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Open access

Shunt freedom in slit ventricle syndrome: using paradoxical ventriculomegaly following lumbar shunting to our advantage. Illustrative cases

Kevin Gilbert, Jillian H. Plonsker, Jessica Barnett, Omar Al Jammal, Arvin R. Wali, Mihir Gupta, and David Gonda

BACKGROUND

The authors present two cases of paradoxical ventriculomegaly after lumboperitoneal (LP) shunting in patients with slit ventricle syndrome (SVS).

OBSERVATIONS

After placement of an LP shunt, both patients rapidly developed radiographic and clinically symptomatic ventricular enlargement. The then generous ventricular corridors allowed both patients to be treated by endoscopic third ventriculostomy (ETV) with concurrent removal of their LP shunt. The patients then underwent staged increases in their shunt resistance to the maximum setting and remain asymptomatic.

LESSONS

The authors suggest that this paradoxical ventriculomegaly may have resulted from a pressure gradient between the shunt systems in the intra- and extraventricular spaces due to a noncommunicating etiology of their hydrocephalus. ETV may successfully exploit this newfound obstructive hydrocephalus and provide resolution of the radiographic and clinical hydrocephalus through allowing for improved communication between the cranial and lumbar cerebrospinal fluid spaces in SVS.

Open access

Normal pressure hydrocephalus due to an iatrogenic giant lumbar pseudomeningocele after posterior lumbar interbody fusion: illustrative case

Yoshiomi Kobayashi, Kanehiro Fujiyoshi, Toshiyuki Shimizu, Yosuke Kawano, Toshiki Okubo, Yoshihide Yanai, Takashi Kato, Kohei Matsubayashi, Keitaro Matsukawa, Mitsuru Furukawa, Tsunehiko Konomi, Junichi Yamane, Masakazu Takemitsu, and Yoshiyuki Yato

BACKGROUND

Iatrogenic pseudomeningocele incidence after lumbar surgery is 0.068%–2%, and most lumbar pseudomeningoceles are smaller than 5 cm; however, in rare cases, “giant” pseudomeningoceles greater than 8 cm in size may develop. Normal pressure hydrocephalus (NPH) is another rare condition in which the ventricles expand despite the presence of normal intracranial pressure. To date, pseudomeningocele associated with NPH has not been reported.

OBSERVATIONS

An 80-year-old woman underwent L3–5 laminectomy and posterior lumbar interbody fusion, and her symptoms improved after surgery. However, dementia appeared 1 month after surgery. Repeated brain computed tomography showed ventricular enlargement, and lumbar magnetic resonance imaging showed a long pseudomeningocele in the subcutaneous tissues at the L4 level. Here, the authors report a rare case of an iatrogenic giant pseudomeningocele accompanied by NPH after lumbar surgery. The symptoms of NPH in the present case occurred after spinal surgery and recovered after dural repair surgery, indicating that the changes in cerebrospinal fluid circulation and/or pressure due to pseudomeningoceles may cause NPH.

LESSONS

The prevention of dural tears through precise surgical technique and primary repair of dural tears are the best approaches to prevent pseudomeningocele incidence and subsequent events.

Open access

Embolization of a third ventricular choroid plexus papilloma: illustrative case

Jordan C. Xu, Shuichi Suzuki, Jennifer Chrislip, Ali Nael, and William G. Loudon

BACKGROUND

Choroid plexus tumors are rare neoplasms that are typically found in the lateral ventricles. They have infrequently been reported in the third ventricle, and treatment strategies have varied.

OBSERVATIONS

The authors described a 6-month-old patient who presented with irritability and hypotonia. The patient was found to have a large tumor in the third ventricle with obstructive hydrocephalus. Preoperative angiography revealed a feeding artery from the right medial posterior choroidal artery (MPChA). The feeding artery was effectively embolized, and the patient subsequently received open resection of the tumor. Pathology revealed features consistent with atypical choroid plexus papilloma (CPP).

LESSONS

Choroid plexus tumors are often hypervascular, which can often make gross total resection (GTR) difficult. Preoperative angiography of tumors identifies feeding vessels, and embolization has the potential to decrease perioperative blood loss and allow for a higher GTR rate. Third ventricular CPPs appear to invariably receive vascular supply from the MPChA, arising from the right posterior cerebral artery. Embolization followed by resection of a choroid plexus tumor in the third ventricle is an effective treatment strategy.

Open access

Endovascular retrieval of a broken distal ventriculoatrial shunt catheter within the heart: illustrative case

Jordan Xu, Gira Morchi, and Suresh N. Magge

BACKGROUND

Displacement of a distal catheter of a ventriculoatrial (VA) shunt is a rare complication and can lead to a challenging extraction requiring endovascular retrieval of the distal catheter.

OBSERVATIONS

The authors describe a patient in whom the distal catheter of the VA shunt had become displaced and traveled through the tricuspid valve into the right ventricular outflow tract.

LESSONS

In this case report, the authors present a multidisciplinary approach to retrieving a displaced distal catheter from a VA shunt.

Open access

Umbilical hernia causing ventriculoperitoneal shunt dysfunction: illustrative cases

Lacey M. Carter, Alejandro Ruiz-Elizalde, and Naina L. Gross

BACKGROUND

When ventriculoperitoneal (VP) shunts and umbilical hernias coexist in the same patient, unique complications can occur. Typically, these are readily identified problems such as cerebrospinal fluid (CSF) fistulas or entrapment of the peritoneal catheter in the hernia. The authors present cases of two children whose VP shunt dysfunction resolved after repair of their umbilical hernias.

OBSERVATIONS

The authors present two cases of infant patients with shunted hydrocephalus and umbilical hernias. In both cases, the patients presented with distal shunt malfunctions not due to infection. Their shunt function improved once the umbilical hernia was repaired by pediatric surgery. Neither has required shunt revision since umbilical hernia repair.

LESSONS

Although there are case reports of VP shunts eroding through the umbilicus, developing CSF fistulas, or becoming trapped inside umbilical hernias, there is no case of VP shunt dysfunction caused by just the presence of an umbilical hernia. The authors suspect that the catheter may intermittently enter and exit the hernia. This may cause intermittent obstruction of the distal catheter, or inflammation in the hernia may occur that limits CSF absorption.

Open access

Atlantoaxial wiring hardware failure resulting in intracranial hemorrhage and hydrocephalus: illustrative case

Anass Benomar, Harrison J. Westwick, Sami Obaid, André Nzokou, Sung-Joo Yuh, and Daniel Shedid

BACKGROUND

Atlantoaxial sublaminar wiring has many known complications related to hardware failure, but intracranial hemorrhage is a rare complication.

OBSERVATIONS

A 61-year-old female patient with prior atlantoaxial sublaminar wiring for odontoid fracture nonunion experienced decreased level of consciousness due to a subarachnoid and subdural hemorrhage of the posterior fossa with intraventricular extension and hydrocephalus. Rupture of the sublaminar wire with intramedullary protrusion was the cause of the hemorrhage. The patient was treated with ventriculostomy for hydrocephalus and occipital cervical fusion for spinal instability, along with removal of the broken wire and drainage of a hematoma.

LESSONS

This uncommon cause of intracranial hemorrhage highlights an additional risk of atlantoaxial sublaminar wiring compared with other atlantoaxial fusion techniques. In addition, this case suggests cervical instrumentation failure as a differential diagnosis of subarachnoid and subdural hemorrhage of the posterior fossa when a history of prior instrumentation is known.

Open access

Multifocal metastases to choroid plexus from papillary thyroid carcinoma: illustrative case

Isidora R. Beach, Adam M. Olszewski, Alissa A. Thomas, John C. DeWitt, and Brandon D. Liebelt

BACKGROUND

Choroid plexus metastases are extremely rare from all types of malignancy, with only 42 cases reported in the literature thus far. Most of these originate from renal cell carcinoma and present as a solitary choroid plexus lesion; only two cases of multifocal choroid plexus metastases have been reported to date.

OBSERVATIONS

The authors report the third case of multifocal metastases to the choroid plexus, that of a 75-year-old man who developed three measurable choroid plexus lesions approximately 3.5 years after undergoing total thyroidectomy and chemotherapy for papillary thyroid carcinoma. He underwent intraventricular biopsy of the largest lesion and subsequently died of hydrocephalus after opting for comfort care only.

LESSONS

This is the third case of multifocal choroid plexus metastasis in the literature and the second case of multifocal metastasis from thyroid carcinoma. As such, the natural disease course is not well characterized. This case is compared with the previous eight reports of choroid plexus metastases from thyroid carcinoma, seven of which involved solitary lesions. The eight prior cases are evaluated with attention to treatment modalities used and factors potentially influencing prognosis, specifically those that might contribute to hydrocephalus, a reported complication for this pathology.

Open access

Sinking skin flap syndrome in a patient with bone resorption after cranioplasty and ventriculoperitoneal shunt placement: illustrative case

Camryn R. Rohringer, Taryn J. Rohringer, Sumit Jhas, and Mehdi Shahideh

BACKGROUND

Sinking skin flap syndrome (SSFS) is an uncommon complication that can follow decompressive craniectomy. Even less common is the development of SSFS following bone resorption after cranioplasty with exacerbation by a ventriculoperitoneal (VP) shunt.

OBSERVATIONS

A 56-year-old male sustained a severe traumatic brain injury and subsequently underwent an emergent decompressive craniectomy. After craniectomy, a cranioplasty was performed, and a VP shunt was placed. The patient returned to the emergency department 5 years later with left-sided hemiplegia and seizures. His clinical presentation was attributed to complete bone flap resorption (BFR) complicated by SSFS likely exacerbated by his VP shunt and the resultant mass effect on the underlying brain parenchyma. The patient underwent surgical intervention via synthetic bone flap replacement. Within 6 days, he recovered to his baseline neurological status.

LESSONS

SSFS after complete BFR is a rare complication following cranioplasty. To the authors’ knowledge, having a VP shunt in situ to exacerbate the clinical picture has yet to be reported in the literature. In addition to presenting the case, the authors also describe an effective treatment strategy of decompressing the brain and elevating the scalp flap while addressing the redundant tissue, then using a synthetic mesh to reconstruct the calvarial defect while keeping the shunt in situ.

Open access

Erratum. Cerebral vasculopathy and strokes in a child with COVID-19 antibodies: illustrative case

Gillian Shasby

Open access

Cerebral vasculopathy and strokes in a child with COVID-19 antibodies: illustrative case

Chase H. Foster, Anthony J. Vargas, Elizabeth Wells, Robert F. Keating, and Suresh N. Magge

BACKGROUND

The ability of coronavirus disease 2019 (COVID-19) to cause neurological insults in afflicted adults is becoming increasingly understood by way of an ever-growing amount of international data. By contrast, the pandemic illness’s neurological effects in the pediatric population are both poorly understood and sparsely reported.

OBSERVATIONS

In this case, the authors reported their experience with a preschool-age child with hydrocephalus who suffered multiterritory strokes presumed secondary to immune-mediated cerebral vasculopathy as a result of asymptomatic COVID-19 infection.

LESSONS

Growing evidence indicates that COVID-19 can cause neurological sequelae such as encephalitis and strokes. In this case report, the authors discussed a case of cerebral vasculopathy and strokes in a pediatric patient who was positive for COVID-19.