Fatal intratumoral hemorrhage in tectal plate glioblastoma multiforme following ventriculoperitoneal shunt

Ventriculo-peritoneal (V-P) shunting is an accepted procedure before a direct approach to large tumors producing obstructive hydrocephalus. However, it has been associated with some complications. Intratumoral hemorrhage is an uncommon but fatal complication of V-P shunt insertion. The exact mechanism of this complication is unknown, but several mechanisms have been proposed including rapid lowering of intracranial pressure following V-P shunt placement or cerebrospinal fluid (CSF) drainage and sudden decrease in CSF volume and pressure after V-P shunting. We report an 8-year-old girl who presented with severe headache, double vision, and bilateral papilledema. Brain magnetic resonance imaging with and without gadolinium administration revealed a large tectal plate tumor compressing the aqueduct which caused hydrocephalus. Due to progressive decline in consciousness level, an emergency CSF diversion was planned and she underwent left side posterior parietal V-P shunt placement. Eight hours after V-P shunt insertion, she suddenly developed tonic-clonic seizures and collapsed into deep coma with dilated pupils and stopped breathing and died 1-day later. Histological examination of the autopsy specimen showed the tumor was a glioblastoma multiforme with massive intratumoral hemorrhage. The possible pathophysiological mechanisms of this fatal complication are discussed here and the pertinent literature is reviewed. It seems that endoscopic third ventriculostomy is the procedure of choice for CSF diversion in patients with tectal plate gliomas and decreases the occurrence of intratumoral hemorrhage.