Outcomes of Ventriculoperitoneal Shunt in Patients With Idiopathic Normal-Pressure Hydrocephalus 2 Years After Surgery

Programmable gravitational valves in idiopathic normal pressure hydrocephalus: long-term outcomes after a 3-year follow-up

BACKGROUND

The development of shunting valve technologies for the surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) has advanced significantly over the decades, with adjustable gravitational valves (GV) emerging as a promising alternative to traditional fixed-pressure valves. This study aimed to investigate the safety and effectiveness of adjustable GV for the surgical treatment of iNPH after a 3-year follow-up.

METHODS

Adult patients treated with ventriculoperitoneal shunt (VPS) using programmable GVs were retrospectively evaluated. Neurological outcome was assessed according to the iNPH Grading Scale (INPHGS). Postoperative early and late complications, pre- and post-implantation pressure settings, and type and number of post-implantation pressure adjustments were recorded at each follow-up.

RESULTS

A total of 76 patients were evaluated, with a median postoperative follow-up of 36 (24-42) months. The mean preoperative and postoperative iNPHGS scores were 4.2 ± 1.6 and 3.5 ± 1.5, respectively, demonstrating a significant overall clinical improvement after VPS surgery (p < 0.001). Overall, 7 (9.2%) patients required surgical intervention due to late complications. No cases of valve dysfunction were reported. During follow-up, 54 (71.1%) patients underwent valve setting adjustments, with a median number of post-implantation valve setting modifications of 1. No significant associations were found between postoperative outcomes and preoperative characteristics including age and initial opening pressure parameters.

CONCLUSIONS

Adjustable GVs are a safe and effective alternative to traditional fixed differential pressure valves for the surgical treatment of iNPH. After a 3-year follow-up, the overall postoperative complication rate was acceptable, with a significantly lower rate of valve dysfunction compared to previous literature findings.

Advancing treatment strategies for idiopathic normal pressure hydrocephalus: a systematic review on studies comparing ventricular and lumbo-peritoneal shunts

Idiopathic normal-pressure hydrocephalus (iNPH) is characterized by the clinical triad of gait disturbance, cognitive decline, and urinary incontinence. Cerebrospinal fluid (CSF) diversion is the gold standard treatment. Despite ventriculo-peritoneal shunt (VPS) is more commonly used, lumbo-peritoneal shunt (LPS) offers a minimally invasive alternative, raising questions about their relative efficacy and safety. A systematic review was conducted on multiple databases with a two-step selection process in order to exclude studies with insufficient data, irrelevance, and lacking of comparative analysis between the two procedures. From the included studies we comparatively analyzed preoperative clinical-radiological characteristics, surgical details and clinical-radiological outcome. We included 6 studies matching out inclusion criteria. Both VPS and LPS improved functional and cognitive performance. VPS provided faster symptoms relief, but has been related with higher risks of infection, whereas LPS showed a safer profile but required more frequent revisions due to mechanical issues. VPS and LPS are both effective treatments for iNPH. The choice of intervention should be tailored on the individual patient risk profiles, resource availability, and surgical expertise. Future research should focus on standardizing assessment scores, solve controversies, and evaluate long-term outcomes.

Long-term outcomes of ventriculoperitoneal shunt therapy in idiopathic normal pressure hydrocephalus

BACKGROUND

Limited data are available regarding the long-term functional outcomes and associated factors in patients with idiopathic normal pressure hydrocephalus (iNPH) undergoing ventriculoperitoneal shunt (VPS) placement. This study aimed to retrospectively evaluate the long-term outcomes of iNPH patients treated with VPS.

METHODS

Functional outcomes were assessed preoperatively and at 1-year, 2-year, and 3-year intervals postoperatively using the modified Rankin Scale (mRS), the iNPH grading scale (iNPHGS), and the Mini-Mental State Examination (MMSE).

RESULTS

Significant improvements were observed in mRS and iNPHGS scores at 1, 2, and 3 years post-surgery compared to the baseline level. MMSE scores showed significant improvement at 1-year and 3-year follow-ups. Multivariate regression analysis identified key factors influencing changes in mRS scores: postoperative complications and education level at 1 year, postoperative complications at 2 years, and sex, education level, postoperative complications, and smoking at 3 years. For iNPHGS scores, significant factors included sex, age at surgery, and smoking at 1 and 2 years. Changes in MMSE scores were associated with sex and the duration of preoperative symptoms at 1 year, and postoperative complications, education level, and smoking at 3 years.

CONCLUSION

This study affirmed the efficacy and safety of VPS in managing iNPH. Factors influencing postoperative outcomes predominantly included education level, smoking, duration of preoperative symptoms, and postoperative complications. However, further research is required to validate these findings.

Physical activity and gait in patients with idiopathic normal pressure hydrocephalus: a literature review

Background

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by impaired gait and cognition, and urinary incontinence. Even though iNPH still lacks standardized diagnostic criteria, many patients may potentially benefit from treatment which are often invasive procedures.

Objectives

To provide an overview of the current state of research on physical activity behavior and gait in patients with iNPH, and examine potential changes after treatment (i.e., shunt surgery, spinal tap test or lumbar drainage).

Methods

This literature review was carried out based on the PRISMA statement and we searched PubMed, Web of Science and Scopus databases in April 2023.

Results

In total, 32 studies were included: 29 focusing on gait, 2 focusing on gait and physical activity, and 1 focusing on physical activity. All studies reported improvements in gait, such as reduced gait ataxia or shuffling gait and greater variability of gait cycle length, after an intervention or treatment. Improvements may depend on patients' age, symptom duration, and treatment method, among others.

Conclusion

Improvements in gait after iNPH treatment (e.g., shunt surgery) are well documented, whereas results on physical activity behavior in iNPH patients are inconsistent. More research on physical activity and gait outcomes before and after treatment is needed, also with regard to treatment success.

Treatment of iNPH: novel insights

This review advocates for a shift from traditional symptom-based diagnosis of idiopathic normal pressure hydrocephalus (iNPH) to a deeper investigation into its underlying pathophysiological mechanisms, particularly the role of altered cerebral hydrodynamics as an important pathological hallmark. We explore the heterogeneity of iNPH, emphasizing its frequent overlap and cooccurrence with neurodegenerative conditions like Alzheimer and Parkinson disease, and subcortical vascular encephalopathy, complicating diagnosis and treatment strategies. The lumbar infusion test emerges as a useful diagnostic tool, offering quantitative insights into CSF outflow resistance that should be considered as a useful biomarker related to cerebral hydrodynamics and iNPH pathophysiology. Furthermore, we propose the hypothesis that shunt placement, by regulating brain fluid mechanics, may also serve as a form of neuromodulation, potentially enhancing neuronal function and mitigating clinical symptoms. This review advocates for an interdisciplinary, physics-based and patient-centered approach that emphasizes early detection, accurate diagnostics, and personalized treatment plans to enhance patient outcomes and quality of life, particularly in the aging population.

Automated Idiopathic Normal Pressure Hydrocephalus Diagnosis via Artificial Intelligence-Based 3D T1 MRI Volumetric Analysis

BACKGROUND AND PURPOSE

Idiopathic normal pressure hydrocephalus (iNPH) is reversible dementia that is underdiagnosed. The purpose of this study was to develop an automated diagnostic method for iNPH using artificial intelligence techniques with a T1-weighted MRI scan.

MATERIALS AND METHODS

We quantified iNPH, Parkinson disease, Alzheimer disease, and healthy controls on T1-weighted 3D brain MRI scans using 452 scans for training and 110 scans for testing. Automatic component measurement algorithms were developed for the Evans index, Sylvian fissure enlargement, high-convexity tightness, callosal angle, and normalized lateral ventricle volume. XGBoost models were trained for both automated measurements and manual labels for iNPH prediction.

RESULTS

A total of 452 patients (200 men; mean age, 73.2 [SD, 6.5] years) were included in the training set. Of the 452 patients, 111 (24.6%) had iNPH. We obtained area under the curve (AUC) values of 0.956 for automatically measured high-convexity tightness and 0.830 for Sylvian fissure enlargement. Intraclass correlation values of 0.824 for the callosal angle and 0.924 for the Evans index were measured. By means of the decision tree of the XGBoost model, the model trained on manual labels obtained an average cross-validation AUC of 0.988 on the training set and 0.938 on the unseen test set, while the fully automated model obtained a cross-validation AUC of 0.983 and an unseen test AUC of 0.936.

CONCLUSIONS

We demonstrated a machine learning algorithm capable of diagnosing iNPH from a 3D T1-weighted MRI that is robust to the failure. We propose a method to scan large numbers of 3D T1-weighted MRIs with minimal human intervention, making possible large-scale iNPH screening.

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.

An Interdisciplinary Protocol for Ventriculoperitoneal Shunt Patient Selection in Normal Pressure Hydrocephalus

BACKGROUND

Normal pressure hydrocephalus can be treated with ventriculoperitoneal shunt (VPS) placement, but no broadly implemented indication for VPS exists.

METHODS

Our protocol consists of physical therapy and occupational therapy practitioners administering validated tests of gait, balance, and cognition before and after lumbar drain placement. Specific tests include: Timed "Up & Go", Tinetti Gait and Balance Assessment, Berg Balance Scale, Mini Mental Status Exam, Trail Making Test Part B, and the Rey Auditory and Visual Learning Test. Minimal clinically important difference values for each test were determined from literature review. A retrospective review of patients treated under this protocol was performed. The primary outcomes were candidacy for VPS based on the protocol and patient-reported symptomatic improvement after VPS placement.

RESULTS

A total of 48/75 (64%) patients received VPS. A total of 43/48 (89.6%) of those shunted reported improved symptoms at 6-week follow-up. However, 10/22 (45.5%) reported worsening symptoms at 1-year follow-up. The mean Tinetti score significantly increased after lumbar drain in patients who improved with VPS compared to the no shunt group (4.27 vs. -0.48, P < 0.001). A total of 6/33 (18%) patients with postoperative imaging had a subdural fluid collection identified and 3/49 (6%) had other complications, including 1 seizure, 1 intracerebral hemorrhage, and 1 stroke.

CONCLUSIONS

Standardized assessment of gait, balance, and cognition before and after temporary cerebrospinal fluid diversion identifies patients with normal pressure hydrocephalus likely to benefit from VPS placement with a low complication rate. One year after VPS, approximately one half of patients had symptoms recurrence.

Ventriculoperitoneal Shunt Placement Safety in Idiopathic Normal Pressure Hydrocephalus: Anticoagulated Versus Non-Anticoagulated Patients

BACKGROUND

Many patients with idiopathic normal pressure hydrocephalus (iNPH) have medical comorbidities requiring anticoagulation that could negatively impact outcomes. This study evaluated the safety of ventriculoperitoneal shunt placement in iNPH patients on systemic anticoagulation versus those not on anticoagulation.

METHODS

Patients >60 years of age with iNPH who underwent shunting between 2018 and 2022 were retrospectively reviewed. Baseline demographics, comorbidities (quantified by modified frailty index and Charlson comorbidity index), anticoagulant/antiplatelet agent use (other than aspirin), operative details, and complications were collected. Outcomes of interest were the occurrence of postoperative hemorrhage and overdrainage.

RESULTS

A total of 234 patients were included in the study (mean age 75.22 ± 6.04 years; 66.7% male); 36 were on anticoagulation/antiplatelet therapy (excluding aspirin). This included 6 on Warfarin, 19 on direct Xa inhibitors, 10 on Clopidogrel, and 1 on both Clopidogrel and Warfarin. Notably, 70% of patients (164/234) used aspirin alone or combined with anticoagulation or clopidogrel. Baseline modified frailty index was similar between groups, but those on anticoagulant/antiplatelet therapy had a higher mean Charlson comorbidity index (2.67 ± 1.87 vs. 1.75 ± 1.84; P = 0.001). Patients on anticoagulants were more likely to experience tract hemorrhage (11.1 vs. 2.5%; P = 0.03), with no significant difference in the rates of intraventricular hemorrhage or overdrainage-related subdural fluid collection.

CONCLUSIONS

Anticoagulant and antiplatelet agents are common in the iNPH population, and patients on these agents experienced higher rates of tract hemorrhage following ventriculoperitoneal shunt placement; however, overall hemorrhagic complication rates were similar.

17 years of experience with shunt systems in normal pressure hydrocephalus - From differential pressure to gravitational valves

Objective

Complication rate of shunting for normal pressure hydrocephalus (NPH) has significantly improved over the last decades. Especially the use of overdrainage protection has reduced the incidence of subdural hematoma and collections. However, gravitational valves were associated with other complications of shunt dysfunction. We present our 17 years of experience with patients with normal pressure hydrocephalus who changed from a differential pressure valve to a gravitational valve system.

Methods

We retrospectively identified all patients with the diagnosis of normal pressure hydrocephalus, in whom primary shunt implantation was performed between 2004 and 2020. Shunt implantation was performed as per our internal standard. Review of imaging, charts and patient reports was performed.

Results

In total, 409 patients were included in the analysis. Mean age was 73.0 ± 7.1years. Between 2004 and 2010, predominantly Hakim valves (n = 100, 24.4%) were implanted, whilst from 2009 until 2020, proGAV valves (n = 296, 72.4%) were used. Mean follow-up was 8.9 ± 4.5 years. Initial subjective improvement of symptoms was reported in 69.9%, whilst this number decreased at the last follow-up to 29.8%. No significant differences were observed between the valves in the frequency of surgery for subdural hematoma. Shunt assistant implantation was performed in 17% of patients with Hakim valve, in 9.5% of patients with proGAV, a shunt assistant was added. Shunt obstruction was significantly higher in proGAV valves (p < 0.001).

Conclusions

Our findings confirm the observation of frequent overdrainage in shunts without anti-siphon/gravitational component. Gravitational valves on the other hand may be associated with more obstruction.

Abnormal characteristic static and dynamic functional network connectivity in idiopathic normal pressure hydrocephalus

AIMS

Idiopathic Normal pressure hydrocephalus (iNPH) is a neurodegenerative disease characterized by gait disturbance, dementia, and urinary dysfunction. The neural network mechanisms underlying this phenomenon is currently unknown.

METHODS

To investigate the resting-state functional connectivity (rs-FC) abnormalities of iNPH-related brain connectivity from static and dynamic perspectives and the correlation of these abnormalities with clinical symptoms before and 3-month after shunt. We investigated both static and dynamic functional network connectivity (sFNC and dFNC, respectively) in 33 iNPH patients and 23 healthy controls (HCs).

RESULTS

The sFNC and dFNC of networks were generally decreased in iNPH patients. The reduction in sFNC within the default mode network (DMN) and between the somatomotor network (SMN) and visual network (VN) were related to symptoms. The temporal properties of dFNC and its temporal variability in state-4 were sensitive to the identification of iNPH and were correlated with symptoms. The temporal variability in the dorsal attention network (DAN) increased, and the average instantaneous FC was altered among networks in iNPH. These features were partially associated with clinical symptoms.

CONCLUSION

The dFNC may be a more sensitive biomarker for altered network function in iNPH, providing us with extra information on the mechanisms of iNPH.

Improve the diagnosis of idiopathic normal pressure hydrocephalus by combining abnormal cortical thickness and ventricular morphometry

Background

The primary imaging markers for idiopathic Normal Pressure Hydrocephalus (iNPH) emphasize morphological measurements within the ventricular system, with no attention given to alterations in brain parenchyma. This study aimed to investigate the potential effectiveness of combining ventricular morphometry and cortical structural measurements as diagnostic biomarkers for iNPH.

Methods

A total of 57 iNPH patients and 55 age-matched healthy controls (HC) were recruited in this study. Firstly, manual measurements of ventricular morphology, including Evans Index (EI), z-Evans Index (z-EI), Cella Media Width (CMW), Callosal Angle (CA), and Callosal Height (CH), were conducted based on MRI scans. Cortical thickness measurements were obtained, and statistical analyses were performed using surface-based morphometric analysis. Secondly, three distinct models were developed using machine learning algorithms, each based on a different input feature: a ventricular morphology model (LVM), a cortical thickness model (CT), and a fusion model (All) incorporating both features. Model performances were assessed using 10-fold cross validation and tested on an independent dataset. Model interpretation utilized Shapley Additive Interpretation (SHAP), providing a visualization of the contribution of each variable in the predictive model. Finally, Spearman correlation coefficients were calculated to evaluate the relationship between imaging biomarkers and clinical symptoms.

Results

iNPH patients exhibited notable differences in cortical thickness compared to HC. This included reduced thickness in the frontal, temporal, and cingulate cortices, along with increased thickness in the supracentral gyrus. The diagnostic performance of the fusion model (All) for iNPH surpassed that of the single-feature models, achieving an average accuracy of 90.43%, sensitivity of 90.00%, specificity of 90.91%, and Matthews correlation coefficient (MCC) of 81.03%. This improvement in accuracy (6.09%), sensitivity (11.67%), and MCC (11.25%) compared to the LVM strategy was significant. Shap analysis revealed the crucial role of cortical thickness in the right isthmus cingulate cortex, emerging as the most influential factor in distinguishing iNPH from HC. Additionally, significant correlations were observed between the typical triad symptoms of iNPH patients and cortical structural alterations.

Conclusion

This study emphasizes the significant role of cortical structure changes in the diagnosis of iNPH, providing a novel insights for assisting clinicians in improving the identification and detection of iNPH.

Utility of cortical tissue analysis in normal pressure hydrocephalus

Clinical improvement following neurosurgical cerebrospinal fluid shunting for presumed idiopathic normal pressure hydrocephalus is variable. Idiopathic normal pressure hydrocephalus patients may have undetected Alzheimer's disease-related cortical pathology that confounds diagnosis and clinical outcomes. In this study, we sought to determine the utility of cortical tissue immuno-analysis in predicting shunting outcomes in idiopathic normal pressure hydrocephalus patients. We performed a pooled analysis using a systematic review as well as analysis of a new, original patient cohort. Of the 2707 screened studies, 3 studies with a total of 229 idiopathic normal pressure hydrocephalus patients were selected for inclusion in this meta-analysis alongside our original cohort. Pooled statistics of shunting outcomes for the 229 idiopathic normal pressure hydrocephalus patients and our new cohort of 36 idiopathic normal pressure hydrocephalus patients revealed that patients with Aβ + pathology were significantly more likely to exhibit shunt nonresponsiveness than patients with negative pathology. Idiopathic normal pressure hydrocephalus patients with Alzheimer's disease -related cortical pathology may be at a higher risk of treatment facing unfavorable outcomes following cerebrospinal fluid shunting. Thus, cortical tissue analysis from living patients may be a useful diagnostic and prognostic adjunct for patients with presumed idiopathic normal pressure hydrocephalus and potentially other neurodegenerative conditions affecting the cerebral cortex.

[Intrascopic predictors of favorable outcomes after ventriculoperitoneal shunting in Hakim-Adams syndrome: a single-center retrospective non-randomized study]

The main feature of idiopathic normal pressure hydrocephalus is reversible clinical manifestations after timely ventriculoperitoneal shunting. However, the effectiveness of such interventions does not exceed 85%. Invasive diagnostic methods are used to select candidates for surgery. At the same time, literature data indicate neuroimaging symptoms predicting postoperative outcomes without invasive examination.

OBJECTIVE

To identify intrascopic predictors of favorable outcomes after ventriculoperitoneal shunting in Hakim-Adams syndrome; to present a model for evaluating MRI data and selecting candidates for surgery.

MATERIAL AND METHODS

A single-center retrospective non-randomized study enrolled head MRI data in patients with idiopathic normal-pressure hydrocephalus who underwent ventriculoperitoneal shunting between September 2020 and March 2022. There were 34 patients including 15 ones in the main group (significant improvement after surgery) and 19 ones in the control group. We analyzed quantitative neuroimaging features: ventriculocranial indices, DESH syndrome (DESH score), angle of corpus callosum at the level of anterior and posterior commissures, dimensions of temporal horns of lateral ventricles, the number of lacunar infarcts in basal ganglia and white matter of hemispheres.

RESULTS

We identified the most significant predictors of favorable outcomes after ventriculoperitoneal shunting: Evans index, indexed longitudinal size of lateral ventricles, angle of corpus callosum (at the level of anterior and posterior commissures) and DESH score. We created a classification model using discriminant analysis. This model allows us to predict the outcomes after ventriculoperitoneal shunting.

CONCLUSION

A comprehensive assessment of intrascopic symptoms allows us to predict the outcomes after ventriculoperitoneal shunting in patients with Hakim-Adams syndrome. In the future, we can avoid invasive diagnostic manipulations in some patients.

Diffusion tensor imaging helps identify shunt-responsive normal pressure hydrocephalus patients among probable iNPH cohort

The aim of this study was to investigate whether white matter changes as measured by diffusion tensor imaging (DTI) can help differentiate shunt-responsive idiopathic normal pressure hydrocephalus (iNPH) patients from patients with other causes of gait disturbances and/or cognitive decline with ventriculomegaly whose clinical symptoms do not improve significantly after cerebrospinal fluid derivation (non-iNPH). Between 2017 and 2022, 85 patients with probable iNPH underwent prospective preoperative magnetic resonance imaging (MRI) and comprehensive clinical workup. Patients with clinical symptoms of iNPH, positive result on lumbar infusion test, and gait improvement after 120-h lumbar drainage were diagnosed with iNPH and underwent shunt-placement surgery. Fractional anisotropy (FA) and mean diffusivity (MD) values for individual regions of interest were extracted from preoperative MRI, using the TBSS pipeline of FSL toolkit. These FA and MD values were then compared to results of clinical workup and established diagnosis of iNPH. An identical MRI protocol was performed on 13 age- and sex-matched healthy volunteers. Statistically significant differences in FA values of several white matter structures were found not only between iNPH patients and healthy controls but also between iNPH and non-iNPH patients. ROI that showed best diagnostic ability when differentiating iNPH among probable iNPH cohort was uncinate fasciculus, with AUC of 0.74 (p < 0.001). DTI methods of white matter analysis using standardised methods of ROI extraction can help in differentiation of iNPH patients not only from healthy patients but also from patients with other causes of gait disturbances with cognitive decline and ventriculomegaly.

Fixed versus Adjustable differential pressure valves in case of idiopathic normal pressure hydrocephalus treated with ventriculoperitoneal shunt. A systematic review and meta-analysis of proportion

INTRODUCTION

Idiopathic normal pressure hydrocephalus is a common cause of communicating hydrocephalus in adult age, presenting with classic Hakim-Adam's triad. Ventriculoperitoneal shunting is the treatment of choice in these cases. The main objective of this study is to compare the complication rate of Adjustable differential pressure valves with fixed differential pressure valves in these cases.

LITERATURE SEARCH

We systematically searched PubMed/Medline, Embase, LILACS, and ClinicalTrials.gov from their date of inception to 30th Jan 2023. We included observational studies, Randomized Controlled Trials (RCTs), and comparative and noncomparative studies in the search. The literature search resulted in 1394 studies, and only 22 studies were eligible to be included in the meta-analysis. We performed the meta-analysis of proportion to compare incidence rates by performing a Freeman-turkey double arcsine transformation.

RESULTS

The summary of the proportions of the incidence rate of complications was less for Adjustable Differential Pressure Valves (ADPV) as compared to Fixed Differential Pressure Valves (FDVP) but the confidence intervals overlapped. The summary proportion of surgical revision of shunt in the case of ADPV was 0.081 (95% CI (0.047, 0.115)), and in the case of FDPV was 0.173 (95% CI (0.047, 0.299)). Similarly, the summary proportion of subdural fluid collection in the case of ADPV was 0.090 (0.058, 0.122), and in the case of FDPV was 0.204 (0.132, 0.277). The incidence of complication was low in population implanted with DPV along with gravitational or anti-siphon unit (GASU).

CONCLUSION

Complication rates in the case of ADPV plus GASU were the lowest. Though the summary proportion of complication rate in the case of ADPV was low as compared to FDPV, the statistical significance of this difference is doubted due to overlapping confidence intervals.

Idiopathic Normal Pressure Hydrocephalus and Progressive Supranuclear Palsy: Two Single Entities or Neurodegenerative Overlap Syndrome? A Case Report

The differential diagnosis of idiopathic normal pressure hydrocephalus (iNPH) and progressive supranuclear palsy (PSP) is difficult. The importance of proper diagnosis is particularly important for iNPH, which can be effectively treated with a ventriculoperitoneal (VP) shunt. In our case report, we present a unique case of a patient with overlapping symptoms and radiological findings of iNPH and PSP. Our patient underwent the VP shunt after a differential diagnostic evaluation which resulted in significant improvement in their clinical condition and quality of life, albeit for a short time.

Endoscopic Third Ventriculostomy in a 12-Year-Old With Recurrent Failure of Ventriculoperitoneal Shunts

With a success rate of about 80%, ventriculoperitoneal (VP) shunts are widely used for the treatment of hydrocephalus. Whether congenital or acquired, hydrocephalus is not a single disease entity. It can be caused by abnormal cerebrospinal fluid (CSF) reabsorption, obstruction along the ventricular pathways, or, very rarely, increased production of CSF itself. This case presents a patient with a history of congenital hydrocephalus with multiple failed VP shunts. Through various clinical examinations and diagnostic measures, an endoscopic third ventriculostomy was eventually performed. This case highlights the rare complications, yet a large possibility, that can lead to failure of VP shunts in more than one way and when it is appropriate for shunt reversal versus removal.

Ventriculoperitoneal Shunt Failure 3-year after Shunt Surgery Caused by Migration of Detached Ventricular Catheter into the Cranium: A Case Study of Idiopathic Normal-pressure Hydrocephalus

Idiopathic normal-pressure hydrocephalus (iNPH) is a neurological disorder that typically presents with gait disturbance, cognitive impairment, and urinary incontinence. Although most patients respond to cerebrospinal-fluid shunting, some do not react well because of shunt failure. A 77-year-old female with iNPH underwent ventriculoperitoneal shunt implantation, and her gait impairment, cognitive dysfunction, and urge urinary incontinence improved. However, 3 years after shunting (at the age of 80), her symptoms gradually recurred for 3 months and she did not respond to shunt valve adjustment. Imaging studies revealed that the ventricular catheter detached from the shunt valve and migrated into the cranium. With immediate revision of the ventriculoperitoneal shunt, her gait disturbance, cognitive dysfunction, and urinary incontinence improved. When a patient whose symptoms have been relieved by cerebrospinal-fluid shunting experiences an exacerbation, it is important to suspect shunt failure, even if many years have passed since the surgery. Identifying the position of the catheter is crucial to determine the cause of shunt failure. Prompt shunt surgery for iNPH can be beneficial, even in elderly patients.

Idiopathic normal pressure hydrocephalus: postoperative patient perspective and quality of life

BACKGROUND

Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible disease. Surgical results have been well described in the literature, but only a few studies investigated the subjective outcome. This study aimed to investigate the patient's expectations about surgery, the perceived improvement after treatment, and its impact on the quality of life (QoL).

METHODS

A new dedicated survey was created to investigate subjectively different aspects of the treatment pathway of iNPH (diagnosis, symptoms, expectations from surgery, surgical operation, surgical results, and postoperative QoL), together with the SF-12 and EQ-5D as validated, standardized tools.

RESULTS

Forty-five patients were included. Forty-three percent of cases received the diagnosis after at least 1 year, with symptoms worsening in 73%, and frustration in 93%. Reaching a diagnosis was important for 100% of patients, with high expectations from surgery; 86% of them hoped to return to a normal life. Seventy-two percent of patients reported a significant postoperative improvement (walking 68%, mood 57%). Memory and incontinence did not improve in 64% of cases. Subjectively, QoL improved in 72% of cases. The SF-12 score is comparable to controls >75 years, but lower than the 65-75 years group. The EQ-5D index was 0.66 (lower than those of the 65-75 years group = 0.823, and >75 years group = 0.724). Pain and discomfort, instead, were lower compared to the healthy population (43% vs 56%). The idea of having an implanted device and of long-term follow-up is not worrying for 80% of patients; approximately two-thirds of them reported a regained control of their lives.

CONCLUSIONS

The importance of early diagnosis and patients' perspective, alongside clinical evaluation, is highlighted. The self-reported evaluations on symptoms and QoL, along with the balance between postoperative worries and benefits, should be discussed preoperatively with patients and relatives, and included postoperatively to comprehensively assess the surgical outcome.