Abstract
Background:The consensus on most reliable supplemental test to predict the shunt responsiveness in patients with idiopathic normal pressure hydrocephalus (iNPH) is lacking. The aim of this study is to discuss the utility of external lumbar drain (ELD) in evaluation of shunt responsiveness for iNPH patients.Methods:A retrospective review of 66 patients with iNPH was conducted. All patients underwent 4-day ELD trial. ELD-positive patients were offered ventriculoperitoneal shunt (VPS) surgery. The primary outcome evaluation parameters were gait and mini mental status examination (MMSE) assessment. The family and patient perception of improvement was accounted for in the outcome evaluation.Results:There were 38 male and 28 female with mean age of 74 years (range 45-88 years). ELD trial was positive in 86% (57/66) of patients. No major complications were encountered with the ELD trial. A total of 60 patients (57 ELD-positive, 3 ELD-negative) underwent VPS insertion. The negative ELD trial (P = 0.006) was associated with poor outcomes following shunt insertion. The positive ELD trial predicted shunt responsiveness in 96% patients (P < 0.0001, OR = 96.2, CI = 11.6-795.3). A receiver operating characteristic (ROC) curve analysis revealed that the ELD trial is reasonably accurate in differentiating shunt responder from non-responder in iNPH patients (area under curve = 0.8 ± 0.14, P = 0.02, CI = 0.52-1.0). The mean follow-up period was 12-months (range 0.3-3 years). The significant overall improvement after VPS was seen in 92% (55/60). The improvement was sustained in 76% of patients at mean 3-year follow-up. The number of comorbid conditions (P = 0.034, OR = 4.15, CI = 1.2-9.04), and a history of cerebrovascular accident (CVA) (P = 0.035, OR = 4.4, CI = 1.9-14.6) were the predictors of poor outcome following shunt surgery.Conclusion:The positive ELD test predicted shunt responsiveness in 96% of patients. With adequate technique, maximal results with minimal complications can be anticipated. The number of comorbidities, history of CVA and negative ELD test were significantly associated with poor shunt outcomes.
Highlights
Since the seminal description of classical symptom triad by Hakim and Adams; gait disturbance, urinary incontinence, and cognitive impairment, the definition of normal pressure hydrocephalus (NPH) has evolved.[15]
Idiopathic normal pressure hydrocephalus is defined as the presence of any one or more of the triad symptoms associated with normal cerebrospinal fluid (CSF) pressure (60-240 mm H2O) and computerized tomography (CT) scan evidence of ventriculomegaly
The receiver operating characteristic (ROC) curve analysis revealed that the external lumbar drain (ELD) trial is reasonably accurate in differentiating shunt responder from nonresponder in idiopathic normal pressure hydrocephalus (iNPH) patients
Summary
Since the seminal description of classical symptom triad by Hakim and Adams; gait disturbance, urinary incontinence, and cognitive impairment, the definition of normal pressure hydrocephalus (NPH) has evolved.[15]. Despite a number of studies, the expert consensus on most reliable predictors of favorable outcome after shunt surgery is still lacking.[7,12,16,18,20,24,30,33,44,45] The commonly used prognostic tools to select the patients for shunt surgery are the radionucleotide cisternography, high volume tap test (TT), CSF outflow resistance determination, external lumbar drain (ELD) trial, and long‐term recording of ICP to identify B wave activity.[31] The current neurosurgical literature supports ELD. We aim to discuss our technique of ELD trial and to analyze if ELD is optimal supplemental test for prediction of shunt responsiveness. The aim of this study is to discuss the utility of external lumbar drain (ELD) in evaluation of shunt responsiveness for iNPH patients
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