Delayed Intraventricular Hemorrhage following a Ventriculoperitoneal Shunt Placement: Exploring the Surgical Anatomy of a Rare Complication

Abstract

Ventriculoperitoneal shunt (VPS) placement is one of the commoner neurosurgical procedures worldwide. The purpose of this article is to report a case of delayed intraventricular hemorrhage (IVH) following a VPS and to review the literature regarding anatomic factors that could potentially explain this rare complication. A 78-year-old man with normal pressure hydrocephalus, who underwent an uneventful right VPS placement, suffered from a catastrophic isolated IVH five days later. The reported cases of delayed intracerebral hemorrhage (ICH) following VPS are rare and those with IVH are even rarer. Potential factors of surgical anatomy that could cause delayed ICH/IVH following a VPS procedure include erosion of vasculature by catheter cannulation, multiple attempts at perforation, puncture of the choroid plexus, improper placement of the tubing within the brain parenchyma, VPS system revision, venous infarction, vascular malformations, head trauma, and brain tumors. Other causes include generalized convulsion, VPS system malfunction, increased intracranial or blood pressure, sudden intracranial hypotension, and bleeding disorders. According to the current literature, our case is the first reported delayed isolated IVH after a VPS placement so far. Neurosurgeons should be aware of the delayed ICH/IVH as a rare, potentially fatal complication of VPS, as well as of its risk factors.

Risk factors for delayed intracranial hemorrhage secondary to ventriculoperitoneal shunt: A retrospective study

“…An EVD and VP shunts are inserted using the same frontal approach, which is an invasive brain procedure that may cause neural injury in patients[ 21 ]. Some authors have proposed that catheter insertion may lead to a disturbance in venous return or hemostasis of a cortical vein and then contribute to subcortical hemorrhage[ 15 , 17 , 22 ]. Brain edema around the catheter is regarded as a radiographic sign of vascular erosion and could be used to predict DICH.…”

A new inflammatory parameter can predict delayed intracranial hemorrhage following ventriculoperitoneal shunt

“…The mechanisms underlying the DICH secondary to VP shunt are still controversial. Several hypotheses have been proposed: (1) erosion of cerebral vasculature by the insertion of catheter; (2) fragility of cerebral tissue caused by advanced age, craniotomy, trauma or stroke; (3) disseminated intravascular coagulation (DIC) induced by VP shunt; (4) coagulopathy, anticoagulant or antiplatelet therapy; (5) sudden change of intracranial pressure after manipulation of the valve system 7 , 19 . Savitz and Bobroff 5 pointed out that the mechanism of DICH was more likely erosion of surface or deeper small vessel by catheter.…”

“…Mild hemorrhage is frequently observed in the ventricle or in the parenchyma soon after operation 5 , and the rate could be up to 43.1% 6 . However, the delayed intracerebral hemorrhage (DICH) is considered to be a rare but potentially severe event 7 , the mortality is as high as 50% 4 . The risk factors and underlying mechanisms of DICH are still not fully elucidated.…”

High-Resolution MRI for Evaluation of Ventriculostomy Tubes: Assessment of Positioning and Proximal Patency

“…Delayed intracranial hemorrhage at the site of catheter placement is an uncommon-but-severe complication of ventriculoperitoneal shunt placement and is associated with predisposing factors, including degenerative vascular change and puncture of the choroid plexus. 29 Similarly, intracranial hemorrhage and intraventricular hemorrhage have long been documented as potential complications of shunt removal and are commonly attributed to the disruption of the choroid plexus that has grown around and into the catheter. [30][31][32][33] A retrospective review of 35 pediatric patients with a total of 52 shunt revisions found that 25% of the revisions resulted in intraventricular hemorrhage, though only 2% of such revisions were deemed clinically relevant, resulting in .5 mL of blood.…”