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Hemianopic visual field defects in children with intracranial shunts: report of two cases
L Molia1, J M Winterkorn, S J Schneider
1Division of Neuro-ophthalmology, North Shore University Hospital, Great Neck, New York, USA.
Insights
Subtle visual changes in children with intracranial shunts can signal serious complications like shunt displacement. Early detection of these neuro-ophthalmic signs is crucial for timely intervention and potential visual recovery.
Area of Science:
- Pediatric Neurosurgery
- Neuro-ophthalmology
Background:
- Intracranial shunts are vital for managing hydrocephalus in children but frequently require revision due to growth.
- Shunt malfunction often presents with overt signs of increased intracranial pressure, but subtle neuro-ophthalmic signs are frequently overlooked.
Observation:
- Two cases illustrate homonymous hemianopsia in children due to shunt catheter migration.
- One patient experienced optic tract impalement, while another had shunt embedding in the midbrain tegmentum, leading to posterior cerebral artery compression.
Findings:
- Subtle visual field deficits and motility abnormalities are critical early indicators of shunt displacement and increased intracranial pressure.
- Optic atrophy can mask papilledema, emphasizing the need for vigilant monitoring of visual function.
Implications:
- Routine ophthalmological examinations, including visual field testing and serial disc photography, are essential for children with intracranial shunts.
- Prompt diagnosis and surgical revision of shunts can significantly improve visual outcomes and prevent permanent visual impairment.
Objective And Importance:
Intracranial shunts are commonly placed in children and frequently require replacement during the child's growing years. Severe signs of increased intracranial pressure often are the first indication of shunt displacement and malfunction. Subtle neuro-ophthalmic signs in children are usually overlooked.
Clinical Presentation:
Two cases are described in which homonymous hemianopsia resulted from unsuspected movement of the shunt catheter in growing children. In one male patient, the catheter tip impaled the optic tract, and in the other male patient the shunt became embedded in the midbrain tegmentum and shunt failure led to compression of the posterior cerebral artery.
Intervention:
In the presence of optic atrophy, papilledema may go unnoticed without serial examinations. This stresses the importance of detecting other early warning signs of shunt displacement and increased intracranial pressure, including visual field changes and subtle abnormalities of motility.
Conclusion:
Because early diagnosis and shunt revision may allow visual recovery, children with shunts should be followed with visual fields and serial disc photographs.