Shunt Surgery In Normal Pressure Hydrocephalus Research Articles

Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis.

Research on age-related complications secondary to shunts in normal pressure hydrocephalus (NPH) is primarily limited to single-center studies and small cohorts. To determine the rates of hospital readmission and surgical complications, and factors that predict them, following shunt surgery for NPH in a large healthcare network. Surgical procedures, complications, and readmissions for adults undergoing ventricular shunting for NPH were determined using de-identified claims from a privately insured United States healthcare network in years 2007-2014. Univariate and multivariate statistics were used to determine factors that predict poor surgical outcomes. The primary outcome variable was surgical complications or readmissions (composite variable for any major perioperative complication or 30-d readmission). The 30-d readmission rate for 974 patients with NPH who underwent ventricular shunting was 7.29%; the most common reasons for readmission were shunt-related complications, infection, hemorrhage, altered mental status, and cardiopulmonary and musculoskeletal problems. The perioperative complication rate was 21.15%, including intraparenchymal hemorrhage (5.85%) and extra-axial (subdural or epidural) hematoma (5.54%). The overall rate of having a surgical complication or 30-d readmission was 25.15%. Age did not predict surgical complication or 30-d readmission. Preoperative comorbidities independently associated with poor outcome were myocardial infarction within 1 yr (OR=3.984, 95% CI=1.105-14.368); existing cerebrovascular disease (odds ratio [OR]=2.206, 95% CI=1.544-3.152); and moderate/severe renal disease (OR=2.000, 95% CI=1.155-3.464). The rate of complications or readmission within 30 d of ventricular shunting for NPH is 25.15%. Preoperative comorbidities of myocardial infarction within 1 yr, cerebrovascular disease, and moderate/severe renal disease are independent risk factors for poor outcome.

White Matter Changes in Corpus Callosum in a Patient with Idiopathic Normal Pressure Hydrocephalus?

I read with great interest the article by Mullaguri et al., in which they describe a normal pressure hydrocephalus (NPH) patient presenting with coma after quetiapine and trazodone overdose, at whom cranial magnetic resonance imaging showed diffuse corpus callosum T2 hyperintensity.[1] They associated the neuroimaging changes with shunt surgery for NPH and gave some crucial insights for clinical concerns.[1] I appreciate the authors for pointing out this interesting patient and for constituting impressive discussions. However, I would like to comment on some aspects for a better understanding of the issue and also, in the light of the related literature data, I would like to suggest some new discussions for further clarifications in this regard.

Apathy, ventriculomegaly and neurocognitive improvement following shunt surgery in normal pressure hydrocephalus

Introduction. Apathy – impaired motivation and goal-directed behaviour – is a common yet often overlooked symptom in normal pressure hydrocephalus (NPH). Caudate atrophy often yields apathetic symptoms; however, this structural and functional relationship has not yet been explored in NPH. Additionally, little is known about the relationship between apathy and post-shunt cognitive recovery. Methods. This audit investigated whether apathetic symptoms improve following shunt surgery in NPH, and whether this relates to cognitive response. In addition, we assessed the relationship between ventriculomegaly and apathy using the bicaudate ratio. Twenty-two patients with NPH completed the Mini-Mental State Examination (MMSE), the Apathy Evaluation Scale (AES) and the Geriatric Depression Scale (GDS) before and 3–9 months after shunt surgery. Pre-operative ventriculomegaly was correlated with pre-operative AES and GDS scores. Difference scores (post-shunt minus baseline values) for AES and GDS were correlated with cognitive outcome. Results. Greater pre-operative ventriculomegaly was associated with increased level of apathy and depression. A reduction in apathetic symptoms following shunt surgery was associated with improved performance on the MMSE. Conclusions. Apathy may be indicative of a greater degree of subcortical atrophy in NPH and may relate to functional outcome.

Normal pressure hydrocephalus: long-term outcome after shunt surgery

Background/objective:Little is known about the long-term clinical course and management of patients with normal pressure hydrocephalus (NPH) treated by cerebrospinal fluid (CSF) shunting.Methods:We retrospectively reviewed records of 55 patients diagnosed...

EVALUATION AND TREATMENT OF PATIENTS WITH SUSPECTED NORMAL PRESSURE HYDROCEPHALUS ON LONG-TERM WARFARIN ANTICOAGULATION THERAPY

Long-term anticoagulation is often considered a contraindication to shunt surgery for elderly patients with normal pressure hydrocephalus (NPH). However, no studies have investigated this question. We evaluated 25 patients who were taking warfarin for NPH between 2001 and 2004 with a protocol of cerebrospinal fluid (CSF) pressure monitoring and controlled CSF drainage via spinal catheter. Warfarin was stopped 5 to 7 days before lumbar puncture or shunt surgery and restarted 3 to 5 days after operation or at the time of discharge from the hospital. Programmable shunts with antisiphon devices set at the high-pressure range were preferentially used and adjusted in small increments. After CSF drainage, 16 patients showed improvement and 15 underwent shunt surgery. Thirteen (87%) out of these 15 patients showed significant improvement in at least one symptom during a mean follow-up period of 8.2 months (range, 1-70 mo) after shunt surgery. There were two bleeding complications. One patient (6.7%) with cirrhosis who developed a subdural hematoma 13 days after operation had the shunt removed; another patient who developed an abdominal subcutaneous hematoma 5 days after operation required surgical evacuation and shunt revision surgery. Otherwise, 14 (93.3%) out of the 15 patients had no subdural hematoma during the follow-up period and there were no thromboembolic complications while the patients were not taking warfarin. Elderly patients on long-term warfarin anticoagulation can be safely evaluated and treated for NPH using a protocol of continuous CSF drainage via spinal catheter for diagnosis, cautious periprocedural management of anticoagulation, and use of programmable shunts with antisiphon devices. The risk of subdural hematoma is not higher than reported series. Long-term anticoagulation with warfarin is not a contraindication per se for shunt surgery in NPH.

Evaluation of shunt function in patients who are never better, or better than worse after shunt surgery for NPH.

We investigated the cause of poor outcome in patients with normal pressure hydrocephalus (NPH) who did not respond as expected after shunt surgery. Two methods were used to evaluate shunts: radionuclide shunt patency study, or continuous ICP monitoring. 33/52 shunted patients (64%) from 1989 to 1995 had poor outcome, and 28/52 (54%) were investigated. Of those investigated, 9/28 (32%) were never better, and 19/28 (68%) were initially better then worse. Of 9 patients who were never better, ineffective shunt function was seen in 7; 5 had shunt revision (2 declined), and 1 improved. Of 19 patients who were initially better then worse, 15 had ineffective shunts; 15 underwent shunt revision, and 13 improved. Poor clinical outcome occurred in two-thirds of all patients after shunt surgery for NPH, but a potentially treatable cause (i.e. obstruction of the shunt or a shunt system that was patent but did not adequately correct the CSF circulatory disorder) was found in nearly 80% (22/28) of those investigated. The predominant cause of ineffective shunt function was obstruction of the peritoneal catheter. Clinical recovery occurred in 70% (14/20) of patients who had shunt revision surgery. We conclude that ineffective shunt function is a frequent cause of poor outcome after shunt surgery to treat NPH that should be sought and treated. These results have implications for longitudinal studies of the diagnosis and treatment of NPH. The effect of unrecognized shunt ineffectiveness on prior studies is unknown. Future studies should be designed to confirm that shunts are functioning before the diagnosis of NPH is considered incorrect.