Acta Neurochir (Wien) (2006) 148: 1205–1207 DOI 10.1007/s00701-006-0898-y
Case Report Umbilical CSF fistula: a rare complication of ventriculoperitoneal shunt A. Gupta1 , F. U. Ahmad1 , A. Kumar2, S. Gaikwad2 , and S. Vaishya1 1 2
Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India Department of Neuroradiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
Received December 6, 2005; accepted August 16, 2006; published online October 9, 2006 # Springer-Verlag 2006
Summary An umbilical CSF fistula following a ventriculoperitoneal shunt is an extremely rare complication. We report a 28-year-old man who presented with leak of clear fluid from the umbilicus, one month after a ventriculo-peritoneal shunt revision. Shuntogram revealed communication between umbilicus and abdominal end of the catheter. He was managed successfully with shunt exteriorization, antimeningitic treatment, and later shunt re-insertion. Keywords: Ventriculoperitoneal shunt; fistula; complications; umblicus.
Introduction Ventriculoperitoneal (VP) shunt is an often-performed surgical procedure for hydrocephalus of diverse etiology. We report a very rare complication of this procedure, which involved formation of an umbilical cerebrospinal fluid (CSF) fistula that was demonstrated with a contrast shuntogram. Only three such reports are available in the English literature [1–3]. Case report A 28-year-old male was admitted to our unit with a history of clear fluid leaking through the umbilicus for the past 3 weeks, and fever with obtundation of sensorium for 7 days. This patient had undergone craniotomy for traumatic brain injury 1 year ago, and also had a low-pressure VP shunt inserted 9 months ago for post-traumatic hydrocephalus. After a month, the shunt required revision owing to a block at the lower end. There was no prior history of a congenital or acquired abnormality or discharge related to the umbilicus. On examination, the patient’s Glasgow Coma Score was E4 V1 M3. There was clear fluid egress visible from the umbilicus (Fig. 1a); the shunt catheter could neither be seen nor palpated per abdomen. The umbilicus itself appeared normal. CT scan showed hydrocephalus. A contrast shuntogram was performed after instilling 10 ml Iohexol (300 mg=ml Iodine; Nycomed
Corp.,) into the shunt chamber which was palpable near the mastoid. This revealed a fistulous tract from the shunt tube into the umbilicus through which the contrast was seen to be emerging (Fig. 1b, c). Ultrasound of the abdomen did not reveal any intra-abdominal fluid collection. Analysis of the leaking CSF revealed meningitis, even though the bacterial culture did not yield any organism after 48 hours of incubation. Based on the above findings, the ventriculoperitoneal shunt was exteriorized from the neck. This led to stoppage of any fluid egress through the umbilicus. The patient was treated with intravenous Cefoperazone and Amikacin in anti-meningitic doses. Over the next 10 days, the CSF became acellular after which the exteriorized shunt was removed and a ventriculoperitoneal shunt was performed on the contralateral side. Patient improved, and was localizing painful stimuli. Patient was discharged from the hospital after 3 days, and has remained stable over last one year.
Discussion Complications of VP shunt are well described. There are only three reports of umbilical CSF fistula following VP shunt in the English literature [1–3]. These cases were associated with persistent umbilical vein, perivisceritis, or local infection. It is difficult to comment as to the likely cause of the fistula between the shunt tubing and the umbilicus in our patient, as he had neither any evidence of infection nor of shunt obstruction prior to the symptom of fluid egress from the umbilicus. The infection may probably have been a causative factor resulting in adhesion of the shunt tube to the urachal remnant=persistent omphalomesentric tract, later on resulting in a fistula possibly due to distal CSF flow obstruction secondary to infection. Since the shunt tract was already demonstrated by the shuntogram, direct cannulation of the umbilicus was avoided. If however
Fig. 1. (a) Clear fluid egress seen from umbilicus. (b) Axial CT image after contrast instillation into shunt chamber demonstrating contrast in the tubing (right arrow), fistulous tract (left arrow) and umbilical opening (arrowhead). (c) Sagittal reconstructed CT image demonstrating the fistula (arrow) in the sagittal plane, with contrast leaking out through the umbilicus
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a persistent urachus=omphalomesentric tract is identified in any patient, it should be operated upon to prevent late complications. We also encountered 2 case reports of shunt tube extrusion through the umbilicus [4, 5]. In one of these cases [4], there was evidence of an umbilical abscess. As in the management of any fistula, proximal diversion of the leaking fluid, as done in this case too, results in healing and closure of the fistula. It is important for clinicians to be aware of this complication, so that they become suspicious of any clear umbilical discharge after VP shunt and early management can be started. References 1. Antunes AC, Ribeirio TR (1975) Spontaneous CSF fistula from ventriculoperitoneal shunt drainage. Report of two cases. J Neurosurg 43: 481–482 2. Das PC, Radhakrishna K, Rao PL (1993) Spontaneous CSF fistula: a rare complication of ventriculoperitoneal shunt. J Pediatr Surg 28: 630–631
3. Pomplili A, Cianfriglia F (1979) Umblical fistula as a complication of ventriculo-peritoneal shunt. Surg Neurol 12: 129–130 4. Silav G, Tun K, Dolgun H, Unlu A, Selcuki M (2002) The spontaneous umbilical perforation of the distal end of ventriculoperitoneal shunt. Neurochirurgie 48: 128–130 5. Wani AA, Ramzan A, Wani MA (2002) Protrusion of a peritoneal catheter through the umblicus: an unusual complication of a ventriculoperitoneal shunt. Pediatr Surg Int 18: 171–172
Comment The authors report on a rare complication related to ventriculoperitoneal csf-shunting. This case report is presented in a clear and appropirate manner. Since there are already comparable cases reported and each neurosurgeon is aware of the possibility of even very rare and abstruse shunt complications, e.g. catheter migrations into and through nearly all anatomical structures, the relevance of its publication can be discussed. Angela-Martina Messing-Junger Dusseldorf Correspondence: Aditya Gupta, Department of Neurosurgery, All India Institute of Medical sciences, New Delhi 110029, India. e-mail:
[email protected],
[email protected]
