Neurochirurgie 62 (2016) 105–107 Disponible en ligne sur ScienceDirect www.sciencedirect.com Clinical case Delayed intracerebral and subdural hematomas after ventriculo-peritoneal shunt in a child: A case report and review of the literature Hématomes intra-parenchymateux et sous-dural chronique retardés secondaires à une dérivation ventriculo-péritonéale chez un enfant : à propos d’un cas avec revue de la littérature O. Coulibaly a,∗ , M. Dama a , O. Diallo a , G. Li a,c , Y. Sogoba b , D. Kanikomo b a Department of Neurosurgery, Hôpital du Mali, University of Bamako, Bamako, Mali Department of Neurosurgery, Hôpital Gabriel Touré, University of Bamako, Bamako, Mali c The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China b a r t i c l e i n f o Article history: Received 16 August 2015 Received in revised form 27 December 2015 Accepted 10 January 2016 Keywords: Hydrocephalus VPS complications Intracranial hematoma a b s t r a c t Ventriculo-peritoneal shunt (VPS) continues to remain the main diverted method to drain the cerebrospinal fluid (CSF) from the ventricles to the peritoneal cavity. It has some complications that must be managed promptly to avoid any eventual fatal evolution. The association of delayed intracerebral and subdural hematomas after VPS insertion is a very rare complication and has, to our knowledge, never previously been reported in the literature. We report a very uncommon association of this entity occurring 11 months after a shunt placement in a 13-year-old boy and discuss the likely pathogenesis, as well as the clinical and the radiological data. © 2016 Elsevier Masson SAS. All rights reserved. r é s u m é Mots clés : Hydrocéphalie Complications de la DVP Hématome intracrânien La dérivation ventriculo-péritonéale (DVP) reste la principale méthode pour drainer le liquide cérébrospinal (LCS) des ventricules à la cavité péritonéale depuis des années. Elle a quelques complications qui doivent être traitées rapidement pour éviter une éventuelle évolution fatale. L’association d’hématomes intra-parenchymateux et sous-dural chronique au décours d’une DVP est une complication très rare et n’a jamais été rapportée dans la littérature. Ici, nous rapportons pour la première fois cette association survenant 11 mois après la mise en place d’un shunt chez un garçon de 13 ans et discutons la probable pathogénie, la clinique et les données radiologiques. © 2016 Elsevier Masson SAS. Tous droits réservés. 1. Introduction The term “hydrocephalus” is from the Greek hydro-, meaning “water”, and kephalos, meaning “head”. ∗ Corresponding author. E-mail address: coulibalynch1@gmail.com (O. Coulibaly). http://dx.doi.org/10.1016/j.neuchi.2016.01.003 0028-3770/© 2016 Elsevier Masson SAS. All rights reserved. In our team, it is defined as an excessive amount of cerebrospinal fluid (CSF) in the ventricles. This entity, usually known in our pediatric practice and commonly managed by a ventriculo-peritoneal shunt (VPS), was firstly introduced in 1908 by Kausch [1]. This popular technique has some common complications, such as shunt malfunctions, shunt infections or over drainage, etc. However, delayed intraparenchymal hematoma associated with a subdural hematoma in the same patient had never previously been reported in the literature and can present a challenging diagnosis. In our 106 O. Coulibaly et al. / Neurochirurgie 62 (2016) 105–107 case study, we report this association in a 13-year-old boy based on clinical observations, radiologic data and therapeutic findings compared to a review of the literature. 2. Case report A 13-year-old boy, the youngest of five children, with no prior medical history, was admitted to our department for a six months history of headache, vomiting and irritability complicated a week before admission due to epilepsy and bilateral lower-limb weakness. Our investigation showed that the child was born from a singleton pregnancy full-term and no consanguinity was found in the parents. The neurological examination showed a happy child with movement disorders, like physical tics. There were no neurological deficits and no papilledema in the ophthalmological test. The remainder of his examination was normal. No abnormalities were noted on biological data, obviously no bleeding disorder. Initial brain CT scan performed at admission showed a marked tetraventricular dilatation with no space occupying lesions (Fig. 1a). The diagnosis of active hydrocephalus was concluded. The laboratory investigations including coagulation tests were normal. The patient had been managed by a medium pressure ventriculo-peritoneal shunt (VPS) with no immediate complications. A brain CT scan, done 3 months later, was satisfactory except for the presence of an asymptomatic bilateral hydroma (Fig. 1b). Eight months later, the patient was readmitted to our department for treatment of epilepsy and irritability. A new brain CT scan with contrast agent injection revealed a right frontoparietal subdural hematoma with an ipsilateral frontal intraparenchymal hypodense lesion mimicking a brain abscess (Fig. 1c). During consultation, the patient confirmed that there was no previous medical history of brain trauma or anti-platelet drug administration. On physical examination, the patient was slightly febrile at 38 ◦ C without no papilledema or neurological deficit. The coagulation tests showed the prothrombin ratio at 100%, activated partial thromboplastin time at 30 seconds and the platelet count was 250,000/mm3 . Fig. 1. a: initial preoperative CT scan shows a communicated active hydrocephalus; b: first follow-up CT scan 3 months later showing an asymptomatic bilateral hydroma with ventricular cannula inside the ventricle; c: delayed intracranial hematomas (subdural and intraparenchymal) contralateral to VPS (black arrows); d and e: frontal intraparenchymal hematoma collected in the cupule; f: last brain CT scan follow-up 3 months after intracranial hematoma evacuation showing porencephalic cavity and ipsilateral ventricle attraction (black arrows). a : TDM cérébrale initiale montrant une hydrocéphalie communicante active ; b : première TDM cérébrale de contrôle à 3 mois montrant un hygrome bilatéral asymptomatique avec le cathéter intra-ventriculaire en place ; c : hématomes intracrâniens rétardés (sous-dural et intra-parenchymateux) controlatéraux au système de dérivation ventriculo-péritonéale (flèches noires) ; d et e : hématome intra-parenchymateux frontal collecté dans la cupule ; f : dernière TDM cérébrale de contrôle 3 mois après évacuation chirurgicale des hématomes intracrâniens montrant la cavité porencéphalique et l’attraction du ventricule homolatéral. O. Coulibaly et al. / Neurochirurgie 62 (2016) 105–107 Due to the presence of an intracranial abscess, an intracranial suppuration was decided. Subsequently, the patient underwent a burr hole craniotomy to evacuate the subdural hematoma and another burr hole trepanation to evacuate the frontal mass under general anaesthesia. Peroperatively, we found liquefied blood in the two sites that were immediately rinsed with isotonic saline solution until clear fluid came out of the burr holes (Fig. 1d and e). The microscopic view of the aspirated blood showed no abnormal structures, in particular no arteriovenous malformation. Our patient was free of symptoms and returned home six days after surgery. A CT scan performed three months later shown no recurrence (Fig. 1f). 3. Discussion Ventriculo-peritoneal shunt (VPS) is one of the most commonly used methods for hydrocephalus in daily neurosurgical practice. This therapeutic option often includes complications, such as shunt infections or malfunctions, under or over drainage, intracranial hemorrhage or hematoma, seizures or abdominal complications. It has been reported in the literature that 50% of patients who undergo shunts in the pediatric population results in failure within two years of placement and repeated neurosurgery is often necessary [2]. Among these complications, intracranial hematoma most frequently occurs due to intracranial vascular injury or a rapid intracranial pressure (ICP) decrease caused by over drainage of cerebrospinal fluid [3]. The intracranial hematoma is usually a subdural hematoma (SDH) or epidural hematoma (EDH). However, in our case, the delayed association of SDH and intraparenchymal hematoma is very uncommon. All intracranial hematomas reported in the literature were observed within fifteen days after surgery and primarily included intraparenchymal or epidural hematoma [4]. Any association, as in our patient, has to our knowledge never previously been reported in the literature. As mentioned by the authors, the likely mechanism of this bleeding in our case was probably due to over drainage. It has been reported that almost all instances of postoperative intracerebral hemorrhage secondary to VP shunt placement occurred soon after the operation [5]. In these cases, the hemorrhage might have been caused by multiple attempts at ventricular puncture, puncture of the choroid plexus or incorrect placement of the tube within the brain parenchyma [6–9]. In the pediatric population, intracranial hemorrhage may occur in 0.4% to 4% of cases after shunt operations [9–11]. In our case, the puncture was performed immediately and the tube was well inserted into the ventricle, perhaps sufficient enough to avoid spontaneous migration of the proximal extremity outside the ventricle after the drainage. In contrast, the mechanisms whereby intracerebral hematoma might occur after ventricular cannulation includes 107 a coexistent bleeding disorder, disruption of an intracerebral vessel, hemorrhage from an occult vascular malformation and head trauma occurring shortly after shunt placement [12]. However, neither of these mechanisms was encountered in our case. Based on the experience of this case, the authors strongly suggest that a programmable valve might be an alternative method, not in an attempt to prevent these delayed intracranial hematomas but to possibly to reduce any complications. 4. Conclusion In conclusion, delayed intracranial hematomas after VPS insertion can be a fatal complication. We suggest that a brain CT scan should be routinely performed in symptomatic patients with VPS and a programmable valve can be an option to reduce this kind of complication. Disclosure of interest The authors declare that they have no competing interest. References [1] Kausch W. 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