Implanted Devices - VP Shunts: EMGuidewire's Radiology Reading Room

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Ventriculoperitoneal Shunts and their Complications and is brought to you by Brandon Friedman, MD, Kelsey Patterson, and L. Erin Miller MD. It is has special guest editor: Scott Wait, MD

1. Imaging Of Medical Devices Ventriculoperitoneal Shunts Brandon Friedman, MD 1 , Kelsey Patterson 2 , L. Erin Miller, MD 3 Carolinas Medical Center & Levine Children’s Hospital Department of Emergency Medicine 1 ; Charlotte Neurosurgery & Spine 3 ; NYU School of Global Public Health & Wagner Graduate School of Public Service 2 Scott Wait, MD, Faculty Editor, Charlotte Neurosurgery & Spine Michael Gibbs, MD 1 , Imaging Mastery Project Lead Editor Medical Device Imaging Mastery Project Presentation #5

2. Disclosures This ongoing imaging interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center. The goal is to promote widespread mastery of imaging interpretation. There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.

3. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Imaging Presentations And Much More!

4. It’s All About The Anatomy!

5. Ventriculoperitoneal Shunts VP Shunt Basics

6. Introduction – Ventriculoperitoneal Shunts Definition: A cerebral shunt drains excess cerebrospinal fluid (CSF) in the setting of an outflow obstruction or decreased reabsorption Shunt Components: Proximal ventricular catheter drains CSF Reservoir (optional) for tapping One-way valve to regulate pressure and flow, and prevent reversal of flow. Distal catheter to deposit fluid into the peritoneum, pleural space or atrium Reservoir One-Way Valve

7. Common Indications and Contraindications Non-Communicating (Obstructive) Hydrocephalus Communicating* (Non-Obstructive) Hydrocephalus Congenital aqueductal stenosis Idiopathic intracranial hypertension Atresia of the Foramen of Monroe Normal pressure hydrocephalus Skull base anomalies Post-hemorrhagic Intracranial tumors Post-infectious (meningitis; ventriculitis) Arachnoid cysts Choroid plexus papilloma/carcinoma ( ↑ secretion) Chiari malformation Dandy-Walker malformation Cerebellar infarction (space-occupying) *Note that there is considerable overlap in the categorizations of these etiologies as Communicating vs Non-Communicating; these lists serve as a general framework Absolute Contraindications: (1) Infection over the entry site, (2) CSF infection, (3) allergy to catheter components Relative Contraindications: (1) Impaired coagulation, (2) high CSF protein, (3) presence of CSF blood *All hydrocephalus is obstructive somewhere in the system, communicating is an old term used to indicate that it is distal to the ventricular system

8. VP Shunt Imaging Modalities Shunt Series (Plain Film Imaging) Frontal head (a), lateral head (b), AP chest (c), and (d) AP abdomen Obtain in all cases of suspected shunt dysfunction Evaluate for shunt damage, shunt kinking, catheter migration, or fluid collections (e.g., pleural effusion) Computed Tomography Obtained in almost all adults CT head to evaluate for ventricular abnormalities (e.g., ventriculomegaly, slit ventricle syndrome) or intracranial hemorrhage/infection CT chest/abdomen/pelvis to evaluate for fluid collections, bowel obstruction, or visceral injury (rarely needed) Magnetic Resonance Imaging Rapid sequence MRI in pediatric patients, in place of a CT head, to spare radiation exposure Consider if high suspicion for intracranial infection Fowler JB, De Jesus O, Mesfin FB. Ventriculoperitoneal Shunt. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459351/

9. Ventriculoperitoneal Shunts Normal VP Shunt Series

10. Normal VP Shunt Series Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252 Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252

11. Normal VP Shunt Series Proximal Catheter Reservoir Reservoir One-Way Valve One-Way Valve Proximal Catheter Distal Catheter Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252 Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252 Distal Catheter

12. Normal VP Shunt Series Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252 Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252

13. Normal VP Shunt Series Distal Catheter Distal Catheter Tip of Distal Catheter Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252 Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252

14. Ventriculoperitoneal Shunts Complications and Diagnostic Imaging

15. Common Shunt Complications Primary Shunt Dysfunction Slit Ventricle Syndrome Catheter Migration Shunt Fracture Shunt Disconnection Shunt Infection Shunt Obstruction Secondary Complications Pleural effusion Bowel Obstruction Intra-Abdominal CSF Pseudocyst Ascites Collection Intracranial Hemorrhage

16. Shunt Complication #1 Coley, Brian & Kosnik , Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009. What do you notice about the distal catheter in this portion of the abdominal x-ray?

17. Shunt Obstruction Coley, Brian & Kosnik , Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009. Abou-Al- Shaar H, Mallela AN, Algattas HN, Rogers R, Friedlander RM. Ventriculoperitoneal Shunt Failure Due to Distal Peritoneal Catheter Kinking. Am J Case Rep. 2022 Apr 5;23:e935077. doi : 10.12659/AJCR.935077. PMID: 35379769; PMCID: PMC8994830. Kinking of the end of the drainage catheter (left) can cause obstruction of the shunt tubing and prevent the drainage of CSF. This may result in ventriculomegaly as a result of the shunt’s failure to drain appropriately (right). Kinking Of The Distal Catheter, Causing Obstruction Tip Of The Distal Catheter Unilateral Ventriculomegaly Secondary To Shunt Obstruction

18. Shunt Complication #2 Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. What do you notice about the tubing from these two catheters? Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.

19. Shunt Fracture These images demonstrate fractures of both the proximal (left) and distal (right) shunt tubing, respectively. This results in inadequate drainage of CSF and can also be associated with recurrent hydrocephalus or ventriculomegaly. Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Fractured Distal Shunt Tubing Coiling Of Distal Tubing In The Pelvis Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol. 2018 Sep;47(5):317-323. doi: 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Fractured Proximal Shunt Tubing

20. Shunt Complication #3 Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. What do you notice about this patient’s shunt? Remember the four components that make up the shunt and where they typically reside in relation to one another. Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.

21. Shunt Disconnection All Images: Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. These images demonstrate disconnection of the distal portion of the shunt tubing from the proximal components of the shunt. A 3D reconstruction of the skull and shunt components is seen in the image to the far right. Disconnected Distal Shunt Tubing Disconnected Distal Shunt Tubing Proximal Catheter

22. Shunt Complication #4 What do you notice about these MRI images? Why might they be asymmetrical? Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127 Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127

23. Unilateral Slit Ventricle These MRI images demonstrate unilateral Slit Ventricle, which results from over-drainage of the CSF; the proximal shunt catheter can be visualized extending from the skull to the right lateral ventricle. Slit ventricle cannot be diagnosed with plain-film imaging but can be seen on CT or MRI. Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127 Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127 Collapse Of The Right Lateral Ventricle From Over-Drainage Proximal Drainage Catheter Collapse Of The Right Lateral Ventricle From Over-Drainage

24. Shunt Complication #5 Chivate R, [Shunt Complication #5]. Case study, Radiopaedia.org (Accessed on 04 Jun 2023) https://doi.org/10.53347/rID-24964 Coley, Brian & Kosnik , Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009. This complication is typically diagnosed with CSF studies, laboratory evaluation, and clinical presentation. But what abnormalities do you see in these images that can help clarify the presenting diagnosis?

25. Shunt Infection Chivate R, Ventriculitis. Case study, Radiopaedia.org (Accessed on 04 Jun 2023) https://doi.org/10.53347/rID-24964 Coley, Brian & Kosnik , Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009. Infections associated with VP shunts can occur at any point along the device’s path. Here we see evidence of an intra-abdominal infection on CT (left) and ventriculitis on MRI (right). One must have a high index of suspicion for shunt infections for any patient with a shunt, presenting with infectious symptoms. Shunt infection cannot be diagnosed with plain-film imaging. Bowel Wall Thickening Distal Catheter Tip Intra-Abdominal Fluid Collection; Suggestive Of Infection Hyper-Intense Signal Outlining The Ventricles; Suggestive Of Ventriculitis

26. Shunt Complication #6 Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. What do you notice about the positioning of the distal portions of the catheters? Could this have implications on their function? Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.

27. Catheter Migration Both catheters show to continuity in the tubing but have migrated. The image to the left demonstrates coiling of the distal catheter in the scrotum, which hinders its ability to properly drain fluid. The image to the right demonstrates a case where the catheter eroded through the vaginal wall and has migrated into the vaginal canal. Both cases required surgical revision. Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Coiling Of Distal Tubing In The Scrotum Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Perforation Of Shunt Tubing Into The Vaginal Canal

28. Shunt Complication #7 Zhao J, Chen Y, Yang K, Hu X. A case of repeated [Shunt Complication #7] secondary to ventriculoperitoneal shunt. Inter- discip Neurosurg . 2015;02(01):48–50. What is the differential for the findings of these images? Can this complication be sub-categorized any further?

29. Intracranial Hemorrhage Zhao J, Chen Y, Yang K, Hu X. A case of repeated intracerebral hemorrhages secondary to ventriculoperitoneal shunt. Inter- discip Neurosurg . 2015;02(01):48–50. Intraparenchymal Hemorrhage Intraventricular Hemorrhage Proximal Catheter Proximal Catheter Here we see two types of intracranial hemorrhage, intraparenchymal and intraventricular. Subarachnoid and subdural hemorrhages can also occur but are not visualized in these images.

30. Shunt Complication #8 Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. What subtle finding do you notice in this patient’s catheter? Why do we obtain plain film imaging in orthogonal planes? Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622.

31. Shunt Fracture Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. This case demonstrates another example of a fracture of the shunt tubing. Note that the fracture is not visible on the AP view but is seen in the lateral view. This demonstrates the importance of obtaining x-rays in orthogonal planes. Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Fractured Distal Shunt Tubing Shunt Fracture Not Visible On AP View Calcified Region Of The Shunt Tubing That May have Caused Tethering That Predisposed To Shunt Fracture

32. Shunt Complication #9 Rahalkar , M. (2017). Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A Pictorial Essay. Indian Journal of Neurosurgery. 07. 10.1055/s-0037-1599786. What’s abnormal about this plain film image of the chest and abdomen in a patient with abdominal pain and distension? Does the bowel gas pattern give you any clue as to what might be going on?

33. Ascites Accumulation CT imaging demonstrates large-volume accumulation of ascites fluid. The bowel gas pattern on the x-ray image shows that the bowel has been displaced secondary to the presence of fluid. The image also shows hypo-inflated lungs, which is likely secondary to the ascites. This complication results from the body’s inability to fully absorb the CSF, once it’s drained into the abdomen. While CT or ultrasound imaging would be required to confirm the diagnosis, the x-ray gives us clues that can help raise suspicion for ascites and prompt further imaging. Ascites Distal Catheter Distal Catheter Tip Bowel Gas Paucity Of Bowel Gas Hypo-Inflated Lungs Rahalkar , M. (2017). Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A Pictorial Essay. Indian Journal of Neurosurgery. 07. 10.1055/s-0037-1599786.

34. Shunt Complication #10 Bacon JL, Sithamparanathan S. A rare cause of [Shunt Complication #10]. Respir Med CME 2011;4:124–5. 10.1016/j.rmedc.2011.01.002 What’s abnormal about this plain film? Remember our standardized approach to reading chest x-rays. A irway B ones C ardiac D iaphragm E ffusion F oreign body G astric H ilum

35. Shunt Complication #11 Radswiki T, Bell D, Deng F, et al. [Shunt Complication #11]. Reference article, Radiopaedia.org (Accessed on 09 Jun 2023) https://doi.org/10.53347/rID-11105 What’s abnormal about this AP view of the abdomen? Does the bowel gas pattern give you any clues to the diagnosis? Does this look similar to a previously-discussed complication?

36. Intra-Abdominal CSF Pseudocyst While the plain film appears similar to the previous case of ascites accumulation, the CT image demonstrates a well-defined region of CSF accumulation, consistent with a pseudocyst. In this case, a CT of the abdomen is necessary to distinguish a pseudocyst from ascites. Radswiki T, Bell D, Deng F, et al. Peritoneal CSF pseudocyst. Reference article, Radiopaedia.org (Accessed on 09 Jun 2023) https://doi.org/10.53347/rID-11105 Distal Catheter Tip CSF Pseudocyst Radswiki T, Bell D, Deng F, et al. Peritoneal CSF pseudocyst. Reference article, Radiopaedia.org (Accessed on 09 Jun 2023) https://doi.org/10.53347/rID-11105 Paucity Of Bowel Gas Distal Catheter Tip

37. Shunt Complication #12 Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. What are we most concerned about with this AP view of the abdomen? What classic imaging findings are present that would help make this diagnosis?

38. Small Bowel Obstruction Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Both the plain film and CT images demonstrate distended loops of bowel and air-fluid levels, suggestive of a small bowel obstruction. Further, on the CT image, a whirlpool sign is visualized, indicative of a small bowel volvulus. Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Whirlpool Sign Distended Loops Of Bowel Air-Fluid Levels

39. Shunt Complication #13 Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. What do you notice about this AP view of the skull? Is there a finding that hints at a diagnosis without a CT or MRI?

40. Intracranial Hemorrhage Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Here we have a rare case, where we can see calcifications on the plain film images, which represent calcified subdural hemorrhages! A CT or MRI would confirm the findings of a chronic subdural bleed Calcifications Within A Subdural Hemorrhage Calcifications Within A Subdural Hemorrhage

41. Test Your Knowledge! Cases From Carolinas Medical Center

42. Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches and vomiting Is there anything abnormal about the shunt tubing in these views?

43. Disconnected Distal Catheter Disconnected Distal Catheter Valve Valve Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches and vomiting The AP and lateral skull views show two intact proximal catheters, but show disconnection of the distal shunt tubing from the valve

44. Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches and vomiting Is there anything abnormal about the shunt tubing in these views?

45. The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches and vomiting

46. Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches and vomiting What do you notice between the patient’s old comparison head CT and the one obtained on this presentation? Comparison CT CT on Presentation

47. There appears to be significant ventriculomegaly secondary to the inability to drain CSF from the disruption of the distal catheter. The patient’s ventriculomegaly and symptoms resolved with surgical reattachment of the catheter. Ventriculomegaly Proximal Catheter Case 1: 13-year-old male with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches and vomiting Proximal Catheter Comparison CT CT on Presentation

48. Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for morning headaches and lightheadedness The skull and chest views of the shunt series are unremarkable. What do you notice about the position of the distal catheter on the two-view plain film of the abdomen?

49. On the lateral view, the catheter appears to overly the abdomen. However, on the AP view, the distal end of the catheter appears to terminate laterally to the abdominal wall. A CT scan was obtained to evaluate further. Distal Catheter Tip Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for morning headaches and lightheadedness Distal Catheter Tip

50. The tip of the distal catheter is in view in all three planes of this CT abdomen, what do you notice about its position? Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for morning headaches and lightheadedness

51. Distal Catheter Tip Case 2: 22-year-old with a history of cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for morning headaches and lightheadedness The catheter is shown to terminate in the subcutaneous space, preventing outflow of CSF into the peritoneal cavity. This can happen spontaneously especially in patients with a pannus. The patient was taken to the OR for distal catheter revision and her symptoms subsequently resolved. Distal Catheter Tip Distal Catheter Tip

52. Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura Is there anything abnormal about the shunt tubing in these views?

53. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the right atrium. Valve Distal Catheter Tip Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura

54. Comparison CT CT on Presentation What do you notice between the patient’s old comparison head CT and the one obtained on this presentation? Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura

55. There appears to be significant ventriculomegaly secondary to the inability to drain CSF. Surgical evaluation identified an obstruction to flow of the proximal catheter, which was corrected. The patient’s symptoms subsequently resolved. Case 3: 20-year-old female with a history of cerebral palsy, seizures, and hydrocephalus of prematurity and ventriculoatrial shunt placement, presents to the Emergency Department for headaches with an aura Comparison CT CT on Presentation Ventriculomegaly Proximal Catheter Proximal Catheter

56. Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for routine annual shunt evaluation Is there anything abnormal about the shunt tubing in these views?

57. Disconnected Distal Catheter Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for routine annual shunt evaluation Disconnected Distal Catheter Here we see both a disconnection of the distal shunt tubing from the valve, as well as a fractured distal catheter overlying the right anterior chest.

58. Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for routine annual shunt evaluation Is there anything abnormal about the shunt tubing in these views?

59. Case 4: 14-year-old male with a spina bifida and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for routine annual shunt evaluation The shunt tubing appears to be intact and in an appropriate location on the two views of the abdomen. The patient underwent replacement of the distal catheter, without complications.

60. Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting Is there anything abnormal about the shunt tubing in these views?

61. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the neck. Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting

62. Is there anything abnormal about the shunt tubing in these views? Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting

63. Tracheostomy Tube Gastrojejunostomy Tube The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting

64. Comparison CT CT on Presentation What do you notice between the patient’s old comparison head CT and the one obtained on this presentation? Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting

65. Chronic Subdural Hematoma Mass Effect On Ventricles Comparison CT CT on Presentation Case 5: 3-year-old with an anoxic brain injury due to a gunshot wound to the head complicated by bilateral subdural hemorrhage, is evaluated as an inpatient due to ongoing intractable vomiting The new CT image shows enlargement of the patient’s subacute bilateral subdural hematomas. The patient underwent surgical evacuation of the bilateral hemorrhages, with resolution of his intractable vomiting. Chronic Subdural Hematoma

66. Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating Is there anything abnormal about the shunt tubing in these views?

67. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the neck. Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating

68. Is there anything abnormal about the shunt tubing in these views? Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating

69. The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen. Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating

70. Comparison CT What do you notice about the ventricles when comparing the patient’s old CT to the one obtained on presentation? Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating CT On Presentation

71. The CT demonstrates a decreased size of the lateral ventricles consistent with Overshunting that results from over-drainage of CSF. This fits with the clinical picture of headaches that improved when recumbent. The patient’s shunt was modified to slow the drainage of CSF, and her symptoms resolved. Slit-Like Lateral Ventricle Decompression Of The Lateral Ventricles Case 6: 22-year-old female with cerebral palsy and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches that improve when recumbent and difficulty ambulating CT On Presentation Comparison CT

72. Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes Is there anything abnormal about the shunt tubing in these views?

73. The shunt tubing appears to be intact throughout its course from the lateral ventricles to the neck. Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes

74. Is there anything abnormal about the shunt tubing in these views? Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes

75. The shunt tubing appears to be intact and in an appropriate location on the x-rays of the chest and abdomen Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes

76. This patient presented with the CT on the left and underwent operative intervention. What do you notice as differences between the presentation CT and the post-surgical CT? CT on Presentation Post-operative CT Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes

77. The CT on the left shows hydrocephalus and the patient was found to have a proximal shunt disconnection (not seen on imaging). The post-operative CT shows improvement of the hydrocephalus and a replacement catheter in a new position. Old Proximal Catheter Bilateral Hydrocephalus Improved Ventricular Size Case 7: 22-year-old female with a right thalamic glioma and hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department for headaches, nausea, vomiting, and vision changes CT on Presentation Post-operative CT New Proximal Catheter

78. Case 8: 47-year-old female with grade 3 astrocytoma and craniectomy and pseudomeningocele and VP shunt placement, presents to the Emergency Department cranial soft tissue mass, hypertension, and vomiting Comparison CT CT on Presentation What do you notice between the patient’s old comparison head CT and the one obtained on this presentation? The patient’s plain-film shunt series showed an intact shunt in an appropriate position.

79. The patient has a pseudomeningocele that was noted on the prior CT. But the repeat scan appears to show enlargement of the communicating extracranial fluid collection. The patient underwent operative evaluation and was found to have a malfunctioning valve. Enlarging Extracranial Fluid Collection Proximal Catheter Tip Comparison CT CT on Presentation Pseudomeningocele Case 8: 47-year-old female with grade 3 astrocytoma and craniectomy and pseudomeningocele and VP shunt placement, presents to the Emergency Department cranial soft tissue mass, hypertension, and vomiting

80. Here we see the coronal view demonstrating the increased size of the extracranial fluid collection with some worsening midline shift. The fluid collection improved with replacement of the malfunctioning valve. Comparison CT CT on Presentation Pseudomeningocele Enlarging Extracranial Fluid Collection Case 8: 47-year-old female with grade 3 astrocytoma and craniectomy and pseudomeningocele and VP shunt placement, presents to the Emergency Department cranial soft tissue mass, hypertension, and vomiting

81. Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department with headaches, nausea, and dizziness Is there anything abnormal about the shunt tubing in these views?

82. The proximal shunt tubing appears to be intact and in an appropriate place, but we cannot identify any distal tubing in these plain-film images of the skull. Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department with headaches, nausea, and dizziness

83. Is there anything abnormal about the shunt tubing in these views? Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department with headaches, nausea, and dizziness

84. The distal shunt is not visible on the chest x-ray, but is noted to be coiled in the pelvis, consistent with disconnection of the distal shunt from the proximal tubing. The patient underwent successful distal shunt replacement. Case 9: 33-year-old with hydrocephalus and ventriculoperitoneal shunt placement, presents to the Emergency Department with headaches, nausea, and dizziness

85. If You Have Interesting Cases Demonstrating Ventriculoperitoneal Shunts We Invite You To Send A Set Of Digital PDF Images And A Brief Clinical History To: [email protected] Your De-Identified Case(s) Will Be Posted On Our Education Website And You And Your Institution Will Be Recognized!

86. Selected Embedded References : Abou-Al- Shaar H, Mallela AN, Algattas HN, Rogers R, Friedlander RM. Ventriculoperitoneal Shunt Failure Due to Distal Peritoneal Catheter Kinking. Am J Case Rep. 2022 Apr 5;23:e935077. doi : 10.12659/AJCR.935077. PMID: 35379769; PMCID: PMC8994830. Bacon JL, Sithamparanathan S. A rare cause of [Shunt Complication #10]. Respir Med CME 2011;4:124–5. 10.1016/j.rmedc.2011.01.002. Bates P, Rajderkar D. Common and Uncommon Causes of Ventriculoperitoneal Shunt Malfunction Diagnosed on Plain Radiographs. Curr Probl Diagn Radiol . 2018 Sep;47(5):317-323. doi : 10.1067/j.cpradiol.2017.07.006. Epub 2017 Jul 29. PMID: 28830622. Chivate R, Ventriculitis. Case study, Radiopaedia.org (Accessed on 04 Jun 2023) https://doi.org/10.53347/rID-24964. Coley, Brian & Kosnik , Edward. (2006). Abdominal Complications of Ventriculoperitoneal Shunts in Children. Seminars in ultrasound, CT, and MR. 27. 152-60. 10.1053/j.sult.2006.01.009. Fowler JB, De Jesus O, Mesfin FB. Ventriculoperitoneal Shunt. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459351/. Murphy A, Jones J, Shunt series. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-77252. Radswiki T, Bell D, Deng F, et al. Peritoneal CSF pseudocyst. Reference article, Radiopaedia.org (Accessed on 09 Jun 2023) https://doi.org/10.53347/rID-11105 Rahalkar , M.. (2017). Complications of Cerebrospinal Fluid Diversion (Shunt) Catheters: A Pictorial Essay. Indian Journal of Neurosurgery. 07. 10.1055/s-0037-1599786. Venkatesh M, Baba Y, Yap J, et al. Slit ventricle syndrome. Reference article, Radiopaedia.org (Accessed on 31 May 2023) https://doi.org/10.53347/rID-26127. Zhao J, Chen Y, Yang K, Hu X. A case of repeated intracerebral hemorrhages secondary to ventriculoperitoneal shunt. Inter- discip Neurosurg . 2015;02(01):48–50.

87. Thank You!