Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus
Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA 94143-0112, USA. Journal of Clinical Neuroscience
(Impact Factor: 1.38).
06/2012; 19(8):1107-11. DOI: 10.1016/j.jocn.2011.11.019
Ventriculoperitoneal shunt placement is the standard of care for idiopathic normal pressure hydrocephalus (iNPH). Studies have reported shunt complication rates up to 38%, with subdural hemorrhage rates as high as 10%. Lumboperitoneal (LP) shunts with horizontal-vertical valves (HVV) are an alternative for cerebrospinal fluid (CSF) diversion that avoids direct cerebral injury and may reduce the risk of overdrainage. Here we reviewed our experience with LP-HVV shunt placement for iNPH. We retrospectively reviewed our 33 patients with LP-HVV shunts inserted for the treatment of iNPH from 1998 to 2009. Patients were evaluated for improvements in gait, urinary function, and dementia after shunt placement. All patients had evidence of ventriculomegaly and a positive response to pre-operative lumbar puncture or extended lumbar drainage. All 33 (100%) patients had pre-operative gait dysfunction, 28 (85%) had incontinence, and 20 (61%) had memory deficits. Mean follow-up time was 19 months. Following shunt placement, 33/33 (100%) patients demonstrated improved gait, 13/28 (46%) had improvement in incontinence, and 11/20 (55%) had improvement in memory. Shunt failures requiring revision occurred in nine patients (27%), with an average time to failure of 11 months. Infections occurred in two patients (6%). There were no neurologic complications, including no hemorrhages. Thus, LP-HVV shunt placement is a safe and effective alternative to ventriculoperitoneal shunting for iNPH, resulting in significant symptomatic improvement with a low risk of overdrainage. It should be considered as an option for the treatment of patients with iNPH who demonstrate clinical improvement following lumbar drainage.
Available from: Erkan Kurt
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In treating idiopathic normal pressure hydrocephalus (INPH) with a shunt there is always a risk of underdrainage or overdrainage. The hypothesis is tested whether patients treated using an adjustable valve preset at the highest opening pressure leads to comparable good clinical results with less subdural effusions than in a control group with an opening pressure preset at a low pressure level.
A multicentre prospective randomised trial was performed on a total of 58 patients suspected of INPH. Thirty patients were assigned to (control) group 1 and received a Strata shunt (Medtronic, Goleta, USA) with the valve preset at a performance level (PL) of 1.0, while 28 patients were assigned to group 2 and received a Strata shunt with the valve preset at PL 2.5. In this group the PL was allowed to be lowered until improvement or radiological signs of overdrainage were met.
Significantly more subdural effusions were observed in the improved patients of group 1. There was no statistically significant difference in improvement between both groups overall.
On the basis of this multicentre prospective randomised trial it is to be recommended to treat patients with INPH with a shunt with an adjustable valve, preset at the highest opening pressure and lowered until clinical improvement or radiological signs of overdrainage occur although slower improvement and more shunt adjustments might be the consequence.
Available from: Manoj Bohara
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ABSTRACT: The migration of lumboperitoneal shunt cathe-ters into the abdominal subcutaneous space is not uncom-mon. To prevent migration we devised a new method for installing the peritoneal tube. After catheter insertion into the lumbar spinal subarachnoid space, the tube on the peritoneal side is pulled into the areolar space between the abdominal fat and the anterior rectus sheath. A 4cm incision is made in the sheath and the tip of the catheter is obliquely passed through the rectus abdominis muscle using a mosquito clamp. The tube is then inserted into the abdominal cavity through small openings in the posterior sheath and peritoneal membrane, located 3 cm inferior and 3 cm medial to the opening on the anterior rectus sheath. Consequently, the peritoneal tube runs obliquely, upper lateral to lower medial, through the anterior sheath, the rectus abdominis muscle, the posterior sheath, and the peritoneum. To date, we operated on 59 patients using this method. No migration of the abdominal shunt cathe-ter occurred during a follow-up period of 5.51 ± 3.6months (mean ± standard deviation). Our technique is safe, effec-tive without migration of the peritoneal tube, and can be performed in less well-equipped operating rooms.
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ABSTRACT: Cerebrospinal fluid (CSF) overdrainage after lumboperitoneal (LP) shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is mainly caused by insufficient management of pressure settings of the shunt valve and/or siphon effect of shunt systems induced by the patient's postural changes. We here report a unique case of intracranial hypotension (IH) due to CSF leakage after LP shunt placement in which another mechanism leads to the CSF leakage. A 67-year-old man suffered from persistent headache worsening with postural change 2 months after LP shunt reconstruction for iNPH. Brain computed tomography scan showed bilateral chronic subdural hematomas (CSDH). Lumbar images including shuntography and magnetic resonance imaging showed the tip of the lumbar catheter was spontaneously pulled out close to the dura mater with expansion of the epidural space due to CSF leakage from a shunt side hole of the lumbar catheter to the epidural space. Shunt removal and subsequent irrigation of CSDH improved his headache. CSF leakage in our case differs from those in previous reports, because early and enormous CSF leakage into the epidural space can be explained only by a different mechanism through a side hole just located in the epidural space in our case. We must pay attention to the possibility of this rare cause of IH due to CSF leakage in patients suffering from postural headache after LP shunt placement.
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