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Don’t lose your head: Ventriculoperitoneal (VP) shunt issues
Case presentation
An 83-day-old female, with a history of congenital hydrocephalus and chronic subdural fluid collections, presents with a 1-week history of increasing fussiness and decreasing oral intake. She has a ventriculoperitoneal (VP) shunt that was placed soon after birth; there has been no revision of the shunt since placement. The mother reports to you that there has been no fever, vomiting, diarrhea, or rash, and there has been good urine output. She tells you that the child was seen by her primary care provider several days ago and was noted to have an increased head circumference compared to previous measurements, but she cannot elaborate further except to say she was told to make a follow-up appointment with the child’s pediatric neurosurgeon.
The child’s physical exam reveals an irritable, yet nontoxic, child. She is afebrile. Her respiratory rate is 40 breaths per minute with a heat rate of 180 beats per minute. A blood pressure is not documented. She has a small anterior fontanelle that seems full although the mother is unable to tell you how the fontanelle usually feels. She has palpable shunt tubing on the right parietal portion of her scalp; you are unable to feel a reservoir. The rest of her examination is unremarkable.
Imaging considerations
Plain radiography
A series of plain radiographs, more commonly known as a shunt series, is often the first step in the evaluation of a possible shunt malfunction. The purpose of these images is to examine the shunt tubing for cracks, kinking, or disconnections. A full series will evaluate the entire length of the shunt. The tubing is often coiled in the peritoneal cavity; this is to allow a patient to “grow” into their shunt and reduce the number of revisions necessary to compensate for a child’s growth. Recently, however, the utility of obtaining a traditional shunt series has come into question. , Some experts have proposed proceeding directly to neuroimaging in children when shunt malfunction is suspected, given the low sensitivity of plain radiography in detecting shunt malfunction. ,
The programmable valve settings on a shunt may be seen with a “valve view.” This view can be used to confirm shunt settings.
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