PMC4533463_01
A: An X-ray image taken during the second operation of lumboperitoneal (LP) shunt placement shows that more than 7 cm of the shunt catheter locates in the subdural space (arrows).
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F1
The revision of the LP shunt system was done using the same valve system after insertion of a new lumbar catheter, 13 cm from the fascia at L3/4 after multiple dural punctures with a Tuohy needle (Fig. 1).
A: Computed tomography (CT) scans before lumboperitoneal shunt surgery show ventricular enlargement, compatible with idiopathic normal pressure hydrocephalus. B: CT scans taken on admission show bilateral chronic subdural hematoma (CSDH) compressing the adjacent brain with slit like ventricles. C: CT scans 2 weeks after the shunt removal reveal the worsening of the bilateral CSDH.
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F2
Computed tomography (CT) of the brain showed bilateral CSDH compressing the adjacent brain and slit like ventricles (Fig. 2B). Two weeks later, his cognitive function had been deteriorated and CT revealed the worsening of the bilateral CSDH (Fig. 2C).
A, B: Sagittal view images of lumbar computed tomography (CT) scan and magnetic resonance imaging showing that the tip of the shunt catheter is spontaneously pulled out and located between the 3rd and 4th lumbar levels and close to the dura mater in the ventral side of the subdural space (arrow). C, D: Coronal (C) and axial (D) views of CT-myelography before the shunt removal reveal spreading of the contrast medium along with the nerve root at the upper lumbar and the lower thoracic levels (arrows).
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F3
Sagittal view images of lumbar magnetic resonance imaging (MRI) and CT scan showed the tip of the shunt catheter was spontaneously pulled out and located close to the aforementioned dura mater in the ventral side of the subdural space (Fig. 3A, B) CT-myelography, punctured at the level between L4/5 to prove the leak point, revealed that contrast medium was spread along with the nerve root at the levels from Th12/L1 to L3/4 (Fig. 3C, D), indicating CSF leakage spreading into epidural space existed although the leak point was not detected clearly.
A: In the early phase of shuntography (left) contrast medium is pushed into the subdural space through the shunt catheter. Early spread of the contrast medium into the epidural space is shown (yellow arrowhead), coincident with spread into the subdural space. In the subsequent phase (right) contrast medium emanates from the upper lumbar to the lower thoracic level of the epidural space with a negative pressure gradient (yellow arrowheads). In addition, there is a minor cerebro-spinal fluid (CSF) leakage from the tip of the shunt catheter (black arrowhead) probably due to multiple dural punctures. B: Computed tomography (CT) scans soon after the shuntography reveal the contrast medium leakage around the inserted lumbar catheter and spreading into the epidural space (black and yellow arrowheads). C: T2-weighted image (T2WI) on magnetic resonance imaging at the same level as the CT scans before shunt removal shows the epidural space is expanded at the lumbar level (black and yellow arrowsheads). D: T2WI after the shunt removal shows disappearance of expansion of the epidural space.
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T2-weighted images on MRI (Fig. 4). On the other hand, lumbar MRI showed disappearance of expansion of the epidural space (Fig. 4D).
An actual figure of the inserted catheter (A) and schemes of the cerebrospinal fluid (CSF) leakage in the present case (B and C) revealed by several images shown in Figs. 3 and 4. The red area means the epidural space. As shown in A and B, actual length between the tip of the shunt catheter and the epidural space corresponds to one of side holes setting 9-10 mm from the tip. The schemes describe two routes of CSF leakage; the main route from the shunt side hole, and another from a small dura hole around the tip of the shunt catheter. ED: epidural space, SD: subdural space.
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F5
CSF intensity. This phenomenon suggested the CSF leakage related to the shunt system. Considering the possibility of the CSF leakage from the side hole to the epidural space as well as minor leakage from the tip of the lumbar catheter (Fig. 5), shunt removal was done.
A: Computed tomography (CT) scans taken soon after the burr-hole drainage show disappearance of the hematoma. B: CT scans before ventriculoperitoneal (VP) shunt shows the ventricle size is quite large with Evans index (0.44). C: CT scans just after VP shunt shows the ventricle size is improving.
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The patient underwent bilateral burr-hole drainage of the CSDH (Fig. 6A). Ventriculoperitoneal (VP) shunt placement was done (Fig. 6B, C) 3 months after the drainage because of gradual regression of the gait and memory disturbances.