NEURORADIOLOGY: Pediatric/Congenital

Case Author: Sumit Pruthi, MBBS, Monroe Carrell Jr. Children’s Hospital at Vanderbilt University

History

6-year-old boy with fever, irritability, and headache.

Imaging Findings

Axial (A) and coronal (B) single-shot T2-weighted MR images show moderate lateral ventricular dilatation with transependymal flow of CSF. Also evident in B is a moderate amount of fluid tracking along the right occipital and parietal region surrounding a shunt reservoir.

Diagnosis

Shunt failure

Teaching Points

The imaging feature most suggestive of shunt failure is interval ventricular enlargement. Comparison with previous images is crucial to detecting subtle changes in ventricular size.

Identification of small ventricles on images does not equal a diagnosis of adequate shunt function.

In approximately 10–15% of cases, shunt failure accompanies small ventricles, and these images should not be used as the only means of shunt evaluation.

Poor ventricular compliance can prevent changes in ventricular size despite clinical shunt failure; hence normal or stable ventricular size does not exclude shunt failure.

In patients with clinical shunt failure and normal or stable ventricular size, fluid tracking along the catheter may be the only imaging sign of shunt failure. Clinical factors are also considered in the diagnosis of shunt malfunction and can greatly influence the decision to proceed with shunt revision.

Suggested Readings

Iskander BJ, McLaughlin C, Mapstone TB, Grabb PA, Oakes WJ. Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size. Pediatrics 1998; 101:1031–1036

Rekate HL. Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst 2008; 24:423–430

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