Upward migration of the L-P shunt catheter into the cranial base

A rare complication of upward migration of the L-P shunt catheter into the cranial base is reported. A 59-year-old female with hydrocephalus underwent L-P shunt with a one-piece catheter. The catheter was secured with a clip but migrataed up to the cranial base without the clip becoming detached from the catheter. We assume that the catheter slipped at the position of the clip as the result of a strong force produced by lumbar movements, and that the clip may have acted like an one-way valve to push the catheter into the spinal canal. To prevent such a complication, we should tighten the clip as firmly as possible and use more clips, or use another type of clip which prevents slipping of a one-piece catheter such as the one described by Imaizumi et al.