal end of a ventriculoperitoneal shunt presenting with recurrent cerebrospinal fluid galactorrhea. J Neurosurg 2013. [13] Moron MA, Barrow DL. Cerebrospinal fluid galactorrhea after ventriculopleural shunting: case report. Surg Neurol 1994;42:227–30. [14] Mudo ML, Amantea AV, Joaquim AF, et al. Distal migration of ventriculoperitoneal shunting catheter under silicon breast implant. Arq Neuropsiquiatr 2009;67:697–8. [15] Nakano A, Tani E, Sato M, et al. Cerebrospinal fluid leakage from the nipple after ventriculoperitoneal shunt: case report. Surg Neurol 1994;42:224–6. [16] Roka YB, Gupta R, Bajracharya A. Unusual cause for ventriculoperitoneal shunt failure: carcinoma breast compressing distal catheter. Neurol India 2010;58:662–4. [17] Schrot RJ, Ramos-Boudreau C, Boggan JE. Breast-related CSF shunt complications: literature review with illustrative case. Breast J 2012;18: 479–83. [18] Shafiee S, Nejat F, Raouf SM, et al. Coiling and migration of peritoneal catheter into the breast: a very rare complication of ventriculoperitoneal shunt. Childs Nerv Syst 2011;27:1499–501. [19] Spector JA, Culliford AT, Post NH, et al. An unusual case of cerebrospinal fluid pseudocyst in a previously augmented breast. Ann Plast Surg 2005;54:85–7. [20] Torres AN, Barraguer EL, Salvador Sanz JF, et al. Late complication of a ventriculoperitoneal shunt in a patient with mammary prosthesis. J Plast Reconstr Aesthet Surg 2008;61:212–4. [21] Vimalachandran D, Martin L, Lafi M, et al. Cerebrospinal fluid pseudocyst of the breast. Breast 2003;12:215–6. [22] Lee D, Cutler B, Roberts S, et al. Multi-centric breast cancer involving a ventriculoperitoneal shunt. Breast J 2010;16:653–5. [23] Patel KB, Wong MS, Whetzel TP, et al. Breast cerebrospinal fluid after ventriculoperitoneal shunt placement. Plast Reconstr Surg 2010;126:261e–2e. [24] Lee SC, Chen JF, Tu PH, et al. Cerebrospinal fluid galactorrhea: a rare complication of ventriculoperitoneal shunting. J Clin Neurosci 2008;15: 698–700.
http://dx.doi.org/10.1016/j.jocn.2014.05.026
Thoracic spinal cord intramedullary aspergillus invasion and abscess Addason F. McCaslin, Rishi R. Lall ⇑, Albert P. Wong, Rohan R. Lall, Patrick A. Sugrue, Tyler R. Koski Northwestern University Feinberg School of Medicine, Department of Neurological Surgery, NMH/Arkes Family Pavilion Suite 2210, 676 N Saint Clair Street, Chicago, IL 60611, USA
a r t i c l e
i n f o
Article history: Received 21 February 2014 Accepted 21 April 2014
Keywords: Abscess Central nervous system vasculitis Fungi Intramedullary aspergilloma Neuroaspergillosis Precursor cell lymphoblastic leukemialymphoma
a b s t r a c t Invasive central nervous system aspergillosis is a rare form of fungal infection that presents most commonly in immunocompromised individuals. There have been multiple previous reports of aspergillus vertebral osteomyelitis and spinal epidural aspergillus abscess; however to our knowledge there are no reports of intramedullary aspergillus infection. We present a 19-year-old woman with active acute lymphoblastic leukemia who presented with several weeks of fevers and bilateral lower extremity weakness. She was found to have an intramedullary aspergillus abscess at T12–L1 resulting from adjacent vertebral osteomyelitis and underwent surgical debridement with ultra-sound guided aspiration and aggressive intravenous voriconazole therapy. To our knowledge this is the first reported case of spinal aspergillosis invading the intramedullary cavity. Though rare, this entity should be included in the differential for immunocompromised patients presenting with fevers and neurologic deficit. Early recognition with aggressive neurosurgical intervention and antifungal therapy may improve outcomes in future cases. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Invasive central nervous system (CNS) aspergillosis is a rare form of fungal infection that may arise in immunocompromised ⇑ Corresponding author. Tel.: +1 312 695 6200; fax: +1 312 695 0225. E-mail address: [email protected] (R.R. Lall).
patients [1–3]. Intracranial disease occurs most commonly and is rapidly fatal without treatment [1]. Spinal aspergillosis is more indolent, but far rarer and typically develops from contiguous vertebral osteomyelitis or systemic infection [3]. Reports in the literature have catalogued multiple patients with epidural or intradural extramedullary abscesses, but never with intramedullary involvement [2,3]. Here we describe to our knowledge the first