Concurrent use of a lumboperitoneal shunt with programmable valve and ventricular access device in the treatment of pseudotumor cerebri: review of 40 cases

Abstract

The authors evaluated the efficacy of treating patients with pseudotumor cerebri (PTC) and headaches due to increased intracranial pressure (ICP) by using a lumboperitoneal (LP) shunt with a programmable valve and ventricular access device (VAD). Forty patients in whom PTC was diagnosed were treated using LP shunts with programmable valves and wand-guided placement of a VAD. All patients had papilledema and high opening pressure during spinal tap. The mean follow-up was 18 months (range 3-72 months). When patients complained of headaches that suggested shunt malfunction, the ventricular reservoir was tapped at bedside to assess ICP. The programmable valve was adjusted based on the patient's headache and ICP. The VAD was tapped in 21 patients, and the LP valve was redialed in 14. Shunt malfunction was diagnosed accurately. The 10 patients undergoing revision were all found to have shunt obstruction except 1 whose valve was replaced because it could not be reprogrammed. No patient treated with a shunt developed a Chiari malformation. The VAD was exposed in 4 patients with infection or wound breakdown. The LP shunt was revised in 2 patients who developed a pseudomeningocele. In 1 patient, a small bowel obstruction responded to conservative management. Seven patients had headaches despite documented normal ICP. That is, the headaches were unrelated to shunt function, and these patients were referred to a pain management clinic. Lumboperitoneal shunts with programmable valves effectively controlled the outflow of lumbar cerebrospinal fluid to ameliorate the symptoms of PTC. The VAD permitted assessment of ICP and thus, indirectly, LP shunt function, and benefits outweighed risks. The programmable valve permitted cerebrospinal fluid flow to be adjusted based on patients' clinical status and ICP to be measured by the VAD.