Tag: Shunting

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The diagnostic value of the lumbar infusion test to predict symptomatic improvement after shunting for normal pressure hydrocephalus. A meta‑analysis

Acta Neurochirurgica (2025) 167:180

This meta-analysis found that the lumbar infusion test (LIT) has poor negative predictive value for predicting non-response to shunting in normal pressure hydrocephalus. LIT cannot reliably exclude patients from shunt surgery and should not be used for this purpose in its current form.

• The lumbar infusion test (LIT) is used to predict which normal pressure hydrocephalus (NPH) patients will benefit from CSF shunting.

• This meta-analysis pooled sensitivity, specificity, and negative predictive value (NPV) of LIT from 10 studies.

• Sensitivity of LIT (using Rout) was moderate (77–82%) at lower cutoffs (12–14 mmHg/ml/min), but specificity was low (34–37%).

• Higher Rout cutoff (18 mmHg/ml/min) increased specificity (78%) but decreased sensitivity (37%).

• NPV was consistently low for all cutoffs (≤33%), meaning LIT is poor at ruling out shunt responders.

• No other LIT parameters (e.g., plateau pressure, CSF amplitude) showed better diagnostic value.

• The test cannot be used to exclude patients from shunt implantation due to high false negative rates.

• Future research should focus on improving the negative predictive value of LIT for NPH.

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Ventriculosinus shunt: a pilot study to investigate new technology to treat hydrocephalus and mimic physiological principles of cerebrospinal fluid drainage

J Neurosurg 139:1412–1419, 2023

Devices draining CSF to the intracranial venous sinus for the treatment of hydrocephalus have been tested in the past, and while clinically effective, have not shown efficacy in the long term. The majority of these devices become obstructed within 3 months due to endothelial overgrowth. In this study, the authors investigated a newly developed ventriculosinus (VS) shunt outlet device with the objective of showing it would remain patent for at least 6 months.

METHODS Twelve patients in need of shunting for hydrocephalus underwent an operation using the investigational device and were followed for 6 months to record patency of the shunt.

RESULTS In 10 patients, the shunt was patent at 6 months, with the outlet device remaining unobstructed. In the remaining 2 patients, one died just before reaching the 6-month endpoint, and in the other the outlet was misplaced during surgery and therefore ceased to function after 3 months. No occlusion of the internal jugular vein or thrombus formation was noted in any of the 12 cases.

CONCLUSIONS These findings indicate that the outlet device can remain patent and has the capability to mimic physiological drainage by diverting CSF to the intracranial sinus. Additional confirmation of its potential as part of a new VS shunt system and ultimately as a viable alternative for ventriculoperitoneal and ventriculoatrial shunting to reduce complication rates requires further clinical trials.

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Placebo-Controlled Effectiveness of Idiopathic Normal Pressure Hydrocephalus Shunting

Neurosurgery 92:481–489, 2023

Multiple prospective nonrandomized studies have shown 60% to 70% of patients with idiopathic normal pressure hydrocephalus (iNPH) improve with shunt surgery, but multicenter placebo-controlled trial data are necessary to determine its effectiveness.

OBJECTIVE: To evaluate the effectiveness of cerebrospinal fluid shunting in iNPH through comparison of open vs placebo shunting groups at 4 months using a pilot study.

METHODS: Patients were randomized to a Codman Certas Plus valve (Integra LifeSciences) set at 4 (open shunt group) or 8 (“virtual off”; placebo group). Patients and assessors were blinded to treatment group. The primary outcome measure was 10-m gait velocity. Secondary outcome measures included functional scales for bladder control, activities of daily living, depression, and quality of life. Immediately after 4-month evaluation, all shunts were adjusted in a blinded fashion to an active setting and followed to 12months after shunting.

RESULTS: A total of 18 patients were randomized. At the 4-month evaluation, gait velocity increased by 0.28 ± 0.28m/s in the open shunt group vs 0.04 ± 0.17m/s in the placebo group. The estimated treatment difference was 0.22 m/s ([P = .071], 95% CI 0.02 to 0.46). Overactive Bladder Short Form symptom bother questionnaire significantly improved in open shunt vs placebo (P = .007). The 4-month treatment delay did not reduce the subsequent response to active shunting, nor did it increase the adverse advents rate at 12 months.

CONCLUSION: This multicenter, randomized pilot study demonstrates the effectiveness, safety, and feasibility of a placebo-controlled trial in iNPH, and found a trend suggesting gait velocity improves more in the open shunt group than in the placebo group.

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Freehand stereotactic ventricular catheter insertion for ventriculoperitoneal shunts based on individualized radio-anatomical landmarks

Acta Neurochirurgica (2021) 163:1103–1112

The accurate placement of the ventricular catheter (VC) is critical in reducing the incidence of proximal failure of ventriculoperitoneal shunts (VPSs). The standard freehand technique is based on validated external anatomical landmarks but remains associated with a relatively high rate of VC malposition. Already proposed alternative methods have all their specific limitations. Herein, we evaluate the accuracy of our adapted freehand technique based on an individualized radio-anatomical approach. Reproducing the preoperative imaging on the patient’s head using common anatomical landmarks allows to define stereotactic VC coordinates to be followed at surgery.

Material and methods Fifty-five consecutive patients treated with 56 VPS between 11/2005 and 02/2020 fulfilled the inclusion criteria of this retrospective study. Burr hole coordinates, VC trajectory, and length were determined in all cases on preoperative computed tomography (CT) scan and were accurately reported on patients’ head. The primary endpoint was to evaluate VC placement accuracy. The secondary endpoint was to evaluate the rate and nature of postoperative VC-related complications.

Results Our new technique was applicable in all patients and no VC-related complications were observed. Postoperative imaging showed VC optimally placed in 85.7% and sub-optimally placed in 14.3% of cases. In all procedures, all the holes on the VC tip were found in the ventricular system.

Conclusions This simple individualized technique improves the freehand VC placement in VPS surgery, making its accuracy comparable to that of more sophisticated and expensive techniques. Further randomized controlled studies are required to compare our results with those of the other available techniques.

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