The patient was operated by me 26 years ago for hydrocephalic and had dorso-lumbar syringomeylia with paraplegia and anesthesia below D10. The patient came to the clinic 01-November-2022 complaining of headache and neck pain for the last 2 weeks. The patient was in other hospital and CT-scan of the brain showed the shunt in place. She is in Depakine Chrono twice daily for long years.

On examination, the patient is in wheelchair with complete paraplegia anesthesia below D10 with more spastic left lower limb and bobbing nystagmus and left abducens paresis for 2 weeks. No fever, nor meningism. The reservoir of the shunt was functioning and the track of the distal tube was palpable, but very tense at the cranio-vertebral area. Plain abdomen showed the distal part very short inside the abdominal cavity.

The patient was sent for investigations and MRI done 2-November-2022 showing the the hydrocephalus and the shunt in place with elements of Arnold Chiari malformation reaching C2, but without compression. There is gross deformity of the lower dorsal and upper lumbar area with tethering of the spinal cord to this level. It was advised to replace the VPS of pediatric brand to adult brand, because when it is tight the lumen of the tube becoming narrow and malfunctioning, threatening rupture of the device.

The patient was brought to the Emergency of Shmaisani hospital 04-November-2002 with convulsions and episode of blindness before convulsion attack. The patient was given Epanutin I/V and Mannitol. The seizure weaned off and vision returned. Palpation of the distal part of the shunt was hard to feel for what CXR done ruling out rupture of the distal part of the shunt. The reservoir is not functioning.

The old pediatric shunt was replaced with new medium pressure Medtronic adult type of VPS. The old one was surrounded by calcification and the distal abdominal end short with its slits in the abdominal wall. Several incision were performed over the previous track, because it was afraid that still having parts of the tube, but it was pure calcification.

Too early now.

The pediatric shunt usually must be replaced at the age of 8-9 years. But here the patient came after 28 years. When the shunt is severely stretched the lumen becoming very narrow or the tube rupture. In both cases it must be replaced with adult type of VPS to avoid possible permanent blindness.