Late ventriculo-atrial shunt migration leading to pericardial cerebrospinal fluid effusion and cardiac tamponade

We present the case of a patient with cardiac tamponade secondary to late intrapericardial migration of a disrupted ventriculo-atrial shunt (VAS). A 48-year old woman was referred for cardiac tamponade. She had a history of congenital hydrocephalus with implantation of a VAS (Codman®) in 1994. The initial neurological examination was normal. Tomodensitometry showed a discontinuity of the VAS at the cervical level with its distal part floating in the pericardium. Immediate surgery through sternotomy allowed the draining of the pressurized translucid liquid. The distal part of the VAS was extracted and the perforation site on the right ventricle was sutured. The patient showed no neurological trouble 3 months after operation. Surprisingly, cardiac tamponade was not related to bleeding but to the accumulation of translucid liquid whose gross aspect and biochemistry were very suggestive of cerebrospinal fluid (CSF). We hypothesize that a fibrin sheath had developed around the VAS at the time of its disconnection and acted as a fibrous tunnel allowing continued CSF drainage through its distal part. Surgical strategies to prevent late VAS disconnection should be considered at the time of implantation.