Central dilemma in CSF pseudocyst - A case series and review of literature

Abstract

Cerebrospinal fluid (CSF) pseudocyst abdomen is a rare but well-described complication following ventriculoperitoneal (VP) shunt. This entity does exist since 1954. This is seen more commonly among pediatric population and cause of CSF pseudocyst is still debated, many theories been postulated in the literature and so are its management. We present our experience with small case series and idea is to provide an alternate management strategy for shunt-independent cases. We did retrospective study of three cases, diagnosed on the basis of clinical profile and imaging. Subclinical infection was ruled out and patients with abdominal complaints predominantly and no ventriculomegaly on Noncontrast computed tomography head were subjected to "shunt-tie" at infraclavicular region. Out of three cases, two had abdominal complaints with no features of raised ICT and no ventriculomegaly. On tying the shunt catheter infraclavicular level for 48-72 h, they did not developed raised ICT/ventriculomegaly. Cyst was drained by percutaneous ultrasound-guided PIGTAIL. Shunt assembly was removed. One patient (shunt dependent) underwent exploratory laparotomy and repositioning of the catheter but experienced shunt malfunction, ultimately VP shunt was converted to ventriculopleural shunt. On follow-ups, there is no residual cyst or recurrence of symptoms. To conclude, evaluation of shunt dependency/non-dependency is of utmost importance. For shunt-independent cases, percutaneous ultrasound-guided PIGTAIL drainage is safe, minimally invasive, and effective procedure and we may avoid many potential complications.

Keywords: Management dilemma; Pseudocyst abdomen; Shunt dependent; Ventriculoperitoneal shunt.

Figure 1:

An X-ray showing the abdominal end of the shunt (black arrow) in the location of pseudocyst (a). Noncontrast computed tomography (NCCT) abdomen showing large pseudocyst abdomen with abdominal catheter lying along its anterior wall, as shown by black and bold white arrows (b and d). NCCT head showing the ventricular end of the shunt (c). NCCT head after removal of the shunt with no hydrocephalous (e).

Figure 2:

Exploratory laparotomy with collapsed pseudocyst abdomen and shunt tip (a-c). Development of pleural effusion following ventriculopleural shunt (d).

Figure 3:

Child showing collapsed pseudocyst lump size after PIGTAIL drainage (on the right lower abdomen shown by black arrow) and site of tying shunt catheter infraclavicular, right side – shown by black arrow (a). Noncontrast computed tomography (NCCT) head showing no ventriculomegaly after tying shunt (b). Before draining, pseudocyst abdomen with shunt tips lying anteriorly and inferiorly (c).

Figure 4:

Proposed algorithm showing management strategies for shunt dependent and shunt non-dependent abdominal CSF pseudocyst.