Intraventricular hemorrhage: A catastrophic complication after removal of old ventriculoperitoneal shunt

A 12-year-old female who was diagnosed as having Chiari I malformation with hydrocephalus had undergone a ventriculo-peritoneal (VP) shunt in another hospital five years back. She presented to us with complaints of intermittent fever, severe holocranial headache, vomiting and progressive deterioration of sensorium of one week duration. On examination, she was drowsy, opening eyes to call, confused but was obeying commands. Right pupil was dilated and fixed, and the left pupil was 2 mm in size and was reacting to light. Fundi showed bilateral papilledema. She was moving all four limbs spontaneously. Computed tomography (CT) brain showed dilated ventricular system with periventricular lucency [Figure 1]. The shunt was seen in situ with its tip in the right lateral ventricle. In view of high fever and rapid deterioration of sensorium, shunt malfunction secondary to an infection was suspected and her shunt was exteriorized and converted into an external ventricular drain (EVD). Cerebrospinal fluid (CSF) was sent for analysis and she was started on intravenous antibiotics. After three CSF culture reports excluded bacterial growth, she was planned for a VP shunt on the opposite side. Under general anesthesia, she underwent left VP shunt and removal of the right ventricular catheter, which was functioning as an EVD. No resistance was felt during removal of the old ventricular catheter. In the postoperative period, she complained of severe headache and nausea. An urgent postoperative CT scan revealed massive intraventricular hemorrhage and the new shunt catheter was seen in the left ventricle outside the blood cast [Figure 2]. However, the ventricular size had reduced and the periventricular lucency had disappeared indicating a functioning shunt. Since she improved in sensorium and also because the scan showed reduced ventricular size, she was managed conservatively with continuous monitoring. She gradually improved further, and her symptoms resolved completely.