Child's Nervous System

https://doi.org/10.1007/s00381-017-3702-9

ORIGINAL PAPER

Management of exposed ventriculoperitoneal shunt on the scalp

in pediatric patients
Osman Akdag 1

Received: 18 November 2017 / Accepted: 14 December 2017

# Springer-Verlag GmbH Germany, part of Springer Nature 2017

Abstract
Purpose The exposure of a ventriculoperitoneal shunt on the scalp is a serious complication. There are limited studies evaluating
this complication’s management in the literature. The aim of this study is to define the management of shunt salvage and the
reconstruction of the scalp.
Methods This retrospective study included seven pediatric patients with ventriculoperitoneal shunts that were exposed on the
scalp for various reasons. The demographic characteristics of the patients and the medical and surgical treatments used were
recorded. The patient follow-up durations and complications associated with these methods were determined.
Results Four female and three male patients with an average age of 5.7 were followed for an average of 9.4 months. All but one of
these patients were treated without removing the shunt. While one skin flap was used in one patient, successful repairs were made
with double skin flaps in five patients. There were no complications during follow-up for the patients treated with these methods.
Conclusion In this study, the appropriate management of shunt exposure, which is common in pediatric cases, has been revealed.
Given appropriate infection prevention, the reconstruction of the scalp is possible without the removal of the shunt.

Keywords Ventriculoperitoneal shunt . Hydrocephalus . Flap surgery . Scalp reconstruction

Introduction cause mortality or serious morbidity if appropriate mea-

Ventriculoperitoneal shunt (VPS) remains the neurosurgi-
cal procedure most commonly used in hydrocephalus
management [1]. Complications related to VPS are report-
ed in adults at rates ranging from 17 to 33% [2]. In the
pediatric patient group, complications are reported in one
out of every three patients [1]. Shunt malfunctions, infec-
tions, obstructions, and abdominal problems are common
complications [3, 4]. VPS exposure through the scalp is a
less common complication, but its management is rather
difficult [5]. These complications, which can lead to ne-
crosis of the scalp or early suture dehiscence, are seen
more commonly in children than in adults. They may
* Osman Akdag
oakdag@gmail.com
1
Department of Plastic Reconstructive and Aesthetic Surgery, Selcuk
University, Konya, Turkey
sures are not taken.
In this study, the methods used in cases of VPS exposure
with scalp erosion in pediatric patients, as well as shunt sal-
vage techniques, were discussed. In addition, the pathophysi-
ology of this condition and what can be done to prevent it are
discussed.
Material and method
This study was designed retrospectively and included sev-
en patients with VPS exposure through the scalp who
applied to our clinic between 2009 and 2016. Patient-
related data were obtained from electronic patient records
and operation notes. Patients were analyzed in terms of
age, gender, neurological problems, medical treatments,
and surgical procedures. The duration and anatomical site
of the exposure were also recorded. The preferred flap or
flaps for use in the revision of the exposed VPS were
determined. Patient follow-up times and complications
were recorded (Table 1).
 Childs Nerv Syst

Table 1 Clinical characteristics and summary of seven pediatric patients

Patient Age Medical treatment Anatomic Treatment/repair Flap type Follow-up Complication
no. (years/ localization of technique (months)
sex) exposure

1 3/F Vancomycin Parietal Local flap repair Transposition + rotation 6 Nil

2 14/F Vancomycin Temporal Local flap repair Rotation 24 Nil
3 1.5/M Ceftriaxone + Vancomycin Temporal Shunt removing – 6 Nil
4 16/M Ceftriaxone + Vancomycin Occipital Local flap repair Transposition + transposition 6 Nil
5 1.5 /F Vancomycin Parietal Local flap repair Transposition + transposition 12 Nil
6 2/M Cefotaxime Parietal Local flap repair Transposition + rotation 6 Nil
7 2/F Vancomycin Parietal Local flap repair Transposition + transposition 6 Nil

Inclusion and exclusion criteria
Patients who had VPS surgery for any reason, had VPS expo-
sure through the scalp, and were determined to be eligible for
skin closure by a neurosurgeon were included in the study.
Because the study was designed only for pediatric patients,
adult patients were excluded from the study. Patients who had
VPS exposure but no functional VPS were not included in the
study.
Surgical technique
After shaving, povidone iodine was applied to the exposed
VPS area. This procedure was repeated several times to reduce
the bacterial contamination of the exposed VPS material.
Relatively low-quality tissue and granulated tissue around
the VPS were removed. One or two flaps were designed to
ensure that the new suture lines and exposed VPS would not
overlap one another. It was noted that the flap axes were in the
same direction as the arteries feeding the scalp, which was
intended to increase the feeding of the flaps. The planned
flaps, which were 30% larger than the defect area, were trans-
posed so as to cover the exposed VPS. The flaps were adapted
to one another without tension. The skin was sutured with
monofilament 3/0 or 4/0 suture materials (Fig. 1).
Results
Seven patients were followed up for VPS exposure through
the scalp. All of these patients had normal VPS function. The
ages of the four female and three male patients ranged from
1.5 to 16 years (mean 5.7 ± 6.389 years). In six patients, VPS
exposure was successfully treated with flap repair.
Cerebrospinal fluid infection was suspected in one patient,
and the shunt was removed. The follow-up period ranged
from 6 to 24 months (mean 9.4 ± 6.803 months). While two
flaps were used in five patients (transposition flap + transpo-
sition flap combination or transposition flap + rotation flap
combination), only one flap was used in one patient. The most
frequent area of exposure was the parietal region. All patients
were given intravenous antibiotics for 1 day prior to and 2–
4 days after surgery. Four patients received vancomycin, one
patient received cefotaxime, and two patients received a cef-
triaxone and vancomycin combination. None of the patients
had any complications.
Discussion
VPS is the most important material in the treatment of hydro-
cephalus. Every year, in the USA, more than 30,000 VPS
procedures are performed [6, 7]. The common complications
associated with VPS include infection, mechanical failure,
and functional defects [5]. Infections due to VPS have been
reported at rates varying from 3.2 to 12.6% [8]. The typical
microorganisms seen in infections due to VPS include
Staphylococcus epidermidis and Staphylococcus aureus.
These bacteria usually form a biofilm on the shunt [9].
There are many risk factors for VPS infections. One of
these is the VPS’s exposure through the skin [5]. If a definitive
reconstruction without the removal of the exposed VPS is
considered, the patient should receive prophylactic antibiotics
and wound care. If there is an infection linked to an ex vivo
VPS and the infection continues despite antibiotic treatment,
the VPS must be removed. In addition, the first thing to con-
sider in VPS exposure is whether the VPS is functional. Early
intervention will both reduce the morbidity of the patient and
ensure the continuation of the VPS.
VPS exposure through the scalp is not a common occur-
rence in adults. However, in children, exposure is more com-
mon because the scalp is thin and fragile during childhood [5].
In cases accompanied by hydrocephalus, the skin becomes
much more thin, and such complications due to VPS are more
common [8, 10]. VPS systems can be exposed from anywhere
along the line where the VPS is placed. However, the inci-
dence of this is extremely rare, and in the literature, most
studies are case reports [4, 11–13].
Childs Nerv Syst

Fig. 1 a Exposed ventriculoperitoneal shunt can be seen on the left are designed. c Both flaps are elevated. d Flaps are adapted to the defect to
parietal side of the patient, who is indicated as patient 1 in Table 1. b cover the shunt. e Flaps are sutured with monofilament sutures. f
Scar tissue and granulated tissue around the shunt are removed, and flaps Postoperative first-month view of the scalp

Several factors are implicated in the pathogenesis of VPS infection should be investigated. If necessary, a CSF (cerebro-
exposure. One such factor is localized infections around the spinal fluid) culture should be taken, and the cell types present
VPS material. An existing infection will form an abscess and in this culture should be examined [18]. Taking a microbio-
fistula on the skin, which will cause the exposure of the VPS. logical culture from a wound or exposed VPS is meaningless
Another factor in the pathogenesis of VPS exposure is contin- due to contamination and the presence of biofilm. Many stud-
uous stress on the skin [14]. In many cases, VPS exposure is ies have shown the presence of Staphylococcus epidermidis
seen in regions where the skin is thin. Long-term pressure on and Staphylococcus aureus in the biofilm layer on VPS de-
the skin leads to ischemia, and if this ischemia becomes per- vices [9, 10, 19].
manent, this will, in turn, cause skin necrosis. The fact that the In the presence of infection, vancomycin may be used
reservoir and valve sections of the VPS are more susceptible for gram-positive bacteria, and ceftazidime, cefepime, or
to exposure also supports this theory. meropenem may be used for gram-negative organisms. [9]
Nyugen and colleagues state that there is a relatively large In addition, the exposed VPS should be covered with
amount of pressure on the scalp in VPS patients and that
exposure in this area may be due to this pressure [5]. There
are studies regarding other biomaterials and tissue expanders
that may become exposed through the scalp [15–17]. In our
cases, the VPS was exposed through the relatively thin parts of
the skin, and usually, the VPS’s reservoir portion was exposed
(Fig. 2).
Regardless of the reason for exposure, the VPS must be
managed in an appropriate way. The first question to ask re-
garding an exposed VPS is whether the VPS is functional. If a
VPS with mechanical or functional defects becomes exposed,
no reconstruction is considered, and the VPS should be re-
moved. If the VPS remains functional, the patient should be
Fig. 2 Exposure of the reservoir part of the ventriculoperitoneal shunt on
checked for infection. To do so, the classical symptoms of the occipitoparietal region

antimicrobial wound care dressings. In our case series,
patients were treated with single or double intravenous
antibiotics (ceftriaxone, vancomycin, and cefotaxime) for
1–5 days. Patients were followed closely for infection
during the early period. In all patients, wounds were
dressed with sodium fusidate-containing pomades or sil-
ver dressings.
If there is still no reduction of the infection despite effec-
tive treatment, the shunt should be removed. The subclinical
findings of infection in one of our cases suggested that the
infection due to the VPS would continue, so the VPS was
removed. The surgical closure of the exposed VPS during
an infectious episode may lead to very serious morbidity
and mortality. However, after the infection is eliminated, it
is essential that the VPS be covered with a high-quality
vascularized skin covering. The algorithm to follow regard-
ing exposed shunts is summarized in Fig. 3. The primary
suturing of the exposing area is not recommended.
Specifically, the primary suturing of the affected wound
sides to one another is an inappropriate repair, and recur-
rence is inevitable because the tension and suture lines will
remain on the VPS. In such cases, one or more
fasciocutaneous flaps that are planned according to the de-
fect may provide tension-free repair. When these flaps are
designed, they must be planned based on the direction of the
scalp arteries (Fig. 4). Where necessary, the localization of
the arteries can be determined via a hand-held Doppler, and
safer flaps can be designed [17]. Scars and incisions from
previous operations should also be considered. Although
Fig. 3 An algorithm for exposed shunt management. The clinical
evidence of infection, functionality of shunt, and presence of persistent
infection are critical points in exposed shunt management
Childs Nerv Syst
Fig. 4 The main arteries vascularizing the scalp and the flaps that can be
designed based on this vascular territory
implantable devices are frequently used in central nervous
system (CNS) surgery, there are no established guidelines
regarding what to do if these devices become exposed
through the skin. Some researchers have argued that ex-
posed materials need not necessarily be removed [17, 20].
The main purpose of VPS salvage is to insert a new VPS in
order to protect the patient from possible morbidities. There
is also an additional cost associated with inserting a new
VPS. However, the most important factor in determining
whether a VPS can be saved is CSF infection. Kouyialis
et al. report a case in which the patient lived with an exposed
VPS for more than 1 year without any infection [20]. The
fundamental mechanism that prevents serious infection in
such cases is the formation of dense granulated tissue
around the VPS, which acts as an important barrier to bac-
teria due to the intense inflammatory cells present in this
granulated tissue. In another case report by Lanote et al., a
deep brain stimulation system that had become exposed
2 months previously was successfully reconstructed using
local flaps [17].
The limitations of our present study are its retrospective
design and the small number of cases. Also, the longer term
follow-up of patients could provide us with more information
about long-term problems.
Conclusion
VPS exposure in children can involve very serious complica-
tions. There is no specific treatment protocol for complex
cases in which a VPS is exposed through the scalp. In this
article, the success of exposed VPS salvage after infection was
discussed, as was the methodology to be followed in such
cases. We believe that this method can be used without creat-
ing additional cost and morbidity.
Childs Nerv Syst
Compliance with ethical standards
Conflict of interest The author declares that author has no conflict of
interest.
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