Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients

2020 ◽  
Vol 132 (1) ◽  
pp. 306-312 ◽  
Author(s):  
Tarek Y. El Ahmadieh ◽  
Eva M. Wu ◽  
Benjamin Kafka ◽  
James P. Caruso ◽  
Om J. Neeley ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Insertion Site ◽  
Normal Pressure ◽  
Csf Leak ◽  
Complication Rates ◽  
Lumbar Drain ◽  
Ventriculoperitoneal Shunting ◽  
History Of ◽  
Subarachnoid Spaces ◽  
The Mean

OBJECTIVEA short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH.METHODSThe authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded.RESULTSThe mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05).CONCLUSIONSThe LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

Ventriculoperitoneal Shunting of Idiopathic Normal Pressure Hydrocephalus Increases Midbrain Size: A Potential Mechanism for Gait Improvement

Neurosurgery ◽  
2006 ◽  
Vol 59 (4) ◽  
pp. 847-851 ◽  
Author(s):  
J Mocco ◽  
Matthew I. Tomey ◽  
Ricardo J. Komotar ◽  
William J. Mack ◽  
Steven J. Frucht ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Ventriculoperitoneal Shunt ◽  
Medical Center ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Cross Sectional ◽  
Mean Values ◽  
Shunt Placement ◽  
Ventriculoperitoneal Shunting ◽  
The Mean

Abstract OBJECTIVE: Idiopathic normal pressure hydrocephalus (INPH) is characterized by a classic clinical triad of symptoms, including dementia, urinary incontinence, and gait disturbance. Recent work has demonstrated that the maximal midbrain anteroposterior (AP) diameter is significantly smaller in patients with INPH than in healthy, age-matched controls. The current study was undertaken to determine the effect of ventriculoperitoneal shunt placement on midbrain dimensions in INPH patients. METHODS: Twelve consecutive INPH patients undergoing ventriculoperitoneal shunt placement with pre- and postoperative computed tomographic scans at the Columbia University Medical Center were enrolled. Each patient's pre- and postoperative maximum AP and left-to-right diameters of the midbrain at the pontomesencephalic junction were independently measured in a blinded fashion by two of the authors. The average value of each dimension was computed by calculating the mean values of the measurements of the two observers. RESULTS: Both the mean AP diameter (preoperative mean, 2.06 ± 0.04 cm; postoperative mean, 2.27 ± 0.05; P = 0.0007) and left-to-right diameter (preoperative mean, 2.80 ± 0.07; postoperative mean, 3.03 ± 0.08; P = 0.0029) increased from pre- to postoperative imaging. The approximate cross-sectional area determined as the product of AP and left-to-right diameters also increased from pre- to postoperative images (preoperative mean, 5.79 ± 0.22 cm2; postoperative mean, 6.90 ± 0.25 cm2; P = 0.00049). CONCLUSION: This study provides supportive evidence that midbrain cytoarchitecture may play a role in the pathophysiology and post-ventriculoperitoneal shunt gait improvement of INPH patients.

scholarly journals Secondary Normal-Pressure Hydrocephalus in Rheumatoid Meningitis

2021 ◽  
pp. 434-440
Author(s):  
Micaela Owens ◽  
Na Tosha Gatson ◽  
Gino Mongelluzzo ◽  
Oded Goren ◽  
Eric Newman ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Normal Pressure Hydrocephalus ◽  
Immune Suppression ◽  
Normal Pressure ◽  
The Elderly ◽  
Common Cause ◽  
Gait Abnormality ◽  
Ventriculoperitoneal Shunting ◽  
Patient Reported ◽  
Rheumatoid Meningitis

Normal-pressure hydrocephalus (NPH) is a common cause of gait apraxia, cognitive impairment, and urinary incontinence in the elderly. It is usually a primary idiopathic disorder but can be secondary. We present a case of secondary NPH due to biopsy-confirmed rheumatoid meningitis initially refractory to intravenous (IV) immunotherapy. Our patient reported an excellent response right after shunting. Her gait remains normal one and a half years later. We searched PubMed for similar cases of rheumatoid meningitis with gait abnormality for additional clinicopathologic discussion. The patient’s movement disorder initially improved with steroid taper. However, she developed progressive symptoms, later on, refractory to IV solumedrol and rituximab. She underwent ventriculoperitoneal shunting (VPS) and reported an outstanding outcome. This is the first reported biopsy-confirmed case of rheumatoid meningitis causing NPH to undergo shunting for immediate improvement. Previous cases of rheumatoid meningitis-associated Parkinsonism have improved with steroid induction. Although our patient’s rheumatoid arthritis is now controlled, her case illustrates that NPH in autoinflammatory conditions may not recover with immune suppression alone. VPS is an option for a faster response in secondary NPH due to rheumatoid meningitis or other inflammatory disorders with progressive symptoms despite standard induction therapy.

scholarly journals Neuroimaging in normal pressure hydrocephalus

2015 ◽  
Vol 9 (4) ◽  
pp. 350-355 ◽  
Author(s):  
Benito Pereira Damasceno
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Cerebral Atrophy ◽  
High Sensitivity ◽  
Normal Pressure ◽  
Evans Index ◽  
Flow Void ◽  
High Positive Predictive Value ◽  
Subarachnoid Spaces ◽  
Magnetic Resonance Imaging Mri ◽  
Improved Accuracy

ABSTRACT Normal pressure hydrocephalus (NPH) is a syndrome characterized by the triad of gait disturbance, mental deterioration and urinary incontinence, associated with ventriculomegaly and normal cerebrospinal fluid (CSF) pressure. The clinical presentation (triad) may be atypical or incomplete, or mimicked by other diseases, hence the need for supplementary tests, particularly to predict postsurgical outcome, such as CSF tap-tests and computed tomography (CT) or magnetic resonance imaging (MRI). The CSF tap-test, especially the 3 to 5 days continuous external lumbar drainage of at least 150 ml/day, is the only procedure that simulates the effect of definitive shunt surgery, with high sensitivity (50-100%) and high positive predictive value (80-100%). According to international guidelines, the following are CT or MRI signs decisive for NPH diagnosis and selection of shunt-responsive patients: ventricular enlargement disproportionate to cerebral atrophy (Evans index >0.3), and associated ballooning of frontal horns; periventricular hyperintensities; corpus callosum thinning and elevation, with callosal angle between 40º and 90º; widening of temporal horns not fully explained by hippocampal atrophy; and aqueductal or fourth ventricular flow void; enlarged Sylvian fissures and basal cistern, and narrowing of sulci and subarachnoid spaces over the high convexity and midline surface of the brain. On the other hand, other imaging methods such as radionuclide cisternography, SPECT, PET, and also DTI or resting-state functional MRI, although suitable for NPH diagnosis, do not yet provide improved accuracy for identifying shunt-responsive cases.

Sterile cerebrospinal fluid ascites, hydrothorax and hydrocele as a complication of ventriculoperitoneal shunting in an elderly patient

2021 ◽  
Vol 14 (7) ◽  
pp. e242593
Author(s):  
Xiancheng Wu ◽  
Michael Sandhu ◽  
Rajat Dhand ◽  
Leen Alkukhun ◽  
Jivan Lamichhane
Keyword(s):  
Elderly Patient ◽  
Cerebrospinal Fluid ◽  
Normal Pressure ◽  
Age Group ◽  
Massive Ascites ◽  
Diagnostic Modality ◽  
Vp Shunt ◽  
Ventriculoperitoneal Shunting ◽  
History Of ◽  
Scrotal Swelling

An 89-year-old man with a history of multiple abdominal surgeries and ventriculoperitoneal (VP) shunt placement for normal pressure hydrocephalus presented for intractable abdominal bloating and scrotal swelling, for which imaging revealed massive ascites, bilateral hydrocele and small bilateral pleural effusions. Cardiac, hepatic and renal workup were insignificant. Culture and cytology of ascitic fluid were negative for infection or malignancy. Aetiology of the ascites as secondary to Cerebrospinal fluid (CSF) from the VP shunt was confirmed via ligation of the shunt. Sterile CSF ascites, hydrothorax and hydrocele are rare complications of VP shunt for hydrocephalus and are mostly presented in paediatric patients. We report the first known case of concurrent CSF ascites, hydrothorax and hydrocele in an elderly patient. We examine the difficulty of shunt replacement as a diagnostic and treatment modality in this age group and propose the use of reversible shunt ligation as a diagnostic modality.

Lateral lumbar interbody fusion without intraoperative neuromonitoring: a single-center consecutive series of 157 surgeries

2019 ◽  
Vol 30 (4) ◽  
pp. 439-445 ◽  
Author(s):  
Sandro M. Krieg ◽  
Lukas Bobinski ◽  
Lucia Albers ◽  
Bernhard Meyer
Keyword(s):  
Interbody Fusion ◽  
Intraoperative Neuromonitoring ◽  
Sensory Deficit ◽  
Leg Pain ◽  
Csf Leak ◽  
Complication Rates ◽  
Lumbar Interbody Fusion ◽  
Motor Weakness ◽  
Lateral Lumbar Interbody Fusion ◽  
The Mean

OBJECTIVELateral lumbar interbody fusion (LLIF) is frequently used for anterior column stabilization. Many authors have reported that intraoperative neuromonitoring (IONM) of the lumbar plexus nerves is mandatory for this approach. However, even with IONM, the reported motor and sensory deficits are still considerably high. Thus, the authors’ approach was to focus on the indication, trajectory, and technique instead of relying on IONM findings per se. The objective of this study therefore was to analyze the outcome of our large cohort of patients who underwent LLIF without IONM.METHODSThe authors report on 157 patients included from 2010 to 2016 who underwent LLIF as an additional stabilizing procedure following dorsal instrumentation. LLIF-related complications as well as clinical outcomes were evaluated.RESULTSThe mean follow-up was 15.9 ± 12.0 months. For 90.0% of patients, cage implantation by LLIF was the first retroperitoneal surgery. There were no cases of surgery-related hematoma, vascular injury, CSF leak, or any other visceral injury. Between 1 and 4 cages were implanted per surgery, most commonly at L2–3 and L3–4. The mean length of surgery was 92.7 ± 35 minutes, and blood loss was 63.8 ± 57 ml. At discharge, 3.8% of patients presented with a new onset of motor weakness, a new sensory deficit, or the deterioration of leg pain due to LLIF surgery. Three months after surgery, 3.5% of the followed patients still reported surgery-related motor weakness, 3.6% leg pain, and 9.6% a persistent sensory deficit due to LLIF surgery.CONCLUSIONSThe results of this series demonstrate that the complication rates for LLIF without IONM are comparable, if not superior, to those in previously reported series using IONM. Hence, the authors conclude that IONM is not mandatory for LLIF procedures if the surgical approach is tailored to the respective level and if the visualization of nerves is performed.

scholarly journals Association between shunt-responsive idiopathic normal pressure hydrocephalus and alcohol

2017 ◽  
Vol 127 (2) ◽  
pp. 240-248 ◽  
Author(s):  
Thu-Trang Hickman ◽  
Matthew E. Shuman ◽  
Tatyana A. Johnson ◽  
Felix Yang ◽  
Rebecca R. Rice ◽  
...  
Keyword(s):  
Alcohol Consumption ◽  
Alcohol Abuse ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Bivariate Analysis ◽  
Medical Centers ◽  
Csf Drainage ◽  
Academic Medical ◽  
History Of

OBJECTIVEIdiopathic normal pressure hydrocephalus (iNPH) is characterized by ventriculomegaly, gait difficulty, incontinence, and dementia. The symptoms can be ameliorated by CSF drainage. The object of this study was to identify factors associated with shunt-responsive iNPH.METHODSThe authors reviewed the medical records of 529 patients who underwent shunt placement for iNPH at their institution between July 2001 and March 2015. Variables associated with shunt-responsive iNPH were identified using bivariate and multivariate analyses. Detailed alcohol consumption information was obtained for 328 patients and was used to examine the relationship between alcohol and shunt-responsive iNPH. A computerized patient registry from 2 academic medical centers was queried to determine the prevalence of alcohol abuse among 1665 iNPH patients.RESULTSBivariate analysis identified associations between shunt-responsive iNPH and gait difficulty (OR 4.59, 95% CI 2.32–9.09; p < 0.0001), dementia (OR 1.79, 95% CI 1.14–2.80; p = 0.01), incontinence (OR 1.77, 95% CI 1.13–2.76; p = 0.01), and alcohol use (OR 1.98, 95% CI 1.23–3.16; p = 0.03). Borderline significance was observed for hyperlipidemia (OR 1.56, 95% CI 0.99–2.45; p = 0.054), a family history of hyperlipidemia (OR 3.09, 95% CI 0.93–10.26, p = 0.054), and diabetes (OR 1.83, 95% CI 0.96–3.51; p = 0.064). Multivariate analysis identified associations with gait difficulty (OR 3.98, 95% CI 1.81–8.77; p = 0.0006) and alcohol (OR 1.94, 95% CI 1.10–3.39; p = 0.04). Increased alcohol intake correlated with greater improvement after CSF drainage. Alcohol abuse was 2.5 times more prevalent among iNPH patients than matched controls.CONCLUSIONSAlcohol consumption is associated with the development of shunt-responsive iNPH.

Overdrainage shunt complications in idiopathic normal-pressure hydrocephalus and lumbar puncture opening pressure

2013 ◽  
Vol 119 (6) ◽  
pp. 1498-1502 ◽  
Author(s):  
Qurat ul Ain Khan ◽  
Robert E. Wharen ◽  
Sanjeet S. Grewal ◽  
Colleen S. Thomas ◽  
H. Gordon Deen ◽  
...  
Keyword(s):  
Lumbar Puncture ◽  
Normal Pressure Hydrocephalus ◽  
Subdural Hematoma ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Complication Rates ◽  
Shunt Surgery ◽  
Opening Pressure ◽  
Presenting Symptoms ◽  
Subdural Hematomas

Object Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable–shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP). Methods The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory. Results Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs 27.0, respectively; p = 0.005). Conclusions Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.

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