Skip to main content
SpringerLink
Log in

Complications Related to the Type of Hydrocephalus: Normal Pressure Hydrocephalus

  • Chapter
  • First Online:
Complications of CSF Shunting in Hydrocephalus

  • 1314 Accesses

Abstract

A clear trend towards better outcomes in patients with normal pressure hydrocephalus (NPH) has been shown in studies published in the last decade. This is due in part to the availability of more sophisticated hardware and a better understanding of the risks and characteristics of these fragile patients. Because there is no robust evidence showing the superiority of specific type of valve, neurosurgeons face a dilemma in choosing the most adequate shunt, an essential step in improving outcome and avoiding “shunt-patient mismatch.” The most commonly known consequence of hydrodynamic mismatch is shunt overdrainage. However, a lesser-known consequence of poor hardware selection is occult shunt dysfunction, which can cause lack of improvement or later deterioration after initial improvement. Shunt selection must be based on the fact that intracranial pressure (ICP) and CSF dynamics are highly heterogeneous in NPH. Patients may present active hydrocephalus (mean ICP >12 mmHg), compensated hydrocephalus (mean ICP of 5–12 mmHg), or even low-pressure hydrocephalus (ICP <5 mmHg). In addition to the valve, which has a specific opening pressure and resistance, the shunt system must include a gravitational device. Clinical symptoms and neuroimaging studies are sufficient to diagnose complications related with overdrainage. However, continuous ICP monitoring helps to identify possible cases of underdrainage that result in a lack of improvement in certain patients. In the management of patients with NPH, ICP values and intra-abdominal pressure, as well as the hydrodynamic proprieties of the shunt system selected, must be considered.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Adams RD, Fisher CM, Hakim S et al (1965) Symptomatic occult hydrocephalus with “normal” cerebrospinal fluid pressure. A treatable syndrome. N Engl J Med 273:117–126

    Article  CAS  PubMed  Google Scholar 

  2. Aschoff A, Kremer P, Benesch C et al (1995) Overdrainage and shunt technology. A critical comparison of programmable, hydrostatic and variable-resistance valves and flow- reducing devices. Childs Nerv Syst 11:193–202

    Article  CAS  PubMed  Google Scholar 

  3. Barami K, Sood S, Ham SD et al (2000) Postural changes in intracranial pressure in chronically shunted patients. Pediatr Neurosurg 33:64–69

    Article  CAS  PubMed  Google Scholar 

  4. Bergsneider M, Black PM, Klinge P et al (2005) Surgical management of idiopathic normal-pressure hydrocephalus. Neurosurgery 57:S29–S39

    PubMed  Google Scholar 

  5. Blomsterwall E, Bilting M, Stephensen H et al (1995) Gait abnormality is not the only motor disturbance in normal pressure hydrocephalus. Scand J Rehabil Med 27:205–209

    CAS  PubMed  Google Scholar 

  6. Blomsterwall E, Svantesson U, Carlsson U et al (2000) Postural disturbance in patients with normal pressure hydrocephalus. Acta Neurol Scand 102:284–291

    Article  CAS  PubMed  Google Scholar 

  7. Boon AJ, Tans JT, Delwel EJ et al (1998) Dutch normal-pressure hydrocephalus study: randomized comparison of low- and medium-pressure shunts. J Neurosurg 88:490–495

    Article  CAS  PubMed  Google Scholar 

  8. Borgbjerg BM, Gjerris F, Albeck MJ et al (1995) Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts. Acta Neurochir (Wien) 136:1–7

    Article  CAS  Google Scholar 

  9. Chapman PH, Borges LF (1985) Shunt infections: prevention and treatment. Clin Neurosurg 32:652–664

    CAS  PubMed  Google Scholar 

  10. Cook SW, Bergsneider M (2002) Why valve opening pressure plays a relatively minor role in the postural ICP response to ventricular shunts in normal pressure hydrocephalus: modeling and implications. Acta Neurochir Suppl 81:15–17

    CAS  PubMed  Google Scholar 

  11. Cordero TN, Roman Cutillas AM, Jorques Infante AM et al (2013) [Adult chronic idiopathic hydrocephalus-diagnosis, treatment and evolution. Prospective study]. Neurocirugia (Astur) 24:93–101

    Article  Google Scholar 

  12. Czosnyka Z, Czosnyka M, Richards HK et al (2002) Laboratory testing of hydrocephalus shunts – conclusion of the U.K. Shunt evaluation programme. Acta Neurochir (Wien) 144:525–538

    Article  CAS  Google Scholar 

  13. Czosnyka ZH, Czosnyka M, Pickard JD (2002) Shunt testing in-vivo: a method based on the data from the UK shunt evaluation laboratory. Acta Neurochir Suppl 81:27–30

    CAS  PubMed  Google Scholar 

  14. da Silva MC, Drake JM (1990) Effect of subcutaneous implantation of anti-siphon devices on CSF shunt function. Pediatr Neurosurg 16:197–202

    Article  PubMed  Google Scholar 

  15. Drake JM, da Silva MC, Rutka JT (1993) Functional obstruction of an antisiphon device by raised tissue capsule pressure. Neurosurgery 32:137–139

    Article  CAS  PubMed  Google Scholar 

  16. Durward QJ, Amacher AL, Del Maestro RF et al (1983) Cerebral and cardiovascular responses to changes in head elevation in patients with intracranial hypertension. J Neurosurg 59:938–944

    Article  CAS  PubMed  Google Scholar 

  17. Eide PK, Sorteberg W (2010) Diagnostic intracranial pressure monitoring and surgical management in idiopathic normal pressure hydrocephalus: a 6-year review of 214 patients. Neurosurgery 66:80–91

    Article  PubMed  Google Scholar 

  18. Eymann R, Chehab S, Strowitzki M et al (2008) Clinical and economic consequences of antibiotic-impregnated cerebrospinal fluid shunt catheters. J Neurosurg Pediatr 1:444–450

    Article  PubMed  Google Scholar 

  19. Farber SH, Parker SL, Adogwa O et al (2011) Effect of antibiotic-impregnated shunts on infection rate in adult hydrocephalus: a single institution’s experience. Neurosurgery 69:625–629

    Article  PubMed  Google Scholar 

  20. Fisher CM (1982) Hydrocephalus as a cause of disturbance of gait in the elderly. Neurology 32:1358–1363

    Article  CAS  PubMed  Google Scholar 

  21. Hakim S, Adams RD (1965) The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 2:307–327

    Article  CAS  PubMed  Google Scholar 

  22. Hebb AO, Cusimano MD (2001) Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:1166–1184

    CAS  PubMed  Google Scholar 

  23. Ishii M, Kawamata T, Akiguchi I et al (2010) Parkinsonian symptomatology may correlate with CT findings before and after shunting in idiopathic normal pressure hydrocephalus. Parkinsons Dis. doi:10.4061/2010/201089

    PubMed Central  PubMed  Google Scholar 

  24. Koto A, Rosenberg G, Zingesser LH et al (1977) Syndrome of normal pressure hydrocephalus: possible relation to hypertensive and arteriosclerotic vasculopathy. J Neurol Neurosurg Psychiatry 40:73–79

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  25. Krauss JK, Regel JP, Droste DW et al (1997) Movement disorders in adult hydrocephalus. Mov Disord 12:53–60

    Article  CAS  PubMed  Google Scholar 

  26. Krauss JK, Regel JP, Vach W et al (1996) Vascular risk factors and arteriosclerotic disease in idiopathic normal-pressure hydrocephalus of the elderly. Stroke 27:24–29

    Article  CAS  PubMed  Google Scholar 

  27. Larsson A, Wikkelso C, Bilting M et al (1991) Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta Neurol Scand 84:475–482

    Article  CAS  PubMed  Google Scholar 

  28. Lemcke J, Meier U, Muller C et al (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 84:850–857

    Article  PubMed Central  PubMed  Google Scholar 

  29. Loman J, Myerson A, Goldman D (1935) Effects of alterations in posture on the cerebrospinal fluid pressure. Arch Neurol Psychiat 33:1279–1295

    Article  Google Scholar 

  30. Magnaes B (1976) Body position and cerebrospinal fluid pressure. Part 1: clinical studies on the effect of rapid postural changes. J Neurosurg 44:687–697

    Article  CAS  PubMed  Google Scholar 

  31. Magnaes B (1976) Body position and cerebrospinal fluid pressure. Part 2: Clinical studies on orthostatic pressure and the hydrostatic pressure indifferent point. J Neurosurg 44:698–705

    Article  CAS  PubMed  Google Scholar 

  32. Malm J, Graff-Radford NR, Ishikawa M et al (2013) Influence of comorbidities in idiopathic normal pressure hydrocephalus – research and clinical care. A report of the ISHCSF task force on comorbidities in INPH. Fluids Barriers CNS 10:22. doi:10.1186/2045-8118-10-22

    Article  PubMed Central  PubMed  Google Scholar 

  33. Mandir AS, Hilfiker J, Thomas G et al (2007) Extrapyramidal signs in normal pressure hydrocephalus: an objective assessment. Cerebrospinal Fluid Res 4:7. doi:10.1186/1743-8454-4-7

    Article  PubMed Central  PubMed  Google Scholar 

  34. Marmarou A, Bergsneider M, Klinge P et al (2005) The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery 57:S17–S28

    Article  PubMed  Google Scholar 

  35. Marmarou A, Bergsneider M, Relkin N et al (2005) Development of guidelines for idiopathic normal-pressure hydrocephalus: introduction. Neurosurgery 57:S1–S3

    Article  PubMed  Google Scholar 

  36. Martinez-Lage JF, Perez-Espejo MA, Almagro MJ et al (2005) Syndromes of overdrainage of ventricular shunting in childhood hydrocephalus. Neurocirugia (Astur) 16:124–133

    Article  CAS  Google Scholar 

  37. Martinez-Lage JF, Ruiz-Espejo AM, Almagro MJ et al (2009) CSF overdrainage in shunted intracranial arachnoid cysts: a series and review. Childs Nerv Syst 25:1061–1069

    Article  PubMed  Google Scholar 

  38. Mataro M, Poca MA, Salgado-Pineda P et al (2003) Postsurgical cerebral perfusion changes in idiopathic normal pressure hydrocephalus: a statistical parametric mapping study of SPECT images. J Nucl Med 44:1884–1889

    PubMed  Google Scholar 

  39. McGirt MJ, Woodworth G, Coon AL et al (2005) Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus. Neurosurgery 57:699–705

    Article  PubMed  Google Scholar 

  40. McQuarrie IG, Saint-Louis L, Scherer PB (1984) Treatment of normal pressure hydrocephalus with low versus medium pressure cerebrospinal fluid shunts. Neurosurgery 15:484–488

    Article  CAS  PubMed  Google Scholar 

  41. McQuarrie IG, Scherer PB (1982) Treatment of adult-onset obstructive hydrocephalus with low- or medium- pressure CSF shunts. Neurology 32:1057–1061

    Article  CAS  PubMed  Google Scholar 

  42. Mirzayan MJ, Koenig K, Bastuerk M et al (2006) Coma due to meteorism and increased intra-abdominal pressure subsequent to ventriculoperitoneal shunt dysfunction. Lancet 368:2032

    Article  PubMed  Google Scholar 

  43. Momjian S, Owler BK, Czosnyka Z et al (2004) Pattern of white matter regional cerebral blood flow and autoregulation in normal pressure hydrocephalus. Brain 127:965–972

    Article  PubMed  Google Scholar 

  44. Mori E, Ishikawa M, Kato T et al (2012) Guidelines for management of idiopathic normal pressure hydrocephalus: second edition. Neurol Med Chir (Tokyo) 52:775–809

    Article  Google Scholar 

  45. Oikonomou J, Aschoff A, Hashemi B et al (1999) New valves: new dangers? 22 valves (38 probes) designed in the ‘nineties in ultralong-term tests (365 days)’. Eur J Pediatr Surg 9(Suppl 1):23–26

    Article  PubMed  Google Scholar 

  46. Ojemann RG, Fisher CM, Adams RD et al (1969) Further experience with the syndrome of “normal” pressure hydrocephalus. J Neurosurg 31:279–294

    Article  CAS  PubMed  Google Scholar 

  47. Pang DL, Altschuler E (1994) Low-pressure hydrocephalic state and viscoelastic alterations in the brain. Neurosurgery 35:643–655

    Article  CAS  PubMed  Google Scholar 

  48. Pattavilakom A, Xenos C, Bradfield O et al (2007) Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: an Australian prospective study. J Clin Neurosci 14:526–531

    Article  CAS  PubMed  Google Scholar 

  49. Pickard JD, Teasdale G, Matheson M et al (1980) Intraventricular pressure waves. The best predictive test for shunting in normal pressure hydrocephalus. In: Shulman K, Marmarou A, Miller JD et al (eds) Intracranial pressure IV. Springer, Berlin, pp 498–500

    Chapter  Google Scholar 

  50. Poca MA, Mataro M, Matarin M et al (2004) Is the placement of shunts in patients with idiopathic normal-pressure hydrocephalus worth the risk? Results of a study based on continuous monitoring of intracranial pressure. J Neurosurg 100:855–866

    Article  PubMed  Google Scholar 

  51. Poca MA, Mataro M, Matarin M et al (2005) Good outcome in patients with normal-pressure hydrocephalus and factors indicating poor prognosis. J Neurosurg 103:455–463

    Article  PubMed  Google Scholar 

  52. Poca MA, Sahuquillo J, Busto M et al (1996) Clinical management of patients with normal pressure hydrocephalus syndrome. Ann Psychiatry 6:273–292

    Google Scholar 

  53. Poca MA, Sahuquillo J, Topczewski T et al (2006) Posture-induced changes in intracranial pressure: a comparative study in patients with and without a cerebrospinal fluid block at the craniovertebral junction. Neurosurgery 58:899–906

    Article  PubMed  Google Scholar 

  54. Poca MA, Solana E, Martinez-Ricarte FR et al (2012) Idiopathic normal pressure hydrocephalus: results of a prospective cohort of 236 shunted patients. Acta Neurochir Suppl 114:247–253

    Article  PubMed  Google Scholar 

  55. Portnoy HD, Schulte RR, Fox JL et al (1973) Anti-siphon and reversible occlusion valves for shunting in hydrocephalus and preventing post-shunt subdural hematomas. J Neurosurg 38:729–738

    Article  CAS  PubMed  Google Scholar 

  56. Pujari S, Kharkar S, Metellus P et al (2008) Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry 79:1282–1286

    Article  CAS  PubMed  Google Scholar 

  57. Raftopoulos C, Massager N, Baleriaux D et al (1996) Prospective analysis by computed tomography and long-term outcome of 23 adult patients with chronic idiopathic hydrocephalus. Neurosurgery 38:51–59

    Article  CAS  PubMed  Google Scholar 

  58. Reilly P (2001) In normal pressure hydrocephalus, intracranial pressure monitoring is the only useful test. J Clin Neurosci 8:66–67

    Article  CAS  PubMed  Google Scholar 

  59. Relkin N, Marmarou A, Klinge P et al (2005) Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 57:S4–S16

    PubMed  Google Scholar 

  60. Richards HK, Seeley HM, Pickard JD (2009) Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry. J Neurosurg Pediatr 4:389–393

    Article  PubMed  Google Scholar 

  61. Rosenfeld JV, Siraruj S (2001) In normal pressure hydrocephalus, intracranial pressure monitoring is the only useful test. J Clin Neurosci 8:68–69

    Article  CAS  PubMed  Google Scholar 

  62. Sahuquillo J, Arikan F, Poca MA et al (2008) Intra-abdominal pressure: the neglected variable in selecting the ventriculoperitoneal shunt for treating hydrocephalus. Neurosurgery 62:143–149

    Article  PubMed  Google Scholar 

  63. Sahuquillo J, Poca MA, Martinez M et al (1994) Preventing shunt overdrainage in hydrocephalus: are anti-siphon devices really physiological? In: Nagai H, Kamiya K, Ishii S (eds) Intracranial pressure IX. Springer, Tokyo, pp 83–86

    Google Scholar 

  64. Sahuquillo J, Rubio E, Codina A et al (1991) Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “normal pressure hydrocephalus” syndrome. Acta Neurochir (Wien) 112:50–61

    Article  CAS  Google Scholar 

  65. Sanchez NC, Tenofsky PL, Dort JM et al (2001) What is normal intra-abdominal pressure? Am Surg 67:243–248

    CAS  PubMed  Google Scholar 

  66. Soelberg Sorensen P, Jansen EC, Gjerris F (1986) Motor disturbances in normal-pressure hydrocephalus. Special reference to stance and gait. Arch Neurol 43:34–38

    Article  CAS  PubMed  Google Scholar 

  67. Sugerman H, Windsor A, Bessos M et al (1997) Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity. J Intern Med 241:71–79

    Article  CAS  PubMed  Google Scholar 

  68. Toole JF (1968) Effects of change of head, limb and body position on cephalic circulation. N Engl J Med 279:307–311

    Article  CAS  PubMed  Google Scholar 

  69. Vanneste J, Augustijn P, Dirven C et al (1992) Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology 42:54–59

    Article  CAS  PubMed  Google Scholar 

  70. Zemack G, Romner B (2002) Adjustable valves in normal-pressure hydrocephalus: a retrospective study of 218 patients. Neurosurgery 51:1392–1400

    PubMed  Google Scholar 

Download references

Acknowledgments

We gratefully acknowledge Sabrina Voss for editorial assistance as well as the nurses of the Neurosurgery Department, especially María Jesus Peñarrubia and Maria Asunción Muns, for their collaboration in the studies performed. The authors of this chapter have no conflicts of interest with regard to the manufacturers or distributors of the devices mentioned in the text.

Author information

Authors and Affiliations

  1. Department of Neurosurgery and Neurotraumatology Research Unit, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain

    María Antonia Poca MD, PhD & Juan Sahuquillo MD, PhD

Authors
  1. María Antonia Poca MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Juan Sahuquillo MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to María Antonia Poca MD, PhD .

Editor information

Editors and Affiliations

  1. Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy

    Concezio Di Rocco

  2. Department of Neurosurgery, Adnan Menderes University School of Medi, Aydin, Turkey

    Mehmet Turgut

  3. Division of Pediatric Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA

    George Jallo

  4. Regional Service of Neurosurgery and Unit of Pediatric Neurosurgery, Virgen de la Arrixaca University Hospital, Murcia, Spain

    Juan F. Martínez-Lage

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Poca, M.A., Sahuquillo, J. (2015). Complications Related to the Type of Hydrocephalus: Normal Pressure Hydrocephalus. In: Di Rocco, C., Turgut, M., Jallo, G., Martínez-Lage, J. (eds) Complications of CSF Shunting in Hydrocephalus. Springer, Cham. https://doi.org/10.1007/978-3-319-09961-3_11

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-09961-3_11

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-09960-6

  • Online ISBN: 978-3-319-09961-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation