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Ultra-low-pressure hydrocephalic state in NPH: benefits of therapeutic siphoning with adjustable antigravity valves

  • Original Article - CSF Circulation
  • Published:
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Abstract

Background

Idiopathic normal-pressure hydrocephalus (NPH) is a condition of the elderly treated by ventriculoperitoneal shunt (VP) insertion. A subset of NPH patients respond only temporarily to shunt insertion despite low valve opening pressure. This study aims to describe our experience of patients who benefit from further CSF drainage by adding adjustable antigravity valves and draining CSF at ultra-low pressure.

Methods

Single-centre retrospective case series of patients undergoing shunt valve revision from an adjustable differential pressure valve with fixed antigravity unit to a system incorporating an adjustable gravitational valve (Miethke proSA). Patients were screened from a database of NPH patients undergoing CSF diversion over 10 consecutive years (April 2008–April 2018). Clinical records were retrospectively reviewed for interventions and clinical outcomes.

Results

Nineteen (10F:9M) patients underwent elective VP shunt revision to a system incorporating an adjustable gravitational valve. Mean age 77.1 ± 7.1 years (mean ± SD). Eleven patients (58%) showed significant improvement in walking speed following shunt revision. Fourteen patients/carers (74%) reported subjective improvements in symptoms following shunt revision.

Conclusions

Patients presenting symptoms relapse following VP shunting may represent a group of patients with ultra-low-pressure hydrocephalus, for whom further CSF drainage may lead to an improvement in symptoms. These cases may benefit from shunt revision with an adjustable gravitational valve, adjustment of which can lead to controlled siphoning of CSF and drain CSF despite ultra-low CSF pressure.

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Abbreviations

CSF:

Cerebrospinal fluid

NPH:

Normal-pressure hydrocephalus

VP:

Ventriculoperitoneal

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Author information

Authors and Affiliations

  1. Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Box 32, Queen Square, London, WC1N 3BG, UK

    Jonathan Perry Funnell, Linda D’Antona, Claudia Louise Craven, Lewis Thorne, Laurence Dale Watkins & Ahmed Kassem Toma

  2. UCL Medical School, London, UK

    Jonathan Perry Funnell

  3. UCL Queen Square Institute of Neurology, London, UK

    Linda D’Antona & Ahmed Kassem Toma

Authors
  1. Jonathan Perry Funnell
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  2. Linda D’Antona
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  3. Claudia Louise Craven
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  4. Lewis Thorne
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  5. Laurence Dale Watkins
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  6. Ahmed Kassem Toma
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Jonathan Funnell, Linda D’Antona and Claudia Craven. The first draft of the manuscript was written by Jonathan Funnell and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jonathan Perry Funnell.

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Conflict of interest

No funding was received for the conduction of this study. LD’s research fellowship is sponsored by B.Braun. LDW has received honoraria from and served on advisory boards for Medtronic, B. Braun and Codman. AKT research time was supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. The other authors have no disclosures to report.

Ethical standards

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. Informed consent was given by all patients for procedures described as part of their routine clinical management.

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This article is part of the Topical Collection on CSF Circulation

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Funnell, J.P., D’Antona, L., Craven, C.L. et al. Ultra-low-pressure hydrocephalic state in NPH: benefits of therapeutic siphoning with adjustable antigravity valves. Acta Neurochir 162, 2967–2974 (2020). https://doi.org/10.1007/s00701-020-04596-z

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  • DOI: https://doi.org/10.1007/s00701-020-04596-z

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