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CSF Shunts and Complications
Miral D. Jhaveri, MD, MBA; Kevin R. Moore, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Abbreviations

                • Shunt types: Ventriculoperitoneal (VP), ventriculoatrial (VA), ventriculopleural (VPL), lumboperitoneal (LP)
              • Definitions

                • Ventriculomegaly
                  • General term for enlargement of cerebral ventricles
                • Hydrocephalus (HCP)
                  • Enlargement of cerebral ventricles secondary to abnormal CSF formation, flow, or absorption resulting in ↑ CSF volume
                    • Subset of ventriculomegaly
                    • Onset over days (acute), weeks (subacute), or months to years (chronic)

              IMAGING

              • General Features

                • Radiographic Findings

                  • Fluoroscopic Findings

                    • CT Findings

                      • MR Findings

                        • Ultrasonographic Findings

                          • Nonvascular Interventions

                            • Nuclear Medicine Findings

                              • Imaging Recommendations

                                DIFFERENTIAL DIAGNOSIS

                                  PATHOLOGY

                                  • General Features

                                    • Gross Pathologic & Surgical Features

                                      • Microscopic Features

                                        CLINICAL ISSUES

                                        • Presentation

                                          • Demographics

                                            • Natural History & Prognosis

                                              • Treatment

                                                DIAGNOSTIC CHECKLIST

                                                • Consider

                                                  • Image Interpretation Pearls

                                                    Selected References

                                                    1. Fowler JB et al: Ventriculoperitoneal shunt, 2020
                                                    2. Kaestner S et al: Revision surgery following CSF shunt insertion: how often could it be avoided? Acta Neurochir (Wien). 162(1):9-14, 2020
                                                    3. Mohammad SA et al: The value of CSF flow studies in the management of CSF disorders in children: a pictorial review. Insights Imaging. 10(1):3, 2019
                                                    4. Ezzat AAM et al: Migration of the distal catheter of ventriculoperitoneal shunts in pediatric age group: case series. World Neurosurg. 119:e131-7, 2018
                                                    5. Kraemer MR et al: Overdrainage-related ependymal bands: a postulated cause of proximal shunt obstruction. J Neurosurg Pediatr. 1-11, 2018
                                                    6. Ros B et al: Shunt overdrainage syndrome: review of the literature. Neurosurg Rev. 41(4):969-81, 2018
                                                    7. Hanak BW et al: Cerebrospinal fluid shunting complications in children. Pediatr Neurosurg. 52(6):381-400, 2017
                                                    8. Rinker EK et al: CSF shunt complications: what the abdominal imager needs to know. Abdom Imaging. 40(6):2030-40, 2015
                                                    9. Symss NP et al: Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst. 31(2):191-202, 2015
                                                    10. Koktekir E et al: Resolution of papilledema after endoscopic third ventriculostomy versus cerebrospinal fluid shunting in hydrocephalus: a comparative study. J Neurosurg. 120(6):1465-70, 2014
                                                    11. Bateman GA: Hypertensive slit ventricle syndrome: pseudotumor cerebri with a malfunctioning shunt? J Neurosurg. 119(6):1503-10, 2013
                                                    12. Rasul FT et al: Is endoscopic third ventriculostomy superior to shunts in patients with non-communicating hydrocephalus? A systematic review and meta-analysis of the evidence. Acta Neurochir (Wien). 155(5):883-9, 2013
                                                    13. Symss NP et al: Theories of cerebrospinal fluid dynamics and hydrocephalus: historical trend. J Neurosurg Pediatr. 11(2):170-7, 2013
                                                    14. Robinson S: Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts. J Neurosurg Pediatr. 9(3):242-58, 2012
                                                    15. Sivaganesan A et al: Neuroimaging of ventriculoperitoneal shunt complications in children. Pediatr Radiol. 42(9):1029-46, 2012
                                                    16. Chan M et al: Prediction of ventriculoperitoneal shunt dependency in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg. 110(1):44-9, 2009
                                                    17. Peraud A et al: Decompensated hydrocephalus causing syringomyelia and tetraparesis: a case report. Childs Nerv Syst. 25(2):263-6, 2009
                                                    18. Willis B et al: Ventricular reservoirs and ventriculoperitoneal shunts for premature infants with posthemorrhagic hydrocephalus: an institutional experience. J Neurosurg Pediatr. 3(2):94-100, 2009
                                                    19. Dusick JR et al: Success and complication rates of endoscopic third ventriculostomy for adult hydrocephalus: a series of 108 patients. Surg Neurol. 69(1):5-15, 2008
                                                    20. Ellis MJ et al: Treatment of recurrent ventriculoperitoneal shunt failure associated with persistent cerebrospinal fluid eosinophilia and latex allergy by use of an "extracted" shunt. J Neurosurg Pediatr. 1(3):237-9, 2008
                                                    21. James HE et al: Management of complicated shunt infections: a clinical report. J Neurosurg Pediatr. 1(3):223-8, 2008
                                                    22. Martínez-Lage JF et al: Acute cholecystitis complicating ventriculo-peritoneal shunting: report of a case and review of the literature. Childs Nerv Syst. 24(6):777-9, 2008
                                                    23. Nfonsam V et al: Laparoscopic management of distal ventriculoperitoneal shunt complications. Surg Endosc. 22(8):1866-70, 2008
                                                    24. Riffaud L et al: Acquired Chiari I malformation and syringomyelia after valveless lumboperitoneal shunt in infancy. Pediatr Neurosurg. 44(3):229-33, 2008
                                                    25. Liao YJ et al: Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report. J Neurosurg. 107(1):173-7, 2007
                                                    26. Tseng JS et al: Motor neuron disease-like syndrome secondary to trapped fourth ventricle and obstruction of cerebrospinal fluid pathway. Clin Neurol Neurosurg. 109(4):383-7, 2007
                                                    27. Woodworth G et al: Prior CSF shunting increases the risk of endoscopic third ventriculostomy failure in the treatment of obstructive hydrocephalus in adults. Neurol Res. 29(1):27-31, 2007
                                                    28. Di Rocco C et al: Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review. Childs Nerv Syst. 22(12):1573-89, 2006
                                                    29. Winston KR et al: CSF shunt failure with stable normal ventricular size. Pediatr Neurosurg. 42(3):151-5, 2006
                                                    30. Zamponi N et al: Bobble head doll syndrome in a child with a third ventricular cyst and hydrocephalus. Childs Nerv Syst. 21(5):350-4, 2005
                                                    31. Arnell K et al: Distal catheter obstruction from non-infectious cause in ventriculo-peritoneal shunted children. Eur J Pediatr Surg. 14(4):245-9, 2004
                                                    32. Blount JP et al: Sports and pediatric cerebrospinal fluid shunts: who can play? Neurosurgery. 54(5):1190-6; discussion 1196-8, 2004
                                                    33. Fewel ME et al: Migration of distal ventriculoperitoneal shunt catheter into the heart. Case report and review of the literature. J Neurosurg. 100(2 Suppl Pediatrics):206-11, 2004
                                                    34. Hashimoto M et al: A case of abdominal CSF pseudocyst associated with silicone allergy. Childs Nerv Syst. 20(10):761-4, 2004
                                                    35. Sgouros S et al: An investigation of structural degradation of cerebrospinal fluid shunt valves performed using scanning electron microscopy and energy-dispersive x-ray microanalysis. J Neurosurg. 100(3):534-40, 2004
                                                    36. Tuli S et al: Predictors of death in pediatric patients requiring cerebrospinal fluid shunts. J Neurosurg. 100(5 Suppl Pediatrics):442-6, 2004
                                                    37. Villarejo FJ et al: Cerebral fluid edema: an unusual complication of ventriculoperitoneal shunts. Childs Nerv Syst. 20(3):195-8, 2004
                                                    38. Braun KP et al: 1H magnetic resonance spectroscopy in human hydrocephalus. J Magn Reson Imaging. 17(3):291-9, 2003
                                                    39. Krassoudakis A et al: Ventriculoperitoneal shunting complicated with cerebrospinal fluid pseudocyst and acute appendicitis. Minerva Pediatr. 54(4):321-3, 2002
                                                    40. Oh A et al: Laparoscopic repositioning of a ventriculo-peritoneal catheter tip for a sterile abdominal cerebrospinal fluid (CSF) pseudocyst. Surg Endosc. 15(5):518, 2001
                                                    41. Drake JM et al: CSF shunts 50 years on--past, present and future. Childs Nerv Syst. 16(10-11):800-4, 2000
                                                    42. Tuli S et al: Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg. 92(1):31-8, 2000
                                                    43. Lee TT et al: Unique clinical presentation of pediatric shunt malfunction. Pediatr Neurosurg. 30(3):122-6, 1999
                                                    44. Salomão JF et al: Abdominal pseudocysts complicating CSF shunting in infants and children. Report of 18 cases. Pediatr Neurosurg. 31(5):274-8, 1999
                                                    Related Anatomy
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                                                    Related Differential Diagnoses
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                                                    References
                                                    Tables

                                                    Tables

                                                    KEY FACTS

                                                    • Terminology

                                                      • Imaging

                                                        • Top Differential Diagnoses

                                                          • Pathology

                                                            • Clinical Issues

                                                              • Diagnostic Checklist

                                                                TERMINOLOGY

                                                                • Abbreviations

                                                                  • Shunt types: Ventriculoperitoneal (VP), ventriculoatrial (VA), ventriculopleural (VPL), lumboperitoneal (LP)
                                                                • Definitions

                                                                  • Ventriculomegaly
                                                                    • General term for enlargement of cerebral ventricles
                                                                  • Hydrocephalus (HCP)
                                                                    • Enlargement of cerebral ventricles secondary to abnormal CSF formation, flow, or absorption resulting in ↑ CSF volume
                                                                      • Subset of ventriculomegaly
                                                                      • Onset over days (acute), weeks (subacute), or months to years (chronic)

                                                                IMAGING

                                                                • General Features

                                                                  • Radiographic Findings

                                                                    • Fluoroscopic Findings

                                                                      • CT Findings

                                                                        • MR Findings

                                                                          • Ultrasonographic Findings

                                                                            • Nonvascular Interventions

                                                                              • Nuclear Medicine Findings

                                                                                • Imaging Recommendations

                                                                                  DIFFERENTIAL DIAGNOSIS

                                                                                    PATHOLOGY

                                                                                    • General Features

                                                                                      • Gross Pathologic & Surgical Features

                                                                                        • Microscopic Features

                                                                                          CLINICAL ISSUES

                                                                                          • Presentation

                                                                                            • Demographics

                                                                                              • Natural History & Prognosis

                                                                                                • Treatment

                                                                                                  DIAGNOSTIC CHECKLIST

                                                                                                  • Consider

                                                                                                    • Image Interpretation Pearls

                                                                                                      Selected References

                                                                                                      1. Fowler JB et al: Ventriculoperitoneal shunt, 2020
                                                                                                      2. Kaestner S et al: Revision surgery following CSF shunt insertion: how often could it be avoided? Acta Neurochir (Wien). 162(1):9-14, 2020
                                                                                                      3. Mohammad SA et al: The value of CSF flow studies in the management of CSF disorders in children: a pictorial review. Insights Imaging. 10(1):3, 2019
                                                                                                      4. Ezzat AAM et al: Migration of the distal catheter of ventriculoperitoneal shunts in pediatric age group: case series. World Neurosurg. 119:e131-7, 2018
                                                                                                      5. Kraemer MR et al: Overdrainage-related ependymal bands: a postulated cause of proximal shunt obstruction. J Neurosurg Pediatr. 1-11, 2018
                                                                                                      6. Ros B et al: Shunt overdrainage syndrome: review of the literature. Neurosurg Rev. 41(4):969-81, 2018
                                                                                                      7. Hanak BW et al: Cerebrospinal fluid shunting complications in children. Pediatr Neurosurg. 52(6):381-400, 2017
                                                                                                      8. Rinker EK et al: CSF shunt complications: what the abdominal imager needs to know. Abdom Imaging. 40(6):2030-40, 2015
                                                                                                      9. Symss NP et al: Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst. 31(2):191-202, 2015
                                                                                                      10. Koktekir E et al: Resolution of papilledema after endoscopic third ventriculostomy versus cerebrospinal fluid shunting in hydrocephalus: a comparative study. J Neurosurg. 120(6):1465-70, 2014
                                                                                                      11. Bateman GA: Hypertensive slit ventricle syndrome: pseudotumor cerebri with a malfunctioning shunt? J Neurosurg. 119(6):1503-10, 2013
                                                                                                      12. Rasul FT et al: Is endoscopic third ventriculostomy superior to shunts in patients with non-communicating hydrocephalus? A systematic review and meta-analysis of the evidence. Acta Neurochir (Wien). 155(5):883-9, 2013
                                                                                                      13. Symss NP et al: Theories of cerebrospinal fluid dynamics and hydrocephalus: historical trend. J Neurosurg Pediatr. 11(2):170-7, 2013
                                                                                                      14. Robinson S: Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts. J Neurosurg Pediatr. 9(3):242-58, 2012
                                                                                                      15. Sivaganesan A et al: Neuroimaging of ventriculoperitoneal shunt complications in children. Pediatr Radiol. 42(9):1029-46, 2012
                                                                                                      16. Chan M et al: Prediction of ventriculoperitoneal shunt dependency in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg. 110(1):44-9, 2009
                                                                                                      17. Peraud A et al: Decompensated hydrocephalus causing syringomyelia and tetraparesis: a case report. Childs Nerv Syst. 25(2):263-6, 2009
                                                                                                      18. Willis B et al: Ventricular reservoirs and ventriculoperitoneal shunts for premature infants with posthemorrhagic hydrocephalus: an institutional experience. J Neurosurg Pediatr. 3(2):94-100, 2009
                                                                                                      19. Dusick JR et al: Success and complication rates of endoscopic third ventriculostomy for adult hydrocephalus: a series of 108 patients. Surg Neurol. 69(1):5-15, 2008
                                                                                                      20. Ellis MJ et al: Treatment of recurrent ventriculoperitoneal shunt failure associated with persistent cerebrospinal fluid eosinophilia and latex allergy by use of an "extracted" shunt. J Neurosurg Pediatr. 1(3):237-9, 2008
                                                                                                      21. James HE et al: Management of complicated shunt infections: a clinical report. J Neurosurg Pediatr. 1(3):223-8, 2008
                                                                                                      22. Martínez-Lage JF et al: Acute cholecystitis complicating ventriculo-peritoneal shunting: report of a case and review of the literature. Childs Nerv Syst. 24(6):777-9, 2008
                                                                                                      23. Nfonsam V et al: Laparoscopic management of distal ventriculoperitoneal shunt complications. Surg Endosc. 22(8):1866-70, 2008
                                                                                                      24. Riffaud L et al: Acquired Chiari I malformation and syringomyelia after valveless lumboperitoneal shunt in infancy. Pediatr Neurosurg. 44(3):229-33, 2008
                                                                                                      25. Liao YJ et al: Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report. J Neurosurg. 107(1):173-7, 2007
                                                                                                      26. Tseng JS et al: Motor neuron disease-like syndrome secondary to trapped fourth ventricle and obstruction of cerebrospinal fluid pathway. Clin Neurol Neurosurg. 109(4):383-7, 2007
                                                                                                      27. Woodworth G et al: Prior CSF shunting increases the risk of endoscopic third ventriculostomy failure in the treatment of obstructive hydrocephalus in adults. Neurol Res. 29(1):27-31, 2007
                                                                                                      28. Di Rocco C et al: Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications? A review. Childs Nerv Syst. 22(12):1573-89, 2006
                                                                                                      29. Winston KR et al: CSF shunt failure with stable normal ventricular size. Pediatr Neurosurg. 42(3):151-5, 2006
                                                                                                      30. Zamponi N et al: Bobble head doll syndrome in a child with a third ventricular cyst and hydrocephalus. Childs Nerv Syst. 21(5):350-4, 2005
                                                                                                      31. Arnell K et al: Distal catheter obstruction from non-infectious cause in ventriculo-peritoneal shunted children. Eur J Pediatr Surg. 14(4):245-9, 2004
                                                                                                      32. Blount JP et al: Sports and pediatric cerebrospinal fluid shunts: who can play? Neurosurgery. 54(5):1190-6; discussion 1196-8, 2004
                                                                                                      33. Fewel ME et al: Migration of distal ventriculoperitoneal shunt catheter into the heart. Case report and review of the literature. J Neurosurg. 100(2 Suppl Pediatrics):206-11, 2004
                                                                                                      34. Hashimoto M et al: A case of abdominal CSF pseudocyst associated with silicone allergy. Childs Nerv Syst. 20(10):761-4, 2004
                                                                                                      35. Sgouros S et al: An investigation of structural degradation of cerebrospinal fluid shunt valves performed using scanning electron microscopy and energy-dispersive x-ray microanalysis. J Neurosurg. 100(3):534-40, 2004
                                                                                                      36. Tuli S et al: Predictors of death in pediatric patients requiring cerebrospinal fluid shunts. J Neurosurg. 100(5 Suppl Pediatrics):442-6, 2004
                                                                                                      37. Villarejo FJ et al: Cerebral fluid edema: an unusual complication of ventriculoperitoneal shunts. Childs Nerv Syst. 20(3):195-8, 2004
                                                                                                      38. Braun KP et al: 1H magnetic resonance spectroscopy in human hydrocephalus. J Magn Reson Imaging. 17(3):291-9, 2003
                                                                                                      39. Krassoudakis A et al: Ventriculoperitoneal shunting complicated with cerebrospinal fluid pseudocyst and acute appendicitis. Minerva Pediatr. 54(4):321-3, 2002
                                                                                                      40. Oh A et al: Laparoscopic repositioning of a ventriculo-peritoneal catheter tip for a sterile abdominal cerebrospinal fluid (CSF) pseudocyst. Surg Endosc. 15(5):518, 2001
                                                                                                      41. Drake JM et al: CSF shunts 50 years on--past, present and future. Childs Nerv Syst. 16(10-11):800-4, 2000
                                                                                                      42. Tuli S et al: Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg. 92(1):31-8, 2000
                                                                                                      43. Lee TT et al: Unique clinical presentation of pediatric shunt malfunction. Pediatr Neurosurg. 30(3):122-6, 1999
                                                                                                      44. Salomão JF et al: Abdominal pseudocysts complicating CSF shunting in infants and children. Report of 18 cases. Pediatr Neurosurg. 31(5):274-8, 1999