Successfully treated delayed upward trans-tentorial herniation (UTTH) following ventriculoperitoneal shunt placement for an acute obstructive hydrocephalus secondary to midline posterior fossa mass in a low-resource setting: case report

Abstract

Introduction: UTTH is an exceedingly rare, deadly complication of ventriculoperitoneal shunt (VPS) placement for hydrocephalus secondary to a posterior fossa mass. Presentation of case: VPS was inserted for a 4-year-old patient with hydrocephalus secondary to a posterior fossa mass before tumor resection. Initially, the child had clinical improvement, but after 9 days, he developed deterioration. Brain computed tomography (CT) revealed a UTTH; therefore, ligation of the VPS, intubation, mechanical ventilator support, dexamethasone, mannitol, and urgent resection of the mass were performed. The patient was discharged in improved condition. Discussion: When patients present with hydrocephalus secondary to a posterior fossa mass, initial treatment can be inserting a VPS. Even though initial VPS insertion has advantages it can rarely lead to UTTH, usually within a few hours after surgery. Even if the prognosis is poor, UTTH can be treated by intubating and putting the patient on a mechanical ventilator, ligating the VPS, and resection of the posterior fossa mass. Conclusion: Although extremely rare, delayed UTTH can occur after VPS insertion for hydrocephalus secondary to a posterior fossa mass. When a patient for whom VPS placement is done shows clinical deterioration, an urgent CT scan must be done to rule out a UTTH, even if the patient was having clinical improvement for several days after the VPS insertion. Presence of slit ventricles, relatively open sylvian fissures despite decreased mentation, and effacement of the quadrigeminal cistern are findings indicative of a UTTH. Prompt treatment of UTTH following VPS insertion can result in a satisfactory outcome.