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Female gender predisposes for cerebrospinal fluid overdrainage in ventriculoperitoneal shunting

  • Clinical Article - Neurosurgical Techniques
  • Published:
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Abstract

Background

Gravitational valves (GVs) prevent overdrainage in ventriculoperitoneal shunting (VPS). However, there are no data available on the appropriate opening pressure in the shunt system when implementing a GV. We performed a retrospective analysis of hydrocephalic patients who were successfully treated with VPS which included one or more GV.

Method

In this retrospective study in adult VPS patients with GVs, we analysed all available data, including the most recent computed tomography (CT) scans, to determine the best adjustments for alleviating any symptoms of overdrainage and underdrainage. Vertical effective opening pressure (VEOP) of the entire shunt system, including the differential pressure valve, was determined.

Results

One hundred and twenty-two patients were eligible for the study. Of these, female patients revealed a higher VEOP compared with males (mean, 35.6 cmH2O [SD ± 2.46] vs 28.9 cmH2O [SD ± 0.87], respectively, p = 0.0072, t-test). In patients older than 60 years, lower VEOPs, by a mean of 6.76 cmH2O ± 2.37 (p = 0.0051), were necessary. Mean VEOP was found to be high in idiopathic intracranial hypertension (IIH; 41.6 cmH2O) and malresorptive and congenital HC (35.9 and 36.3), but low in normal pressure HC (27.5, p = 0.0229; one-way ANOVA). In the total cohort, body mass index (BMI) and height did not correlate with VEOP. Twelve patients required a VEOP of more than 40 cmH2O, and in eight of these patients this was accomplished by using multiple GVs. All but one of these eight patients were of female gender, and none of the latter were treated for normal pressure hydrocephalus (NPH) (p = 0.0044 and p = 0.0032, Fisher’s exact test).

Conclusions

In adult VPS patients, female gender increases the risk of overdrainage requiring higher VEOPs. Initial implantation of adjustable GV should be considered in female patients treated with VP shunts for pathology other than NPH.

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Acknowledgments

We would like to thank to Bawarjan Schatlo for helpful comments for preparing the manuscript.

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Authors and Affiliations

  1. Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany

    Naïma Diesner, Florian Freimann, Christin Clajus, Veit Rohde & Florian Stockhammer

  2. Diagnostic and Interventional Radiology and Neuroradiology, Helios Hospital Erfurt, Erfurt, Germany

    Christin Clajus

  3. Institute for Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany

    Kai Kallenberg

  4. Department of Neurosurgery, Dresden-Friedrichstadt Municipal Hospital, Friedrichstr 41, 01067, Dresden, Germany

    Florian Stockhammer

Authors
  1. Naïma Diesner
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  2. Florian Freimann
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  4. Kai Kallenberg
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  5. Veit Rohde
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  6. Florian Stockhammer
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Corresponding author

Correspondence to Florian Stockhammer.

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Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. F.F., C.C., V.R. and F.S. received speaker fees from Braun-Äskulap/Miethke. C.C. received a price endowed by Braun-Äskulap/Miethke

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

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Comments

In this retrospective study of hydrocephalic patients who were treated with a ventriculoperitoneal shunt (VPS) system that included gravitational valves (GV) to prevent overdrainage, the authors introduce a new parameter, the Vertical Effective Opening. Pressure (VEOP). This was calculated as the combined pressure of all valves in the shunt system that is needed to prevent overdrainage and still give a satisfactory CSF drainage. Not so unexpected, the VEOP differed significantly depending on the type of hydrocephalus, with idiopathic intracranial hypertension requiring the highest pressure and normal pressure hydrocephalus the lowest. More interesting is the finding that the female gender appears to require a higher pressure than males to avoid overdrainage. In the authors’ analyses, this gender difference was however found only in the group of patients with high Body Mass Index (BMI); in patients with normal or subnormal BMI, this difference failed to reach statistical significance.

This study may give some valuable advice when it comes to planning of VPS implantation in adults; the authors themselves conclude: “initial implantation of adjustable GVs should be considered in female patients treated with VP shunts for pathology other than NPH”.

As with all new observations, the findings presented here should however be viewed with precaution until verified by another, preferably prospective, study.

Knut Wester

Bergen, Norway

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Diesner, N., Freimann, F., Clajus, C. et al. Female gender predisposes for cerebrospinal fluid overdrainage in ventriculoperitoneal shunting. Acta Neurochir 158, 1273–1278 (2016). https://doi.org/10.1007/s00701-016-2827-z

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  • DOI: https://doi.org/10.1007/s00701-016-2827-z

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