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Optimized surgical treatment for normal pressure hydrocephalus: comparison between gravitational and differential pressure valves

  • Clinical Article - Neurosurgical Techniques
  • Published:
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Abstract

Objectives

In idiopathic normal pressure hydrocephalus (NPH) ventriculoperitoneal (VP) shunt insertion is the method of choice to improve cardinal symptoms such as gait disturbance, urge incontinence and/or dementia. With reduced compliance, the brain of the elderly is prone for overdrainage complications. This was especially true with the use of differential pressure valve implantation. The present study compares clinical outcome and complication rates after VP shunt insertion with differential pressure valves in the early years and gravitational valves since 2005.

Methods

The authors reviewed patients treated at our institution for NPH since 1995. Differential pressure valves were solely used in the initial years, while the treatment regimen changed to gravitational valves in 2005. Clinical improvement/surgical success rates as well as complications were compared between the two groups.

Results

Eighty-nine patients were enrolled for the present study. Mean age at the time of surgery was 73.5 ± 6.3 years. Male patients predominated with 73, compared with 16 female patients. Median follow-up time was 28 ± 26 months. Date of last follow-up was 1st October 2013. Forty-nine patients received a gravitational valve, while 40 were treated with differential pressure valves. In the gravitational group a significant improvement was observed after shunt insertion for gait disorder, cognitive impairment and urge incontinence (p < 0.0001, resp. p = 0.004), while a significant change in the differential pressure group was only seen for gait disorder (p = 0.03) but not for cognition or urinary incontinency (p > 0.05). The risk of hygroma as a sign of shunt overdrainage requiring surgical intervention was significantly higher in the differential pressure group (5 versus 0 in the gravitational group).

Conclusions

Patients with NPH treated with gravitational valves in the present cohort showed a more profound improvement in their initial symptoms, including gait disorder, cognitive impairment and urinary incontinency without the risk of overdrainage complications requiring surgical intervention when compared with patients who received differential pressure valves in previous years.

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References

  1. Bergsneider M, Black PM, Klinge P, Marmarou A, Relkin N (2005) Surgical management of idiopathic normal-pressure hydrocephalus. Neurosurgery 57:S29–S39, discussion ii-v

    PubMed  Google Scholar 

  2. Black PM (1980) Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg 52:371–377

    Article  CAS  PubMed  Google Scholar 

  3. Black PM (1982) Normal-pressure hydrocephalus: current understanding of diagnostic tests and shunting. Postgrad Med 71(57–61):65–57

    Google Scholar 

  4. Boon AJ, Tans JT, Delwel EJ, Egeler-Peerdeman SM, Hanlo PW, Wurzer HA, Hermans J (2000) The Dutch normal-pressure hydrocephalus study. How to select patients for shunting? An analysis of four diagnostic criteria. Surg Neurol 53:201–207

    Article  CAS  PubMed  Google Scholar 

  5. Chotai S, Medel R, Herial NA, Medhkour A (2014) External lumbar drain: a pragmatic test for prediction of shunt outcomes in idiopathic normal pressure hydrocephalus. Surg Neurol Int 5:12

    Article  PubMed Central  PubMed  Google Scholar 

  6. Gangemi M, Maiuri F, Buonamassa S, Colella G, de Divitiis E (2004) Endoscopic third ventriculostomy in idiopathic normal pressure hydrocephalus. Neurosurgery 55:129–134, discussion 134

    Article  PubMed  Google Scholar 

  7. Hayes J, Roguski M, Riesenburger RI (2012) Rapid resolution of an acute subdural hematoma by increasing the shunt valve pressure in a 63-year-old man with normal-pressure hydrocephalus with a ventriculoperitoneal shunt: a case report and literature review. J Med Case Rep 6:393

    Article  PubMed Central  PubMed  Google Scholar 

  8. Ishikawa M, Hashimoto M, Mori E, Kuwana N, Kazui H (2012) The value of the cerebrospinal fluid tap test for predicting shunt effectiveness in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 9:1

    Article  PubMed Central  PubMed  Google Scholar 

  9. Jahn K, Zwergal A, Schniepp R (2010) Gait disturbances in old age: classification, diagnosis, and treatment from a neurological perspective. Deutsches Arzteblatt Int 107:306–315, quiz 316

    Google Scholar 

  10. Kiefer M, Eymann R, Komenda Y, Steudel WI (2003) A grading system for chronic hydrocephalus. Zentralbl Neurochir 64:109–115

    Article  CAS  PubMed  Google Scholar 

  11. Kiefer M, Eymann R, Meier U (2002) Five years experience with gravitational shunts in chronic hydrocephalus of adults. Acta Neurochir 144:755–767, discussion 767

    Article  CAS  PubMed  Google Scholar 

  12. Lemcke J, Meier U (2010) Improved outcome in shunted iNPH with a combination of a Codman Hakim programmable valve and an Aesculap-Miethke ShuntAssistant. Cent Eur Neurosurg 71:113–116

    Article  CAS  PubMed  Google Scholar 

  13. Lemcke J, Meier U, Muller C, Fritsch M, Kiefer M, Eymann R, Kehler U, Langer N, Schuhmann MU, Speil A, Weber F, Remenez V, Rohde V, Ludwig HC, Stengel D (2012) On the method of a randomised comparison of programmable valves with and without gravitational units: the SVASONA study. Acta Neurochir Suppl 114:243–246

    Article  PubMed  Google Scholar 

  14. Lemcke J, Meier U, Muller C, Fritsch MJ, Kehler U, Langer N, Kiefer M, Eymann R, Schuhmann MU, Speil A, Weber F, Remenez V, Rohde V, Ludwig HC, Stengel D (2013) Safety and efficacy of gravitational shunt valves in patients with idiopathic normal pressure hydrocephalus: a pragmatic, randomised, open label, multicentre trial (SVASONA). J Neurol Neurosurg Psychiatry 84(8):850–857

    Article  PubMed Central  PubMed  Google Scholar 

  15. Lenfeldt N, Hansson W, Larsson A, Birgander R, Eklund A, Malm J (2012) Three-day CSF drainage barely reduces ventricular size in normal pressure hydrocephalus. Neurology 79:237–242

    Article  PubMed  Google Scholar 

  16. Matsubara T, Ishikawa E, Hirata K, Matsuda M, Akutsu H, Masumoto T, Zaboronok A, Matsumura A (2014) A new mechanism of cerebrospinal fluid leakage after lumboperitoneal shunt: a theory of shunt side hole–case report. Neurol Med Chir 54:572–577

    Article  Google Scholar 

  17. McGovern RA, Kelly KM, Chan AK, Morrissey NJ, McKhann GM 2nd (2014) Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus? J Neurosurg 120:1458–1464

    Article  PubMed  Google Scholar 

  18. Meier U (2002) The grading of normal pressure hydrocephalus. Biomedizinische Technik. Biomed Eng 47:54–58

    Article  CAS  Google Scholar 

  19. Meier U, Lemcke J (2006) Clinical outcome of patients with idiopathic normal pressure hydrocephalus three years after shunt implantation. Acta Neurochir Suppl 96:377–380

    Article  CAS  PubMed  Google Scholar 

  20. Pinto FC, Saad F, Oliveira MF, Pereira RM, Miranda FL, Tornai JB, Lopes MI, Ribas ES, Valinetti EA, Teixeira MJ (2013) Role of endoscopic third ventriculostomy and ventriculoperitoneal shunt in idiopathic normal pressure hydrocephalus: preliminary results of a randomized clinical trial. Neurosurgery 72:845–854

    Article  PubMed  Google Scholar 

  21. Rosenbaum RB (2012) Normal pressure hydrocephalus: how often does the diagnosis hold water? Neurology 78:152, author reply 152

    Article  PubMed  Google Scholar 

  22. Schatlo B, Hamed M, Grote A, Schramm J, Neuloh G (2013) Gravity assisted vs. medium pressure valves for communicating hydrocephalus show similar valve-revision rates. Acta Neurochir 155:1987–1991

    Article  PubMed  Google Scholar 

  23. Siraj S (2011) An overview of normal pressure hydrocephalus and its importance: how much do we really know? J Am Med Dir Assoc 12:19–21

    Article  PubMed  Google Scholar 

  24. Tschan CA, Antes S, Huthmann A, Vulcu S, Oertel J, Wagner W (2014) Overcoming CSF overdrainage with the adjustable gravitational valve proSA. Acta Neurochir 156:767–776, discussion 776

    Article  PubMed  Google Scholar 

  25. Verny M, Berrut G (2012) Diagnosis of normal pressure hydrocephalus in elderly patients: a review. Geriatr Psychol Neuropsychiatrie du Vieillissement 10:415–425

    Google Scholar 

  26. Wikkelso C, Hellstrom P, Klinge PM, Tans JT, European i NPHMSG (2013) The European iNPH multicentre study on the predictive values of resistance to CSF outflow and the CSF Tap Test in patients with idiopathic normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 84:562–568

    Article  PubMed  Google Scholar 

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Conflicts of interest

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Author information

Authors and Affiliations

  1. Klinikum Großhadern, Neurochirurgische Klinik und Poliklinik, Marchioninistrasse 15, 81377, München, Germany

    B. Suchorska, M. Kunz, J. C. Tonn & A. Peraud

  2. Klinikum Großhadern, Neurologische Klinik und Poliklinik, Marchioninistrasse 15, 81377, München, Germany

    R. Schniepp & K. Jahn

  3. Asklepios Klinik Nord Heidberg, Abteilung fürNeurochirurgie, Tangstedter Landstr. 400, 22417, Hamburg, Germany

    C. Goetz

Authors
  1. B. Suchorska
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  2. M. Kunz
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  3. R. Schniepp
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  4. K. Jahn
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  5. C. Goetz
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  6. J. C. Tonn
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  7. A. Peraud
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Corresponding author

Correspondence to A. Peraud.

Appendix

Appendix

Kiefer score

 

Mental

Gait disturbance

Incontinence

Headache

Dizziness

0

No apparent deficit

Not or only in special tests handicapped

None

None

None

1

Forgetful, impaired concentration

 

Urge-incontinence

Intermittent or moderate permanent headache

Intermittent spontaneous dizziness

2

 

Broad based but per se safe gait

  

Permanent dizziness

3

  

Intermittent bladder incontinence

  

4

Apathy or only partially oriented

Troublesome gait, only with crutches possible

Permanent bladder incontinence

Permanent severe headache

 

5

 

Only a few steps with the aid of one person possible

   
  1. The Kiefer index is the sum of points reached in each of the five categories

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Suchorska, B., Kunz, M., Schniepp, R. et al. Optimized surgical treatment for normal pressure hydrocephalus: comparison between gravitational and differential pressure valves. Acta Neurochir 157, 703–709 (2015). https://doi.org/10.1007/s00701-015-2345-4

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  • DOI: https://doi.org/10.1007/s00701-015-2345-4

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