Neuroendoscopic Navigated One-Step Removal of Crossed Ventricular Catheter Fragments: Technical Note

Abstract

Introduction Neuroendoscopy plays an important role in minimally invasive neurosurgery. The authors reported an interesting case of a pediatric patient with multiple ventriculoperitoneal shunt (VPS) revision surgeries, presenting with VPS infection and with two crossed intraventricular floating catheter fragments, successfully removed through a neuroendoscopic navigated one-step procedure. A literature review regarding this exceedingly rare condition has also been discussed.

Case Description An 11-year-old female patient with a history of congenital hydrocephalus was admitted to the emergency department with symptoms of intracranial hypertension, psychomotor agitation, and tetraparesis. She had a history of previous multiple VPS revisions. She had an urgent brain computed tomography scan that documented hydrocephalus; the VPS's intraventricular catheter tip was sited at the level of the right frontal horn. Two small floating catheter fragments, not connected to the VPS, were identified: the first close to the right lateral ventricle at the level of the right occipital horn, the second one between the right occipital horn and the third ventricle. First, she underwent an exteriorization of the distal catheter for VPS. Cerebrospinal fluid examination documented hyperproteinorrachia and a positive culture for Staphylococcus aureus. Then a navigated right transfrontal endoscopic approach to the right lateral ventricle was performed extending to the previous burr hole and achieving a wide range of working angle with a rigid 0-degree lens endoscope. Intermittent irrigation generating convective flow was performed such as to mobilize the catheters tip gently upward, to remove them by grasping. Finally, a whole VPS replacement has been performed.

Conclusion Persistence of intraventricular floating catheter fragments can lead to subacute or chronic infections. Neuroendoscopic retrieval represents a safe and effective alternative to a more extensive and invasive surgical approach. However, the exact catheter tip identification, grasping, and removal can be difficult to achieve, due to the technical instrumentation characteristics and altered intraventricular anatomy in chronic congenital hydrocephalus. In our experience, endoscopic convective flow induction through saline irrigation can determine floating intraventricular catheter fragments movement aiming to their identification and subsequent successful endoscopic retrieval.

Keywords

neuroendoscopy - shunt catheter - ventricular system - hydrocephalus - convective flow

Authors' Contributions

Conception and design of study:

Acquisition of data: A.C., G.S., S.M., G.E.U., G.V., C.R.

Analysis and/or interpretation of data: A.C., G.S., S.C., G.F.N., D.G.I.

Drafting the manuscript: G.S., G.E.U., S.M.

Revising the manuscript critically for important intellectual content: S.C., G.F.N., D.G.I.

Approval of the version of the manuscript to be published: A.C., G.S., S.M., C.R., G.V., G.E.U., S.C., D.G.I., G.F.N.

Publication History

Received: 03 August 2021

Accepted: 04 November 2021

Article published online:
13 December 2021

• References

• 1 Guan F, Peng WC, Huang H. et al. Application of neuroendoscopic surgical techniques in the assessment and treatment of cerebral ventricular infection. Neural Regen Res 2019; 14 (12) 2095-2103
• 2 Mohanty A, Manwaring K. Endoscopically assisted retrieval of an intracranial air gun pellet. Pediatr Neurosurg 2002; 37 (01) 52-55
• 3 Duddleston PJ, Gendreau JL, Little KA, Andrews A, Thompson WD. Navigation-guided neuroendoscopic removal of an intracranial migratory pellet from the thalamus of a 4-year-old girl. J Neurosurg Pediatr 2020; 1–4: 1-4
• 4 Quach H, Wait SD, Agarwal V, Teo C. Endoscopic Approaches to Ventricular Tumors and Colloid Cysts. Principles of Neurological Surgery 4th ed. Ellenbogen RG, Sekhar LN, Kitchen N: Elsevier; 2018: 658-665.e2
• 5 Del Bigio MR. Biological reactions to cerebrospinal fluid shunt devices: a review of the cellular pathology. Neurosurgery 1998; 42 (02) 319-325 , discussion 325–326
• 6 Eljamel MS, Sharif S, Pidgeon CN. Total intraventricular migration of unisystem ventriculo-peritoneal shunt. Acta Neurochir (Wien) 1995; 136 (3-4): 217-218
• 7 Gnanalingham KK, Lafuente J, Harkness W. Intraventricular migration of a Rickham reservoir: endoscopic retrieval. Childs Nerv Syst 2003; 19 (12) 831-833
• 8 Sagan LM, Kojder I, Madany Ł. Endoskopowo wspomagana rewizja uwieźnietego drenu komorowego układu zastawkowego. Ocena metody. Neurol Neurochir Pol 2005; 39 (04) 294-299
• 9 Wei Q, Xu Y, Peng K. et al. Value of the application of neuroendoscope in the treatment of ventriculoperitoneal shunt blockage. World Neurosurg 2018; 116: e469-e475
• 10 Schultz P, Leeds NE. Intraventricular septations complicating neonatal meningitis. J Neurosurg 1973; 38 (05) 620-626
• 11 Pettorini BL, Frassanito P, Tamburrini G, Massimi L, Caldarelli M, Di Rocco C. Retrieval of ventricular catheter with the aid of endoscopy: technical note. J Neurosurg Pediatr 2008; 2 (01) 71-74
• 12 Babadagli ME, Cooke D, Walling SA, McNeely PD. Endoscopic retrieval of flanged ventricular catheters. Can J Neurol Sci 2018; 45 (06) 692-695
• 13 Stratchko L, Filatova I, Agarwal A, Kanekar S. The ventricular system of the brain: anatomy and normal variations. Semin Ultrasound CT MR 2016; 37 (02) 72-83
• 14 Hrishi AP, Sethuraman M. Cerebrospinal fluid (CSF) analysis and interpretation in neurocritical care for acute neurological conditions. Indian J Crit Care Med 2019; 23 (Suppl. 02) S115-S119
• 15 Spennato P, Escamilla-Rodrìguez IE, Di Martino G, Imperato A, Mirone G, Cinalli G. Intraventricular bone wax as cause of recurrent cerebrospinal fluid infection: a neuroradiologic pitfall. World Neurosurg 2016; 88: 690.e7-690.e9