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 Table of Contents  
LETTER TO THE EDITOR
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 125-126

Subcutaneous shunt catheter calcification: An uncommon cause of shunt failure


Department of Neurosurgery, Narayna Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

Date of Web Publication18-Jul-2014

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Narayna Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India
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DOI: 10.4103/1658-631X.137014

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How to cite this article:
Agrawal A, Rao GM. Subcutaneous shunt catheter calcification: An uncommon cause of shunt failure. Saudi J Med Med Sci 2014;2:125-6

How to cite this URL:
Agrawal A, Rao GM. Subcutaneous shunt catheter calcification: An uncommon cause of shunt failure. Saudi J Med Med Sci [serial online] 2014 [cited 2017 Nov 22];2:125-6. Available from: http://www.sjmms.net/text.asp?2014/2/2/125/137014

Sir,

Ventriculoperitoneal shunt is a commonly performed neurosurgical procedure for hydrocephalus with well-known complications. [1],[2],[3] A 19-year-old female patient underwent right ventriculoperitoneal shunt at the age of 5 months for non-communicating hydrocephalus. She was apparently alright until 15 days ago, when she had a dull headache and vomiting. No history of trauma or fever. Her general physical and systemic examination was normal. Cranial nerves and higher mental functions were normal. Shunt tube was palpable all along the tract except near to the cranial end. Routine blood investigations were normal. Computed tomography (CT) scan brain showed dilated third and lateral ventricles. Shunt tube was not visualized. X-ray of the chest including neck showed that there was disconnection of the shunt at cervical region and there was extensive calcification along the shunt over the chest and neck region [Figure 1]. A diagnosis of shunt malfunction was made and the shunt was replaced on the left side. The patient did well after surgery.

Usually patients who had shunt malfunction due to abnormal calcification had surgery at an early age and presented years after the initial surgery. [4],[5],[6] Clinically these patients present features of shunt malfunction, i.e., headache, vomiting etc. [4],[5],[6] Dystrophic calcification surrounding the catheter leading to the tethering of the shunt catheter and disconnection is a rare cause of shunt malfunction [4],[5],[6],[7],[8],[9] and patients with metabolic or renal disorders are more prone for dystrophic calcification. [9] As in the present case, there may not be any known disorder of calcium metabolism. [4],[6] Silicone (Silastic) catheters have been used since long for the surgical management of hydrocephalus and are soft and has low incidence of tissue reaction. [10],[11],[12] Degradation of a silicone cerebrospinal fluid shunt system was reported in 1983 [13] and the degradation of shunt system and shunt calcification was recognized in 1988. [5] Various factors have been identified for the abnormal calcification around the shunt tubing. [8],[10],[14],[15],[16] It has been suggested that the variations in the quantity of silica and vulcanizing agent, which are added to medical-grade silicone rubber may be responsible for the soft-tissue reaction. [8],[10],[14],[15],[16] It has also been shown that as a result of hydration the polymers may undergo biodegradation causing splitting of covalent bonds and dissolution and digestion by macrophages leading to abnormal calcification. [8],[10],[14],[15],[16] Most commonly the abnormal calcification involves the shunt catheter in the cervico-thoracic portion of the shunt tube [4],[5],[9] rarely there may be calcification in proximity to ventricular wall. [9] It has been suggested that neck movements' increases tensile stress on the shunt tubing as it passes from the mobile neck to the relatively immobile chest wall causing stress-related degeneration in the cervico-thoracic section of the tubing causing tethering of the shunt tube leading to fracture and disconnection of the tube. [4],[6] Rare involvement of the ventricles may be due to the facts that the brain have fewer mechanical stresses and it is has a relatively poor chemical response against foreign substances. [9]
Figure 1: X-ray chest with neck showing sleeve of calcifi cation along the shunt tube extending over right lateral aspect of neck and anterior chest wall

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CT will be superior to investigate the calcification in around the ventricular catheter, [9] the calcification around the shut tube can be well-visualized on plain radiographs particularly over the neck and thoracic region. [4],[5],[6],[9] The management of these patients includes the removal of shunt catheter (to avoid further calcification particularly when it is intra-ventricular) and placement of the new shunt catheter. [9]

 
  References Top

1.Gupta M, Digra NC, Sharma N, Goyal S, Agrawal A. Migration of the peritoneal catheter of a ventriculoperitoneal shunt into the scrotum. SAJCH 2012;6:93-4.  Back to cited text no. 1
    
2.Agarwal A, Kakani A. Shunt malfunction due to proximal migration and subcutaneous coiling of a peritoneal catheter. J Neurosci Rural Pract 2010;1:120-1.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Teegala R, Kota LP. Unusual complications of ventriculo peritoneal shunt surgery. J Neurosci Rural Pract 2012;3:361-4.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Stannard MW, Rollins NK. Subcutaneous catheter calcification in ventriculoperitoneal shunts. AJNR Am J Neuroradiol 1995;16:1276-8.  Back to cited text no. 4
    
5.Shimotake K, Kondo A, Aoyama I, Nin K, Tashiro Y, Nishioka T. Calcification of a ventriculoperitoneal shunt tube. Case report. Surg Neurol 1988;30:156-8.  Back to cited text no. 5
    
6.Kural C, Kirik A, Pusat S, Senturk T, Izci Y. Late calcification and rupture: A rare complication of ventriculoperitoneal shunting. Turk Neurosurg 2012;22:779-82.  Back to cited text no. 6
    
7.Boch AL, Hermelin E, Sainte-Rose C, Sgouros S. Mechanical dysfunction of ventriculoperitoneal shunts caused by calcification of the silicone rubber catheter. J Neurosurg 1998;88:975-82.  Back to cited text no. 7
    
8.Cakir E, Kuzeyli K, Usul H, Peksoylu B, Karaarslan G, Yildiz K. Shunt dysfunction due to calcification of a ventriculo-peritoneal shunt: A case report. J Clin Neurosci 2004;11:210-1.  Back to cited text no. 8
    
9.Sakai S, Akai T, Iida T, Iizuka H. Calcification on the ventricle wall associated with a shunt tube - Case report. Neurol Med Chir (Tokyo) 2004;44:674-6.  Back to cited text no. 9
    
10.Echizenya K, Satoh M, Murai H, Ueno H, Abe H, Komai T. Mineralization and biodegradation of CSF shunting systems. J Neurosurg 1987;67:584-91.  Back to cited text no. 10
    
11.Post EM. Currently available shunt systems: A review. Neurosurgery 1985;16:257-60.  Back to cited text no. 11
[PUBMED]    
12.Van Noort R, Black M, Harris B. Developments in the biomedical evaluation of silicone rubber. J Mater Sci 1979;14:197-204.  Back to cited text no. 12
    
13.Nakaoka T, Tanaka T. Case of shunt trouble due to silicone degradation. Neurol Med Chir (Tokyo) 1983;23:818-20.  Back to cited text no. 13
[PUBMED]    
14.Griebel RW, Hoffman HJ, Becker L. Calcium deposits on CSF shunts. Clinical observations and ultrastructural analysis. Childs Nerv Syst 1987;3:180-2.  Back to cited text no. 14
    
15.Yamamoto S, Ohno K, Aoyagi M, Ichinose S, Hirakawa K. Calcific deposits on degraded shunt catheters: Long-term follow-up of V-P shunts and late complications in three cases. Childs Nerv Syst 2002;18:19-25.  Back to cited text no. 15
    
16.Sugar O, Bailey OT. Subcutaneous reaction to silicone in ventriculoperitoneal shunts. Long-term results. J Neurosurg 1974;41:367-71.  Back to cited text no. 16
[PUBMED]    


    Figures

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This article has been cited by
1 Intraventricular entrapment of shunt catheter causing shunt malfunction
Amit Agrawal,Reddy V. Umamaheswara,Yashwant Sandeep
Romanian Neurosurgery. 2015; 29(3)
[Pubmed] | [DOI]



 

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