CSF hydrothorax – VP shunt complication without displacement of a peritoneal catheter

Abstract

Cerebrospinal fluid hydrothorax is reported as a rare complication of ventriculoperitoneal (VP) shunt. A 16-month-old boy known to have congenital hydrocephalus and a Dandy-Walker cyst presented with serious respiratory distress. Examination revealed right pleural effusion and congested throat. Thoracocentesis with drainage of the pleural cavity for 10 days failed to free the patient from pleural effusion. Following an intraperitoneal injection of Omnipaque a chest X-ray was done, and samples of pleural fluid taken before and after the injection were compared on X-ray, revealing the presence of contrast in the postinjection pleural effusion. Changing the VP shunt for a ventriculo-atrial shunt resulted in immediate (within 1 day) complete disappearance of the pleural effusion and of the patient's chest symptoms. Probable causes of this rare complication are discussed, and attention is drawn to the possibility of its appearance and early recognition. Intraperitoneal injection of contrast material followed by X-ray examination of fluid in the chest is a simple, safe, and reliable method of diagnosis when it is suspected.

Cerebrospinal Fluid Hydrothorax without Ventriculoperitoneal Shunt Migration in an Infant

“…CSF hydrothorax in a child with a VPS can be due to the following reasons: first, iatrogenic diaphragmatic perforation from misguided surgical insertion of the distal catheter; second, migration of the VPS catheter tip through weakened or inflamed segments and congenital hiatuses of the diaphragm; third, migration of CSF without VPS displacement [4,10,16], of which there are few known reported cases in the literature [9,10,11,12,13,14,15]. …”

“…Hadzikaric et al [12] discussed two factors for migration of CSF from the peritoneal to the pleural space: first, decreased absorption of CSF by the peritoneum; second, a communication between the peritoneal and pleural spaces. Also, children <2 years of age are known to have a small peritoneal absorption capacity [12]. Intraperitoneal CSF diversion through a VPS can exceed this threshold and lead to ascites.…”

“…Cerebrospinal fluid (CSF) hydrothorax is a rare complication that can present with respiratory distress and hypoxia because of a misplaced or dislodged peritoneal catheter into the thoracic cavity [2,3,4,5,6,7,8]. A total of 8 cases of CSF hydrothorax without VPS catheter migration, 6 in children and 2 in adults, have been reported [9,10,11,12,13,14,15]. We present a case of an infant who underwent a VPS placement for hydrocephalus followed by recurrent episodes of hydrothorax despite a well-positioned distal catheter and without any predisposing factors for peritoneal mal-absorption.…”

Hydrothorax Due to Migration of Ventriculoperitoneal Shunt Catheter

“…During respirations, negative inspiratory pressure would then have slowly drawn the entire distal shunt catheter into chest. 1) In cases of transdiaphragmatic intrathoracic migration of a peritoneal catheter, the presence of congenital diaphragmatic hiatuses, foramen of Morgagni or foramen of Boschdalek, might allow a prolapse of the peritoneal catheter into the thoracic cavity 3,7) . These two locations are the weak points of the diaphragm.…”

Hydrothorax: Transdiaphragmatic Migration of a Ventriculoperitoneal Shunt Catheter

“…Secondly, some authors suggest that the catheter could migrate from the peritoneal cavity as the result of an inflammatory process facilitating erosion and perforation of the diaphragm and prolapse into the pleural cavity [1, 3]. Thirdly, hydrothorax can ensue in children with CSF ascites resulting from poor abdominal CSF absorption capacity [4, 5]. There are several reports indicating that children with ventriculoperitoneal shunts, especially those whose shunt was placed before the age of 2 years, have a suboptimal peritoneal absorbtion capacity [6].…”