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The patient was operated 17-April-2007 for malfunctioning shunt and exploration of the abdominal part revealed, that it was functioning properly.

Considering, that the patient was improving, she was kept in the hospital without any medications to see her reaction later.

Suddenly at this morning, the patient got the same clinical picture of acute hypertensive-encephalic syndrome.

CT-scan was done urgently, confirming that the ventricular system still dilated.

The patient was taken to the operating room and the proximal part was explored. It was functioning with the shunt of PS medical adult 1.5 level performance.

Taking into consideration, that the cause could be due to adhesion of the ventricular part by choroid plexus, an attempt to use the most tiny endoscope failed, because the lumen was smaller.  Several rotations of the ventricular part confirmed that it is "free?". The tube was withdrawn accurately, but after 3 cm of withdrawal, the CSF became bloody, confirming, that intraventricular bleeding took place.

The ventricular part was removed completely and inspection of the tip showed that, only 2 holes were free and all the other holes were occluded by the scarous choroid plexus.

The new ventricular end was inserted and lengthy over more than one hour of washing with saline was performed at several depth levels to minimize clot formation and avoid subsequent immediate occlusion of the new shunt.

After completion of washing, the ventricular part was withdrawn and inspected. There is a clot inside the lumen at the holes area. It was decided to cut the tip of this part to prevent clot residence inside this area. After that, the shunt was constructed and checked several times at the peritoneal end for function. It was functioning properly but the CSF is still xanthochromic.

Routine closure of the wounds. Smooth postoperative recovery.

Planned to repeat CT-scan after 4-5 hours.

The patient progressed fulminant picture of meningism and peritonism  with the CT-scan showing a clot parallel to the shunt in the right posterior horn and tiny one at the occluded aqueduct of Sylvius.

The patients vital signs are acceptable, and the shunt was functioning properly, but she was transferred to the ICU and valium given to decrease the peritonism.

The patient got sudden onset hypertensive encephalic syndrome due to unknown reasons of shunt malfunction with deteriorating visual functions, which could lead to complete bilateral blindness.

Direct check of the shunt function is mandatory, to prevent further escalation of the increase intracranial pressure.

The cause of the malfunction was suspected to be be a debris at the first operation, but when recurrence of the hypertensive-encephalic syndrome took place another time after 4 days of the first surgery, the choroid plexus became the most probable cause.

Despite the fact that great precaution was paid to prevent intraventricular hemorrhage, it took place and only lengthy washing by saline and patience were the clue for resolving the issue. Otherwise, putting external drain for 2-3 days is the next option.

There is a problem awaiting for resolution, how to dissect the adherent choroid plexus to the shunt. I suggest to make an end-welling catheter to be introduced and adapted to the ventricular part, so the after dilatation of the holes area could cause rupture of the adhesions with subsequent opening of the holes.  

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