Clinical predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

Abstract Background Positive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). However, multiple pathologies mimic iNPH symptoms, making it difficult to select patients who will respond to shunt surgery. Although presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose. Objective To conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests. Methods Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating clinical predictors of SR in iNPH patients. Included studies were assessed using the QUADAS-2 tool, and eligible studies were evaluated using univariate and bivariate meta-analyses. Results Thirty-five studies were included. Nine studies discussed the diagnostic use of presenting clinical features, 8 studies ELD, 8 studies IT, 11 studies ICPM, and 6 studies TT. A meta-analysis of 21 eligible studies was conducted for TT, ELD, IT, and ICPM. ICPM yielded the highest diagnostic effectiveness, with diagnostic odds ratio (DOR) = 50.9 and area under curve (AUC) = 0.836. ELD yielded DOR = 27.70 and AUC = 0.753, IT had DOR = 5.70 and AUC = 0.729, and TT scored DOR = 3.86 and AUC = 0.711. Conclusion Intraparenchymal ICPM is statistically the most effective diagnostic test, followed by ELD, IT, and lastly TT. Due to the higher accessibility of TT and IT, they are recommended to be used first line, using a timed-up-and-go improvement ≥ 5.6 s or a Rout cut-off range between 13 and 16 mmHg, respectively. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude $$\ge$$ ≥ 4 mmHg, or 1- to 4-day ELD with an MMSE cut-off improvement $$\ge$$ ≥ 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison.

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Cerebrospinal Fluid Biomarkers as Predictors of Shunt Response in Idiopathic Normal Pressure Hydrocephalus: A Systematic Review

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.251 ◽

2017 ◽

Vol 45 (1) ◽

pp. 3-10 ◽

Cited By ~ 7

Author(s):

Tyler Pfanner ◽

Alexandre Henri-Bhargava ◽

Stephanie Borchert

Keyword(s):

Systematic Review ◽

Cerebrospinal Fluid ◽

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Future Research ◽

Csf Biomarkers ◽

Level Of Evidence ◽

Shunt Procedure ◽

Shunt Response

ABSTRACTBackground: The widely accepted treatment for idiopathic normal-pressure hydrocephalus (iNPH) is a cerebrospinal fluid (CSF) diversion shunt procedure, to which approximately 80% of patients will respond. The purpose of this systematic review was to identify which CSF biomarkers have been investigated in predicting shunt responsiveness in iNPH patients, and to analyze the level of evidence for each. Methods: To find all relevant articles, a comprehensive search of Medline, Embase, and PsycINFO was conducted. Results: The literature search identified 344 unique citations, of which 13 studies satisfied the inclusion criteria and were analyzed in our review. These 13 studies reported on 37 unique biomarkers. Conclusions: The available studies suggest that there is evidence for the utility of CSF biomarkers in predicting shunt responsiveness in iNPH patients, though none have been shown to predict shunt response with both high sensitivity and specificity. We found that there is no available evidence for the use of Aβ38, Aβ40, Aβ43, APL1β25, APL1β27, APL1β28, sAPP, aAPPα, sAPPβ, TNF-α, MCP-1, sCD40L, sulfatide, MBP, L-PGDS, cystatin C, transthyretin, TGF-β2, or YKL-40 in predicting shunt response. There is minimal evidence for the use of TGF-β1, TBR-II, homocysteine, and interleukins (particularly IL-1β, IL-6, and IL-10). However, the available evidence suggests that these biomarkers warrant further investigation. Aβ42, tau, p-tau, NFL, and LRG have the greatest amount of evidence for their predictive value in determining shunt responsiveness in iNPH patients. Future research should be guided by, but not limited to, these biomarkers.

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Extended lumbar drainage in idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis of diagnostic test accuracy

British Journal of Neurosurgery ◽

10.1080/02688697.2020.1787948 ◽

2020 ◽

pp. 1-7

Author(s):

Adam C. Nunn ◽

Hayley E. Jones ◽

Cezar O. Morosanu ◽

William G. B. Singleton ◽

Michael A. Williams ◽

...

Keyword(s):

Systematic Review ◽

Diagnostic Test ◽

Normal Pressure Hydrocephalus ◽

Meta Analysis ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Diagnostic Test Accuracy ◽

Test Accuracy ◽

Lumbar Drainage

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Cerebrospinal fluid Aβ42, t-tau, and p-tau levels in the differential diagnosis of idiopathic normal-pressure hydrocephalus: a systematic review and meta-analysis

Fluids and Barriers of the CNS ◽

10.1186/s12987-017-0062-5 ◽

2017 ◽

Vol 14 (1) ◽

Cited By ~ 17

Author(s):

Zhongyun Chen ◽

Chunyan Liu ◽

Jie Zhang ◽

Norman Relkin ◽

Yan Xing ◽

...

Keyword(s):

Systematic Review ◽

Cerebrospinal Fluid ◽

Differential Diagnosis ◽

Normal Pressure Hydrocephalus ◽

Meta Analysis ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

T Tau

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Outcomes and complications of different surgical treatments for idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

Journal of Neurosurgery ◽

10.3171/2018.5.jns1875 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1024-1036 ◽

Cited By ~ 11

Author(s):

Enrico Giordan ◽

Giorgio Palandri ◽

Giuseppe Lanzino ◽

Mohammad Hassan Murad ◽

Benjamin D. Elder

Keyword(s):

Systematic Review ◽

Adverse Events ◽

Normal Pressure Hydrocephalus ◽

Revision Surgery ◽

Meta Analysis ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Ovid Medline ◽

Csf Diversion ◽

Programmable Valves

OBJECTIVEDifferent CSF diversion procedures (ventriculoperitoneal, ventriculoatrial, and lumboperitoneal shunting) have been utilized for the treatment of idiopathic normal pressure hydrocephalus. More recently, endoscopic third ventriculostomy has been suggested as a reasonable alternative in some studies. The purpose of this study was to perform a systematic review and meta-analysis to assess overall rates of favorable outcomes and adverse events for each of these treatments. An additional objective was to determine the outcomes and complication rates in relation to the type of valve utilized (fixed vs programmable).METHODSMultiple databases (PubMed, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) were searched for studies involving patients with idiopathic ventriculomegaly, no secondary cause of hydrocephalus, opening pressure < 25 mm Hg on high-volume tap or drainage trial, and age > 60 years. Outcomes included the proportion of patients who showed improvement in gait, cognition, and bladder function. Adverse events considered in the analysis included postoperative ischemic/hemorrhagic complications, subdural fluid collections, seizures, need for revision surgery, and infection.RESULTSA total of 33 studies, encompassing 2461 patients, were identified. More than 75% of patients experienced improvement after shunting, without significant differences among the different techniques utilized. Overall, gait improvement was observed in 75% of patients, cognitive function improvement in more than 60%, and improvement of incontinence in 55%. Adjustable valves were associated with a reduction in revisions (12% vs 32%) and subdural collections (9% vs 22%) as compared to fixed valves.CONCLUSIONSOutcomes did not differ significantly among different CSF diversion techniques, and overall improvement was reported in more than 75% of patients. The use of programmable valves decreased the incidence of revision surgery and of subdural collections after surgery, potentially justifying the higher initial cost associated with these valves.

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