A 52-year-old Native American male presented to the neurosurgical service with a precipitous decline in mental status. The patient's medical history included hypertension with a previous cerebrovascular accident, metabolic encephalopathy related to chronic alcoholic liver disease, intravenous drug use, and aseptic meningitis for which he had been treated four months earlier. On arrival, he was afebrile and his vital signs were stable. His Glasgow Coma Scale (GCS) score was 4 with extensor posturing noted. A comprehensive emergency room evaluation included a serum toxicology screen positive for cocaine and a basic head computed tomogram (CT) that demonstrated communicating hydrocephalus. There was no evidence of intracranial hemorrhage.
The patient was admitted to the intensive care unit (ICU), and a right frontal external ventricular drain (EVD) was placed after normal coagulation parameters were confirmed. Both lumbar and ventricular CSF cultures were negative for infectious pathogens, including bacteria, fungus, and tuberculosis. A follow-up head CT demonstrated good position of the EVD with ipsilateral ventricular decompression. However, the left ventricular system remained distended. The placement of a contralateral EVD was associated with radiographic improvement of the hydrocephalus. Thereafter, the patient's GCS score improved to 14, and he became alert and purposeful but remained confused. Symptomatic elevations in intracranial pressure (ICP) accompanied efforts to wean the EVDs. The patient was scheduled for placement of a VP shunt, but the procedure was delayed because of infectious complications (blood, urine) and electrolyte abnormalities encountered during the patient's ICU course. His GCS score declined in conjunction with these metabolic issues, fluctuating between 6 and 10 in the midst of stable serial head CT and electroencephalographic (EEG) evaluations.
Following medical clearance, the patient was taken to the operating room. Bifrontal ventricular catheters were inserted given the demonstrated isolation of the lateral ventricles on the patient's first postventriculostomy head CT. These catheters converged through a "Y" connector onto a single medium-pressure valve. The distal aspect of the shunt system was tunneled subcutaneously to a minilaparotomy wound and was placed within the peritoneum. There were no apparent intraoperative complications, and the patient was extubated and returned to the ICU with his neurological examination unchanged.
Given the patient's persistent obtundation, a feeding jejunostomy was placed by a general surgeon five days later through a standard laparoscopic approach without intraoperative difficulty. Insufflation pressures within the peritoneum were maintained at approximately 15 mm Hg for the duration of the procedure (1.5 hours). Postoperatively, the patient tolerated extubation but was markedly more lethargic than his baseline condition. Within the recovery room, he failed to improve from a GCS of 4 (E 1, V 1, M 2) and developed intermittent periods of apnea. He was reintubated and the neurosurgery service was notified. An emergent head CT demonstrated ventriculomegaly with no evidence of intracranial hemorrhage or pneumocephalus. The patient was returned to the operating room for an anticipated shunt revision, with efforts at bilateral shunt taps technically unsuccessful.
Intraoperatively, the shunt valve was disconnected from the distal system tubing. Brisk CSF outflow was observed from the valve. When the two ventricular catheters were disconnected from the proximal aspect of the shunt valve, CSF drained well from both. A manometer connected to the proximal aspect of the distal shunt tubing measured a static fluid column at 35 cm H2O. Irrigation through the distal tubing with sterile saline initially met with resistance but was overcome with approximately 5 ml of fluid. Subsequent manometric testing repeatedly demonstrated distal fluid run off to less than 3 cm H2O. With the individual shunt components verified as functional, the system was reconnected and the single incision reapproximated in a layered fashion. Postoperatively, the patient improved to a GCS of 7 (E 2, M 4, V I) consistent with his prelaparoscopic neurological examination. A follow-up basic head CT obtained the next morning demonstrated a return of the patient's base-line ventricular size. The patient remained neurologically stable throughout the remainder of his acute hospitalization, and no further shunt difficulties were observed.