Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 4, 2010, pp. 662-664

Neurology India, Vol. 58, No. 4, July-August, 2010, pp. 662-664

Case Report

Unusual cause for ventriculoperitoneal shunt failure: Carcinoma breast compressing distal catheter

Roka YamB, Gupta R, Bajracharya A

Neurological Surgery Unit, Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan

Correspondence Address:Neurosurgical Unit, Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, dryamroka@yahoo.com

Date of Acceptance: 01-Feb-2010

Code Number: ni10175

PMID: 20739819

DOI: 10.4103/0028-3886.68704

Abstract

Keywords: Carcinoma breast, hydrocephalus, shunt failure, ventriculoperitoneal shunt

Introduction

Insertion of a ventriculoperitoneal (VP) shunt for various causes is one of the most common surgical procedures performed in any neurosurgical unit worldwide. Some of the common shunt related complications include obstruction of the ventricular or peritoneal end of the tube, infection, fracture, dislodgement and bowel perforation. ^[1],[2],[3] Distal catheter obstruction outside the peritoneum is a rare cause of shunt failure. The common causes for this obstruction are silicone allergy, valve collapse, dislodgement and intrathoracic penetration of the catheter. ^[1],[2],[3]

Case Report

A 70-year-old female was operated for normal pressure hydrocephalus in 2007 with no procedural complications. She had an uneventful follow-up until the present admission. She presented in July 2009 with history of episodic attacks of headache, altered sensorium and drowsiness. There was no history of trauma, fever, vomiting or seizure. On examination, she was conscious but confused with Glasgow Coma Scale score (GCS) of 14. Clinically the shunt valve was not compressible suggesting shunt malfunction. Further systemic examination revealed a six by eight cm right breast lump, with red surface, hard, mobile over the pectoral muscles and with the shunt tube passing right through the lump [Figure - 1]. The shunt tube was fixed to the lump and prevented the latter′s mobility. The family members now confessed that the breast lump had been present for six months before this admission and they had not seen a doctor for the same.

The chest X-ray surprisingly showed a calcified right breast mass with the distal VP shunt catheter passing through and pushed to the left. Computed tomography (CT) scan of head showed dilated ventricles with obvious hydrocephalus with the ventricular catheter in correct position [Figure - 2]. Her serum electrolytes, blood sugar, renal and liver function test were normal and no coagulopathy. There were no enlarged axillary lymph nodes and the ultrasound of the abdomen was normal. Fine needle aspiration cytology showed the lump as carcinoma of breast.

She underwent right side modified radical mastectomy with division of the distal shunt tube in the neck and relocation to the left upper abdomen with a new tube. Intraoperatively, the shunt was seen traversing through the hard breast lump and could not be separated even by giving it moderate pull. On excision of the lump the shunt was in the center with a small angulation at one point distally [Figure - 3]. There was no cerebrospinal fluid (CSF) flow distal to the lump but on transaction of the proximal end, there was CSF flow seen. The breast skin was primarily approximated except for a small defect which was covered by skin graft. There were no procedural complications and her GCS improved to 15 on the first postoperative day. She was discharged on the tenth day with no sequel. Histology showed tumor free margins with infiltrative type of ductal carcinoma. Follow-up for the last two months has been uneventful with no hydrocephalus on repeat scan and she has also been started on further chemotherapy.

Discussion

The common causes of failure of the VP shunt are blockage at the peritoneal or ventricular end, infection, dislodgement, migration, laparoscopic surgery and bowel perforation. ^{[1],[2],[3],[4],[5],[6],[7],[8]} Mechanical causes like knotting of the distal catheter, increased intraabdominal pressure secondary to constipation and silicone allergy leading to obstruction are uncommon and limited to case reports. ^{[1],[2],[3],[4],[5],[6],[7],[8]}

This case is probably the first to report breast lump causing mechanical obstruction of the distal catheter. Clinically the shunt valve was not compressible leading to distal obstruction as diagnosis but breast lump causing obstruction was the last cause one could expect. This case is also important because it highlights the social stigma attached in revealing malignancies in developing countries where diseases are not confessed. As exemplified by this case, routine superficial clinical examination would have led to missing the breast lump until the patient was in the operation theatre. Thus it is important to have a full physical examination done to rule out shunt failure by extra peritoneal mechanical causes and prevent intraoperative embarrassment.

References

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