Teaching NeuroImages: Massive abdominal CSFoma

and Department of Anesthesia, Critical Care and Pain Medicine (N.V.K.), Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Neurology (Impact Factor: 8.3). 03/2013; 80(13):e146. DOI: 10.1212/WNL.0b013e318289705e
Source: PubMed

ABSTRACT A 31-year-old woman with congenital hydrocephalus status after ventriculoperitoneal shunt placement 23 years earlier presented with abdominal distention. The patient denied fever, headache, or sensory or motor abnormalities. Examination was notable for a tense abdomen. CT of the abdomen and pelvis demonstrated a massive, loculated, CSFoma, or CSF pseudocyst (figure). Ventriculoperitoneal shunts are associated with a variety of complications including tubing disruption, tip blockage, infection, intestinal perforation, tip migration, and CSFoma development.(1) CSFoma is a rare complication, thought to be caused by low-grade shunt infection, chronic inflammation, increased cerebral spinal fluid protein, or peritoneal adhesions, and is estimated to occur in 1.0% to 4.5% of cases, with a typical occurrence within 3 weeks to 5 years of shunt placement.(2,3) Treatment consists of external drainage or surgical excision followed by reconstruction of the shunt system.(4.)

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    ABSTRACT: The abdominal intraperitoneal cerebrospinal fluid pseudocyst is an infrequent but important complication in patients with ventriculoperitoneal shunts. Since 1954, 115 cases of paediatric pseudocysts have been reported in the literature. One additional report deals with an adult patient. We report on 14 cases of sonographically diagnosed abdominal pseudocysts. Their aetiology, diagnosis, clinical signs and symptoms and surgical management are investigated. In our hydrocephalus series we have an incidence of pseudocyst formation of 4.5%. The most common presentation of the paediatric patients is with symptoms of elevated intracranial pressure and abdominal pain, whereas the adults have predominantly local abdominal signs. Diagnosis is readily made with ultrasonography. Predisposing factors for pseudocyst formation are multiple shunt revisions and infection. Microscopically, the pseudocysts consist of fibrous tissue without epithelial lining. The treatment involves surgical removal of the catheter with or without excision of the pseudocyst wall and placement of a new catheter intraperitoneally in a different quadrant or an intra-atrial shunt. Recurrences are rare, especially under appropriate medical treatment of infection. In our series, microbiologically proven infection was present in 30% of the cases.
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