Case 38 - Shunt Failure

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

EXAMINATION:MRI NEONATAL BRAIN, MRI COMPLETE SPINE WO CONTRAST

INDICATION: Myelomeningocele T11-L4 per fetal MRI 8/12/2020. Now s/p repair of myelomeningocele w/ complex PRS closure

COMPARISON: Ultrafast brain MRI on 11/4/2020.

TECHNIQUE/PROTOCOL: Noncontrast protocol brain, cervical, thoracic, and lumbar spine MRI performed.

FINDINGS:

MRI brain:

Again noted right frontal approach ventriculostomy shunt catheter with tip ending in left lateral ventricle in a position that is unchanged in comparison to prior study. Mild to moderate dilatation of the ventricles, slightly decreased in size when compared to prior MRI.

Few foci of hemorrhage within the centrum semiovale bilaterally, as well as within the right frontal lobe surrounding the catheter tract. Tiny focus of hemorrhage in the left occipital periventricular white matter and left occipital subcortical white matter.

Right frontoparietal scalp collection surrounding the entry of the ventriculostomy catheter measuring about 3.9 x 0.9 x1.3 cm, previously measured 3.7 x 1.2 x 0.8 cm, slightly increased.

Redemonstration of Chiari II malformation associated findings including small posterior fossa, bilateral cerebellar tonsillar herniation down to C3-C4, small fourth ventricle and tectal beaking. Gray matter lined cleft in the medial left occipital lobe extending towards the left occipital horn (series 12, image 50).

Diffuse white matter volume loss more notable in occipitoparietal regions. Corpus callosum appears to be thin. Septum pellucidum appears to be ruptured or absent.

MRI complete spine:

Syringohydromyelia starting from the cervical cord at approximately C4 and extending inferiorly towards the thoracic cord, measuring up to 2.9 mm in maximum AP dimension.

C-spine syrinx extending from C2 vertebral body for about 1.7 cm inferiorly. The diameter of the syrinx measures up to 2 mm.

Postsurgical changes related to myelomeningocele repair with complete skin covering at the site of defect. No evidence of fluid collection. Cord is slightly the tethered posteriorly at the site of repair.

Dextroscoliosis of the thoracolumbar spine. Vertebral body heights are maintained.

The left kidney is not visualized. The right renal pelvis appears mildly dilated, measuring up to 5 mm in maximum AP dimension.

IMPRESSION:

* In comparison to prior MRI dated 11/4/2020, there is stable position of the right frontal approach ventriculostomy catheter. Slight interval decrease in the size of the ventricles which are now mild to moderately dilated.

* Slight interval increase in the size of the right scalp fluid collection surrounding the ventriculostomy catheter.

* Few foci of hemorrhages in the white matter of bilateral frontal and left occipital lobes. Small amount of layering intraventricular hemorrhage.

* Stigmata of Chiari II malformation with cerebellar tonsillar herniation at least to the level of C3-C4.

* Possible schizencephalic defect in the left mesial occipital lobe.

* Syringohydromyelia involving the cervical cord from C4 through the thoracic cord.

* Expected postsurgical changes related to prior myelomeningocele repair.

* Nonvisualization of the left kidney. The right renal pelvis appears dilated, measuring up to 5 mm. Sonographic correlation would be helpful.

EXAM: MRI BRAIN ULTRAFAST.

INDICATION:  30 days Female. Increasing head circumference with ventriculosubgaleal shunt, evaluating for ventriculomegaly and shunt function

TECHNIQUE: Ultrafast T2 haste MR imaging of the brain was performed without contrast on a 1.5 Tesla magnet.

COMPARISON:  MRI brain 11/11/2020

FINDINGS:

Moderate to marked increased size of the lateral and 3rd ventricles compared to 11/11/2020 with new bulging of the anterior, occipital and temporal horns. Right frontal approach ventriculostomy catheter terminates near the foramen of Monroe in the left lateral ventricle. Cystic change in the right frontal lobe along the catheter tract. The septum pellucidum appears ruptured.

Increased size of the subgaleal fluid overlying the right temporal and parietal bones measuring up to 5.5 x 2.2 x 2.5 cm (AP, transverse, CC) compared to 4.5 x 1.4 x 1.5 cm, using similar technique.

No extra-axial fluid collection or intracranial hemorrhage. No midline shift.

Slight medialization of the uncus of both temporal lobes. Thinning of the perimesencephalic cisterns without complete effacement. No transtentorial herniation.

Moderate to marked periventricular white matter volume loss. Diffuse thinning of the corpus callosum.

Redemonstrated stigmata of Chiari II malformation including a small posterior fossa, tectal beaking and bilateral cerebellar tonsil herniation. Gray matter lined cleft in the medial left occipital lobe, better appreciated on the prior MRI dated 11/11/2020.

Orbital contents are normal.

Partially imaged cervical cord syringohydromyelia, better evaluated on the prior MRI complete spine dated 11/11/2020.

IMPRESSION:

1.  Moderate to marked enlargement of the lateral ventricles compared to 11/11/2020.

2.  Right frontal approach subgaleal shunt is unchanged. Enlarging right subgaleal fluid collection measuring up to 5.5 cm from 4.5 cm previously