VP Shunt Catheter Misplacement Leads to Paralysis

Case Summary

This case involves a young woman with a past medical history of Spina Bifida. Immediately following a ventriculoperitoneal (VP) shunt replacement, she experienced right-sided hemiparesis. Postoperative CT imaging showed that the physician misplaced the VP catheter.

Case Theory

VP shunting is an operative neurosurgical procedure designed to relieve the symptoms of hydrocephalus. A VP shunt is a small plastic tube that helps drain extra cerebrospinal fluid from the brain. Most physicians place VP shunts to treat hydrocephalus. Many patients with Spina Bifida and shunted hydrocephalus will require a VP catheter for life.

The most common problem with shunt placement is blockage and malfunction due to breakage. Roughly 40% of VP shunts will fail and necessitate replacement within one year, with an average of 60% requiring revision within a few years and 80% within 10 years. Approximately 20% of people with Spina Bifida will require more than one shunt revision during their lifetime.

Although ventricular shunt placement is a common neurological procedure, it comes with a relatively high revision rate of 19–33% within 6–12 months of placement. Obstruction and infection are the most common causes of VP shunt malfunction. However, other complications can occur as well, including bowel perforation, pseudocyst formation, and over-draining, which can lead to the formation of a subdural hematoma. Infection, cerebrospinal fluid leak, and intracerebral hemorrhage are also well-understood complications.

Numerous studies have reported the known complications of invasive procedures such as extra ventricular drainage or shunt operation. However, injuries of neural tracts in the brain leading to hemiparesis caused by these procedures have been reported infrequently. Commonly, measures to optimize catheter placement are deemed necessary to reduce risks following ventricular shunt placement.

In this case, negligence in the placement of a VP shunt catheter led to a catastrophic outcome including right-sided hemiparesis.

Expert Witness Specialities

Pediatric Neurosurgery

An expert pediatric neurosurgeon can outline the negligence regarding this VP catheter misplacement that led to right-sided hemiparesis. This expert can speak to causation and the violation of the standard of care.

Questions for Expert Witnesses

• What are the common measures physicians can take to prevent and manage VP shunt catheter misplacement?
• Is hemiparesis a known complication in VP shunt placement?
• What is the prognosis for a VP replacement in a Spina Bifida patient?
• What effect on medical prognosis does the misplaced shunt have on this Spina Bifida patient?

Expert Witness Involvement

Here is what the pediatric neurosurgery expert in this case had to say:

Expert Witness Response E-138800

I frequently perform ventriculoperitoneal shunt placements as this a regular part of a pediatric neurosurgery practice. To prevent and manage VP shunt catheter misplacement in routine situations, a clinician can use tactile feedback, visualization of cerebrospinal fluid return, or clinical response. For complex revisions, endoscopy and image guidance should be used. I have reviewed a couple of spina bifida cases which did not involve shunt revision, and one shunt revision case several years ago.