DOI: 10.1148/radiol.2321011976
(Radiology 2004;232:239-243.)
© RSNA,
Case 72: Pseudocyst around Ventriculoperitoneal Shunt1
Juan Carlos Pernas, MD and
Jordi Catala, MD
1 From the Department of Radiology, Centro Medico Teknon, C/ Vilana 12, 08022 Barcelona, Spain. Received December 3, 2001; revision requested February 15, 2002; revision received February 6, 2003; accepted May 13, 2003. Address correspondence to J.C.P. (e-mail: radiologia@cmteknon.com).
Index terms: Cerebrospinal fluid, 167.458, 74.3123, 791.458 • Diagnosis Please • Shunts, ventriculoperitoneal, 167.458, 74.458, 791.458
 |
HISTORY
|
|---|
A 32-year-old man presented with abdominal pain, distention, and bloating. His white blood cell count and amylase serum levels were normal. No history of malignancy or pancreatic disease was known to exist. A ventriculoperitoneal shunt had been placed 15 years earlier to treat hydrocephalus secondary to spina bifida.
The patient underwent supine abdominal radiography and unenhanced abdominal computed tomography (CT).
|
IMAGING FINDINGS
|
|---|
The abdominal supine radiograph (Fig 1) showed mild distention of small-bowel loops in the left upper quadrant.
View larger version (138K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Supine abdominal radiograph. Nasogastric tube (arrow) was placed because of the patient’s symptoms. There is mild dilatation of the small-bowel loops (arrowhead) in the left upper quadrant. The ventriculoperitoneal shunt is seen in the right upper quadrant.
|
|
Unenhanced abdominal CT scans showed a mesenteric, thin-walled well-defined cystic mass (Fig 2) around the ventriculoperitoneal shunt tip. The cystic mass was independent from the pancreas and encased a small-bowel loop, which was represented by small gas bubbles. Proximal dilated small-bowel loops could be seen, but there was no colonic obstruction.
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Unenhanced midabdominal transverse CT scans. (a) CT scan obtained through the uncinate process shows that the cystic lesion (straight arrow) is independent from the pancreas. Ventriculoperitoneal shunt (arrowhead) and small gas bubble (curved arrow) inside encased small-bowel loop. (b) CT scan obtained through the third duodenal portion shows the greatest diameter of the cystic mass (short straight arrows). There are no inflammatory changes in the surrounding mesenteric fat. Note the ventriculoperitoneal shunt (long straight arrow), dilated small-bowel loop (curved arrow) but no colonic obstruction, and small gas bubble (arrowhead). (c) CT scan obtained 2 cm below the lower pole of both kidneys shows the lower limit of the mass (arrows) and its relationship with the encased small-bowel loop (arrowhead).
|
|
View larger version (129K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Unenhanced midabdominal transverse CT scans. (a) CT scan obtained through the uncinate process shows that the cystic lesion (straight arrow) is independent from the pancreas. Ventriculoperitoneal shunt (arrowhead) and small gas bubble (curved arrow) inside encased small-bowel loop. (b) CT scan obtained through the third duodenal portion shows the greatest diameter of the cystic mass (short straight arrows). There are no inflammatory changes in the surrounding mesenteric fat. Note the ventriculoperitoneal shunt (long straight arrow), dilated small-bowel loop (curved arrow) but no colonic obstruction, and small gas bubble (arrowhead). (c) CT scan obtained 2 cm below the lower pole of both kidneys shows the lower limit of the mass (arrows) and its relationship with the encased small-bowel loop (arrowhead).
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2c. Unenhanced midabdominal transverse CT scans. (a) CT scan obtained through the uncinate process shows that the cystic lesion (straight arrow) is independent from the pancreas. Ventriculoperitoneal shunt (arrowhead) and small gas bubble (curved arrow) inside encased small-bowel loop. (b) CT scan obtained through the third duodenal portion shows the greatest diameter of the cystic mass (short straight arrows). There are no inflammatory changes in the surrounding mesenteric fat. Note the ventriculoperitoneal shunt (long straight arrow), dilated small-bowel loop (curved arrow) but no colonic obstruction, and small gas bubble (arrowhead). (c) CT scan obtained 2 cm below the lower pole of both kidneys shows the lower limit of the mass (arrows) and its relationship with the encased small-bowel loop (arrowhead).
|
|
A diagnosis of peritoneal pseudocyst around ventriculoperitoneal shunt causing small-bowel obstruction was suspected. Percutaneous drainage was performed (Fig 3), and 300 mL of clear fluid was drained.
View larger version (123K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3. Unenhanced midabdominal tranverse CT scan obtained through the greatest diameter of the mass. Percutaneous drainage with an 18-gauge needle (arrows) was performed. Ventriculoperitoneal shunt (arrowhead) is seen.
|
|
The immediate postdrainage scan showed that the size of the cystic mass decreased markedly, and the small-bowel obstruction was relieved in a few hours (Fig 4).
View larger version (126K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Unenhanced midabdominal transverse CT scan obtained immediately after percutaneous drainage shows decrease in size of the cystic mass (straight arrows). Small-bowel loops still remain mildly dilated (curved arrows).
|
|
The findings at fluid analysis were consistent with cerebrospinal fluid, with negative cultures and absence of microbian flora.
No further procedures were needed to relieve abdominal obstruction. The patient was referred to another hospital for elective surgery, where he underwent shunt replacement and pseudocyst resection.
|
DISCUSSION
|
|---|
Placement of a ventriculoperitoneal shunt is an established procedure for treatment of hydrocephalus. With increasing longevity following successful treatment, however, complications can occur.
The reviewed literature enumerates common complications, such as tube disconnection, blockage of the shunt tip, infection, bowel obstruction, and perforation (1). Uncommon complications that are described include subphrenic abscess; small-bowel perforation with secondary formation of a cerebrospinal-enteric fistula; untreatable cerebrospinal fluid ascites; migration of the tip of the shunt to distant locations, such as intrathoracic or subphrenic areas; protrusion of the shunt from the anus; and pseudocyst formation (2,3,4).
Peritoneal pseudocyst is a rare complication; the incidence ranges from less than 1.0% to 4.5%, depending on the report (5–7). The time from the last shunting procedure to the development of an abdominal pseudocyst ranges from 3 weeks to 5 years (8). There has been a reported case of pseudocyst formation 10 years after ventriculoperitoneal shunt placement (9).
Cerebrospinal fluid pseudocysts are seen as a thin-walled cystic mass around the shunt tip. The wall is composed of fibrous tissue without an epithelial lining and is filled with cerebrospinal fluid. Debris is identified in the majority of the fluid collections.
Some authors suggest that infection is the principal cause of pseudocyst development, despite the frequent lack of systemic signs of infection (10,11).
The pseudocyst can either move freely within the peritoneal cavity or adhere to small-bowel loops, the serosal surface of solid organs, the parietal peritoneum, or small-bowel loops. The latter would explain why some bowel loops may become engulfed when the pseudocyst increases in size or why the pseudocyst may be prone to torsion.
Pediatric patients commonly present with symptoms of elevated intracranial pressure and abdominal pain, whereas adults predominantly present with abdominal signs only.
Ultrasonography (US) or CT can indicate the definitive diagnosis. US is the method of choice in the evaluation of the pseudocyst and other complications at the distal end of the ventriculoperitoneal shunt (6,11,12,13). Measurement of attenuation values with CT characterizes the contents as water attenuation and demonstrates the relationships of portions of the shunt catheter with the pseudocyst.
Differential diagnoses of an abdominal cystic mass include abdominal causes and metastatic disease from a primary site in the brain, with peritoneal seeding through the ventriculoperitoneal shunt. In patients with metastatic disease, some thickening or nodularity of the capsule is present. No brain tumor or history of malignancy was reported in our patient.
Abdominal causes can include mesenteric abscess, lymphocele, seroma, cystic lymphangioma, cystic mesothelioma, mesenteric cyst, benign cystic teratoma, cystic spindle cell tumor, pancreatic pseudocyst, and duplication cyst. According to the imaging features in this case, the most likely differential diagnoses are abdominal abscess, pancreatic pseudocyst, and urinoma. The absence of infectious symptomatology and clinical data and the lack of any inflammatory changes in surrounding tissues make the diagnosis of abscess highly unlikely. The absence of a history of pancreatic disease or manipulation of the urinary tract makes the diagnosis of pancreatic pseudocyst or urinoma unlikely. The clinical setting and the relationship of the cyst with the ventriculoperitoneal shunt make the diagnosis of pseudocyst around the ventriculoperitoneal shunt the most likely diagnosis.
It may be difficult to differentiate seroma, urinoma, abscess, lymphocele, and cerebrospinal fluid on the basis of imaging findings alone. Fine-needle aspiration with US or CT guidance has a high diagnostic yield (7).
Excision or repositioning of the shunt tip with minimally invasive laparoscopic techniques is usually performed. This technique in the setting of a noninfected pseudocyst has proved to be safe, with results comparable to those of a conventional open surgical technique (5). If infection is present, the pseudocyst wall should be excised and the peritoneal shunt tube removed. Percutaneous drainage of the pseudocyst can be both diagnostic and therapeutic (7).
|
FOOTNOTES
|
|---|
Part 1 of this case appeared 4 months previously and may contain larger images.
|
REFERENCES
|
|---|
- Murtagh FR, Quencer RM, Poole CA. Extracranial complications of cerebrospinal fluid shunt function in childhood hydrocephalus. AJR Am J Roentgenol 1980; 135:763-766.[Abstract]
- Agha FP, Amendola MA, Shirazi KK, Amendola BE, Chandler WF. Unusual abdominal complications of ventriculo-peritoneal shunts. Radiology 1983; 146:323-326.[Abstract/Free Full Text]
- Yamamura K, Kodama O, Kajikawa H, et al. Rare intra-abdominal complications of a ventriculoperitoneal shunt: report of three cases. No Shinkei Geka 1998; 26:1007-1011. [Japanese].[Medline]
- Mata J, Alegret X, Llauger J. Splenic pseudocyst as a complication of ventriculoperitoneal shunt: CT features. J Comput Assist Tomogr 1986; 10:341-342.[Medline]
- Oh A, Wildbrett P, Golub R, Yu LM, Goodrich J, Lee T. Laparoscopic repositioning of a ventriculo-peritoneal catheter tip for a sterile abdominal cerebrospinal fluid (CSF) pseudocyst. Surg Endosc 2001; 15:518.
- Rainov N, Schobess A, Heidecke V, Burkert W. Abdominal CSF pseudocyst in patiens with ventriculo-peritoneal shunts: report of fourteen cases and review of the literature. Acta Neurochir (Wien) 1994; 127:73-78.[CrossRef][Medline]
- Besson R, Hladky JP, Dhellemmes P, Debeugny P. Peritoneal pseudocyst-ventriculo-peritoneal shunt complications. Eur J Pediatr Surg 1995; 5:195-197.[Medline]
- Ersahin Y, Mutluer S, Tekeli G. Abdominal cerebrospinal fluid pseudocysts. Childs Nerv Syst 1996; 12:755-758.[Medline]
- Rovlias A, Kotsou S. Giant abdominal CSF pseudocyst in an adult patient 10 years after a ventriculo-peritoneal shunt. Br J Neurosurg 2001; 15:191-192.[CrossRef][Medline]
- Hahn YS, Engelhard M, McLone DG. Abdominal CSF pseudocyst: clinical features and surgical management. Pediatr Neurosci 1985–86; 12:75-79.
- Egelhoff J, Babcock DS, McLaurin R. Cerebrospinal fluid pseudocyst: sonographic appearance and clinical management. Pediatr Neurosci 1985–86; 12:80-86.
- Salomao JF, Leibninger RD. Abdominal pseudocyst complicating CSF shunting in infants and children: report of 18 cases. Pediatr Neurosurg 1999; 31:274-278.[CrossRef][Medline]
- Chuang VP, Fried AM, Oliff M, Ellis GT, Sachatello CR. Abdominal CSF psuedocyst secondary to ventriculo-peritoneal shunt: diagnosis by computed tomography in two cases. J Comput Assist Tomogr 1978; 2:88-91.[Medline]
Congratulations to the 177 individuals who submitted the most likely diagnosis (peritoneal pseudocyst around ventriculoperitoneal shunt) for Diagnosis Please, Case 72. The names and locations of the individuals, as submitted, are as follows:
- Pablo Jose Abbona, MD, Mar del Plata, Argentina
- Hisashi Abe, Osaka, Japan
- Gholamali Afshang, MD, Tinley Park, Ill
- Oguz Akin, MD, New York, NY
- Canan Altay, MD, Izmir, Turkey
- Albert J. Alter, Madison, Wis
- A. Anbarasu, MD, FRCR, Coventry, United Kingdom
- Mehmet Haydar Atalar, Sivas, Turkey
- Patricia A. Athey, MD, Houston, Tex
- Mirela Ávila, Recife, Brazil
- Angus Baird, Birmingham, Ala
- Ken Baliga, Rockford, Ill
- Ronald L. Becker, MD, Rolling Hills, Calif
- Alvaro Belmar, MD, Santiago, Chile
- Aldo Benjamim Rodrigues Barbosa, São José do Rio Preto, Brazil
- Debra M. Berger, MD, New York, NY
- Brian Bigoni, Del Mar, Calif
- Antonio Botero, MD, Bogota, Colombia
- Eric L. Bressler, MD, Minnetonka, Minn
- Stephen J. Buetow, MD, Evans, Ga
- María Jesús Díaz Candamio, La Coruña, Spain
- Dr Tirso Cascajares Murillo, Los Mochis, Mexico
- Antonio Cavalcanti, MD, São Paulo, Brazil
- Luisa Fernanda Cervantes, Miami, Fla
- Timothy Clark, Greenville, NC
- Jay M. Colby, MD, Pawcatuck, Conn
- James W. Cole, MD, Cincinnati, Ohio
- Y. S. Cordoliani, MD, Paris, France
- Jezreel Corrêa, da Costa Rondônia, Brazil
- Sebastián Costantino, MD, Mar del Plata, Argentina
- Marco Cura, New York, NY
- Mukul Das, MD, Olney, Md
- Marc G. de Baets, Lugano, Switzerland
- Peter C. De Baets, MD, Sijsele, Belgium
- Wagner Diniz de Paula, MD, Brasilia, Brazil
- J. F. K. de Villiers, Gisborne, New Zealand
- Jon De Witte, Phoenix, Ariz
- Jacques Demers, MD, La Pocatière, Québec, Canada
- Mustafa Kemal Demir, MD, Istanbul, Turkey
- Thaworn Dendumrongsup, MD, Songkla, Thailand
- Mark Thomas DiMarcangelo, DO, MS, FACR, Cherry Hill, NJ
- Heratch Doumanian, Merrillville, Ind
- Shella Farooki, MD, Dublin, Ohio
- James Fitzgerald, Orchard Park, NY
- Ricardo Fonseca, MD, Nashville, Tenn
- Ángeles Franco, Madrid, Spain
- Arie Franco, MD, PhD, Pittsburgh, Pa
- Dr Thiago Junqueira Franco, São Paulo, Brazil
- Akira Fujikawa, Tokyo, Japan
- Ann S. Fulcher, MD, Richmond, Va
- Dr Sandro Galea Soler, MD, MRCP (UK), Malta
- Thomas C. Gallagher, DO, Yardley, Pa
- Dr Cristine Norwig Galvão, São Paulo, Brazil
- Roberto Garcia Figueiras, MD, Santiago De Compostela, Spain
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Randy Gehl, MD, Grand Junction, Colo
- Gilles Genin, MD, Annecy, France
- Marco Antonio De Negri Germano, São Paulo, Brazil
- Adam M. Gittleman, MD, Mineola, NY
- Ronald B. J. Glass, New York, NY
- Ted Glass, MD, Ridgeland, Miss
- Mark Goldshein, MD, Andover, Mass
- Philip Goodman, MD, Binghamton, NY
- Tom Grant, DO, Chicago, Ill
- Dan Gridley, MD, Goodyear, Ariz
- John D. Grizzard, MD, Midlothian,Va
- D. Joseph Grunz, MD, Ladue, Mo
- Flavius Guglielmo, MD, Basking Ridge, NJ
- Fernando Gurgel, Recife, Brazil
- Jean-Pierre Gurret, Annecy, France
- Ferris M. Hall, MD, Boston, Mass
- Yukihiro Hama, MD, Tokorozawa, Japan
- Ian Hammond, MD, Ottawa, Ontario, Canada
- Felix A. Hughes, III, MD, FACR, Virginia Beach, Va
- Alberto Iaia, MD, Wilmington, Del
- Waleed Ibrahim, MD, Durham, NC
- Barry F. Jeffries, MD, Atlanta, Ga
- Hirotsugu Kado, Akita Prefecture, Japan
- Sanjeeva Prasad Kalva, Boston, Mass
- Shinichi Kan, Kangawa, Japan
- Kamil Karaali, MD, Antalya, Turkey
- Nuri Karabay, MD, Izmir, Turkey
- Ajit Singh Kashyap, MD, Pune, India
- Katsuhiko Kato, MD, PhD, Nagoya, Japan
- Nurettin Katranci, MD, Antalya, Turkey
- Eric Kinder, MD, Seattle, Wash
- Adem Kiris, MD, Elazig, Turkey
- Jacobo Kirsch, MD, Cleveland, Ohio
- Mitchell A. Klein, MD, Milwaukee, Wis
- Steven A. Klein, MD, Shrewsbury, Mass
- Jacob Sam Koruth, MD, Worcester, Mass
- Tasvinder Kour, MBBS, Chandigarh, India
- Mark Kutler, MD, Dallas, Tex
- Dan Leatherwood, MD, Indianapolis, Ind
- Peter Leyman, MD, Aalst, Belgium
- John T. Lim, MD, Newport Coast, Calif
- David A. Lisle, Brisbane, Australia
- Dr Roussel Luc, Sijsele, Belgium
- Walter Mak, MD, Peoria, Ill
- N. B. S. Mani, MD, Nassau, Bahamas
- Javier E. Martínez, MD, Chubut, Argentina
- Dr Peter Maslin, New York, NY
- Dr P. B. Mattelaer, Brugge, Belgium
- John A. Mattingly, MD, Belleville, Ill
- Walter P. Maynard, MD, Los Angeles, Calif
- Frank McKowne, MD, Vancouver, Wash
- Manabu Minami, MD, Tokyo, Japan
- Sankar Ranjan Mondal, MD, Nassau, Bahamas
- Eduardo Mondello, MD, Buenos Aires, Argentina
- Gaspar-Alberto Motta-Ramirez, MD, Cleveland, Ohio
- Annamalai Muthiah, Jr, MD, Charlottesville, Va
- Tetsuro Nakahara, Shiga, Japan
- Tetsuo Nakayama, MD, Osaka, Japan
- Tammam Nehme, Wenatchee, Wash
- Vung Duy Nguyen, San Antonio, Tex
- Maura Noordhoorn, Long Island City, NY
- Anietie Okon, MD, Coralville, Iowa
- Mike O’Loughlin, MD, West Hartford, Conn
- Ann Owen, MD, Murfreesboro, Tenn
- Eduardo C. Padilla, MD, San Ysidro, Calif
- Anoop Kumar Pandey, Chandigarh, India
- David M. Panicek, MD, New York, NY
- Harish Panicker, Washington, DC
- Lee Papell, MD, Millwood, NY
- Narendrakumar P. Patel, MD, Newburgh, NY
- Víctor Pérez-Candela, Las Palmas de Gran Canaria, Spain
- Carlo L. E. Petralli, MD, Bruderholz, Switzerland
- Hilton Pittman, Pensacola, Fla
- Rubem Pochaczevsky, MD, Bronx, NY
- Dr S. P. Prabhu, Bristol, United Kingdom
- Shawn P. Quillin, MD, Charlotte, NC
- Dr Santosh B. Rai, Coventry, United Kingdom
- Mauricio C. Ramos, El Paso, Tex
- Lorenz (Larry) Ramseyer, MD, Enid, Okla
- Dr Neelash P. Ratanjee, Queensland, Australia
- Ryan Rebello, Toronto, Ontario, Canada
- Randall Rhodes, MD, Belvidere, Ill
- Uri Rimon, Tel-Hashomer, Israel
- Manoel de Souza Rocha, MD, São Paulo, Brazil
- Luiz Antonio Rossi, MD, São Paulo, Brazil
- Dr Sabujan, Chandigarh, India
- Satyajit Sarangi, Lewes, Del
- N. Saravanan, MD, Chandigarh, India
- Pierre J. Sauvage, MD, Mâcon, France
- Stephen Irwin Schabel, MD, Charleston, SC
- Steven M. Schultz, MD, Fort Worth, Tex
- Gerald Scidmore, MD, Corona del Mar, Calif
- Mustafa Secil, MD, Izmir, Turkey
- Matt Shapiro, MD, Charlottesville, Va
- Taro Shimono, MD, Osaka, Japan
- Richard Silberstein, Monte Sereno, Calif
- Darrin S. Smith, MD, Fresno, Calif
- Stephen Smith, Peoria, Ill
- Ronald M. Sokoloff, MD, San Diego, Calif
- James D. Sprinkle, Jr, MD, Spotsylvania, Va
- Kouichi Sugiyama, Hamamatsu, Japan
- Norio Takahashi, MD, Fukui, Japan
- Antonio Talegón Meléndez, Sevilla, Spain
- Ukihide Tateishi, MD, PhD, Tokyo, Japan
- Douglas L. Teich, MD, Brookline, Mass
- Ross L. Titton, MD, Cherry Hill, NJ
- Eugene Tong, MD, Austin, Tex
- Carlos Tulla, MD, Yonkers, NY
- Hiroyuki Ueda, Kyoto, Japan
- Rick R. van Rijn, MD, PhD, Amsterdam, The Netherlands
- Piet Vanhoenacker, MD, Aalst, Belgium
- Jose Ramon Varela Romero, La Coruña, Spain
- Dr Bonny Varghese, Abu-Dhabi, United Arab Emirates
- Kai Vilanova Busquets, MD, Girona, Spain
- Christopher Vittore, MD, Rockford, Ill
- Jeff West, MD, Jacksonville, Fla
- David J. Wright, MD, Lake Oswego, Ore
- Tatsuya Yamamoto, Obama, Japan
- Stanko Yovichevich, MD, Sydney, Australia
- Joe Yut, Olathe, Kan
- Jeffrey H. Zapolsky, MD, Oshkosh, Wis
- Sérgio Zoriki, MD, São Paulo, Brazil
TOP
HISTORY
IMAGING FINDINGS
