- 33-year-old male presents to the ED with 2 year history of severe but stable headaches
- He was shunted during early childhood for the management of hydrocephalus.
- Headaches are global in nature with a 'feeling of pressure behind both eyes'
- Symptoms are noted most when he needs to ambulate for long-distances.
- No history of fevers.
PMH: Mild mental retardation. Otherwise unremarkable.
General exam: Atraumatic, macrocephalic. Well nourished.
- Awake and oriented x 3
- CN II-XII intact
- Slight proximal RUE paresis (4/5)
- No pathologic reflexes
Figure 3. (Below)
MRI of the brain reveals evidence of contrast enhancement of dura on T1W gadolinium enhanced images (a). An arachnoid cyst of the posterior T1-weighted sagittal images (b). On FLAIR imaging (c), periventricular trans-ependymal CSF flow is absent. Hemosiderin and mixed density contents are seen within the large left frontal mass on susceptibility weighted MR-images (d).
Figure 1. The patient was macrocephalic with evidence of a right parietal ventriculo-peritoneal shunt system seen on skull X-rays. The remainder of the shunt series was negative.
Figure 2. Axial CT Head without contrast reveals the presence of a large calcified lesion in the left frontal region. Another calcified mass is seen in the right occipital region. Additionally, a shunt catheter is seen in the right parietal region.
What is the most common chronic complication of shunting in adults?
2. What is likely the cause of this patient's headaches?
3. What surgical option would you recommend for this calcified subdural hematoma?
4. How would you utilize anti-epileptic drugs (AED) in this setting if you did perform surgery?
5. Which of the following describes you?
6. I practice in one of the following locations.
7. Please add any suggestions or comments regarding this case:
- great case!
- This complication of calcified frontal region sdh has arisen because of mismatch between opening pressure and type of hydrocephalus at the time of csf diversion.Now it is a space occupying lesion with visible and significant mass effect.He would benefit from surgery if we debulk it taking care that we do not create extra damage to the rest of brain.His headache should disappear or would be easily manageable post surgery.He will also be spared from the aftereffects of visual changes because of raised ICP.
- Just did a case similar to this last week
- Pt is ataxic in addition to headache, so it is local meningeal involvement in additon to focal left frontal compression, seen clearly in imaging. It need to be treated. I will like to insert a programmable valve to see that the ventricles get expnaded and opening pressure adjusted appropriately. I will try to excise the lesion if it is possible without damaging the cerebral cortex, that should be. If not I shall not chase it. AED actually should be withheld and started only if patient develops epilepsy but as I would not like any complication, I shall cover the patient peri-operative for one week and then closely follow the patient.
- J Neurosurg. 2008 Feb;108(2):401. Shunt revision after 33 years in a patient with bilateral calcified chronic subdural hematomas. Case illustration. Papanikolaou PG, Paleologos TS, Triantafyllou TM, Chatzidakis EM. Neurosurgical Department, General Nikaia Piraeus Hospital, Athens, Greece. email@example.com PMID: 18240942 [PubMed - indexed for MEDLINE]
- Please intend recommended surgical option as initial ,not definitive. thasnk you
- 1. Indication for shunting justified? 2. Adequate postop followup?
- I would like to know what was the management for this gentleman ? Thank you very much Yasser ElSawaf, MD Associate Professor of Neurosurgery at Tanta University , Egypt
- Interesting, difficult case where different strategies can be considered. I CHOOSE AN AGGRESSIVE BEHAVIOUR BECAUSE OF THE EASINESS OS SURGERY AND THE YOUNG AGE OF THE PATIENT
- I would start by revising the shunt alone, ie not also remove the hematoma. I am a full-time peds NS. My approach is that the calcified hematomas have been there a very long time and probably are not the cause of new headache. However, shunts can stop working at any time and then become symptomatic. The transependymal flow would support that. We are now seeing shunts that last up to 35 years, and also see young adults with very longstanding calcified hematomas which are not doing anything. The set-up for this (unavoidable when he was a child) is that he was overshunted when he was a macrocephalic infant. This is avoided today by starting with a non-siphoning valve, perhaps even a programmable one.
- I have had a similar case with good results post surgery. Thnaks
- Jolly, interesting!!
- Good case. I believe that this is a case primarily of overshunting or overdrainage. The positional or postural headache was a clue. As for the commonest complication of shunts in adults, the slit ventricle syndrome did put me off. If you said "slit ventricles", I would have struggled abit as slit ventricles are commoner than slit ventricle syndrome. The best modality of treatment would be to tie or ligate the shunt and evacuate the hematoma. If the ventricles blow up, then measure the opening pressure and revise it to a higher pressure valve. I am suprised that you called it calcified chronic SDH. The radiologic appearance is more in favor of an epidural hematoma. Regards.
- Jolly, interesting!!
- Excellent case. A complilation of these cases should be made into a book called "neurosurgical 'fascinomas'"
- a good brain exercise......should be continued..
- There is definite shunt dysfunction with posterior herniation. I believe that I would first revise the shunt, get an intraoperative pressure and use a programmable to slowly chnge the intracranial pressurw before craniotomy. Just draining the cyst won't solve the problem and at least a part of the calcification will need to be removed. Great care will need to be taken post op as to intracranial pressure will be very difficult to manage .
- This a non-frequent finding in an adult many years after the shunting V-P for hydrocephalus in the infancy.
- This a non-frequent finding in an adult whom was treated with a V-P shunt for hydrocephalus in the infancy.
- A programmable shunt valve would be useful
- Nice case !
- Clinically the head ache is not suggestive of raised ICP since he has no associated visual symptoms-visual blurring or papilloedema inspite of long duration of the pathology.Additionaly there is no alteration of conciousnes.Patient has more headache when he is travelling long distance-probably he has to sit longer during travel and the shunt will overdrain -causing low pressure headache.Periventriular ependymal CSF flow absent in MRI indicates that the hydrocephalus is not significant or the shunt is overdraining. After removing the calcified mass -which can be achieved only with a craniotomy-the shunt should be tied temporarily so that the brain should expand and he should be followed up periodically for development of hydrocephalus -clinical and radiological evaluvation to be done regularly. Later if he develops hydrocephalus-should convert to a high pressure shunt to ensure there is no overdrainage of CSF.
- 1-a slit ventricle syndrome,stroke,subdural hematoma are less common than shunt malfunction.
- Would assess the function of the shunt, and consider changing to higher pressure valve if shunt is still functional.