Skip to main content

Advertisement

SpringerLink
Log in

Neuroimaging of ventriculoperitoneal shunt complications in children

  • Review
  • Published:
Pediatric Radiology Aims and scope Submit manuscript

Abstract

The ventriculoperitoneal shunt is the mainstay of treatment for hydrocephalus. Despite its widespread use and safety record, it often malfunctions due to complications such as obstruction, breakage, migration and infection. This necessitates a systematic approach to diagnosing the etiology of shunt failure. Any evaluation should begin with an appraisal of the patient’s symptoms. In acute malfunction, nausea, vomiting, irritability, seizures, headache, lethargy, coma and stupor are seen. In chronic malfunction, neuropsychological signs, feeding pattern changes, developmental delay, decline in school performance, headaches and increased head size are often seen. The next step in evaluation is a CT scan of the head to evaluate ventricular size. Prior imaging studies should be obtained for comparison; if the ventricles have enlarged over time, shunt malfunction is likely. If there is no such increase or dilation in the first place, other diagnoses are possible. However, “slit ventricle syndrome” should also be considered. When prior imaging is not available, pumping the reservoir, a radionuclide shuntogram, a shunt tap or even surgical exploration are options. The goals of this paper are to provide an algorithm for evaluating shunt malfunction and to illustrate the radiographic findings associated with shunt failure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 25
Fig. 26
Fig. 27
Fig. 28

Similar content being viewed by others

References

  1. Wu Y, Green NL, Wrensch MR et al (2007) Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61:557–562

    Article  PubMed  Google Scholar 

  2. Patwardhan RV, Nanda A (2005) Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery 56:139–145

    PubMed  Google Scholar 

  3. Olson S (2004) The problematic slit ventricle syndrome. A review of the literature and proposed algorithm for treatment. Pediatr Neurosurg 40:264–269

    Article  PubMed  Google Scholar 

  4. Browd SR, Ragel BT, Gottfried ON et al (2006) Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol 34:83–92

    Article  PubMed  Google Scholar 

  5. Drake JM (1993) Ventriculostomy for treatment of hydrocephalus. Neurosurg Clin N Am 4:657–666

    PubMed  CAS  Google Scholar 

  6. Hopf NJ, Grunert P, Fries G et al (1999) Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery 44:795–804 discussion 804–806

    Google Scholar 

  7. Dias MS, Li V (1998) Pediatric neurosurgical disease. Pediatr Clin N Am 45:1539–1578

    Article  CAS  Google Scholar 

  8. Khorasani L, Sikorski CW, Frim DM (2004) Lumbar CSF shunting preferentially drains the cerebral subarachnoid over the ventricular spaces: implications for the treatment of slit ventricle syndrome. Pediatr Neurosurg 40:270–276

    Article  PubMed  Google Scholar 

  9. Yadav YR, Pande S, Raina VK et al (2004) Lumboperitoneal shunts: review of 409 cases. Neurol India 52:188–190

    PubMed  CAS  Google Scholar 

  10. Lollis SS, Mamourian AC, Vaccaro TJ et al (2010) Programmable CSF shunt valves: radiographic identification and interpretation. AJNR 31:1343–1346

    Article  PubMed  Google Scholar 

  11. Eastwood S (ed) (1986) About hydrocephalus. A book for parents. The Hydrocephalus Association and the University of California at San Francisco

  12. Mataro M, Poca MA, Sahuquillo J et al (2000) Cognitive changes after cerebrospinal fluid shunting in young adults with spina bifida and assumed arrested hydrocephalus. J Neurol Neurosurg Psychiatry 68:615–621

    Article  PubMed  CAS  Google Scholar 

  13. McGirt MJ, Leveque JC, Wellons JC 3rd et al (2002) Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience. Pediatr Neurosurg 36:248–255

    Article  PubMed  Google Scholar 

  14. Tuli S, Drake J, Lawless J et al (2000) Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 92:31–38

    Article  PubMed  CAS  Google Scholar 

  15. Garton HJ, Kestle JR, Drake JM (2001) Predicting shunt failure from clinical symptoms and signs. J Neurosurg 94:202–210

    Article  PubMed  CAS  Google Scholar 

  16. Li V, Dias MS (1999) The results of a practice survey on the management of patients with shunted hydrocephalus. Pediatr Neurosurg 30:288–295

    Article  PubMed  CAS  Google Scholar 

  17. Ramamurthi R (2005) Textbook of operative neurosurgery. B.I. Publications, New Delhi

    Google Scholar 

  18. Udayansankar UK, Braithwaite K, Arvaniti M et al (2008) Low-dose nonenhanced head CT protocol for follow-up evaluation of children with ventriculoperitoneal shunt: reduction of radiation and effect on image quality. AJNR 29:802–806

    Article  Google Scholar 

  19. Desai KR, Babb JS, Amodio JB (2007) The utility of the plain radiograph “shunt series” in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients. Pediatr Radiol 37:452–456

    Article  PubMed  Google Scholar 

  20. Ouellette D, Lynch T, Bruder E et al (2009) Additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department. Pediatr Emerg Care 25:827–830

    Article  PubMed  Google Scholar 

  21. Kurwale NS, Agrawal D (2010) Phase contrast MRI of intracranial shunt tube: a valuable adjunct in the diagnosis of ventriculo-peritoneal shunt malfunction. Neurosurgery 67:552–553

    Article  Google Scholar 

  22. Iskander BJ, Sansone JM, Medow J et al (2004) The use of quick-brain magnetic resonance imaging in the evaluation of shunt-treated hydrocephalus. J Neurosurg Pediatr 101:147–151

    Article  Google Scholar 

  23. Collins P, Hockley AD, Woollam DH (1978) Surface ultrastructure of tissues occluding ventricular catheters. J Neurosurg 48:609–613

    Article  PubMed  CAS  Google Scholar 

  24. Kast J, Duong D, Nowzari F et al (1994) Time-related patterns of ventricular shunt failure. Childs Nerv Syst 10:524–528

    Article  PubMed  CAS  Google Scholar 

  25. Drake JM, Sainte-Rose C (1995) Shunt complications. In: Drake JM, Sainte-Rose C (eds) The shunt book. Blackwell, Cambridge

    Google Scholar 

  26. Piatt JH Jr (1996) Pumping the shunt revisited: a longitudinal study. Pediatr Neurosurg 25:73–76

    Article  PubMed  Google Scholar 

  27. Uvebrant P, Sixt R, Bjure J et al (1992) Evaluation of cerebrospinal fluid shunt function in hydrocephalic children using 99mTc-DTPA. Childs Nerv Syst 8:76–80

    Article  PubMed  CAS  Google Scholar 

  28. May CH, Aurisch R, Kornrumpf D et al (1999) Evaluation of shunt function in hydrocephalic patients with the radionuclide 99mTc-pertechnetate. Childs Nerv Syst 15:239–424 discussion 245

    Google Scholar 

  29. O’Brien DF, Taylor M, Park TS et al (2003) A critical analysis of ‘normal’ radionucleotide shuntograms in patients subsequently requiring surgery. Childs Nerv Syst 19:337–341

    Article  PubMed  Google Scholar 

  30. Buxton N, Punt J (1999) Subtemporal decompression: the treatment of noncompliant ventricle syndrome. Neurosurgery 44:513–519

    Article  PubMed  CAS  Google Scholar 

  31. Obana WG, Raskin NH et al (1990) Antimigraine treatment for slit ventricle syndrome. Neurosurgery 27:760–763

    Article  PubMed  CAS  Google Scholar 

  32. Linder M, Diehl J, Sklar FH (1983) Subtemporal decompressions for shunt dependent ventricles: mechanism of action. Surg Neurol 19:520–525

    Article  PubMed  CAS  Google Scholar 

  33. Di Rocco C, Marchese E, Velardi F (1994) A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991–1992 Education Committee on the ISPN. Childs Nerv Syst 10:321–327

    Article  PubMed  Google Scholar 

  34. Kestle J, Drake J, Milner R et al (2000) Long-term follow-up data from the Shunt Design Trial. Pediatr Neurosurg 33:230–236

    Article  PubMed  CAS  Google Scholar 

  35. Vernet O, Campiche R, de Tribolet N (1995) Long-term results after ventriculo-atrial shunting in children. Childs Nerv Syst 11:176–179

    Article  PubMed  CAS  Google Scholar 

  36. Major O, Fedorcsak I, Sipos L et al (1994) Slit-ventricle syndrome in shunt operated children. Acta Neurochir 127:69–72

    Article  CAS  Google Scholar 

  37. Sgouros S, Malluci C, Walsh AR et al (1995) Long-term complications of hydrocephalus. Pediatr Neurosurg 23:127–132

    Article  PubMed  CAS  Google Scholar 

  38. Epstein F, Lapras C, Wisoff JH (1988) ‘Slit ventricle syndrome’: etiology and treatment. Pediatr Neurosci 14:5–10

    Article  PubMed  CAS  Google Scholar 

  39. Holness RO, Hoffman HJ, Hendrick EB (1979) Subtemporal decompression for the slit ventricle syndrome after shunting in hydrocephalic children. Childs Brain 5:137–144

    PubMed  CAS  Google Scholar 

  40. Eldredge EA, Rockoff MA, Medlock MD et al (1997) Postoperative cerebral edema occurring in children with slit ventricles. Pediatrics 99:625–630

    Article  PubMed  CAS  Google Scholar 

  41. Ghotme K, Drake J, Lamberti-Pasculli M et al (2007) Management of shunt disconnections and fractures in children: experience at the Hospital for Sick Children. AANS Pediatric Section Meeting, South Beach, FL

  42. Storrow AB (1998) Intracranial shunt assessment. In: Hedges JR (ed) Clinical procedures in emergency medicine, 3rd edn. Saunders, Philadelphia

    Google Scholar 

  43. Nelson JD (1984) Cerebrospinal fluid shunt infections. Pediatr Infect Dis 3:S30–S32

    Article  PubMed  CAS  Google Scholar 

  44. Tunkel AR, Scheld WM (2000) Acute meningitis. In: Mandell GL, Bennett JE, Dolin R (eds) Principles and practice of infectious diseases. Churchill Livingstone, Philadelphia

    Google Scholar 

  45. Upchurch K, Raifu M, Bergsneider M (2007) Endoscope-assisted placement of a multiperforated shunt catheter into the fourth ventricle via a frontal transventricular approach. Neurosurg Focus 22:1–8

    Article  Google Scholar 

  46. Browd SR, Ragel BT, Gottfried ON et al (2006) Failure of cerebrospinal fluid shunts: part II: overdrainage, loculation, and abdominal complications. Pediatr Neurol 34:171–176

    Article  PubMed  Google Scholar 

  47. Park DH, Chung J, Yoon SH (2009) The role of distraction osteogenesis in children with secondary craniosynostosis after shunt operation in early infancy. Pediatr Neurosurg 45:437–445

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We would like to acknowledge the assistance of Mrs. Shireen Hayatghaibi in creating the flowchart in Figure 23 using Microsoft Visio software, and the assistance of Dr. Serife Kavuk in the preparation of the images.

Author information

Authors and Affiliations

  1. Baylor College of Medicine, Houston, TX, USA

    Ahilan Sivaganesan

  2. EB Singleton Department of Pediatric Radiology, Texas Children’s Hospital, 6701 Fannin St., Suite 1280, Houston, TX, 77030, USA

    Rajesh Krishnamurthy

  3. Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA

    Deshdeepak Sahni

  4. Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Chitra Viswanathan

Authors
  1. Ahilan Sivaganesan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rajesh Krishnamurthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Deshdeepak Sahni
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chitra Viswanathan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rajesh Krishnamurthy.

Additional information

CME activity

This article has been selected as the CME activity for the current month. Please visit the SPR Web site at www.pedrad.org on the Education page and follow the instructions to complete this CME activity.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sivaganesan, A., Krishnamurthy, R., Sahni, D. et al. Neuroimaging of ventriculoperitoneal shunt complications in children. Pediatr Radiol 42, 1029–1046 (2012). https://doi.org/10.1007/s00247-012-2410-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00247-012-2410-6

Keywords

Search

Navigation