Ventriculo-Venous Cerebrospinal Fluid Shunts

Voi. No. 112, 2 Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved VENTRICULO-VENOUS FLUID CEREBROSPINAL SHUNTS* ROENTGENOLOGIC By JEREMY ALTMAN, ANALYSIS t and A. M.D., BALTIMORE, T HERE has been recent increased interest and technical improvement in treatment of hydrocephalus by ventriculovenous shunts. Radiologists should be familiar with pearance the of tations of attendant reports describing valve normal these roentgenologic shunts and have systems 2. appeared in used the liter- but no comparison of various valve systems and emphasis on their roentgenologic features could be found.7”5 The purpose of this communication is to characterize the most common ventriculo-venous shunts emphasizing the roen tgenologi c features useful in assessing complications and reasons for therapeutic failures. There are 3 ventriculo-atrial valve systems commonly in use for the treatment of hydrocephalus. Each maintains unidirectional diversion of cerebrospinal fluid (CSF) from the lateral cerebral ventricle to the cardiac right atrium. In each shunt system there is a ventricular catheter, one or more unidirectional valves, a flushing device and a cardiac catheter. ature, VALVE I. HOLTER In 1956, John not Holter SYSTEM designed a unidi- valve system for release of excess ventricular fluid into the blood stream. The i, il-C): system consists of8 (Fig. i.A radiopaque right angle catheter made of silicone rubber for cannulating the ventricular system. The catheter tip has rectional * Presented Florida, From t Resident Advanced emy as a Scientific Exhibit at September 29-October 2, 1970. the Department of Radiology, and Fellow, Academic Department Fellow of the of Science, National Research Health, Baltimore, Maryland. the The Seventy-first Johns Council. Department in of holes or mouth” “fish lose its for influx of CSF. consisting check elasticity; remain the of valves intact its resistance system’s 2 con- of sili- proper- 237 distal as 8 years limb; resume its indicates failure of of the Holter common of Institutions, Sciences, through the American Baltimore, the Roentgen Johns Ray valve facial vein Miami Beach, Society, Maryland. Baltimore, Maryland. of the Committee The the normal shape after obstruction in the is threaded Hopkins Hospital, on recommendation Radiological for as long proximal limb. The cardiac catheter Meeting Medical The Johns Foundation side assembly tubing to compression Annual Hopkins of Radiology, James Picker small after implantation.4 Another property of silicone rubber is that it produces minimal tissue reaction. Thrombus formation is also discouraged by its nonwettable surface.24 The Holter valve is designed so that the system’s patency can be tested by compressing the tubing linking the valves against the skull. Normally, fluid can be easily forced through the outlet valve and cardiac catheter. Following compression, the tubing will resume its normal shape when fluid is drawn in from the ventricular catheter and inflow valve. Inability to compress the tubing indicates obstruction ties SYSTEMS VALVE NI.D4 JR., cone rubber housed in stainless-steel jackets and linked by flexible tubing. 3. A cardiac catheter made of radiopaque silicone rubber tubing connected to the distal end of the valve assembly. The use of silicone rubber in the valve assembly is important because of its properties of self-adherence. This adherence allows the slit-like orifice in the valve cap to open at constant pressure and close as soon as CSF pressure falls.’7 Silicone rubber does Isolated commonly JAMES, A valve dom manifes- complications. several multiple ap- the EVERETTE MARYLAND Hopkins on Radiology, School of Hygiene National and AcadPublic Jeremy Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved 238 (A) I .me I. 11G. end and Altman A. Everette James, Jr. Holter valve S stem in place. Rickham reservoir catheter. (B) l)iagram of twin Holter valves showing slit l)iagram of Rickham reservoir seated in burr hole. Cap has side in drawing. burr of cardiac valves. right. (C) arm valve system. the into atrium rigilt ia ular vein and superior inal Holter catileter stant diameter. its tip in the atrial arose that the stiff injure mural thrombosis B catileter soft, silver (Type or catheter to a T\’pe thin, this thin A perforation. tilat end. seen ilaS Because roelltgellograpilicallv, modification important valve system was Penn2’ skull. Iile ventricle ated. traindica ted (as part LS assembled, funnel-shaped ventricular in access infected the wide aspiration of cerebro- intrathecal flushing of the s\stefll of instillation ventricu- tile valve of establisiles CSF. Correct is readil\- is simple design silunt crease tilrombotic liliS coIl- 1 end mod end . 2. may and ates is capped A flushing tile iloles the nects ing and in evaluadaptable I EM developed an a dif- attempt occlusive to de- problems. 2, il-C): device. catheter. tube a closed which SVS of (Fig. catheter. has multiple radiopaque to a puncturable device VAlVE 1957, and system consists A ventricular A cardiac The ventricular itself. of 111 5\stefll . be i-V ER et al.,- Pudenz tile 1tDENZ-H ferellt meningomvsystem accom tile to is or narrow reservoir catileter; 11. of a stain- diversion hvdrocephalus), of tile shunting Witil \Vhen consists permits for situations. Holter Rickham by primar\ many be punctured ma\ Holter dia- Ihe a sitle-arnl valve. Tilis measurement the The is left to Holter tile reservoir that Call trepilille opening in the reservoir wilen elocele liliS funnel-silaped into tile and diversion of distal flow into with Hoiter needle and functioning tapered of diapilragnl. pressure, unidirectional Note incorporation available to the catheter. In summar -, to for is self-sealing spinal fluid of antibiotics, lar a of introduced in 1965. less-steel, be inserted used of the impregnated silicone rubber catheter C) is currentl\’ being assessed. An and be concern hole. l)irection rubber also with a hypodermic ventricular fluid, leading devised distal cannot end a silicone phragm is for connection s -stem with intra- AS popular, distal was tapered tip cava. endocardium, tile with jug- to end designed vena became might internal cava. ihe origA) was of con- (Type It was superior placement tile vena 1971 JUNE, tip. silicone is seated rubber in tile side It conflushcranial Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved \o .. Ventriculo-Venous 2 No. 112, Cerebrospinal Fluid Shunts 239 I. ---I ‘1 0 (A) Line l’IG. 2. pressed. fluid out anti core the hole. cardiac and contains a With the central that the catheter cardiac in from tencv of clinically the Holter system. A single the valve system. distal streamlined veloped is of this system can cardiac and core” purpose by of of flushing opening cardiac of catheter device slit being com- tube forcing (black arrow) ventricular illustrating outer diameter tube. in the valve consists The manometric of the tile cardiac in the intake placement recently portion of the floats to tile choroid plexus. the air saline balloon etrating occluded. with tile prevents brain introduced malfu nction system. the anterior After of During air-filled portion of Monro foramen in- Ventricu- been of the catheter, the past a distal Balloon preventing in 111. car- catheter. tile has aids with (Garner Catheter) self-adherence rubber. catheter balloon balloon tile of the and replacement or CSF, the catheter the tip substance of distended from pen- and becoming tie- of multiple of flatable on of silicone A ventricular to mainof depend ventricles, A was valve be catheter. valve a constant properties as same He\’er tain end is drawn Thus, pa- in the Pudenzis contained in diac slits the very fluid the used valve the “slit for the much ihis tip seals which normal catheter. limb evaluated Heyer tip lar ven- through release, as ventricular each the fluid Upon is resumed the (B) i)iagram Place. characteristics with to flushes catheter. of in momentarily Hever shape free passage of the diaphragm opening and configuration in diaphragm permit seals tricular is discoid compression, momentarily system valve. device holes valve of central diaphragm (C) l)iagram of distal catheter. arrow) This peripheral Pudenz-Heyer depression (white burr fluid. drawing. Further Pudenz- of Hakim both valves sterilized HAKIM et al.’3 the because in an VM.VE have SYSTEM criticized Pudenz-Heyer tilese autoclave tile design and systems prior Holter cannot to use, be and Jeremy Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved 240 Altman and A. Everette James, Jr. l9 1 JUNE, L &I IS I \, 0 r . -I --5- 5S-- 5do tile\’ at tile remove not valve slits or petence feel wilich detritus can obstruction.1’ tilat Silicolle cilangeS opening pressures increased with use to vary illtracranial tile incom- Ilakinl rul)ber physical stainless-steel accumulating produce susceptible anti tinle, (and) its (11. also et is to leading to or deh\ dra- pressure In an eflort of to use of shunt valve claved. liliS . A valve let this crook.” silicone optional linked by The 3. solid Hakim distal oblique end. syntiletic sapphire end of the ical is a 1 mm. Inof the is an an with hole conical a 1.5 cylinder cilannel. to valve mm. this be s\stem. operating of these radius with of the jugular immediatel ’ prior of the tile unit. II mm. oblique in tile polished Connecting the with the A calibrated con- and time, valve catheter plexus. valve closing obstructing the small brospinal tricular debris antechamber hypodermic fluid pressures. use, ventricular of on brain tis- tile inner units maintain constant pressures despite use, In procedures. sapphire contact with onk the the valve seat, thus The to contact minimizes Tile stainless-steel sterilization assembly vein. tile risk of infection. configuration in the and are length cardiac catheter is and passes to the reducing the choroid pres- proposed advantages of tile components ma All theoretically The curved of in valves a compressible tile internal several autoclaved tip ball tubing. via are springs opening antecham- whicil ball. proximal hole to cylinder is seated end. radius connector and In a vertical end inner b- the tile catheter prevents penetration sue. Locating tile inlet holes radiopaque rubber valve, stainless-steel following distal tile a metallic catheter ball auto- 13): of on An ventricular the has in its curved placed are “shepherd’s 2. ber s stem the Iwo rubber to retains determines in tandem There of a end system. rigilt atrium Pudenz-Hever catheter rubber iloles prob- be and of the of silicone attendant and 3, iland (Fig. ventrici,lar silicone infection Hakim et al.” developed assembly tilat can components I and Holter tile systems, tile major to overcome occlusion attached distal 4. lile radiopaque made of silicone rubber tioll. lems seat sure linked causing spring oblique circular grinding into ma\ lleedle samples \Vhen perimeter of potentially smaller be the I)all makes particles. punctured b to cere- and obtain to the record outlet a venof tile Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved VOL. No. 112, Ventriculo-Venous 2 antechamber is occluded manual by valves presence pres- will flush the ventricular catheter. Experimentally, the Hakim valve was found to have the greatest flow capacsure, ity compression at to the The varying pressures Pudenz-Hever and ball-and-spring pressure while valve tile slit-valve compared Holter systems.26 s\’stems the outlet systems, of the tubing compression connecting valve Holter and evaluation as well cardiac regu- eter tilat and the il-C; 2 voir, ma radiopaque forms a right a high posterior Table if present, of as the flushing catheter. API’EARANCE system tile straigilt tilrougil in other palpation permit clinical of obstruction Ihe regulates late flow. As 241 Shunts ROEN’IGENOGRAPHIC when system Fluid Cerebrospinal i). A metallic is located be angle by identified ventricular as cathit passes trephine Rickham in tile burr (Fig. reserhole. 4, Altman Jeremy 242 A. Everette and Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved straight Valve metallic, hole burr in (optional) l’uden z-H ever silicone flushing hole straight Hakim 1971 - Reservoir Catneter Helter JUNE, SYSTEMS Ventricular Type Jr. I tABlE VALVE James, “shepherd’s rubber, device silicone crook” rubber chamber curve with burr ante- proximal valve in twin “fish in metallic mouth” slits in catheter distal atrial ball valves in me- twin tallic to Con nectors valves housing n v Ion metallic, between ventricular eter and Ilousin (optional) cathante- chamber It connects to the ventricular catheter and to the valve. The Holter valves are metal-encased and connected by a short length of tubing. They are characteristically placed in a subgaleal tunnel behind the mastoid area, but ma be located in parietal or occipital areas. The cardiac a tube leading catheter right and is radiopaque jugular internal vena cava Type stant tally. to the region descends vein and of the right A ventricular catheters diameter; Type B anti The Holter system can its by radiopaque the mastoid atrium. have a conC taper disbe identified ventricular twin valve housings density connected by area, in the superior catheter, of uniform metallic a short tube behind anti radiopaque cardiac The The valve appearance the characteristic and ball seat mastoid area. The and descends vein of to the nected by These catheter components only catheter device, a constant Pudenz-Hever system. is minimally radiopaque posterior 5B). The right side of the Its the at its tip connects distal region feature The tip and the hole descends superior is radiopaque of the device is located burr catheter neck of flushing and temporal cardiac (Fig. gil; to the right in a (Fig. in the mediastiand atrium should (Fig. of the an type The distinctive curved ventricular “shepherd’s catheter crook” identifies the systems evaluation tification shunt ticular ventricular cylinder con- several is valve valve and present, housings i). the design whether or and the in the mas- iden- and consideration of the parattendant to that system. engineering and ra- has been radioden- Roentgenographic an understanding requires and the basic the should begin with proper of tile t\’pe of ventriculo-venous ical In con- are However, catheter, (Table present hazards the the catheter have antechamber area to 6C). or valves metallic of metallic toid This SC). yen tricular can identif ’ which by the configuration not cava apparatus, in common. sity internal features. valve diologist utilized conthe is ra- right (Fig. Hakim characteristic is charac- a short behind vena atrium antechamber, a small end Me- catheter in the superior curved nected distal recognized. cardiac of the radiopaque be right identification antein roentgenoHolter system by are linked usually placed and the ven- radiopaque often diopaque A i). the oblique can twin valves tube and region the is similar to the tallic necting jugular Table 6i1; connects to but assembly flushing in catheter ventricular that is radiopaque Table i). This num. tricular b’ a straigilt (Fig. cylinder chamber. graphic Pudenz-Hever terized lie apparatus metallic most catheter. right Hakim small of the principles function of these phys- employed shunts. in \entriculo-\enous Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved 112, The position catheters genographic ventricular tal horn lateral tip of the is ver ’ ventricular assessment. catheter should of skull and important the lateral roen tgenogram, should be anterior The radiopaque tip l ’luid (. erebrospinal in The be the tip of the in the fron- ventricle.’9 the a trial roent- On the radiopaque to the coronal of the cardiac suture. cath- 5, Silunts eter is usually inferior aspect positioned of the bra roentgenograms portable tion. may prove other on chest unit at the Roen tgenograph be instilled into visualization method at to level taken time ic tile during is the sixtil thoracic fill of the contrast catileter insertion. tile catileter ) of the vertewith operama ten al to imAnWitil Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved 244 Jel ell1Y .Altlllall alld A. Fverette james, S_S S ,S Jr. S b. NU, 1971 Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved VOL. Ventricubo-Venous 2 No. 112, saline and use it as an electrode for placement by intracardiac electrocardiography.3’ In addition to examination for catheter position and physical integrity of the s ’stem, introduction of a radiopharmaceu tical into the CSF space to image CSF dynamics ( cisternography) function. A placed into along the catheter evaluate tients the with in followed the right to the shunt entire shunt the from be images system in pa- lumbar the atrium. be injected area lateral and its ventricles In studies contributor fluid ttl res into pleural subdural space, two decades, made circulatory in has in in The vascular Payr, in with reported successful cases.8 most common clinical use of tile var- the the until 1948. the be next vein, years, 30 various success to the work and in 3 of 8 little shunts the ven- decomfluid into compartment. the lateral jugular with to establish in cere- that could internal met tempting lateral decompression During investigators the cerebrospinal 1908, past been cardiac right atrium. treated with these lymphatic first connected or ventricle the have increased. suggested 895, by shunting pressed al.’4 shunt systems is in treatment of hydrocephalus. Hydrocephalus refers to any condition in which there is an excess of cerebrospinal fluid in proportion to the cerebral volume. Two general categories of hydrocephalus with increased pressure are :8 recognized i. Obstructive, in which there exists a mechanical block at some point between the lateral ventricles and the outlet foramina of the fourth ventricle. 2. Communicating, in which no obstruction to the flow of cerebrospinal fluid in tile ventricular system is found. In addition, an occult form of hydrocephalus with CSF pressure in the normal range but different from that associated with brain atrophy or degeneration has been characterized b .Adams et i1.’ Therapeu tic approaches have consisted of the extirpation and obliteration of the from hydrocephalus circulation ious i In of neurosurgical CSF greatly CSF shunting advances to the of patients Gartner, tricles anti development the peritoneal system.29 to divert ventricles number cerebrospinal including cavity, major the of spaces, ureter, the the to the (choroid communication di version , into bral The the extracranial mastoid, shunts DISCUSSION restoring , cisternostomv) of this type, the radiopharmaceutical should not diffuse across the CSF membrane (luring the period of the study and must have an appropriate effective half life (I”HSA, Tc99” albumin, Yb’69 DTPA have been used in our laboratory). In patients with noncommunicating hydrocephalus, the radiopharmaceutical may be injected directly into the lateral ventricles. a major cerebrospinal producing and absorbing struc(thi rd yen triculostomy , yen tn cub- shunts in- 245 of piexectomy) between Shunts plexus, formation cavity, and over atrium. hydrocephalus, may cardiac and choroid fluid assess may communicating trathecally into utilized shunt pathwa ’ tip in the right a radiopharmaceutical course be radiopharmaceutical directly obtained the distal To can Fluid Cerebrospinal of Hydrocephalus in at- systemic et Ingraham produced ex- perimentally in dogs was treated with a polyethylene shunt tube connecting the lateral ventricles to the sagittal sinus or Superior vena cava. In the anesthetized state, the system functioned well, but obstruction due to blood clot occurred of the catheter when the (logs concluded that be necessary to the shunt during trathoracic In Nulsen successful shunt steel and artificial system. Two ball valves pump prevented diverted the episodes increased in- superior design rubber “fish unidirectional connected from vena the cava. in 1956, mouth” Ventricubo-venous advantages Spitz2#{176}reported valve used backflow CSF Spitz ous of pressure. 1952, first awakened. Ingraham et a!. a unidirectional valve would prevent reflux of blood into in by the in a stainlessa rubber in a system that ventricle into lateral Holter modified substituting the silicone valves.8 shunting ot}ers numerthe palliation of hydro- 246 e l’em v A ItIll a 11 a nd .A. F V ma\ provoke acute pulmonar\’ heart congestive Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved It e I.e t te ja Illes, J r. crease in brain ular decompression bridging as SiOll and epi- J3). 2tt is frequent ill such thickening of sutures of ef}ective sequeiae tear and il and , Cal va rial closure scribed stretch bones ile- ventric- subdural (Fig. ces. premature acute may and sudden following dural hematomata Overlap of cranial 11 Tile causing vessels ci rcu msta edenla failure. size NI a Ild have been decompres- de- .‘ I NI I’ RI) I’ i : K (‘.\I’H Proper great position of Ventricular catheter penetration of or ‘05 ting tip is of obstruction. occlusion tile from 1 II I) N tile catileter in prevei importance tissue 1’I’ I’ K occurs catheter tip til brain 1)\’ the encasement wi into choroid site is reported in plexus. Blockage at tilis per cent of patients treated with tile 33 Pudenz-He ’er valvea2 and in 24 per cent of patients treated Of 455 cases in 74 cases tion r Arteriogram R,deni-Fleyer Three weeks region of the gram. in the right-sided fol occurred valve and l(IWI rig epidural insertion (II) Skull system. later calcification hematoma of is present (arrows). mal organ l -tes operation tile the tile tilese risk various without trictilo-atrial l)tlt tile of shulltillg fllost of tile Ilot are yen- varied Ac infection2’’’’12 a 11(1 man! requires the Hakim of tile Iii rapid \IIl) l)LCOMIR1N lt)\ tile i111111Ct ii a te di tricular version CSL” of into P to IhrOml)osis tue lit t()j)Cl ttiye rge Voitlille tile circulatory ( )t, ciude veil- Don pert of system ‘e1la i by is Ilot cava. wiii til at is placed Ihe jugular tile v tip occur catlleter balloon system I)egins ill to th the aiwavs in bus tile incidence tile impor- entrance and tubing.24 along of catheter represent vein almost mlii and hema- these problems. placement is also catileter tiistall ma ventricular tile indi- displace- subdural large and avoid catheter first tissue Inferior Pudenz-He\-er catileter )S curved system attempts .Atrial tile brain catheter a to tile of Monro.’1 be of of fron tab all tenor ma\- of The toma.’’ agates K is in the tile foramen ventricular presence behind placement tip penetration of tile occlusions Ideal ventricle, and by reported located of tile svstenl. the tile Sequeiac. lateral of tant. estations was catileter obstruction in tip ill position cation caused #{231}$ catileter the suture Cilanges ment obstruction, assessillent tile types of are of are roelltLrellObogic knowledge eiectrosystem procedures and llOr- However, Complications devices important tilroml)oemboiisnl curate fluid and a closed infection.-’’ siiunt ilazar(i. 110 was Nulsen’ of Monro. the obstructile choroid by anti their ventricular of catheter cases 32 when ibm is sifllple; is sacrificed; retained; and are reduces in tile foramen roentgeno- Holter s\stem.’’ Holter valve, tile encasement Becker of 55 occurred coronal cephalus: to tilronl bus.’’ showing which he,15,atolna titie plexus, the with ventricular tile was that lie. 7. (.1) with treated of proplile become oc- if the distal P heart or superiol’ of catileter tip Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved \o . No. 112, \entricubo-Venous 2 obstruction increases position4 with tile level above cardiac catheter. tout tip cm. to in tile firsts Low atrial tubing the need placement to the neck for shunt of the and revision.”2 OCClUSioN The over-all catileter valve tip of distal atrial placement and right Trauma right tic vegea trial wall VAlVE incidence also ill reported too far throm- when distally. MECHANISM of shunt there mechanism valve valve cases was with by valve was in blood was ren- In an- to detritus. tile wrong with treated 6 inStances blocked the by detri- other cases were where blocked and traced to use opening pres- found the Hakim valve resistant to failure of the valve mechanism. of this valve, tile sapphire ball In tile design nlakes contact with the perimeter of its valve seat, grinding debris into small non- sure.” Ojemann2l ratus is the presence occurs The I lakim function well particies. obstructing reported Another occlusion blood, incompetent due 6 cases, obstruction a from The ma v become tissue, of 455 H ranges cent.21-22’21 valve, and proximal per a review the clot Improper Ver ’ right are which 40 itself Flolter dered other results is piaced OF reduce the 247 of the apparatus to of In fl s. 6 often perforation.’”2 throml)i of the tricuspid to cent fragments 8, il-C). of tile reporte(i cardiac atrium tile catheter (Fig. portion 14 per Dl ecila nism mas- Shunts in an tile b\’ stretciling and botic obstruction.22 is associated with ventricular tation and from Fluid can of increases of life are tho- patient distance years the right the fourth retraction process placement in proximal tile of ihe xiphoid i ore of racic vertebra. Growth become a factor causing Cerebrospinal wilere to of grossly type the of bloods’ mechanical shunt tubing appa- even CSF. occlusion separates in Jeremy 248 .Altman and A. Everette James, throm 1)i n’i a y Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved ci rcula tion.’ witil enl bol ize At ‘ patibologic was follild Jt Jr. evidence of per 57 ill tile of repeated embolization and iibatiOll, em bolt s ofpatients treated shunts.’2 pertension onary pulnl exai i pulmonary cent ventricubo-atriab been to poStfllortem 1971 Il, N Progressioll to pulmonar cor pulmonale ily- also ilave tiescribed.’ IN FEC’IION tile reported iilfection 23 per cent, cephalus is ebocele.’ lile tioil sepsis, valve scalp aneurysms nla\’ picture.6 Organisms of I loiter (arr system is cardiac The fractured in catheter neck the region mation tws). in infection from its connectors motion. cent or i orrest and cases, tile silr.,nt tubing rated from brea motion (Fig. ) atrium or k at a pot Careful t of lb ventricle.’6 l)een examination will alert the reill these the of on elbtire tile radiologist fuse produces tilese coagulase ment of renloval of the chest or tiple Ihroni 1)osis catheter a trial alld 22 wail a ill initiate ma obstruction.’ tiiural IIO)I1t’ by I’l_1C F1ON tile cardiac superior ‘ena of tip catileter fornlation, tamponade.’’ ma S nialpositioned Iraumati’i,ation thronihus cardiac COM caval tile rigilt has led to perloratioll, Ca al and a trial pvrexia, I)if- tile nepilrotic in association silunts with infected Treat- ventricubo-venous shunts antibiotic administration the apparatus.6’22 roentgenogram ma septic infiltrates e produced tile signs Illegal of bac- anemia.6 reported of b\ and be helpful eml)oli are chronic 110 roentgenobogic of progressive for Chronic and cavitating ilave persist Staphylococci.” infected of Indolent may s\ ndrome negative consists tile inflam- tissues. glomerubonepilritis s ’ ndrom lit) l’ \i colonize obvious progressive ill tile evaluation complications. ‘Il-I RO\1 a and vir- coagu- and recognition)’ ilave been s ’ndrome with ventriculo-atrial roentto bacteremia witibout teremia to tile right accomplisiled surrounding Splenomegal\’ frequent Successful lellgtil of Siltlllt ttlbillg present genogram important of a 3 per sinlplv sepaThe cardiac embolize anti right has cases. points ill most had valve. Ilolter the can moval at found of tilis complication: incidence catheter breaks Cooper’’ months tile this low vulgaris without and and complicate Stap/zvlococci, apparatus Ill tile em boli, relatively Proteus negative silunting Staphy- infection ia, septic m -cotic lase roentgenugram. or- positive cause as em- virulent coagulase Septicem such or- (wound ventricular Highly frequently wound. infec- the of infection colonization, as tile virulence of tile is 6 to ilydro- meningomyof tile site such 5, ulence, (,hest wi th meningitis). ga ni sni lococci, 9. the aild conlplicating shunts Wllen tile manifestations upon gallism of ted associa depend p\’ema, 110;. incidence ventricuio-atrial rising greatl\’ ill if mulThe seen. bacterem findings anemia ia except spleno- and \‘. A roen t ation al shunt edge of c approacil tgenologi of tile patiellt 1l1 V these be witil a yen developed complications. to tile eval- triculo-atrifrom .Attelltioll knowlto Downloaded from www.ajronline.org by 52.73.204.196 on 05/17/22 from IP address 52.73.204.196. Copyright ARRS. For personal use only; all rights reserved VOL. No. 112, Ventricubo-Venous 2 Cerebrospinal the patient’s symptoms and progression of findings on sequential roentgenograms is important. Observations should include the following points: I. Identify the type of shunting device and inspect the tubing for discontinuities. Separation of tubing from other components of the system will most likely occur at points of connection to valve assemblies and reservoirs. 2. Location and position of the ventricand ular cardiac 3. In the in a patient catheters immediate must be note(1. postoperative with respiratory period, difficulty, chest roentgenogram may reveal edema dary large an(i congestive heart to fluid overload from amounts of CSF into the the of systemic circulation. . With symptoms cranial of increasing pressure, should be ping of skull obtained to cranial search bones which intra- There are of CSF ventricles tems have into the One I. prevent be or more . Prevention major A. I)epartment Johns anti electrolyte throm boem bobism tgenographicably A sequential check list frequently detectable approach and will aid greatly diagnosis. James, Jr., M.I). of Radiology Hopkins Hospital Maryland 21205 Obstruction by III, ogy, M.D., Associate Professor for reviewing this manuscript. space. also indebted be Miss Monica ning after assessed introduction ceutical into the 6. Embolic on chest of pulmonary of hypertension vasculature, changes or should helpful may by Sequential be heart early changes anti cor anti Lung scans are of anemia Knowledge various shunt roen tgenographic of show 2. ANDERsON, the approach. of the yen tricubo-a a guideline Utilizing complications anti Miss J. Fred Arlene Masanielo for of ProHodges, of Radio!\Ve are Berger anti secretarial the 3. as- these 4. H. paediat. BECKER, after Ventriculo-auriculostomy in 7. Craniosynostosis operation for scandinav., 1). P., anti 1966,55, NeLSEN, by shunt: of complications avoidance 226. 7. Neurosurg., as complica- Ala hydrocephalus. hydrocephalus maintenance. of I)., lISHER, H. ANDERsON, tion trial for R. treatment of hydrocephalus. 1959, i#{243}, 551-557. splenomegaly. of Walk- 126. or em- components of radiologist Radiology to A. Earl anti Chairman P. Dorst, M.D., C. Ni., HAKIM, S., OJEMANN, R. G., and SwEE’r, W. H. 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