Multiple ultrafast shunt failure in oncological COVID-19 pediatric patient

Introduction: Ventriculoperitoneal shunts (VPS) are one the most frequents interventions performed in Pediatric Neurosurgery, but their failure rate continues to be high. A relation between early and repeated VPS failure and the characteristics of cerebrospinal fluid (CSF) has been previously described, and there have also been reports of alterations in CSF due to coronavirus infectious disease (COVID-19). Case presentation: A ten-year-old girl with a low grade thalamic glioma previously treated with two partial resections, chemotherapy and proton beam radiotherapy, developed hydrocephalus with intracranial hypertension. After emergent management with external ventricular drain, a VPS shunt with a programmable valve was implanted. The patient was diagnosed of COVID-19 in between these two procedures. Afterwards, she suffered from multiple shunt complications, with several events of obstruction. Her CSF had always very high protein concentration and COVID-19 tests were persistently positive. Discussion: Obstruction is the main cause of VPS malfunction in children, and many studies have tried to elucidate risk factors for failure, as younger age or type of shunt. High protein concentration and cells count in CSF could influence shunt failure, but evidence is controversial. Moreover, COVID19 could also be related to such CSF alterations. Conclusion: Early and repeated shunt failures are a clinical problem with no clear treatment stablished. Many factors can be associated to such complications, including CSF alterations, which may also be related to COVID19. Evidence is scarce and contradictory in many aspects, and pediatric neurosurgeons have to face this problem frequently, so more studies with management recommendations are needed.