Thromboembolic infarction caused by an unknown patent foramen ovale 30 years after VA shunt insertion: a case report and review of the literature

Acta Neurochir (Wien). 2019 Jul;161(7):1381-1384. doi: 10.1007/s00701-019-03946-w. Epub 2019 May 20.

Abstract

Background: Ventriculoatrial shunt (VA) insertion is one of the possible surgical procedures to treat hydrocephalus. However, it is also associated with several complications such as obstruction and shunt infection as well as life-threatening complications like intraatrial thrombus or thrombosis on the distal catheter. In this case report, we share a rare case of a patient with a VA shunt, who was admitted to our hospital with a stroke.

Case description: A 56-year-old female patient with suspected acute stroke was admitted to the stroke unit. CT and MRI scans showed multiple cerebral infarctions in both hemispheres. The transesophageal echocardiography (TEE) showed at the tip of the VA shunt catheter, which was implanted about 30 years ago due to aqueduct stenosis, also a thrombotic formation as the reason of stroke. Interestingly, the tip of the catheter was not in the right atrium as expected, but in the left atrium. Further evaluation showed a patent foramen ovale (PFO), through which the catheter migrated from the right to the left side. At first, conservative treatment with anticoagulation was started with the aim to dissolve the thrombotic formation; however, a control TEE showed an unchanged mass at the catheter tip. Therefore, a ventriculoperitoneal shunt was implanted and the proximal shunt catheter was removed with an additional closure of the PFO by our heart surgeons. Postoperatively, the patient was discharged 10 days later in good condition to a rehabilitation center.

Conclusions: Thromboembolic events due to a PFO are rare but possible life-threatening complication after VA shunt insertion. Therefore, preoperative cardiac diagnostic might be clinically relevant prior to a VA shunt implantation to avoid such complications.

Keywords: Migrated catheter tip; Stroke; Unknown PFO; Ventriculoatrial shunt.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Cerebrospinal Fluid Shunts / adverse effects*
  • Echocardiography, Transesophageal
  • Female
  • Foramen Ovale, Patent / complications*
  • Foramen Ovale, Patent / diagnostic imaging
  • Humans
  • Hydrocephalus / surgery*
  • Middle Aged
  • Postoperative Complications / diagnostic imaging
  • Postoperative Complications / etiology*
  • Prostheses and Implants / adverse effects
  • Stroke / diagnostic imaging
  • Stroke / etiology*
  • Thromboembolism / diagnostic imaging
  • Thromboembolism / etiology*