|Year : 2015 | Volume
| Issue : 2 | Page : 70-72
Perioperative ipsilateral extradural hematoma at the site of ventriculoperitoneal shunt burr hole
Snehjeet Hemant Wagh, Nilesh Balkrishna Bakale, Srikant Balasubramaniam, Devendra K Tyagi, Hemant V Savant
Department of Neurosurgery, T N Medical College and BYL Nair Hospital, Mumbai Central, Mumbai, Maharashtra, India
|Date of Web Publication||22-Mar-2016|
Dr. Snehjeet Hemant Wagh
202 Janki Sahnivas, 158 Shivaji Nagar, Nagpur - 440 010, Maharashtra
Source of Support: None, Conflict of Interest: None
Ventriculoperitoneal (VP) shunt, a common neurosurgical procedure, has a long list of known complications associated with it. An unusual complication of VP shunt procedure is extradural hemorrhage (EDH), more common in children. Described here is a case of a 30 years old male with hydrocephalus due to posterior fossa tumor, who underwent shunt procedure for raised intracranial pressure but postoperatively developed extra-dural hematoma at the site of VP shunt burr hole which presented as hemiparesis. Craniotomy with evacuation of hematoma improved the hemiparesis.
Keywords: Burr-hole site extradural hematoma, hemiparesis, ventriculoperitoneal shunting
|How to cite this article:|
Wagh SH, Bakale NB, Balasubramaniam S, Tyagi DK, Savant HV. Perioperative ipsilateral extradural hematoma at the site of ventriculoperitoneal shunt burr hole. Afr J Trauma 2015;4:70-2
|How to cite this URL:|
Wagh SH, Bakale NB, Balasubramaniam S, Tyagi DK, Savant HV. Perioperative ipsilateral extradural hematoma at the site of ventriculoperitoneal shunt burr hole. Afr J Trauma [serial online] 2015 [cited 2022 Aug 8];4:70-2. Available from: https://www.afrjtrauma.com/text.asp?2015/4/2/70/179224
| Introduction|| |
Ventriculoperitoneal (VP) shunt, a commonly performed neurosurgical procedure, also has the longest list of postoperative complications.  Although hematomas following VP shunt procedures are not very common, subdural hematomas (SDH) are far more frequent than extradural hematomas (EDH).  Only a few cases of EDH following a shunt procedure have been reported.  This complication is avoidable as well as easy to diagnose and manage. Timely evacuation in large hematomas has good outcomes. 
| Case Report|| |
A 30-year-old male patient presented with history of a persistent headache associated with nausea, vomiting, and imbalance while walking since 3 months. The patient was conscious and oriented and showed cerebellar signs on the right side. Magnetic resonance imaging brain was done which was suggestive of a diffuse mass arising from the parenchyma of the right cerebellar region displacing the fourth ventricle and causing obstructive hydrocephalus [Figure 1]. After commencement of antiedema measures, the VP shunt procedure was done on the left side, as the space occupying lesion was on the right side. The tumor excision was planned at a later sitting.
|Figure 1: Mass arising from the parenchyma in the right cerebellar region displacing the fourth ventricle|
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In the immediate postoperative period, the patient was conscious, oriented but had right sided hemiparesis with grade 3/5 power in the upper limb and grade 4/5 power in the lower limb. Immediate computed tomography (CT) scan brain revealed a large EDH at site of VP shunt site burr hole [Figure 2] and [Figure 3].
|Figure 2: Postventriculoperitoneal shunt scan, Axial view (black arrows showing extradural hematomas on the side of ventriculoperitoneal shunt)|
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|Figure 3: Postventriculoperitoneal shunt scan, Sagittal view (black arrows showing extradural hematomas on the side of ventriculoperitoneal shunt)|
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The coagulation profile was normal. The patient underwent an urgent craniotomy. A left-sided posterior parietal craniotomy around the VP shunt burr hole was done. EDH was evacuated, and the shunt was found to be in proper position and functioning well [Figure 4]. Postoperatively, intensive monitoring showed fast and uneventful recovery. The patient regained normal power in affected limbs in the immediate postoperative period.
Two weeks later, the patient underwent a right retrosigmoid craniectomy with radical decompression of the tumor. Histopathological report proved it to be a glioblastoma multiforme, and the patient received sessions of postoperative chemotherapy and radiotherapy.
| Discussion|| |
Since its introduction by Cushing in 1902, the ventricular drainage procedures are being used as a way to reduce the raised intracranial pressure. Schorste in 1942 reported the first complication of VP shunt.  Epidural bleeding after ventriculoatrial shunting in 5.6% of adult patients and 0% of pediatric ones between 1965 and 1973 were reported by Driesen and Elies.  Fujimoto et al. reported the incidence of EDH after ventricular drainage procedures (including VP shunt procedures) as 0.4%. 
Because of firm attachment of the dura to the inner surface of the skull, EDH is quite rare after ventricular drainage.  However, there might be many reasons for EDH formation. The main mechanism for hematoma formation after ventricular decompression is sudden lowering of intracranial pressure, which results in a suction force on structures between the cortex and the inner table of the skull.  We propose that a possible cause is separation of the dura from calvarium due to compression of dura with brain needle during ventriculostomy. This causes a potential space for EDH formation. The other reasons could be bleeding from calvarial venous lakes.
The usage of valve-regulated shunt systems has lowered the incidence of SDH and EDH after ventricular drainage.  After the introduction of valve-regulated shunt placement, only 18 cases of EDH have been reported in literature.  Most were acute hematomas, with only five of them presenting as chronic calcified/ossified hematomas. These patients aged between 15 and 35 years. 
A postoperative epidural hematoma usually causes symptoms immediately after surgery. However, the diagnosis may be delayed in a case with VP shunt insertion because of a reduction in cerebrospinal fluid volume in the ventricles via a properly functioning shunt. The most common initial symptom is a headache, and there may be seizures in delayed cases or can be asymptomatic. ,
The hematomas were unrelated to the burr-hole sites in most of the EDH cases due to a VP shunt. In a series of five cases with chronic hematomas, hematomas in two patients were related to the burr-hole sites. In the other three cases, the hematomas were at sites away from the burr holes. Three of them were in the frontal region, which may be because of the lax attachment of dura mater in the anterior half of the cranial vault as compared to that in the posterior half. 
Management of a postshunt EDH can be either surgical or conservative. The choice between surgical intervention and conservative management depends upon:
- Clinical scenario
- Volume and thickness of EDH
- Midline shift and
- Amount of fresh blood present on CT scan.
Usually, surgical treatment is required for huge acute or subacute collections in adults or children with closed fontanelles. 
Ours was a young patient who presented with an acute onset EDH in immediate postoperative period with sudden onset hemiparesis. The hematoma was large, causing pressure effect on the brain parenchyma resulting in hemiparesis. This is an unusual presentation of a VP shunt site EDH, which has not yet been encountered. Strong suspicion of the condition led to its early diagnosis on CT scan. The patient underwent an immediate craniotomy with evacuation of the EDH and recovered completely without any residual deficit.
| Conclusion|| |
EDH following VP shunt is unusual, can present in various forms, from being asymptomatic to trivial headaches to hemiparesis as in our case. Careful clinical observation and monitoring result in early diagnosis and prompt treatment. This in turn makes complete recovery possible. Good surgical technique and the use of pressure regulated valve shunt systems minimize the incidence of this complication.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Balasubramaniam S, Tyagi DK, Sawant HV. Intraparenchymal pericatheter cyst following disconnection of ventriculoperitoneal shunt system. J Postgrad Med 2013;59:232-4.
Kalia KK, Swift DM, Pang D. Multiple epidural hematomas following ventriculoperitoneal shunt. Pediatr Neurosurg 1993;19:78-80.
Paiva WS, Oliveira AM, de Andrade AF, Brock RS, Teixeira MJ. Remote postoperative epidural hematoma after subdural hygroma drainage. Case Rep Med 2010;2010:417895.
Jain SK, Sundar IV, Sharma V, Arora R, Prasanna KL. Chronic ossified extradural hematoma on the opposite side of the ventriculoperitoneal shunt procedure: A rare case report. Saudi J Health Sci 2012;1:159-61.
Sengupta RP, Hankinson J. Extradural haemorrhage - A hazard of ventricular drainage. J Neurol Neurosurg Psychiatry 1972;35:297-303.
Driesen W, Elies W. Epidural and subdural haematomas as a complication of internal drainage of cerebrospinal fluid in hydrocephalus. Acta Neurochir (Wien) 1974;30:85-93.
Fujimoto Y, Aguiar PH, Carneiro JD, Martins RS, Ciquini O Jr, de Andrade AF, et al.
Spontaneous epidural hematoma following a shunt in an infant with congenital factor X deficiency. Case report and literature review. Neurosurg Rev 1999;22:226-9.
Seyithanoglu H, Guzey FK, Emel E, Ozkan N, Aycan A. Chronic ossified epidural hematoma after ventriculoperitoneal shunt insertion: A case report. Turk Neurosurg 2010;20:519-23.
Byrappa V, Redhu S, Varadarajan B. Delayed incidental diagnosis of postoperative extradural hematoma following ventriculoperitoneal shunt. J Neurosci Rural Pract 2015;6:94-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]