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A 4-month-old boy with history of communicating hydrocephalus, who was 5 days postoperative
from a parieto-occipital ventriculoperitoneal (VP) shunt placement, presented to the
emergency department with fussiness and clear drainage from the postoperative incision.
The patient was afebrile, mildly tachycardic for age, awake, fussy, and difficult
to console. His physical examination revealed a markedly sunken anterior fontanelle
and a 5 cm × 1 cm × 2 cm area of fluctuance underlying the parietal incision. Clear
fluid was observed leaking from the suture line. A shunt series demonstrated marked
intraventricular pneumocephalus (Figure 1), presumably due to a ball valve effect of the leaking shunt, causing it to backfill
with air. During neurosurgical repair, the patient was noted to have a pseudomeningocele
formation (a pseudomeningocele is an extradural collection of cerebrospinal fluid
that results from a dural or arachnoid tear; it is an uncommon complication of spinal
surgery). The patient was admitted and underwent prompt neurosurgical revision, including
shunt externalization and dural repair. His postoperative course was complicated by
a brief episode of meningitis based sepsis. After clinical stabilization, he underwent
placement of a revised VP shunt without complication and was subsequently discharged
home on the second postoperative day.
Figure 1Shunt series images demonstrate profound intraventricular pneumocephalus at arrows.
