Cerebrovascular Diseases Complicating Ventriculoperitoneal Shunt Response in Secondary Normal Pressure Hydrocephalus (P07.191)

Abstract

Objective: To describe outcomes in two patients with cerebrovascular disease and secondary normal pressure hydrocephalus (NPH) with poor response to ventriculoperitoneal shunting (VPS). Background The prediction of VPS response in secondary NPH remains challenging, given its complex etiologies and comorbidities. Cerebrovascular disease (CVD) is a common comorbidity in NPH, and previous CVD insults may contribute to the development of secondary NPH, making it an important consideration in patient selection and outcome of VPS in secondary NPH. Design/Methods: We report the pre-operative and post-operative clinical features, surgical, neuroimaging, and ancillary testing data in two such cases, with videotaped exam in the second case. Results: Patient #1, a 79-year- old woman with known basilar tip aneurysm and pituitary macroadenoma, developed progressive gait disturbance/ataxia, cognitive decline, and urinary and fecal incontinence in the setting of moderate ventriculomegaly and transependymal CSF migration on brain MRI. Right-sided occipital VPS provided minimal improvement and post-operative imaging demonstrate enlarging basilar tip aneurysm with mild midbrain compression. Clinically, three months after VPS, she developed mild features of akinetic mutism. Patient #2, an 81- year- old woman with recent history of a right-sided subdural hematoma and evacuation, who upon recovery developed fluctuating cognition with mildly decreased interactiveness and gait dysfunction, was found to have significant ventriculomegaly and moderate ischemic white matter disease on head CT. After a robust response in gait speed to a large volume lumbar puncture, a right pre-coronal VPS was placed, with only temporary benefits. After shunt malfunctions were revised twice, benefits could not be recaptured, and she developed significant akinetic mutism. Conclusions: Decisions to place a VPS in secondary NPH in the setting of CVD, large artery aneurysms, and after subdural hematomas are challenging and may prove to be negative predictive factors to shunt response. Disclosure: Dr. Rao-Frisch has nothing to disclose. Dr. Shams has nothing to disclose. Dr. Smyth has nothing to disclose. Dr. Lerner has nothing to disclose.