Abstract
BackgroundPositive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). However, multiple pathologies mimic iNPH symptoms, making it difficult to select patients who will respond to shunt surgery. Although presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose.ObjectiveTo conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests.MethodsEmbase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating clinical predictors of SR in iNPH patients. Included studies were assessed using the QUADAS-2 tool, and eligible studies were evaluated using univariate and bivariate meta-analyses.ResultsThirty-five studies were included. Nine studies discussed the diagnostic use of presenting clinical features, 8 studies ELD, 8 studies IT, 11 studies ICPM, and 6 studies TT. A meta-analysis of 21 eligible studies was conducted for TT, ELD, IT, and ICPM. ICPM yielded the highest diagnostic effectiveness, with diagnostic odds ratio (DOR) = 50.9 and area under curve (AUC) = 0.836. ELD yielded DOR = 27.70 and AUC = 0.753, IT had DOR = 5.70 and AUC = 0.729, and TT scored DOR = 3.86 and AUC = 0.711.ConclusionIntraparenchymal ICPM is statistically the most effective diagnostic test, followed by ELD, IT, and lastly TT. Due to the higher accessibility of TT and IT, they are recommended to be used first line, using a timed-up-and-go improvement ≥ 5.6 s or a Rout cut-off range between 13 and 16 mmHg, respectively. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude ge 4 mmHg, or 1- to 4-day ELD with an MMSE cut-off improvement ge 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison.
Highlights
Normal pressure hydrocephalus (NPH), a syndrome discovered by Hakim and Adams [1], classically presents with dementia, gait disturbance, and urinary incontinence [23]
McGirt et al [40] found that patients with gait disturbance as a primary symptom were twice as likely to respond than others, complete triad presentation compared to the absence of one symptom did not affect shunt response (SR)
The findings suggest that a patient with shunt-responsive idiopathic normal pressure hydrocephalus (iNPH) is 50.1 × more likely to have positive intracranial pressure monitoring (ICPM) than a shunt-unresponsive iNPH patient, compared to 27.7 × more likely with extended lumbar drainage (ELD)
Summary
Normal pressure hydrocephalus (NPH), a syndrome discovered by Hakim and Adams [1], classically presents with dementia, gait disturbance, and urinary incontinence [23]. Clinical improvement has been reported in up to 90% of patients following shunt surgery [34], this value has been as low as 46.7% [5]. Positive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). Presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose. Objective To conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude ≥ 4 mmHg, or 1- to 4-day ELD with an MMSE cut-off improvement ≥ 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison
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