Client is a 27-year-old female with a history of IIH/pseudotumor cerebri (diagnosed in 06/2016), morbid obesity, hypertension, Type 2 diabetes (6/16/2023); migraines. An LP shunt was placed in 2015 and revised to Codman Certas Valve (siphon guard, set to 5) in 04/2022. A right optic nerve sheath fenestration was performed 2016. In short, client's distal LP shunt catheter was confirmed disconnected from valve (sitting in pelvis) as of 07/07/2025 x-ray. Neurosurgeon declined revision on two admissions (7/7–7/11 and 7/13–7/16) citing absence of papilledema on ophthalmology exam. On 07/21/2025, patient suffered acute right eye vision loss, bilateral papilledema confirmed on MRI orbits, CT showed left occipital hypoattenuation (possible ischemic infarction), and IR LP opening pressure >60 cm H2O. LP shunt revision finally performed 07/23/2025.
Timeline:
On July 7, 2025, our client's neurologist sent her to the ER for a possible shunt blockage based on worsening headache x 3 weeks, nausea, eye pain, neck pain, back pain. Shunt series x-ray: distal catheter disconnected from valve, coiled in pelvis. CT head: no hemorrhage. MRI brain: tonsillar ectopia/possible Chiari. Ophthalmology: NO papilledema. Neurosurgery did not perform any surgical intervention despite catheter disconnect; signed off. Migraine cocktail, improvement. Psychiatry consulted. Discharged 7/11; Aimovig recommended outpatient.
07/12/2025–07/13/2025 — Hospitalization #2 for Headache, intermittent shaking × ~2 weeks, near fall. Neurology consult: IIH; hypokalemia/metabolic acidosis noted; Diamox deferred. Transferred for neurosurgical evaluation.
07/13/2025–07/16/2025 — Hospitalization #3 (transfer): Neurosurgery confirmed catheter discontinuity; NO shunt revision — "will not revise in absence of papilledema"; weight loss recommended. CT abdomen/pelvis 7/14: retained pelvic catheter confirmed. Started Aimovig. Discharged 7/16.
07/19/2025–07/20/2025 — Hospitalization #4 begins for syncopal episodes (~5 min unresponsive), spastic clonic movements, somnolence, persistent headache, worsening vision. CT head: optic nerve sheath prominence. CT abdomen: catheter disconnected, 2.9 cm right abdominal wall fluid collection. Neurosurgery consult 7/20: LP shunt malfunction confirmed; IR LP and shunt revision planned if OP elevated.
On 07/21/2025, Acute right eye vision loss — inpatient Stroke Alert. CT head showed a NEW left occipital hypoattenuation, acute ischemic infarction suspected. Thrombolytics denied (outside 4.5 hr window). MRI orbits/brain: bilateral papilledema confirmed (significant worsening from 6/22/2025); no MRI infarct. MR venogram: no dural sinus thrombosis; bilateral decreased transverse/sigmoid sinus caliber. ICU transfer: right eye ptosis/complete vision loss, left facial droop, mild RUE weakness, BP 194/104.
07/22/2025 — IR fluoroscopic lumbar puncture with ELEVATED opening pressure >60 cm H2O.
07/23/2025 — SURGERY: Right LP shunt revision + laparoscopic intra-abdominal shunt placement. General anesthesia, ASA III; no complications.
07/24/2025–07/26/2025 — Post-op and discharge: CT head 7/24: interval improvement in posterior globe flattening (decreased ICP). XR shunt series/CT abdomen 7/25: revised shunt intact; post-op pneumoperitoneum; left lower lobe pulmonary nodular opacities; bilateral adnexal hydrosalpinx noted. Discharged 07/26/2025 to home (declined inpatient rehab); home health arranged; ophthalmologist follow-up 07/29/2025.
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No questions yet!
Do you believe there might have been medical error?
Elevated ICP can exist without papilledema. Also there is no clear time frame of developping papilledema. Absence of this finding does not rule it out. Optic nerve fenestration can prevent or significantly delay papilledema development in the fenestrated eye, even when elevated ICP persists.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Shunt revision promptly improved imaging and decreased posterior globe flattening and stabilized the patient.
What makes you a good expert for this case?
In my practice as an adult and pediatric neurosurgeon I lead a dedicated multidisciplinary clinic for idiopathic intracranial hypertension (IIH). In this clinic we manage hundreds of complex IIH
How often do you encounter cases similar to this one in your practice?
Once or twice a year we see a complicated case that is a miss or near miss
Do you believe there might have been medical error?
Evaluation of a shunt in IIH is notoriously difficult, but the data here points to a shunt failure from the outset so the index of suspicion should have been high. Furthermore, choosing not to revise based on the absence of papilledema when the patient was clearly symptomatic and the shunt series demonstrated a disconnection was an error. Papilledema does not develop immediately. This was a symptomatic shunt malfunction left for too long because of a misjudgment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Severe intracranial hypertension was caused by failing to treat the shunt malfunction in a timely fashion. This led to visual loss as a result of optic nerve injury.
What makes you a good expert for this case?
I am a pediatric neurosurgeon with extensive experience managing patients with shunted hydrocephalus, and routinely take care of children and adults with IIH (pseudotumor cerebri).
How often do you encounter cases similar to this one in your practice?
Several times per month in inpatient and outpatient settings.
Do you believe there might have been medical error?
These are very complicated patients. There are national discussion concerning whether to use shunts and, if so, what kind(lumbo-peritoneal vs ventriculo-peritoneal). Once you place a CERTAS valve in an LP shunt, you have gone far down the neurosurgical intervention. CERTAS are approved for VP shunts. LP shunt use(which I have done) is off label. In this patient's case, there seems to be multiple errors. Whose service was she on for her initial admissions? Why didn't they do an LP(or some test to check opening pressure) in a patient with neurological symptoms, a shunt, and a known disconnect? One of the phrases I use for the residents is that there is no such thing as a neurosurgical emergency in the IIH patient population. The reason for that is the the fastest way to lower pressure is an LP. So, the first error is failure to perform an LP earlier. That would have prevented this entire series of events. The second failure is ignoring the broken shunt. Clearly, once her elevated pressure is diagnoses, they operated within a day. Papilledema is a late finding, not an early finding.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Cerebral Perfusion Pressure(CPP) = Mean Arterial pressure - Intracranial pressure(ICP) - Central Venous pressure(CVP). This higher either ICP or CVP go, the less blood is getting into the brain(the lower the CPP). This is the danger in IIH patients. Most patient with IIH and visual issues have issues with optic nerve pressure. While her ischemia is clearly related to her IIH, this is such a late finding, I have never seen it. Neither I, nor any of my partners, in my 30+ year career, have ever delayed treatment this long. Documented shunt discontinuity is all the more alarming in this delay of care.
What makes you a good expert for this case?
I'm a double board certified(adult and pediatric) neurosurgeon who performs many shunts, including on patients with IIH. I have a 30+ year career caring for similar patients. In 2014, Florida Neurosurgical Society, as part of their annual meeting, hosted a point-counterpoint discussion on IIH. University of Miami was the don't shunt invited speaker, I was the pro-shunt invited speaker.
How often do you encounter cases similar to this one in your practice?
I treat IIH weekly(many just for routine follow-up), place 3-5 shunts annually for IIH, and evaluate 6-10 for IIH(meaning, either see them prior to shunt, or have admissions for head-ache in the setting of a shunt). This is a relatively common diagnosis.
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