Diagnostic imaging of ventriculoperitoneal shunt malfunctions and complications

Most pediatric patients with hydrocephalus are treated with ventriculoperitoneal (VP) shunt placement. However, shunt malfunction is common and is usually caused by mechanical failure. Shunt obstructions may be confirmed with radioisotope examination or with fluoroscopically guided injection of iodinated contrast material into the shunt reservoir. Disconnections or breaks are more readily detected at radiography in cases in which barium-impregnated shunt tubing was used. Migration and leakage may also occur. Cerebrospinal pseudocysts may be demonstrated with plain radiography and further evaluated with computed tomography (CT) and sonography. In increasing hydrocephalus, plain radiography may reveal sutural diastasis and increased cranial cavity size, and CT can be used to evaluate ventricle size. In cases of enlarging intracranial cysts, injection of iodinated contrast material followed by CT can help document a connection between the cyst and the ventricles. Ventriculitis and meningitis can be visualized at CT and magnetic resonance imaging as enhancement of the ventricular ependymal lining or cerebral cortical sulci. Other complications associated with VP shunts include surgery-related complications, shunt overdrainage and slit-ventricle syndrome, neoplastic metastasis, pleural effusion, and complications related to shunt variants. Imaging analysis is an essential adjunct to the clinical evaluation of patients with suspected VP shunt malfunctions or complications. Radiologists should be familiar with these potential problems and the diagnostic utility of various imaging modalities.