Management of idiopathic intracranial hypertension with repeated lumboperitoneal shunt malfunction

Abstract

IntroductionThe incidence of idiopathic intracranial hypertension is 1/100,000 population per year. The widely accepted surgical treatment for idiopathic intracranial hypertension (IIH) in the last four decades has been the insertion of lumboperitoneal (LP) shunt (Greer, Clin Neurosurg 15:161–174, 1968; Weisberg, Medicine 54:197–207, 1975). The LP shunt is associated with high revision rates.Patients and methodsThis is a prospective study that was done between 1 January 2014 and 31 December 2014, including seven patients with IIH and a lumboperitoneal shunt malfunction. These patients were treated by an insertion of a ventriculoperitoneal (VP shunt). The Medtronic medium pressure shunt was used. The patients were followed up at 1, 3, 6, and 12 months.ResultsIn four patients, the shunt malfunction was due to slippage of the peritoneal end either into subcutaneous fat of the abdomen in three patients or into subcutaneous fat of the back (with occurrence of shunt infection) in one patient. In one patient, the failure was due to the slippage of both tubes into the subcutaneous abdominal layer, while in two patients, shunt failure was due to obstruction with adequate shunt position.All patients were females (100%). Age ranged from 22 to 48 years with mean age at 32 years. Five patients (71%) had previous one LP shunt revision surgery while two patients (29%) had previous two revision surgeries. Six patients (85%) showed elevated ICP on CSF manometry, and one patient with wound collection, who showed evident infection, was enrolled in the algorithm for positive infection. Brain imaging showed slit ventricles in five patients and near normal ventricles in two patients. All patients experienced smooth postoperative recovery. Postoperative images were satisfactory regarding position of distal and proximal shunt tubes. Headache was improved in all patients within the first postoperative day, while visual symptoms improved markedly within 2 weeks postoperatively.ConclusionThe use of VP shunts is extremely beneficial in the treatment of IIH-associated LP shunt malfunction especially with the new technologies in the placement of the ventricular end, and conducting a multicenter trial is recommended to re-evaluate if the primary surgical treatment of IIH will continue to be the LP shunts or shift to the use of VP shunts.