VENTRICULO-PLEURAL SHUNT IN AN ADULT RESULTING IN PLEURAL EFFUSION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: In patients with hydrocephalus, ventriculoperitoneal(VP) shunts are the most common treatment due to the ease of insertion and a more favorable risk profile. However, in instances such as infections and anatomical variations, where ventriculoperitoneal shunts are unable to be placed then ventriculoatrial or ventriculopleural shunts can be placed. Ventriculopleural(VPL) shunts are more commonly placed in children than adults. However, decreased rates of revision have been found in older children compared to younger (2). While VPL shunts are well tolerated, they tend to have a higher complication rate than ventriculoatrial shunts(3). One of the complications of a VPL shunt is a pleural effusion. The invention and improvement of valves, pressure control devices and anti-siphon devices in the shunts have reduced the amount of pleural effusions developed by helping control for the intrathoracic pressure. The estimated rate of pleural effusion in VPL shunts is believed to be anywhere from 4.5- 62% (1,4). These shunts can also become infected at a rate of 8-12% (1). Due to the rarity of VPL shunts and their complications, these estimations are based on often small, single institution studies. CASE PRESENTATION: Our patient is a 20 year old male with a past medical history of spina bifida, seizure disorder, hydrocephalus s/p VP shunt, history of Antegrade Colonic Enema(ACE) procedure about 10 years ago and urostomy with ileal augmentation presented with a complaint of abdominal pain. He was found to have a perforated stercoral ulcer and subsequently underwent right colectomy and loop ileostomy. During this procedure, his VP shunt was exteriorized due to frank pus and necrosis in the peritoneal cavity. He was started on broad spectrum antibiotics, but he continued to have purulent drainage from his abdominal JP drain due to the extensive nature of the infection. After discussions between neurosurgery and cardiothoracic surgery, he underwent a VPL shunt placement. Imaging later showed a moderate sized pleural effusion, but the patient remained asymptomatic. DISCUSSION: Ventriculoperitoneal shunts are the most common way to decompress cerebrospinal fluid, but if a VP shunt cannot be placed then a VPL shunt can be placed instead. Generally VPL shunts are well tolerated. Occasionally, patients can develop pleural effusions, but the rate of this complication has greatly decreased after the development of pressure control devices and anti-siphon devices in the shunt. CONCLUSIONS: VPL shunts are a viable treatment option to consider if VP shunts are contraindicated; however, in these patients it is important to be vigilant in assessment for possible complications including pleural effusions. REFERENCE #1: Küpeli, E., Yilmaz, C., & Akçay, S. (2010). Pleural effusion following ventriculopleural shunt: Case reports and review of the literature. Annals of thoracic medicine, 5(3), 166–170. https://doi.org/10.4103/1817-1737.65048 REFERENCE #2: Melamed, Edward, Christian, Eisha, Krieger, Mark, Berry, Cherisse, Yashar, Parham & McComb, J. (2016). 200 Age as a Novel Risk Factor for Revision of Ventriculopleural Shunt in Pediatric Patients. Neurosurgery, 63, 178-179. https://doi.org/10.1227/01.neu.0000489769.74513.e8 REFERENCE #3: Craven, C., Asif, H., Farrukh, A., Somavilla, F., Toma, A. K., & Watkins, L. (2016). Case series of ventriculopleural shunts in adults: a single-center experience, Journal of Neurosurgery JNS, 126(6), 2010-2016. Retrieved Apr 27, 2021, from Case series of ventriculopleural shunts in adults: a single-center experience DISCLOSURES: No relevant relationships by Brittany Gabbert, source=Web Response No relevant relationships by Michael Gabbert, source=Web Response No relevant relationships by Akhil Gade, source=Web Response No relevant relationships by Steven Kim, source=Web Response No relevant relationships by Machaiah Madhrira, source=Web Response No relevant relationships by Srinivasan Rajaganapathy, source=Web Response