Cerebrospinal fluid shunting protocol for idiopathic intracranial hypertension for an improved revision rate

OBJECTIVE Cerebrospinal fluid (CSF) shunting in idiopathic intracranial hypertension (IIH) is associated with high complication rates, primarily because of the technical challenges that are related to small ventricles and a large body habitus. In this study, the authors report the benefits of a standardized protocol for CSF shunting in patients with IIH as relates to shunt revisions. METHODS This was a retrospective study of consecutive patients with IIH who had undergone primary insertion of a CSF shunt between January 2014 and December 2020 at the authors’ hospital. In July 2019, they implemented a surgical protocol for shunting in IIH. This protocol recommended IIH shunt insertion by neurosurgeons with expertise in CSF disorders, a frontal ventriculoperitoneal (VP) shunt with an adjustable gravitational valve and integrated intracranial pressure monitoring device, frameless stereotactic insertion of the ventricular catheter, and laparoscopic insertion of the peritoneal catheter. Thirty-day revision rates before and after implementation of the protocol were compared in order to assess the impact of standardizing shunting for IIH on shunt complications. RESULTS The 81 patients included in the study were predominantly female (93%), with a mean age of 31 years at primary surgery and mean body mass index (BMI) of 37 kg/m2. Forty-five patients underwent primary surgery prior to implementation of the protocol and 36 patients after. Overall, 12 (15%) of 81 patients needed CSF shunt revision in the first 30 days, 10 before and 2 after introduction of the protocol. This represented a significant reduction in the early revision rate from 22% to 6% after the protocol (p = 0.036). The most common cause of shunt revision for the whole cohort was migration or misplacement of the peritoneal catheter, occurring in 6 of the 12 patients. Patients with a higher BMI were significantly more likely to have a shunt revision within 30 days (p = 0.022). CONCLUSIONS The Birmingham standardized IIH shunt protocol resulted in a significant reduction in revisions within 30 days of primary shunt surgery in patients with IIH. The authors recommend standardization for shunting in IIH as a method for improving surgical outcomes. They support the notion of subspecialization for IIH shunts, the use of a frontal VP shunt with sophisticated technology, and laparoscopic insertion of the peritoneal end.

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Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review

Cephalalgia ◽

10.1177/0333102411423305 ◽

2011 ◽

Vol 31 (16) ◽

pp. 1627-1633 ◽

Cited By ~ 74

Author(s):

Alexandra J Sinclair ◽

Sarin Kuruvath ◽

Diptasri Sen ◽

Peter G Nightingale ◽

Michael A Burdon ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Visual Acuity ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Low Pressure ◽

Shunt Revision ◽

Common Symptom ◽

Csf Diversion ◽

Low Pressure Headache ◽

Pressure Headache

Background: The role of cerebrospinal fluid (CSF) diversion in treating idiopathic intracranial hypertension (IIH) is disputed. Method: We conducted a 10-year, retrospective case note review to evaluate the effects of CSF diversion in IIH. Symptoms, signs and details of shunt type, complications and revisions were documented at baseline, 6, 12 and 24 months post-operatively. Results: Fifty-three IIH patients were shunted [predominantly lumboperitoneal (92%)]. The most common symptom pre-surgery was headache (96%). Post-operatively, significantly fewer patients experienced declining vision and visual acuity improved at 6 ( p = 0.001) and 12 months ( p = 0.016). Headache continued in 68% at 6 months, 77% at 12 months and 79% at 2 years post-operatively. Additionally, post-operative low-pressure headache occurred in 28%. Shunt revision occurred in 51% of patients, with 30% requiring multiple revisions. Conclusion: We conclude that CSF diversion reduces visual decline and improves visual acuity. Unfortunately, headache remained in the majority of patients and low-pressure headache frequently complicated surgery. Over half of the patients required shunt revision with the majority of these requiring multiple revisions. We suggest that CSF shunting should be conducted as a last resort in those with otherwise untreatable, rapidly declining vision. Alternative treatments, such as weight reduction, may be more effective with less associated morbidity.

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Rapidly Rising Incidence of Cerebrospinal Fluid Shunting Procedures for Idiopathic Intracranial Hypertension in the United States, 1988–2002

Neurosurgery ◽

10.1227/01.neu.0000163094.23923.e5 ◽

2005 ◽

Vol 57 (1) ◽

pp. 97-108 ◽

Cited By ~ 82

Author(s):

William T. Curry ◽

William E. Butler ◽

Fred G. Barker

Keyword(s):

United States ◽

Cerebrospinal Fluid ◽

Risk Factor ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Survey Methodology ◽

Relative Rate ◽

Weighted Least Squares ◽

The United States ◽

Csf Shunting

Abstract OBJECTIVE: Obesity, a major risk factor for idiopathic intracranial hypertension (IIH), is rapidly increasing in all ages of the United States population. We studied trends in the incidence of cerebrospinal fluid (CSF) shunts for IIH in the United States between 1988 and 2002, using a national hospital discharge database. METHODS: This was a retrospective study using the Nationwide Inpatient Sample and robust weighted least-squares regression, adjusted for stratified survey methodology. RESULTS: There were 2779 admissions for CSF shunting procedures (new or revision) in IIH patients in the database. In-hospital mortality for new shunts was 0.5% (0.9% for ventricular shunts and 0.2% for lumbar shunts). The estimated total United States caseload of CSF shunting procedures for IIH increased 350% between 1988 and 2002 (P < 0.001). (The 2002 United States caseload was 1370 admissions.) New shunt placements increased 320% during this interval (P < 0.001). In some subpopulations in which obesity is less important as a risk factor for IIH, caseload increases were less marked: pediatric IIH shunting (age <13 yr) increased 52% and shunting in male IIH patients increased 38%, but shunting in older patients (age >44 yr) increased 240% during the study period. Bariatric procedures (e.g., gastric bypass) increased very rapidly in incidence since 1998, with nearly 200 such procedures performed on IIH patients in 2002. CONCLUSION: The incidence of CSF shunting for IIH is increasing in the population of the United States at about the same relative rate as morbid obesity. Studies to establish the best shunting method in IIH and to explore alternative treatment strategies, such as optic nerve sheath fenestration and bariatric surgery, are urgently needed.

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Cerebrospinal fluid shunting protocol for idiopathic intracranial hypertension improves revision rate

Brain and Spine ◽

10.1016/j.bas.2021.100757 ◽

2021 ◽

Vol 1 ◽

pp. 100757

Author(s):

L. Galloway ◽

K. Karia ◽

A. White ◽

M. Byrne ◽

A. Sinclair ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Revision Rate ◽

Cerebrospinal Fluid Shunting

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A comparison of lumboperitoneal and ventriculoperitoneal shunting for idiopathic intracranial hypertension: an analysis of economic impact and complications using the Nationwide Inpatient Sample

Neurosurgical FOCUS ◽

10.3171/2014.8.focus14436 ◽

2014 ◽

Vol 37 (5) ◽

pp. E4 ◽

Cited By ~ 35

Author(s):

Richard P. Menger ◽

David E. Connor ◽

Jai Deep Thakur ◽

Ashish Sonig ◽

Elainea Smith ◽

...

Keyword(s):

Health Care ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Nationwide Inpatient Sample ◽

Shunt Revision ◽

Benign Intracranial Hypertension ◽

Vp Shunt ◽

Shunt Placement ◽

Study Population ◽

First Time

Object Complications following lumboperitoneal (LP) shunting have been reported in 18% to 85% of cases. The need for multiple revision surgeries, development of iatrogenic Chiari malformation, and frequent wound complications have prompted many to abandon this procedure altogether for the treatment of idiopathic benign intracranial hypertension (pseudotumor cerebri), in favor of ventriculoperitoneal (VP) shunting. A direct comparison of the complication rates and health care charges between first-choice LP versus VP shunting is presented. Methods The Nationwide Inpatient Sample database was queried for all patients with the diagnosis of benign intracranial hypertension (International Classification of Diseases, Ninth Revision, code 348.2) from 2005 to 2009. These data were stratified by operative intervention, with demographic and hospitalization charge data generated for each. Results A weighted sample of 4480 patients was identified as having the diagnosis of idiopathic intracranial hypertension (IIH), with 2505 undergoing first-time VP shunt placement and 1754 undergoing initial LP shunt placement. Revision surgery occurred in 3.9% of admissions (n = 98) for VP shunts and in 7.0% of admissions (n = 123) for LP shunts (p < 0.0001). Ventriculoperitoneal shunts were placed at teaching institutions in 83.8% of cases, compared with only 77.3% of first-time LP shunts (p < 0.0001). Mean hospital length of stay (LOS) significantly differed between primary VP (3 days) and primary LP shunt procedures (4 days, p < 0.0001). The summed charges for the revisions of 92 VP shunts ($3,453,956) and those of the 6 VP shunt removals ($272,484) totaled $3,726,352 over 5 years for the study population. The summed charges for revision of 70 LP shunts ($2,229,430) and those of the 53 LP shunt removals ($3,125,569) totaled $5,408,679 over 5 years for the study population. Conclusions The presented results appear to call into question the selection of LP shunt placement as primary treatment for IIH, as this procedure is associated with a significantly greater likelihood of need for shunt revision, increased LOS, and greater overall charges to the health care system.

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Evaluation of cerebrospinal fluid flow dynamic changes in patients with idiopathic intracranial hypertension using phase contrast cine MR imaging

The Egyptian Journal of Neurology Psychiatry and Neurosurgery ◽

10.1186/s41983-020-00227-7 ◽

2020 ◽

Vol 56 (1) ◽

Author(s):

Tamer Belal ◽

Abd-Elhalim Al Tantawy ◽

Fatema Mohamed Sherif ◽

Alshaimaa Ramadan

Keyword(s):

Cerebrospinal Fluid ◽

Medical Treatment ◽

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Phase Contrast ◽

Cine Mri ◽

Mean Flow ◽

Csf Flow ◽

Flow Dynamic ◽

Dynamic Changes

Abstract Background Idiopathic intracranial hypertension (IIH) mainly affects overweight women in the middle age period. The pathophysiology of IIH stays unclear, but suggested mechanisms include excess CSF production, reduced CSF absorption, increased brain water content, and increased cerebral venous pressure Objectives To assess the cerebrospinal fluid (CSF) flow dynamic changes in aqueduct of Sylvius in patients of idiopathic intracranial hypertension (IIH) with new MRI technique: phase contrast cine MRI (PCC-MRI). Methods Thirty patients diagnosed with idiopathic intracranial hypertension were divided into 3 groups according to treatment options (no treatment, medical treatment, and medical treatment with repeated lumbar tapping). CSF flow data were evaluated by phase contrast cine MRI. Results PCC-MRI parameters were significantly higher in group who was on medical treatment (group II) than other groups. The sensitivity of PCC MRI parameters ranged from 56.7 (stroke volume (SV) and mean flow (MF)) to 83.3% (peak systolic velocity (PSV)). A statistically significant difference was found for the mean flow value (p 0.039) between the control group and IIH patients. Conclusion The most specific CSF flowmetry parameter detected to help diagnosis of IIH is mean flow especially among early discovered patients. PCC MRI can be used as non-invasive technique for diagnosis of IIH and treatment follow-up.

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Cerebrospinal fluid biomarkers of neuroinflammation in children with hydrocephalus and shunt malfunction

Fluids and Barriers of the CNS ◽

10.1186/s12987-021-00237-4 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Carolyn A. Harris ◽

Diego M. Morales ◽

Rooshan Arshad ◽

James P. McAllister ◽

David D. Limbrick

Keyword(s):

Cerebrospinal Fluid ◽

Inflammatory Cytokines ◽

Protein Concentration ◽

Shunt Revision ◽

Csf Shunt ◽

Shunt Failure ◽

Revision Operation ◽

Protein Levels ◽

Anti Inflammatory ◽

Pro Inflammatory Cytokines

Abstract Background Approximately 30% of cerebrospinal fluid (CSF) shunt systems for hydrocephalus fail within the first year and 98% of all patients will have shunt failure in their lifetime. Obstruction remains the most common reason for shunt failure. Previous evidence suggests elevated pro-inflammatory cytokines in CSF are associated with worsening clinical outcomes in neuroinflammatory diseases. The aim of this study was to determine whether cytokines and matrix metalloproteinases (MMPs) contribute towards shunt failure in hydrocephalus. Methods Using multiplex ELISA, this study examined shunt failure through the CSF protein concentration profiles of select pro-inflammatory and anti-inflammatory cytokines, as well as select MMPs. Interdependencies such as the past number of previous revisions, length of time implanted, patient age, and obstruction or non-obstruction revision were examined. The pro-inflammatory cytokines were IL-1β, IL-2, IL-5, IL-6, IL-8, IL-12, IL-17, TNF-α, GM-CSF, IFN-γ. The anti-inflammatory cytokines were IL-4 and IL-10, and the MMPs were MMP-2, MMP-3, MMP-7, MMP-9. Protein concentration is reported as pg/mL for each analyte. Results Patient CSF was obtained at the time of shunt revision operation; all pediatric (< 18), totaling n = 38. IL-10, IL-6, IL-8 and MMP-7 demonstrated significantly increased concentrations in patient CSF for the non-obstructed subgroup. Etiological examination revealed IL-6 was increased in both obstructed and non-obstructed cases for PHH and congenital hydrocephalic patients, while IL-8 was higher only in PHH patients. In terms of number of past revisions, IL-10, IL-6, IL-8, MMP-7 and MMP-9 progressively increased from zero to two past revisions and then remained low for subsequent revisions. This presentation was notably absent in the obstruction subgroup. Shunts implanted for three months or less showed significantly increased concentrations of IL-6, IL-8, and MMP-7 in the obstruction subgroup. Lastly, only patients aged six months or less presented with significantly increased concentration of IL-8 and MMP-7. Conclusion Non-obstructive cases are reported here to accompany significantly higher CSF cytokine and MMP protein levels compared to obstructive cases for IL-10, IL-6, IL-8, MMP-7 and MMP-9. A closer examination of the definition of obstruction and the role neuroinflammation plays in creating shunt obstruction in hydrocephalic patients is suggested.

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Overshunting-Related Cervical Myelopathy Causing Progressive Gait Disturbance: A Case Report

Case Reports in Neurology ◽

10.1159/000514551 ◽

2021 ◽

pp. 312-317

Author(s):

Eva Vister ◽

Sebastiaan Hammer ◽

Rudolf W.M. Keunen ◽

Astrid L. Rijssenbeek ◽

Niels A. van der Gaag

Keyword(s):

Cerebrospinal Fluid ◽

Cervical Myelopathy ◽

Complete Resolution ◽

Late Complication ◽

Gait Disturbance ◽

Shunt Revision ◽

Proper Treatment ◽

Cervical Stenosis ◽

Vp Shunt ◽

Associated Symptoms

A complication of ventriculoperitoneal (VP) shunting is overdrainage or overshunting of cerebrospinal fluid, which can cause formation of hygroma but in rare cases also cervical myelopathy at a later stage. In this article, we describe a very late complication of VP shunting. We present a 75-year-old man, previously given a VP shunt at the age of 46, who developed a progressive gait disturbance and ataxia of the limbs after 27 years. MRI showed a cervical stenosis and myelopathy as a result of venous engorgement due to chronic overshunting of the VP shunt. Revision of the VP shunt resulted in complete resolution of his neurological symptoms and the cervical myelopathy. Cervical myelopathy due to chronic overshunting is a rare and potentially very late complication of a VP shunt. Our case underlines the importance of awareness of this complication while proper treatment can reverse the associated symptoms fully.

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