Federal University of São Paulo Department of Neurology and NeurosurgeryCampinas State University Department of Neurology and NeurosurgeryUNIFESP, Department of Neurology and NeurosurgerySciEL

Amantéa, Andrea Vieira

Cavalheiro, Sergio

Joaquim, Andrei Fernandes

Mudo, Marcelo Luis

Arquivos de Neuro-Psiquiatria

Mudo, Marcelo Luis [UNIFESP]

Amantéa, Andrea Vieira [UNIFESP]

Cavalheiro, Sergio [UNIFESP]

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Migração distal de catéter de derivação ventrículo-peritoneal para implante mamário de silicone

Marcelo Luis Mudo

Andrea Vieira Amantéa

Andrei Fernandes Joaquim

Sérgio Cavalheiro

Directory of Open Access Journals

Distal migration of ventriculoperitoneal shunting catheter under silicon breast implant Migração distal de catéter de derivação ventrículo-peritoneal para implante mamário de silicone

Repositório Institucional UNIFESP

Arq Neuropsiquiatr 2009;67(3-A):697-698 697Clinical / Scientific noteDiStal migration of ventriCuloperitoneal Shunting Catheter unDer SiliCon breaSt implantMarcelo Luis Mudo1, Andrea Vieira Amantéa1, Andrei Fernandes Joaquim2, Sérgio Cavalheiro1,3migração DiStal De Catéter De Derivação ventríCulo-peritoneal para implante mamário De SiliCone1MD, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo SP, Brazil; 2MD, Department of Neurology and Neurosurgery, Campinas State University (UNICAMP), Campinas-SP, Brazil; 3MD, PhD, Professor of Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo SP, Brazil.Received 5 November 2008, received in final form 1 April 2009. Accepted 29 May 2009.Dr. Marcelo Luis Mudo – Rua dos Apeninos 930 / 14º - 04104-020 São Paulo SP - Brasil. E-mail: mlmudo@uol.com.brVentriculoperitoneal (VP) shunt is a common form of treatment for hydrocephalus. Although simple tech-nically, a high level of surgical complications have been described1,2. We reported a case of ventriculoperitoneal shunt failure due to migration of the distal catheter un-der a silicone breast implant. CaSeA 34-year-old woman, previously submitted to a silicone breast implant 10 years before, presented in the emergence de-partment with a 5-days history of breast swelling and pain. She also complained of a nipple discharge. Nine months before, she had also been submitted to a right frontal ventriculoperitoneal shunt for hydrocephalus secondary to a cerebellar desmoplastic medulloblastoma operated at the same occasion, with disease control and no residual symptoms. Chest x-rays (Fig 1) showed a coiled distal catheter on the right breast region and breast ultra-sound showed liquid collection on the same region. An elective replacement of the distal catheter into the peri-toneal cavity was undergone with drainage of the cerebrospi-nal fluid (CSF) pseudocyst (Fig 2), preserving the implant. We used the previous inframmary and abdominal incisions. The pa-tient discharged home with no symptoms the following day. At 6 months after surgery, she was asymptomatic yet. DiSCuSSionSurgical complications of VP are very common, espe-cially dysfunction and infections3. Many authors reported distal catheter migration as a cause of shunt failure1,2, that can be attributed, among many others causes, to inade-quate surgical technique. Distal migrations are described to the scrotum4, heart5, gastrointestinal tract6, thoracic cavity7, bladder8, vagina9, gallbladder10, among others.However, distal catheter migration under a mammary implant is rare. We found just two similar reports; Spec-tor et al., reported a patient with pain and swelling in her right breast 6 weeks after a ventriculoperitoneal shunt to treat hydrocephalus due to a acoustic schwannoma neu-roma11. At the time of shunt placement, the neurosurgeon was not aware that the patient has been undergone a bi-lateral breast augmentation some years before. A chest x-ray showed the coiled distal shunt catheter in the right breast, exactly like our patient. The patient was treated with a small incision at the level of clavicle, breast de-compression through the stab incision and replacement of the distal catheter intraperitoneally via the previous in-cision. The patient had full recovery and was discharged home in the day after surgery. Iyer et al., reported a case of a woman with a 4 month history of ventriculoperito-neal shunt for hydrocephalus who was submitted to an elective breast augmentation after neurosurgery evalua-tion12. Ten weeks later, the patient came to the emergen-cy with light-headness and right breast pain and swelling Fig 1. Chest X-ray showing the distal catheter coiled in the region of the right breast of the patient.Arq Neuropsiquiatr 2009;67(3-A)698Distal migration shunting catheter under silicon Mudo et al.of 5 days’ duration. Chest scan showed a coiled catheter around the implant and peri-implant fluid collection. The patient was submitted to distal catheter replacement into the peritoneal cavity, avoiding contact of the implant with the catheter, discharged home within 24 hours complete-ly symptom free. Breast complication of shunt none related to breast implants has also been reported. Moro’n et al., report-ed a complication of ventriculopleural shunting in which the pleural end of the catheter retracted out of the pleu-ral cavity with drainage of CSF into the subcutaneous and breast tissue, developing breast enlargement and drainage via the nipple 12 days after her last revision13. The patient was a 24-year-old girl that had undergone to 22 shunt re-visions due to dysfunction. She was submitted to a revi-sion surgery where the catheter was replaced into the pleural cavity. Lee et al. and Nakano et al. reported similar cases of retrograde cerebrospinal fluid and leaked from the nipple orifice due to intra-abdominal pseudocyst located at the peritoneal catheter tip and lactiferous duct injured fol-lowed ventriculo-peritoneal shunt implantation14,15. The distal catheter replacement into the peritoneal cavity was sufficient to treat both patients.As noted for other authors, who desire augmentation mammaplasty, it is important to note the possibility of shunt migration around the breast implant. To prevent this complication, it is recommended to take care when plac-ing the shunt near the breast area, placing the catheter in a more medial thoracic position. The patient and the neu-rosurgeon must be aware of the risks, even after the tis-sue has healed completely.Discussing pasting medical and surgical history and a good surgical technique are important factors to prevent this complication. Although rare, breast swelling, cystic mass, or clear nipple discharge should be due to shunt complications, even in patients without a breast implant. Surgical management of this complication consisted in replacement shunt, drainage of CSF and preservation of the implant. referenCeS 1. Lund-Johansen M, Svendsen F, Wester, K. Shunt failures and complica-tions in adults as related to shunt type, diagnosis, and the experience of the surgeon. Neurosurgery 1994;35:839-844. 2. Benzel EC, Pelletier AL, Levy PG. Communicating hydrocephalus in adults: prediction of outcome after ventricular shunting procedures. Neurosurgery 1990;26:655-660.  3. Henriques JGB, Pinho AS, Pianetti G. Complicação de derivação ven-trículo-peritoneal: hérnia inguinal com migração do cateter para o saco escrotal: relato de caso. Arq Neuropsiquiatr 2003;61:486-489.  4. Ramani PS. Extrusion of abdominal catheter of ventriculoperitoneal shunt into the scrotum: case report. J Neurosurg 1974;40:772-773. 5. Kim MS, Oh CW, Hur JW, Lee JW, Lee HK. Migration of the distal cathe-ter of a ventriculoperitoneal shunt into the heart: case report. Surg Neu-rol 2005;63:185-187.  6. Cheng JY, Lo WC, Liang HH, Kum IH. Migration of ventriculoperitone-al shunt into the stomach, presenting with gastric bleeding. Acta Neu-rochir (Wien) 2007;149:1269-1270. 7. Sahin S, Shaaban AF, Iskandar BJ. Recurrent pneumonia caused by transdiaphragmatic erosion of a ventriculoperitoneal shunt into the lung. J Neurosurg 2007;107:156-158. 8. Surchev J, Georgiev K, Enchev Y, Avramov R. Extremely rare com-plications in cerebrospinal fluid shunt operations. J Neurosurg Sci 2002;46:100-102. 9. Patel CD, Matloub H. Vaginal perforation as a complication of ventric-uloperitoneal shunt: case report. J Neurosurg 1973;38:761-762. 10. Pormoy HD, Croissant PD. Two unusual complications of a ventricu-loperitoneal shunt. Case report. J Neurosurg 1973;39:775-776.11. Spector JA, Culliford AT, Post NH, Weiner H, Levine JP. An unusu-al case of cerebrospinal fluid pseudocyst in a previously augmented breast. Ann Plast Surg 2005; 54:85-87. 12. Iyer HP, Jacob LP, Chaundhry NA. Breast cerebrospinal fluid pseudo-cyst. Plast Reconstr Surg 2006;118:87-89. 13. Moro’n MA, Daniel L, Barrow DL. Cerebrospinal fluid galactorrhea af-ter ventriculopleural shunting: case report. Surg Neurol 1994;42:227-230.14. Lee SC, Chen JF, Tu PH, Lee ST. Cerebrospinal fluid galactorrhea: a rare complication of ventriculoperitoneal shunting. J Clin Neurosci 2008;15:698-700. 15. Nakano A, Tani E, Sato M, Shimiz Y. Cerebrospinal fluid leakage from the nipple after ventriculoperitoneal shunt: case report. Surg Neurol 1994;42:224-226.  Fig 2. Swelling of the right breast of the pa-tient due to CSF pseudocyst. 

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Migração distal de catéter de derivação ventrículo-peritoneal para implante mamário de silicone

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Repositório Institucional UNIFESP