How late is too late? Delayed intracerebral hemorrhage 15 years after ventriculoperitoneal shunting − a unique case report and review of the literature

The ventriculoperitoneal shunting (VPS) is a frequently performed neurosurgical procedure with common complications. Delayed intracerebral hemorrhage (DICH) is one of the rarest, with mechanisms and etiology still under debate. The currently described cases of DICH occur within 2 weeks of shunt placement.

We report on a unique case of extremely delayed intracerebral hemorrhage (eDICH) 15 years after ventricular catheter placement. The patient, an otherwise healthy female aged 30, was admitted with an acute onset of headache and vomiting for 4 days. She had a VPS procedure shortly after birth due to hydrocephalus secondary to perinatal intraventricular hemorrhage. Subsequent ventricular catheter replacement was required 15 years later due to acute catheter obstruction. On admission, the head CT showed a small volume of intracerebral hemorrhage adjacent to the catheter with even smaller intraventricular breakthrough. Current medical history was unremarkable, and the patient had none of the already recognized risk factors. Conservative management was undertaken with satisfactory results. Serial imaging showed a significant variation in ventricle volume by 6 weeks after the incident.

Currently, the few case reports and series of DICH offer a glimpse into the possible sensitizing factors for its occurrence. Management is on a case-by-case basis since clinical manifestations vary widely. This unique case of eDICH was managed conservatively with a good patient outcome. We believe that variation in ventricle volume and contraction/expansion of brain parenchyma around the ventricular catheter could explain the etiology behind this case and be a yet undescribed mechanism of DICH.