Intraventricular hemorrhage after ventriculoperitoneal shunt removal.

Sir,

Ventriculoperitoneal (VP) shunt insertion is commonly carried out for management of symptomatic hydrocephalus. Infection, hemorrhage, neural trauma, shunt malfunction, and obstruction are well-recognized complications of the procedure.[1] Neurologic deterioration after a short surgical procedure is a matter of concern. Deterioration of sensorium owing to intracranial hemorrhage after shunt removal is rare. We report acute neurologic deterioration in a 28-year-old man after VP shunt removal was done under monitored anesthesia care (MAC). The patient presented with external displacement of abdominal end of VP shunt (in situ). He had a history of tuberculous meningitis with hydrocephalus for which the shunt was inserted. Except for signs of infection at the abdominal incision site, the patient had no other physical, neurologic, or hematologic abnormality. VP shunt removal was planned under MAC. In the operation theater, an intravenous (IV) access was secured and routine monitors were connected. After ascertaining a negative intradermal sensitivity test, various sites in the scalp, neck, and abdomen were infiltrated with lignocaine 2% and adrenaline (1:200000). As the patient was apprehensive, propofol 20 mg and fentanyl 50 μg was given IV and oxygen was administered by facemask (4 L/ min). The patient remained calm and was responsive to verbal commands with stable vitals. The procedure lasted for 30 min. At the end of procedure, the patient was shifted to the recovery room where his Glasgow Coma Scale (GCS) was observed to be deteriorated (after 20 min) from a full score of 15 to 10. Meanwhile, signs of respiratory obstruction were observed and the oxygen saturation decreased to 85%. The patient was immediately shifted to the intensive care unit after securing the airway. An arterial blood gas analysis of the patient did not reveal any significant abnormality. However, the computed tomographic scan of brain revealed intraventricular hemorrhage [Figure 1]. An external ventricular drain (EVD) was inserted following which the GCS improved to full score after 2 h. The patient's trachea was extubated 12 h later and the EVD was removed 48 h after insertion. The patient was discharged on third postoperative day without any residual neurologic deficit.

Figure 1

Computed tomographic scan of brain with ventriculoperitoneal shunt in situ; (a) before shunt removal and intraventricular hemorrhage and (b) after shunt removal

In patients with tuberculous meningitis, hydrocephalus may occur due to blockage of basal cistern and sylvian fissure by exudates, vascular adhesive arachnoiditis, 4th ventricular outlet, or aqueductal obstruction. Insertion of VP shunt is indicated in such patients when hydrocephalus is associated with signs of raised intracranial pressure.[2] Neurologic deterioration after short surgical procedures may be attributed to both surgical and anesthetic causes. Anesthetic causes, such as drug overdose, hypoxia, hypercarbia, hypothermia, and metabolic and electrolyte imbalance were ruled out, in our case. A neurosurgical complication, such as intraventricular hemorrhage, venous air embolism, pneumocephalus, acute hydrocephalus or seizures, was suspected. VP shunt surgery is known to be complicated by intracerebral and intraventricular hemorrhage.[34] In long-standing cases the shunt catheter may adhere to the ventricular wall or choroid plexus owing to arachnoiditis. In such a scenario, if the shunt is not carefully removed, that may lead to inadvertent intracranial bleeding.[5] Probably, a similar event occurred in our patient that led to acute neurologic deterioration during early postoperative period. This case re-emphasises the importance of careful postoperative monitoring and radiologic evaluation of all neurosurgical cases even when the procedure is of short duration and is performed under MAC.