Treatment for secondary deterioration in idiopathic normal pressure hydrocephalus in the later course of the disease: a retrospective analysis

The effectiveness of various CSF diversion surgeries in idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

Background

Idiopathic normal pressure hydrocephalus (iNPH) is commonly treated using cerebrospinal fluid (CSF) diversion procedures, most commonly ventriculoperitoneal (VP) but also lumboperitoneal (LP), ventriculoatrial (VA) shunting, and endoscopic third-ventriculostomy (ETV). Despite the prevalence of these interventions and recent advancements in iNPH diagnostic processes, there is limited up-to-date evidence regarding surgical outcomes.

Methods

A systematic review and meta-analysis were conducted to analyse the effects of CSF diversion surgeries among iNPH patients. The primary outcome was efficacy of the CSF diversion procedure, defined as symptomatic improvement, and secondary outcomes included surgical complications. Several major databases were searched for original studies from inception up to June 4, 2024, which were evaluated using random-effects meta-analyses, meta-regression, and influence analyses. This study was registered with PROSPERO: CRD42023458526.

Findings

Out of the 1963 studies screened, 54 were included in this review, and 4811 patients were pooled. Overall, more than 74% of patients experienced improvement after surgical treatment (95% CI: 70-78%). VP shunting demonstrated an efficacy of 75% (95% CI 70-79%), VA shunting at 75% (95% CI: 70-80%), and LP shunting at 70% (95% CI: 52-83%). ETV had a success rate of 69% (95% CI: 58-78%). Gait improvement was high at 72% (95% CI: 67-77%), while urinary and cognitive dysfunction each improved in approximately 50% of patients. The efficacy of surgery did not increase between 2005 and 2024 (p = 0.54). Complications occurred in 20.6% of cases, with a surgery revision rate of 15.1%.

Interpretation

This meta-analysis found that the overall efficacy of CSF diversion procedures for iNPH remained unchanged from 2005 to 2024, with 74% of cases showing improvement. No procedure was found to be clearly superior, and only half of the patients saw improvements in urinary and cognitive dysfunction. The stagnant efficacy over time and frequent complications highlight the need for improved patient selection criteria to best identify those most likely to benefit from CSF shunting.

Funding

None for this study.

Preexisting Ventricular Shunts Are Associated with Failed Evacuation of Acute Subdural Hematomas: Single-Institution Case Series of Complications and Management Strategies

BACKGROUND

The effect of ventricular shunts on radiographic outcomes after evacuation of acute subdural hematomas (aSDHs) has not yet been established. We studied a series of patients who had undergone craniotomy for aSDH, exploring a possible relationship between the occurrence of a postoperative extra-axial collection (EAC) and the presence of a ventricular shunt.

METHODS

We reviewed all craniotomies for convexity aSDH performed between July 2015 and June 2020. The medical record review included perioperative coagulation studies, platelet counts, and antiplatelet and anticoagulation agent use. Univariate and multivariate analyses were conducted to identify the factors associated with postoperative EACs and reevacuation.

RESULTS

A total of 58 patients had undergone craniotomy for aSDHs, including 9 with ventricular shunts. The median age was 67 years (interquartile range, 54-78 years), and 40% of the patients were women. Of the 58 patients, 16 were taking antiplatelet agents, and 6 were taking anticoagulation agents. Ten patients had developed perioperative thrombocytopenia (platelet count, <100,000/μL). Twelve patients had perioperative coagulopathy (international normalized ratio, ≥1.5). A postoperative EAC >10 mm occurred in 17 patients (29.3%). Eight patients (13.8%) had undergone reevacuation. The presence of a shunt and an increasing preoperative aSDH size were independently associated with an EAC >10 mm (P = 0.013 and P = 0.003, respectively). Only the presence of a shunt predicted for the need for reevacuation (P = 0.001). The shunts were explanted (n = 3) or valves were adjusted (n = 3) in all but 3 cases.

CONCLUSIONS

We found that a lack of brain reexpansion after aSDH evacuation worsens radiographic outcomes and was more common in patients with shunts. Increasing shunt valve resistance might help prevent the formation of large EACs after aSDH evacuation.