Abstract
Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.
Highlights
Ventriculoperitoneal (VP) shunt surgery has a long history and is one of the most established neurosurgeries
The guidelines for the management of idiopathic normal pressure hydrocephalus (iNPH) have consistently recommended to be used as some subjective evaluation scales along with objective and quantitative methods such as the 3-meter Timed Up & Go test (TUG) and Mini-Mental State Examination (MMSE) [18, 19, 21]
As reliable quantitative tests in patients with iNPH, TUG is widely used for assessment of gait and balance [14, 30, 31], and MMSE is for cognitive impairment [32]
Summary
Ventriculoperitoneal (VP) shunt surgery has a long history and is one of the most established neurosurgeries. Until the 1970s, several fixed differential pressure valves had been used in patients with idiopathic normal pressure hydrocephalus (iNPH), but the improvement rate of symptoms was poor and the risk of CSF over-drainage was extremely high. This led experts to question the surgical need for iNPH, and, for the 20 years, CSF shunt surgery for iNPH was rarely performed. This review was conducted to examine the history and current outcome of VP shunt surgery with recent shunt valve systems for iNPH patients. The intention was to avoid repeating negative history of VP shunt surgery and to lead to the future of surgical intervention in elderly patients who require long-term care
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