Case Report

Long-termevaluation of a new ventriculoperitoneal

shunt valve systemin a dog
Richard da Rocha Filgueiras, DVM, PhD, DCBCAV; Christine de Souza Martins, DVM, MSc; Ricardo
Miyasaka de Almeida, DVM, PhD, DCBCAV; Rosana Marques Silva, DVM, PhD; Martha de Souza
Teixeira da Rocha, DVM; Fernanda de Paula Firmino, DVM, MSc; Samara Maguilnik, DVM and
Lu za Quintao Medeiros, DVM
Abstract
Objective To report on the use of a new ventriculoperitoneal shunt (VPS) valve system utilized in a dog with
hydrocephalus and to describe the clinical course over 20 months after implantation.
Case Summary A 3-month-old female Lhasa Apso dog was presented with lateral strabismus, domed
calvarium, and visual decits. A lateral skull radiograph revealed a persistent fontanelle. Transfontanellar
ultrasonographic examination and computed tomographic examination showed excessive accumulation of
uid within the ventricles. The owner had observed symptoms as early as 1 month after birth, suggesting
congenital hydrocephalus. AVPS with a new valve system that inhibits cerebrospinal uid overdrainage and
obstruction of the catheter was implanted. The dog showed clinical improvement 48 hours after the procedure.
Twenty days after shunt implantation, another computed tomography scan was performed that showed
reduction in ventricle size. The evaluation of VPS patency was carried out 20 months after surgery and
demonstrated that the system was working properly without obstruction.
New or Unique Information Provided There are reports in the literature describing the use of several devices
to perform VPS in dogs. A new device not previously described in the veterinary literature was used in this case
report, and according to the manufacturers description, this device inhibits proteinaceous build-up, which is
usually responsible for subsequent catheter obstructions.
(J Vet Emerg Crit Care 2009; 19(6): 623628) doi: 10.1111/j.1476-4431.2009.00484.x
Keywords: cerebral drainage, cerebrospinal uid, congenital hydrocephalus, ventricular catheter
Introduction
The term hydrocephalus implies the presence of an
excessive accumulation of cerebrospinal uid (CSF)
within the cranial cavity with dilation of the ventricular
system.
1
CSF protects, supports, and nourishes the
central nervous system. It originates from the choroid
plexus of the lateral, third, and fourth ventricles di-
rectly from the brain by way of the ependymal lining of
the ventricular system and pial-glial membrane cover-
ing the external brain surface as well as from the blood
vessels of the pia and arachnoid.
2
Causes of hydrocephalus can be congenital or ac-
quired. In veterinary patients, congenital hydrocephalus
is more common than acquired.
1
Causes of congenital
hydrocephalus are reported as follows: fusion of rostral
colliculi with secondary mesencephalic aqueductal steno-
sis; prenatal inammation with lesions of the ependymal
surface; and malformations of the cerebellum, as in
caudal occipital malformation syndrome. In the latter 2
causes, secondary cerebellar herniation and syringo-
hydromyelia may occur and obstruct CSF drainage.
1
Clinical signs of hydrocephalus reect the anatomic
level of disease involvement. Forebrain, vestibular, or
cerebellar signs are most common. A ventral or lateral
strabismus or both, alterations in cognition, dementia,
circling gait, paresis, and seizures are common in
dogs with hydrocephalus. Congenital hydrocephalus is
typically recognized in patients 23 months of age. An-
imals with congenital hydrocephalus are often smaller
than their littermates and show calvarium distortion
according to the rate of uid accumulation and stage of
ossication of cranial sutures.
2
The work was carried out at the Veterinary Teaching Hospital of University
of Brasilia.
The authors declare no conicts of interest.
Address correspondence and reprint requests to
Dr. Richard da Rocha Filgueiras, Hospital Veterinario de Pequenos Ani-
mais, Campus Universitario Darcy Ribeiro, Avenida L4 norte, Asa Norte,
Bras lia DF. Cep: 70330-050, Brazil.
Email: richardlgueiras@gmail.com
Faculdade de Agronomia e Medicina Veterinaria, Campus Universitario
Darcy Ribeiro, Universidade de Bras lia, Asa Norte, DF 70 879-130, Brazil
Journal of Veterinary Emergency and Critical Care 19(6) 2009, pp 623628
doi:10.1111/j.1476-4431.2009.00484.x
& Veterinary Emergency and Critical Care Society 2009 623
Treatment of hydrocephalus may be medical or
surgical. Medical treatment involves the use of gluco-
corticoids, such as prednisone, and diuretics, such
as furosemide and acetazolamide, which reduce CSF
production.
1
Medical therapy usually does not provide
long-term resolution of clinical signs unless a specic
cause can be identied and resolved with treatment.
2
Surgical treatment may be recommended for those
animals that do not improve within 2 weeks or if
deterioration occurs during corticosteroid therapy. The
goal of surgical intervention is to provide drainage
of CSF from the brain to another site for absorption.
3
The most common surgical procedure in veterinary
patients is implantation of a ventriculoperitoneal shunt
(VPS), because it is easiest to install and is frequently
used in human neurosurgery. In this technique, a
fenestrated catheter is inserted into the ventricular
system (right or left lateral ventricle), and then, a valve
that controls gravity-induced hydrostatic pressure and
a distal catheter are tted together. The distal catheter
is guided through the SC tissues until reaching the
abdominal cavity.
4
A less common alternative shunt
is the ventriculoatrial shunt, in which the distal catheter
is inserted into the jugular vein until it reaches the right
atrium.
1
In a retrospective human study of 321 shunts
carried out in Japan, only 3% of patients had a vent-
riculoatrial shunt implanted.
5
Case Report
A 3-month-old female Lhasa Apso (2.45 kg) was pre-
sented with lateral strabismus, domed calvarium
(Figure 1), and bilateral blindness. According to the
owner, the dog did not respond appropriately to verbal
training cues and seemed obtunded. During ophthal-
mologic examination, it was observed that the dog
had no menace response and bumped into obstacles,
but pupillary light and palpebral reexes were normal.
A lateral skull radiograph revealed a persistent fonta-
nelle (Figure 2) and transfontanellar ultrasonographic
examination showed excessive accumulation of uid
within the ventricles.
Because the clinical signs and imaging ndings were
compatible with congenital hydrocephalus, the dog re-
ceived prednisone
a
(0.5 mg/kg, PO, q 24 h) for 13 days.
In the follow-up examination, the dog had no improve-
ment and showed a circling gait to the right, symmet-
rical and generalized tonic-clonic seizures, and head
pressing. Furosemide
b
(2 mg/kg, PO, q 24 h) was pre-
scribed in combination with prednisone and the dog
underwent a computed tomographic (CT) examination
that showed a severe enlargement of the ventricles
(Figure 3). Fifteen days after initiation of medical treat-
ment, the dog presented with no changes in the circling
gait, visual decits, and persistent fontanelle but
no further seizures had occurred. Intracranial pres-
sure (ICP) measurement is not currently available in
our hospital. As a result, a transfontanellar ventricu-
lostomy, described by Feldman and Narayan,
6
was at-
tempted in order to assess the ICP. However,
immediately after the fontanelle perforation, an intense
hemorrhage occurred, and the procedure was aborted
because of the risk of subdural hematoma occurrence.
With the owners permission, surgical treatment was
undertaken and a VPS as described by Harrington et al
2
and Bayston et al
7
was performed using a catheter with
Figure1: Three-month-old Lhasa Apso demonstrating domed
calvarium.
Figure2: Lateral skull radiograph showing persistent fontanelle
(arrow).
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00484.x 624
R. da Rocha Filgueiras et al.
a 70 mm H
2
O operating valve system.
c
Before the
procedure, a complete blood count and biochemistry
prole were performed and all parameters evaluated
were found to be within reference intervals.
General anesthesia was induced with propofol
d
(0.5 mg/kg/min, IV) and fentanyl
e
(0.6 mg/kg/min,
IV) diluted in 0.9% NaCl solution. Fluids were admin-
istered at 20 mL/kg/h using an infusion pump.
f
Moni-
toring of physiological parameters was performed
during anesthesia using a multiparametric monitor.
g
End-tidal carbon dioxide was maintained at a pressure
of approximately 3545 mm Hg using manual venti-
lation when necessary and mean arterial pressure
was maintained at 70100 mm Hg with an infusion of
dopamine
h
(5.0 mg/kg/min).
The dog was positioned in right lateral recumbency,
and left side of skull, thorax, and abdomen was asep-
tically prepared. A skin incision was made between the
zygomatic arch and occipital crest, and the temporalis
muscle was resected to expose the parietal bone. Per-
foration of the left parietal bone, near the parieto-
occipital suture, was performed with an electric drill
i
and 3.0 mm drill bit. The dura mater was punctured
and a fenestrated ventricular (proximal) catheter mea-
suring 2.5 mm in external diameter and 1.2 mm in in-
ternal diameter was placed in the left ventricle due
to its greater enlargement (Figure 4).
An intraoperative radiograph demonstrated that
approximately 50.0 mm of the catheter was inserted in-
side the skull. The remaining proximal catheter exiting
from the skull was xed over the mid-dorsal nuchal
region at the level of C1-C2 with a 901 plastic adaptor
and Chinese nger-trap suture pattern with 3-0 nylon.
Figure4: (A) Perforation in left parietal bone with electric drill. (B) Dura mater exposed (arrow). (C) Catheter insertion in the left
ventricle. (D) CSF draining from the catheter extremity (arrow).
Figure3: Computed tomographic examination (axial view) per-
formed before surgery showing enlarged ventricles. Left lateral
ventricle53.40cm2.18cm (#). Third ventricle53.09 cm1.78 cm
(n ). Right lateral ventricle53.46cm1.64 cm (f).
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00484.x 625
New ventriculoperitoneal shunt valve system
A high-pressure Hakim precision valve system
c
(Figure
5) with a silicone reservoir for CSF (Rickham reservoir)
was connected to the proximal catheter. After lling the
reservoir, the CSF was aspirated with a 26-Ga needle
and sent to laboratory for cytologic analysis and bac-
teriologic and fungal culture and susceptibility testing.
A SC tunnel was made from the cervical plane to the
left paralumbar region at the level of L2 using a plastic
rod. The distal catheter was connected to the valve, and
after visualization of CSF drainage, it was pulled
through the SC tunnel and placed in the abdominal
cavity (Figure 6). All SC tissues were sutured with 3-0
polyglactin in a simple continuous pattern and the skin
sutured with 3-0 nylon in a simple interrupted pattern.
The dog was kept under constant observation for
7 days after surgery and received cephalexin
j
(30mg/kg,
PO, q 12h), prednisone
a
(0.5mg/kg, PO, q 24h), tram-
adol
k
(2.0mg/kg, PO, q 8h), and ranitidine
l
(2.0mg/kg,
PO, q 12h). During this observation period, physiological
variables such as pulse, temperature, heart rate, and non-
invasive blood pressure were evaluated every 4 hours,
and all values were normal.
The cytologic analysis of CSF showed a mild increase
of cells and protein (WBC, 9 10
6
/L; reference interval,
58 10
6
/L; RBC, 270 10
6
/L; reference interval,
0 10
6
/L; and CSF protein, 420 mg/L, reference inter-
val, 250300 mg/L). These alterations were probably
the result of the hemorrhage that originated during the
ventriculostomy procedure. The bacteriologic and fun-
gal cultures of the CSF uid were negative for growth.
The signs of head pressing disappeared 24 hours af-
ter the procedure, and after 48 hours, the dog had a
menace response and reduced circling gait. Initially, the
dog was obtunded and according to the owner dem-
onstrated poor ability to learn commands, which has
been reported with other dogs with hydrocephalus.
8
During clinical examination carried out at 20 days after
surgery, the dogs command learning was improved as
observed by the reaction after its name had been called.
In this period the dog gained 300 g in weight.
Another CT was performed 20 days after surgery and
showed marked reduction in ventricle size (Figure 7).
Thirty days after the surgical procedure, the dog
returned to the hospital presenting with seizures and
was treated with phenobarbital
m
(2mg/kg, PO, q 24 h).
Because of this sign, VPS patency was evaluated with
injection of nonionic-iodinated contrast
n
into the silicone
reservoir as described by Goeser et al.
9
After 15 minutes,
an abdominal radiograph revealed contrast in the peri-
toneal cavity, demonstrating no VPS obstruction.
Another VPS patency evaluation, as described before,
was carried out 20 months after surgery and demon-
strated that the system was working properly without
obstruction (Figure 8).
Discussion
Several devices have been described in the literature
for performing a VPS in dogs.
3,4,8,10
However, a high
number of these devices can become obstructed with
Figure5: Ventriculoperitoneal catheter with Codman Hakim
precision valve system and Rickham reservoir (arrow).
Figure6: Computed tomography 20 d after surgery showing
the ventriculoperitoneal shunt from its insertion into skull into
the abdomen. Codman Hakim Precision Valve (arrow).
Figure7: Computed tomographic examination (axial view)
performed 20 d after surgery showing reduction of ven-
tricle size. Left lateral ventricle 53.02 cm 2.04 cm (#). Third
ventricle 51.89 cm 0.71 cm (n ). Right lateral ventricle 5
2.79 cm 1.14 cm (f). Proximal catheter (arrow).
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00484.x 626
R. da Rocha Filgueiras et al.
proteinaceous build-up, leading to drainage reduction
and return of intracranial hypertension.
9,11
There are
low (o70 mm H
2
O), medium (70120 mm H
2
O), and
high-pressure (4120 mm H
2
O) valves for maintaining
ventricular pressures within preset ranges. The normal
ICP in dogs is between 8 and 12 mm Hg (108.7 and
163.1 mm H
2
O)
4
and CSF production occurs at a mean
rate of 2.82 mL of CSF/h.
2
Although we could not
monitor the ICP in the dog in this case report, the me-
dium pressure valve (70 mm H
2
O) was chosen because
its valve works nearly at the normal ICP of dogs
and may prevent overdrainage. In a serial study of
5 dogs with VPS with a medium-pressure valve, valve
obstruction was encountered in 1 case and overdrain-
age in other.
10
Overdrainage may occur in catheters without a valve
system. The absence of a control valve immediately
after the proximal catheter, leads to an excessive
and abrupt reduction of CSF, causing headache, vom-
iting, subdural hematoma, proximal obstruction, and
changes in vision.
12,13
In its nal evaluation, 20 months
after surgery, the dog did not demonstrate any sign
of overdrainage, and with continued phenobarbital
prescription there were no further seizures.
In a recent report of VPS performed with a low-pressure
valve in a hydrocephalic Dachshund, an excessive ven-
tricular contraction occurred, and the authors attrib-
uted this to the excess outow of CSF during the
surgical procedure.
8
However, it is possible that the use
of a low-pressure valve allowed overdrainage.
Complications associated with shunt placement such
as infection and obstruction are similar in veterinary
and human medicine.
2,14
Evidence of erythema along
the shunt tract or insertion site can indicate infection
11
and at the time of writing there were no signs of com-
plications in our patient.
Although they have been observed up to 30 days af-
ter surgery, seizures are not reported as a common
complication following placement of a VPS, possibly
because many patients have seizures before surgery as
a consequence of brain abnormalities.
2
Caudal occipital malformation and cerebellar verm-
ian hypoplasia are the most common causes of con-
genital hydrocephalus in dogs,
1,2
and according to Kim
et al,
3
magnetic resonance imaging is the best method
for diagnosing these causes. In this case, we had no
access to this equipment and could not determine
the true cause of the disease. However, the laboratory
Figure8: Shunting patency evaluation with nonionic iodinated injection into the Rickham reservoir performed 20 mo after implan-
tation. Lateral radiograph (A) of abdomen before injection showing no contrast. Lateral (B) and ventrodorsal (C) radiographs of
abdomen 15 min after injection showing contrast in the abdomen (arrows).
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00484.x 627
New ventriculoperitoneal shunt valve system
results, the CT images and the early manifestation of
disease can rule out some causes of acquired hydro-
cephalus such as infectious/inammatory diseases and
intraventricular hemorrhage, which cause secondary
obstruction of CSF drainage.
2,15
Gait decits and blindness in affected animals can
range in severity based on how much of the cerebellum
and occipital cortex have been compromised, respec-
tively.
1
Therefore, the recovery of head pressing suggests
a reduction of presumed intracranial hypertension,
allowing a better accommodation of brain structures
and consequent recovery of gait and vision.
Johnson et al
16
surveyed intracranial pressure in dogs
with experimentally induced obstructive hydrocepha-
lus. All dogs in this study had elevated intracranial
pressure with a mean of 52 mm Hg and developed
lethargy and gait abnormalities. According to these au-
thors, the CSF accumulation in the ventricular system is
responsible for elevated intracranial pressure and mor-
phological alterations in the cortex. In a similar study,
Bayston et al
7
placed VPSs with a 10 mm H
2
O Hakim
precision valve in dogs with induced hydrocephalus
and observed intracranial pressure reduction with im-
provement of clinical signs 48 hours after surgery, as
observed in this case report.
According to the manufacturers instructions, the
Hakim precision valve system used in this case differs
fromother such devices because inside the valve there is a
small synthetic ruby ball that controls the CSF ow. This
synthetic ruby has an extremely smooth surface without
irregularities thus impeding the adhesion of protein-
aceous material responsible for long-term obstruction.
Conclusions
The VPS implanted with a medium-pressure Codman
Hakim precision valve system allowed, until the pres-
ent, good recovery of the patient without obstruction
and overdrainage. Based on an initially positive result,
further studies with larger numbers of animals for
longer periods of time will be helpful to determine the
optimal VPS system.
Acknowledgements
The authors wish to thank Dr. Concepta Margaret
McManus and Dr. Albert Leyva for English review and
Mr. Paulo Hoffman of Johnson & Johnson Company for
the catheter donation. Dr. Paulo Mendlovitz from Med-
icine Department of University of Brasilia, Brazil, per-
formed CT diagnostic support.
Footnotes
a
Meticorten, Schering-Plough Pharmaceutical Products, Duque de
Caxias, RJ, Brazil.
b
Furosemida, Teuto Laboratory, Anapolis, GO, Brazil.
c
Codman Hakim Precision Valve System, Johnson & Johnson Company,
Raynham, MA.
d
Propovan, Cristalia Chemical and Pharmaceutical Products, Itapira, SP,
Brazil.
e
Fentanest, Cristalia Chemical and Pharmaceutical Products.
f
Infusion Pump 660 T, Samtronic Ltda, Sao Paulo, SP, Brazil.
g
DX 2010 LCD, Dixtal, Manaus, AM, Brazil.
h
Dopamina 5 mg, Billy Pharmaceutics, Sao Paulo, SP, Brazil.
i
Micro motor LB100, Beltec, Araraquara, SP, Brazil.
j
Keex, Eli Lilly Brasil, Sao Paulo, SP, Brazil.
k
Tramal 100 mg/2 mL, Carlo Erba S.A., Duque de Caxias, RJ, Brazil
l
Ranitidina, Teuto Laboratory.
m
Gardenal, Aventis Pharma, Sao Paulo, SP, Brazil.
n
Omnipaque, GE Healthcare, Shanghai, China.
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