Implausible, not impossible: delayed supradiaphragmatic thoracic migration of a ventriculoperitoneal shunt in a 17-month-old

Abstract

Background: Intrathoracic migration of a ventriculoperitoneal shunt (VPS) is a phenomenally rare complication, with the supradiaphragmatic intercostal variant even more so. Whereas it can prove debilitating or even fatal via massive hydrothorax, the causative mechanism and proper management of this occurrence are undefined.

Case presentation: A 17-month-old girl who had undergone VPS insertion at one month of age was brought to our department for somnolence and dyspnea, which had a sudden onset. Despite a previous thoracostomy provided temporary symptom relief, she had relapsed. Computed tomography (CT) of the chest showed a large loop of the right-sided VPS penetrating into the thorax through the anterior wall, as well as marked right hydrothorax. She was subjected to VPS revision and thoracostomy, with the swift, complete, and lasting remission of her complaints.

Conclusion: It is possible that local reaction coupled with negative inspiratory pressure caused the catheter loop to break into the pleural cavity. Our case demonstrates an exceedingly rare event that has a favorable prognosis if diagnosed and treated quickly and appropriately.

Keywords: Dyspnea; Hydrothorax; Migration; Supradiaphragmatic; Thoracic; Thoracostomy; Ventriculoperitoneal shunt (VPS).

Fig. 1

Preoperative chest CT scan demonstrating the massive pleural effusion, with the ventriculoperitoneal catheter visible inside the pleural cavity. A Before initial thoracostomy and (B) 2 weeks after thoracostomy. C 3d reconstruction at 2 weeks after thoracostomy

Fig. 2

Postoperative CT scan, after the catheter was reinserted over the sternum. A Coronal reconstruction and (B) axial view of the cranium, demonstrating the placement of the ventricular catheter inside the right ventricle. C and D Axial chest CT scan showing no remaining pleural effusion, with the thoracostomy drain still in place (visible in C)