Vol 54, No 6 (2020)
Research Paper
Published online: 2020-10-12

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In NPH, setting valve opening pressure close to lumbar puncture opening pressure decreases overdrainage

Tito Vivas-Buitrago1, Ricardo Domingo1, Shashwat Tripathi2, Juan Pablo Herrera1, Johan Heemskerk1, Sanjeet Grewal1, Nicholas L. Zalewski1, Alfredo Quinones-Hinojosa1, Ronald Reimer1, Robert E. Wharen1, Neil R. Graff-Radford1
Pubmed: 33047786
Neurol Neurochir Pol 2020;54(6):531-537.

Abstract

Background. The management of normal pressure hydrocephalus (NPH) can be difficult, partly because there are frequent treatment complications such as overdrainage which, when serious, may require surgical intervention. We previously reported a correlation between the difference of lumbar puncture opening pressure minus the valve opening pressure setting (LPOP–VOP) (which we refer to as the delta) and increased rates of overdrainage. This led to a modification in our practice, whereby we now set the VOP equal to, or close to, the LPOP, resulting in lower deltas. Objective. In this new study, our aim was to compare the rate of overdrainage in our patients with higher and lower deltas and assess the significance of setting the VOP equal, or close, to the patient’s LPOP. Methods. 1. We reproduced the association between delta and overdrainage. 2. We compared the incidence of overdrainage in those whose VOP was set close to LPOP (low delta) versus those with VOP setting distant from the LPOP (higher delta). 3. We compared symptom improvement in those with a low versus higher delta. Results. We confirmed the relation between high delta and an increased rate of overdrainage, lower rates of overdrainage in those whose VOP was set close to the LPOP (Delta Adjusted Practice), and better improvement of symptoms when the VOP was set closer to the LPOP. Conclusion. We propose that the initial VOP should be set as close as possible to the patient’s LPOP to decrease overdrainage without compromising symptom improvement.

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References

  1. ADAMS RD, FISHER CM, HAKIM S, et al. SYMPTOMATIC OCCULT HYDROCEPHALUS WITH "NORMAL" CEREBROSPINAL-FLUID PRESSURE.A TREATABLE SYNDROME. N Engl J Med. 1965; 273: 117–126.
  2. Duinkerke A, Williams MA, Rigamonti D, et al. Cognitive recovery in idiopathic normal pressure hydrocephalus after shunt. Cogn Behav Neurol. 2004; 17(3): 179–184.
  3. Graff-Radford NR, Jones DT. Normal Pressure Hydrocephalus. Continuum (Minneap Minn). 2019; 25(1): 165–186.
  4. Hakim S, Adams RD. The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci. 1965; 2(4): 307–327.
  5. Hung AL, Vivas-Buitrago T, Adam A, et al. Ventriculoatrial versus ventriculoperitoneal shunt complications in idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg. 2017; 157: 1–6.
  6. Jusué-Torres I, Jeon LH, Sankey EW, et al. A Novel Experimental Animal Model of Adult Chronic Hydrocephalus. Neurosurgery. 2016; 79(5): 746–756.
  7. Kiefer M, Eymann R, Steudel W. Outcome redictors for normal-ressure hydrocehalus. Brain Edema XIII: Sringer; 2006. p. : 364–7.
  8. Klinge P, Marmarou A, Bergsneider M, et al. Outcome of shunting in idiopathic normal-pressure hydrocephalus and the value of outcome assessment in shunted patients. Neurosurgery. 2005; 57(3 Suppl): S40–52; discussion ii.
  9. McGirt MJ, Woodworth G, Coon AL, et al. Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005; 57(4): 699–705; discussion 699.
  10. McGovern RA, Kelly KM, Chan AK, et al. Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus? J Neurosurg. 2014; 120(6): 1458–1464.
  11. Murakami Y, Matsumoto Y, Hoshi K, et al. Rapid increase of 'brain-type' transferrin in cerebrospinal fluid after shunt surgery for idiopathic normal pressure hydrocephalus: a prognosis marker for cognitive recovery. J Biochem. 2018; 164(3): 205–213.
  12. Pujari S, Kharkar S, Metellus P, et al. Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008; 79(11): 1282–1286.
  13. Vivas-Buitrago T, Lokossou A, Jusué-Torres I, et al. Aqueductal Cerebrospinal Fluid Stroke Volume Flow in a Rodent Model of Chronic Communicating Hydrocephalus: Establishing a Homogeneous Study Population for Cerebrospinal Fluid Dynamics Exploration. World Neurosurg. 2019; 128: e1118–e1125.
  14. Vivas-Buitrago T, Pinilla-Monsalve G, Jusué-Torres I, et al. Ventricular Volume Dynamics During the Development of Adult Chronic Communicating Hydrocephalus in a Rodent Model. World Neurosurg. 2018; 120: e1120–e1127.
  15. Wu EM, El Ahmadieh TY, Kafka B, et al. Ventriculoperitoneal Shunt Outcomes of Normal Pressure Hydrocephalus: A Case Series of 116 Patients. Cureus. 2019; 11(3): e4170.
  16. Esmonde T, Cooke S. Shunting for normal pressure hydrocephalus (NPH). Cochrane Database Syst Rev. 2002(3): CD003157.
  17. Boon AJ, Tans JT, Delwel EJ, et al. Dutch Normal-Pressure Hydrocephalus Study: randomized comparison of low- and medium-pressure shunts. J Neurosurg. 1998; 88(3): 490–495.
  18. Delwel EJ, de Jo, Dammers R, et al. van den Brink W, Dirven CM. A randomised trial of high and low pressure level settings on an adjustable ventriculoperitoneal shunt valve for idiopathic normal pressure hydrocephalus: results of the Dutch evaluation programme Strata shunt (DEPSS) trial. Journal of neurology, neurosurgery, and psychiatry. 2013; 84(7): 813–7.
  19. Khan QU, Wharen RE, Grewal SS, et al. Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure. J Neurosurg. 2013; 119(6): 1498–1502.
  20. Kang YS, Park EK, Kim JS, et al. Efficacy of endoscopic third ventriculostomy in old aged patients with normal pressure hydrocephalus. Neurol Neurochir Pol. 2018; 52(1): 29–34.
  21. Vanneste J, Augustijn P, Dirven C, et al. Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology. 1992; 42(1): 54–59.
  22. Saper CB. The Emperor has no clothes. Ann Neurol. 2016; 79(2): 165–166.
  23. Sharkey P, Pinilla-Monsalve G, Rigamonti A, et al. Health Care Expenditures of Medicare Beneficiaries with Normal Pressure Hydrocephalus. World Neurosurg. 2019; 127: e548–e555.
  24. Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology. 1990; 1(1): 43–46.



Neurologia i Neurochirurgia Polska