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Shunt malfunction presenting with symptomatic syringomyelia: Demonstrated on contrast ventriculogram

Ventriculoperitoneal (VP) shunt malfunction commonly presents as raised intracranial pressure. Rarely, when the central canal of the spinal cord communicates with the 4th ventricle, shunt malfunction can present as an expanding syrinx. The diagnosis is often delayed, resulting in severe morbidity. Some of these patients undergo repeated syrinx surgeries without much benefits. We report a case of chronic tuberculous meningitis with shunt malfunction presenting as an expanding spinal canal syrinx and quadriparesis. Fourth ventricular communication with syrinx was demonstrated with the help of a contrast ventriculogram. After shunt revision, syrinx resolved completely and the patient made significant improvement in his neurological deficits. The present case illustrates that a historical and rarely used investigation like contrast ventriculogram aids in the diagnosis and management even in the current neurosurgical practice. All patients with late onset syrinx and a previous VP shunt need to be investigated for shunt malfunction before considering syrinx surgery. A simple shunt revision resolves the syrinx in such conditions and avoids more complex procedures like Foramen magnum decompression. Relevant literature has been reviewed; pathophysiology and management options have been discussed.