430 Trans-cerebellar Stereotactic-guided Cisternoperitoneal Shunt Placement for Idiopathic Intracranial Hypertension

Abstract

INTRODUCTION: Idiopathic intracranial hypertension (IIH, pseudotumor cerebri) mainly affects young, obese females and can cause debilitating symptoms as well as optic nerve ischemia if not treated. Cerebrospinal fluid (CSF) diversion is often necessary to reduce intracranial pressure (ICP). Ventriculoperitoneal shunts (VPS) and lumboperitoneal shunts (LPS) are the main methods of CSF diversion but both are fraught with high rates of shunt failures in IIH patients. We propose the novel trans-cerebellar stereotactic-guided cisternoperitoneal shunt (TCSG-CPS) technique, which places the proximal shunt catheter in the posterior cisterna magnum, which is a non-collapsible CSF space. METHODS: Retrospective data regarding perioperative and postoperative data from all patients who underwent TCSG-CPS placement from 2015-2020 for IIH were collected. Intraoperatively, patients are positioned as for VPS but with the head turned further laterally to adequately expose the retrosigmoid space. Using neuronavigation, the transverse and sigmoid sinuses are located and an opening is made at the transverse-sigmoid junction. The proximal catheter is then inserted transcerebellarly into the posterior foramen magnum using electromagnetic neuronavigation to accurately track the catheter tip. RESULTS: Thirty-two patients underwent TCSG-CPS placement. 91% were female, with a mean BMI of 36.0 ± 7.5. Fourteen patients had undergone prior VPS or LPS placement with shunt failures. Shunt placement, including removal of prior shunts when applicable, took an average of 150 minutes. There were no intraoperative complications and patients were discharged uneventfully after mean 1.7 days. On follow-up visits at 6 months, 81% had relief of their presenting symptoms. Shunt survival without revision at 1 and 3 year were 86% and 67%, respectively. Overall infection rate was 0% in the study period. CONCLUSION: The TCSG-CPS offers an alternative solution to VPS and LPS for CSF diversion in patients with IIH and demonstrates a lower failure rate and more durable symptom relief compared to historical data on VPS and LPS. Using the proper techniques and equipment promotes safe and facile placement of the proximal catheter.