Lumboperitoneal and Ventriculoperitoneal Shunt Surgery for Posthemorrhagic Communicating Hydrocephalus: A Comparison

Lumboperitoneal shunt and ventriculoperitoneal shunt for chronic hydrocephalus after aneurysmal subarachnoid hemorrhage: a comparison

Objective

Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) results in poor neurological outcomes and cognitive deficits. Currently, the main treatments for chronic hydrocephalus include ventriculoperitoneal shunt (VPS) and lumboperitoneal shunt (LPS); however, the optimal treatment for chronic hydrocephalus after aSAH remains controversial.

Method

The records of 82 patients were retrospectively analyzed, and the patients were divided into VPS and LPS groups based on surgical methods. The efficacy, shunt successful rate and complications were compared. The assessments of treatment efficacy included the Evans index score (EIS), Keifer's hydrocephalus score (KHS), Mini-Mental State Examination (MMSE) score and functional independence measure (FIM). Patients were followed up for three months to observe the postoperative curative effects and complications.

Results

The rate of shunt obstruction was significantly higher in the LPS group than that in the VPS group (p < 0.05), and the shunt successful rate was significantly higher in the VPS group than that in the LPS group (p < 0.05). The total rate of complications was 24.4% for LPS and 39% for VPS. The improvements in EIS, KHS, MMSE, and FIM within each group after the shunt were significantly different compared to those before shunt (p < 0.05). Compared to those in the LPS group, the improvements in EIS, KHS, MMSE, and FIM were significantly different in the VPS group after shunt (p < 0.05).

Conclusion

Compared with LPS, VPS in the treatment for chronic hydrocephalus after aSAH had greater therapeutic efficacy, as indicated by improved radiological outcomes, improved shunt successful rate, improved clinical outcomes, and improved quality of life. Therefore, we believe that VPS is the preferred treatment option for chronic hydrocephalus after aSAH, while LPS should only be used as an alternative to VPS.

Post-traumatic hydrocephalus: An overview of classification, diagnosis, treatment, and post-treatment imaging evaluation

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy's report in 1914. The pathogenesis of PTH has not been fully clarified. At present, it is believed that the obstacles of cerebrospinal fluid (CSF) secretion, absorption and circulation pathways are the reasons for the development of PTH. However, recent studies have also suggested that the osmotic pressure load of CSF and the pathological changes of CSF dynamics are caused by the development of hydrocephalus. Therefore, a better understanding of the definition, classification, diagnostic criteria, treatment, and evaluation of post-treatment effects of PTH is critical for the effective prevention and treatment of PTH. In this paper, we reviewed the classification and diagnosis of PTH and focused on the treatment and the imaging evaluation of post-treatment effects of PTH. This review might provide a judgment criterion for diagnosis of PTH and a basis for the effective prevention and treatment of PTH in the future.

Effectiveness and safety of ventriculoperitoneal shunt versus lumboperitoneal shunt for communicating hydrocephalus: A systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

The current standard surgical treatment for cerebrospinal fluid diversion is a ventriculoperitoneal shunt (VPS) implantation. Lumboperitoneal shunts (LPS) are an alternative treatment for communicating hydrocephalus. Prior studies comparing these two included a limited number of participants.

METHODS

We performed a meta-analysis determined the treatment failure, complications and effectiveness of lumboperitoneal shunt for communicating hydrocephalus. We reviewed studies with clinical and imaging diagnoses of communicating hydrocephalus, all causes and subtypes of communicating hydrocephalus, and studies that analyzed the primary and secondary outcomes listed below. We included randomized controlled trials (RCTs), non-RCTs and retrospective studies. We performed the meta-analysis in R, using a random-effects model and reporting 95% confidence intervals.

RESULTS

Data from 25 studies, including 3654 patients, were analyzed. The total complication rates were 12.98% (188/1448) for lumboperitoneal shunt and 23.80% (398/1672) for ventriculoperitoneal shunt. The odds ratio for lumboperitoneal shunt versus ventriculoperitoneal shunt complication rates was 0.29 (95% CI 0.19 to 0.45, p < 0.0001), and the I² was 72%. The shunt obstruction/malfunction rate was 3.99% (48/1204) for lumboperitoneal shunt and 8.31% (115/1384) for ventriculoperitoneal shunt (Odds ratio 0.54, 95% CI 0.37 to 0.79, p = 0.002, I²  = 0%). Based on the Modified Rankin Scale score, there were no differences in effectiveness between lumboperitoneal shunt and ventriculoperitoneal shunt. Nevertheless, lumboperitoneal shunt improved radiological outcomes.

CONCLUSIONS

This analysis demonstrated that lumboperitoneal shunt is a safe and equally effective choice for treating communicating hydrocephalus. More studies are needed to confirm the safety of lumboperitoneal shunt.

Failure of Internal Cerebrospinal Fluid Shunt: A Systematic Review and Meta-Analysis of the Overall Prevalence in Adults

OBJECTIVE

Reported rates of failures of internal cerebrospinal fluid shunt (ICSFS) vary greatly from less than 5% to more than 50% and no meta-analysis to assess the overall prevalence has been performed. We estimated the failure rate after ICSFS insertion and searched for associated factors.

METHODS

Six databases were searched from January 1990 to February 2022. Only original articles reporting the rate of adult shunt failure were included. Random-effects meta-analysis with a generalized linear mixed model method and logit transformation was used to compute the overall failure prevalence. Subgroup analysis and meta-regression were implemented to search for associated factors.

RESULTS

Of 1763 identified articles, 46 were selected, comprising 70,859 ICSFS implantations and 13,603 shunt failures, suggesting an accumulated incidence of 19.2%. However, the calculated pooled prevalence value and its 95% confidence interval (CI) were 22.7% (95% CI, 19.8-5.8). The CI of the different estimates did not overlap, indicating a strong heterogeneity confirmed by a high I² of 97.5% (95% CI, 97.1-97.8; P < 0.001; τ² = 0.3). Ninety-five percent prediction interval of shunt failure prevalence ranged from 8.75% to 47.36%. A meta-regression of prevalence of publication found a barely significant decreasing failure rate of about 2% per year (-2.11; 95% CI, -4.02 to -0.2; P = 0.031).

CONCLUSIONS

Despite being a simple neurosurgical procedure, ICSFS insertion has one of the highest risk of complications, with failure prevalence involving more than 1 patient of 5. Nonetheless, all efforts to lower this high level of shunt failure seem to be effective.

Review of the prevention and treatment of hydrocephalus after aneurysmal subarachnoid hemorrhage

Hydrocephalus following a ruptured aneurysm portends a poor prognosis. Patients have to face the risk of infection and shunt obstruction after shunt surgery, which may require a second procedure and greatly reduce the quality of life for survivors. It is crucial to minimize the incidence of hydrocephalus and reduce cerebrospinal fluid shunt dependency. This article reviews current interventions before and after hydrocephalus formation after aneurysmal subarachnoid hemorrhage, focusing on the relationships between treatment options and the incidence of postoperative hydrocephalus, management of cerebrospinal fluid drainage and shunt dependent hydrocephalus, and advocates the combination of prevention and treatment to develop individualized treatment plans for patients.

Prediction of adult post-hemorrhagic hydrocephalus: a risk score based on clinical data

There is lacking research on risk factors and prediction models associated with Post-hemorrhagic hydrocephalus (PHH). Thus, this present study aimed to analyze the risk factors of PHH and establish a risk-scoring system through a large-scale study. A retrospective study of 382 patients with intracranial hemorrhage assessed age, history and diagnosis, Glasgow coma score (GCS), and fever time. After univariate and logistic regression analysis, a risk scoring system was established according to independent risk factors and evaluated using the area under the curve (AUC). Of the 382 patients, 133 (34.8%) had PHH, 43 (11.3%) received surgical treatment. Factor classification showed that age > 60 years old [odds ratio (OR): 0.347, II = 5 points], GCS < 5 (OR: 0.09, IV = 10 points), GCS 6‒8 (OR = 0.232, III = 6 points), fever time > 9 (OR: 0.202, III = 7 points), fever time 5-9 (OR: 0.341, II = 5 points), CSF-TP x time > 14,4000 group (OR: 0.267, IV = 6 points), and CSF-TP x time 9,601‒14,400 group (OR: 0.502, III = 3 points) were independent risk factors. The result of the receiver operating characteristic (ROC) prediction showed that AUC = 0.790 (0.744‒0.836). Low-risk (IV-VII), moderate (VIII-X), and high-risk group (XI-XIII) incidence of PHH were 11.76%, 50.55%, and 70.00% (p < 0.001), respectively. The coincidence rates in the validation cohort were 26.00%, 74.07%, and 100.0% (p < 0.001), respectively. AUC value was 0.860 (0.780‒0.941). The predictive model was conducive to determining the occurrence of PHH and facilitating early intervention.

Feasibility of Nonintubated Anesthesia for Lumboperitoneal Shunt Implantation

Lumboperitoneal shunt (LPS) implantation is a cerebrospinal fluid diversion therapy for the communicating type of normal-pressure hydrocephalus (NPH); NPH mainly affects older adults. However, endotracheal intubation for mechanical ventilation with muscle relaxant increases perioperative and postoperative risks for this population. Based on knowledge from nonintubated thoracoscopic surgery, which has been widely performed in recent years, we describe a novel application of nonintubated anesthesia for LPS implantation in five patients. Anesthesia without muscle relaxants, with a laryngeal mask in one patient and a high-flow nasal cannula in four patients, was used to maintain spontaneous breathing during the surgery. The mean anesthesia time was 103.8 min, and the mean operative duration was 55.8 min. All patients recovered from anesthesia uneventfully. In our experience, nonintubated LPS surgery appears to be a promising and safe surgical technique for appropriately selected patients with NPH.

The Value of the Correlation Coefficient Between the ICP Wave Amplitude and the Mean ICP Level (RAP) Combined With the Resistance to CSF Outflow (Rout) for Early Prediction of the Outcome Before Shunting in Posttraumatic Hydrocephalus

Objective

To evaluate the value of the correlation coefficient between the ICP wave amplitude and the mean ICP level (RAP) and the resistance to CSF outflow (Rout) in predicting the outcome of patients with post-traumatic hydrocephalus (PTH) selected for shunting.

Materials and Methods

As a training set, a total of 191 patients with PTH treated with VP shunting were retrospectively analyzed to evaluate the potential predictive value of Rout, collected from pre-therapeutic CSF infusion test, for a desirable recovery level (dRL), standing for the modified rankin scale (mRS) of 0–2. Eventually, there were 70 patients with PTH prospectively included as a validation set to evaluate the value of Rout-combined RAP as a predictor of dRL. We calculated Rout from a CSF infusion test and collected RAP during continuous external lumbar drainage (ELD). Maximum RAP (RAPmax) and its changes relative to the baseline (ΔRAPmax%) served as specific parameters of evaluation.

Results

In the training set, Rout was proved to be a significant predictor of dRL to shunting, with the area under the curve (AUC) of 0.686 (p &lt; 0.001) in receiver-operating characteristic (ROC) analysis. In the validation set, Rout alone did not present a significant value in the prediction of desirable recovery level (dRL). ΔRAPmax% after 1st or 2nd day of ELD both showed significance in predicting of dRL to shunting with the AUC of 0.773 (p &lt; 0.001) and 0.786 (p &lt; 0.001), respectively. Significantly, Rout increased the value of ΔRAPmax% in the prediction of dRL with the AUC of 0.879 (p &lt; 0.001), combining with ΔRAPmax% after the 1st and 2nd days of ELD. RAPmax after the 1st and 2nd days of ELD showed a remarkable predictive value for non-dRL (Levels 3-6 in Modified Rankin Scale) with the AUC of 0.891 (p &lt; 0.001) and 0.746 (p &lt; 0.001).

Conclusion

Both RAP and Rout can predict desirable recovery level (dRL) to shunting in patients with PTH in the early phases of treatment. A RAP-combined Rout is a better dRL predictor for a good outcome to shunting. These findings help the neurosurgeon predict the probability of dRL and facilitate the optimization of the individual treatment plan in the event of ineffective or unessential shunting.

Risk Factor of Posthemorrhagic Hydrocephalus: Cerebrospinal Fluid Total Protein

Objective

Cerebrospinal fluid total protein (CSF-TP) levels in adults with posthemorrhagic hydrocephalus (PHH) are poorly studied. The objective of this study was to explore the characteristics of CSF-TP levels in patients with PHH.

Methods

The clinical data of 156 patients with hemorrhagic brain disease were retrospectively studied and divided into PHH and NPHH groups. Single-factor and multi-factor analyses were performed, and the key role of CSF-TP was evaluated using linear analysis.

Results

Among the 156 patients, 85 (54.5%) had PHH and 34 (21.8%) underwent surgeries. Hypertension (p = 0.017), days [total fever time when body temperature ≥ 38.5°C (p = 0.04)], Glasgow Coma Scale (GCS) score (p < 0.001), and time (from the onset of the disease to the obtainment of CSF-TP after lumbar puncture (p < 0.001) were important factors for PHH. Logistic regression analysis revealed that GCS score < 8 [odds ratio (OR) = 2.943 (1.421–6.097), p = 0.004] and CSF-TP × time ≥ 9,600 [OR = 2.317 (1.108–4.849), p = 0.026] were independent risk factors for PHH. All CSF-TP values were averaged every 2 days. CSF-TP was negatively correlated with time. Linear analysis showed that CSF-TP in the PHH group was higher than that in the NPHH group at the same onset time, and that the duration of detectionin the CSF was longer.

Conclusion

Cerebrospinal fluid total protein (CSF-TP) × time ≥ 9,600 and GCS score <8 were independent risk factors for PHH. CSF-TP was higher in the PHH group than in the NPHH group.

Lumboperitoneal shunt surgery via continuous two-stage procedure: Technique notes and outcomes

Background

Lumboperitoneal shunt (LPS) is an effective procedure for managing communicating hydrocephalus. LPS is performed as a one-stage procedure with the patient placed in the lateral position or as a two-stage procedure in which the patient's position is changed. Both methods can be bothersome to neurosurgeons. We designed a continuous two-stage LPS procedure in which the operative sites did not need to be sterilized again, and the surgical drapes did not have to be changed after changing the patient's position. In this study, we analyzed this procedure in terms of the technical features and outcomes.

Methods

All patients from our institute who underwent LPS using the continuous two-stage procedure from October 2019 to August 2021 were reviewed retrospectively. The patient's demographic information, clinical features, operative data, and outcomes were analyzed.

Results

A total of 46 consecutive patients who underwent LPS using the continuous two-stage procedure were enrolled. The mean operative duration was 70.6 ± 12.7 min. The 180-day revision rate for these patients was 2.2% (1/46). Moreover, 76.1% of the patients (35/46) experienced clinical improvement after LPS during the 180-day follow-up, and 70.0% of the patients (32/46) experienced an improvement in neuroimaging.

Conclusion

We described a continuous two-stage LPS procedure. This method simplified the two-stage LPS procedure and maintained a low malfunction rate and shunt infection rate in our series.

Association of Preoperative Cerebrospinal Fluids Parameters With Early Shunt Obstruction in Patients With Post-hemorrhagic Hydrocephalus Treated by Lumboperitoneal Shunt

Background: Early shunt obstruction (SO) remains the most common cause of lumboperitoneal shunt (LPS) failure. Although there is anecdotal evidence that the level of cerebrospinal fluid (CSF) parameters might affect shunt performance, its association with early LPS obstruction in adults with post-hemorrhagic hydrocephalus (PHH) is unclear.

Methods: The retrospective study was performed by reviewing the adults with PHH treated by LPS from years 2014 to 2018. We included patients with CSF samples analyzed within 1 week prior to shunt insertion or at the time of shunt insertion. Baseline characteristics of each patient were collected. The primary outcomes were the incidence rate and associated factors of SO occurring within 3 months of shunt placement. The secondary outcomes included scores on the National Institute of Health Stroke Scale (NIHSS) and Evans Index at discharge.

Results: A total of 76 eligible patients were analyzed, of whom 61 were obstruction-free and 15 were early SO. The overall rate of early SO was 15.6%. The RBCs count and nucleated cells count in preoperative CSF were actually higher in patients with early SO, compared to patients in the control group. Multivariate analysis identified RBC elevation (>0 × 10⁶/L; OR: 10.629, 95% CI: 1.238–91.224, p = 0.031) as a dependent risk factor for early SO. NIHSS dramatically decreased at discharge while the alteration of ventricular size was not observed.

Conclusions: This study suggested that the presence of RBCs in preoperative CSF was associated with early SO in patients with PHH treated by LPS.

Shunting outcomes in communicating hydrocephalus: protocol for a multicentre, open-label, randomised controlled trial

INTRODUCTION

Ventriculoperitoneal shunt (VPS) remains the most widely used methods to treat communicating hydrocephalus. More recently, lumboperitoneal shunt (LPS) has been suggested as a reasonable option in some studies. However, there is lack of high-quality studies comparing these two techniques in order to certain the benefits and harms to use one of these two methods. The purpose of the current study is to determine the effectiveness and safety of the LPS versus the VPS in patients with communicating hydrocephalus.

METHODS AND ANALYSIS

All eligible patients aged 18-90 years with communicating hydrocephalus will be recruited and then randomly allocated into LPS or VPS group in a ratio of 1:1. All patients will be analysed before shunt insertion, at the time of discharge, 1 month, 6 months, 12 months and 24 months postoperatively. The primary outcome measure is the rate of shunt failure at a 2-year follow-up term. The secondary outcomes include Keifer's Hydrocephalus Scale, National Institute of Health Stroke Scale, Glasgow Outcome Scale Extended, Evans index, safety endpoints and cost-effectiveness of hospital stay.

ETHICS AND DISSEMINATION

The study will be performed in compliance with the Declaration of Helsinki (2002) of the World Medical Association. The study was approved by Institutional Review Board of West China Hospital. All patients will be fully informed the potential benefits, potential risks and responsibilities, those who will sign the informed consents once they are included. Preliminary and final results will be published in peer-reviewed journals and presented at national and international congresses.

TRIAL REGISTRATION NUMBER

ChiCTR2100043839.

Comparison of ventriculoperitoneal shunt to lumboperitoneal shunt in the treatment of idiopathic: A monocentric, assessor-blinded, randomized controlled trial

BACKGROUND

Ventriculoperitoneal shunt (VPS) and lumboperitoneal shunt (LPS) remain the mainstay of idiopathic normal pressure hydrocephalus (INPH). There are no randomized controlled trials completed to compare the efficacy of these 2 shunt techniques.

METHODS/DESIGN

We will conduct a monocentric, assessor-blinded, and randomized controlled trial titled "Comparison of Ventriculoperitoneal Shunt to Lumboperitoneal Shunt for the treatment of Idiopathic Normal Pressure Hydrocephalus: Phase I (COVLINPH-1)" trial and recruit patients at West China Hospital of Sichuan University since June 2021. And this trial is expected to end in December 2030. Eligible participants will be randomly assigned into LPS group and VPS group at ratio of 1:1 followed by evaluation before surgery, 1 month, 12 months, and 5 years after surgery. The primary outcome is the rate of shunt failure within 5 years. The secondary outcomes include modified Rankin Scale (mRS), INPH grading scale (INPHGS), mini-mental state examination (MMSE), and Evans index. We will calculate the rate of favorable outcome, which is defined as shunt success and an improvement of more than 1 point in the mRS at evaluation point. We will also analyze the complications throughout the study within 5 years after shunt insertion.

DISCUSSION

The results of this trial will provide state-of-the-art evidence on the treatment option for patients with INPH, and will also generate the discussion regarding this subject.

TRIAL REGISTRATION NUMBER

ChiCTR2000031555; Pre-results.

Development of Valve Reversal After Lumboperitoneal Shunt Construction

OBJECTIVE

The current study aimed to assess the risk factors and preventive measures for valve inversion after lumboperitoneal shunt (LPS) construction.

METHODS

The medical records of patients who were admitted to Mito Brain Heart Center from July 2015 to October 2018 were retrospectively analyzed. Next, clinical and neuroimaging data were collected from electronic medical charts and operative notes. The cause of valve reversal was investigated. In addition, a simulated shunt device was established and the efficacy of countermeasures was evaluated.

RESULTS

The mean age of the participants was 69.3 (range: 46-88) years, and there were 15 men and 22 women. In total, 20 and 17 patients presented with secondary and idiopathic normal pressure hydrocephalus, respectively. Further, 8 patients had valve reversal.

CONCLUSIONS

The distance between the valve and spinous process was found to be significantly correlated with valve reversal. However, the condition can be prevented by fixing the tube at the nuchal ligament.

Shunting outcomes in post-hemorrhagic hydrocephalus: A protocol for systematic review and meta-analysis

BACKGROUND

The best treatment option for patients with post-hemorrhagic hydrocephalus (PHH) remains controversial. The objective of the current meta-analysis is to systematically evaluate the long-term outcomes of patients with PHH treated by ventriculoperitoneal shunt (VPS) and lumboperitoneal shunt (LPS).

METHODS

We search literatures through PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), the Chinese Science and Technology Periodical Database (VIP) and Wan fang databases, and Chinese Biomedical Literature Database (CBM) from its beginning to June 15, 2020. Randomized controlled trials (RCTs) and non-RCTs in English or Chinese studies will be considered. The primary outcome is the rate of shunt failure after shunt implantationThe secondary outcome is the rate of complications that are associated with shunt surgery.

RESULTS AND CONCLUSION

The study will compare the 2 types of shunt surgery in the treatment of PHH, providing evidence for the treatment option for the patients with PHH.

STUDY REGISTRATION NUMBER

The study is priorly registered through International Platform of Registered Systematic Review and Meta-analysis Protocols on June 17, 2020 (INPLASY202060063).

Comparison of ventriculoperitoneal shunt to lumboperitoneal shunt in the treatment of posthemorrhagic hydrocephalus: A prospective, monocentric, non-randomized controlled trial

BACKGROUND

Ventriculoperitoneal shunt (VPS) surgery remains the most widely accepted and used option method to treat post-hemorrhagic hydrocephalus (PHH) worldwide while lumboperitoneal shunt (LPS) serves as an effectively alternative treatment. However, the outcomes of VPS and LPS in the treatment of PHH have not been compared in a prospective trial.

METHODS AND DESIGN

In this monocentric, assessor-blinded, non-randomized controlled trial, 75 eligible patients with PHH for each group will be recruited to compare the outcomes of VPS cohort with that of LPS cohort. Each participant is evaluated before surgery, at the time of discharge, 3, and 6 months after surgery by experienced and practiced assessors. The primary outcome is the rate of shunt failure 6 months after shunt surgery. The secondary measure of efficacy is National Institute of Health stroke scale, together along with Glasgow coma scale, modified Rankin Scale, and Evans index at the evaluation point. A favorable outcome is defined as shunt success with an improvement of more than 1 point in the National Institute of Health stroke scale. Complication events occurring within 6 months after surgery are investigated. A serious adverse events throughout the study are recorded regarding the safety of shunts.

DISCUSSION

The results of this trial will provide evidence for the treatment options for patients with PHH.