Attending Physician Moss rehab Elkins Park, Pennsylvania, United States
Case Diagnosis: Trans-oral ventriculoperitoneal shunt migration
Case Description: A 52-year-old female with hydrocephalus due to subarachnoid hemorrhage status post ventriculoperitoneal (VP) shunt was admitted to the hospital for confusion and dysarthria. Workup revealed worsening hydrocephalus which was managed by adjusting the VP shunt settings. She was subsequently discharged to an inpatient rehabilitation facility (IRF). On the sixth day in rehab the patient vomited out a long catheter. She became more lethargic and was transferred to the emergency department. Imaging revealed that the VP shunt catheter was protruding from the patient’s mouth. Empiric antibiotics were started, and she was transferred back to the hospital for emergent neurosurgical and ENT intervention. Direct visualization by laryngoscope revealed that the VP shunt catheter penetrated the hypopharynx via the pyriform sinus. The VP catheter was externalized. CSF cultures were positive for Leclercia adecarboxylata. The patient’s mental status significantly improved following VP shunt externalization. She was discharged back to the IRF weeks later.
Discussions: VP shunts play an important role in the management of hydrocephalus in the acquired brain injury population. However, the complication rate is high. Migration typically occurs at the distal catheter end and has been reported in various anatomical locations. There have been only a few reported cases of trans-oral VP shunt migration in the pediatric population, but to the authors’ knowledge, this is the first reported case of trans-oral VP shunt migration in an adult patient. The IRF physiatrist should be familiar with the different VP shunt devices so they are able to quickly identify trans-oral VP shunt migration and refer the patient for emergent neurosurgical intervention.
Conclusions: We present the first known case of trans-oral VP shunt migration in an adult patient. Due to the rarity of cases, more research is needed to better understand the mechanism of trans-oral VP shunt migration.