Is there a difference in outcomes of patients with idiopathic intracranial hypertension with the choice of cerebrospinal fluid diversion site: A single centre experience

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Abstract

The visual and headache outcomes in patients with idiopathic intracranial hypertension (IIH) undergoing cerebrospinal fluid diversion with a lumboperitoneal (LPS) or ventriculoperitoneal shunting (VPS) have not been well reported. The aims of this study were to: (a) to assess outcomes of CSF diversion in IIH, (b) to understand influence of the type of shunt in outcomes, and (c) to understand factors predisposing in shunt failure.

Methods

The medical records of 34 patients who underwent cerebrospinal fluid diversion (CSFD) between 1996 and 2007 were retrieved and epidemiological and clinical data was collected.

Results

The mean age was 35 (±7.9) years. Thirty-four patients underwent 63 shunt placements in total. 85% follow-up was achieved. The mean follow-up for the entire group was 28.9 (±31.8) months. Headaches improved more than visual disturbances. There was no significant difference between the groups that received a VPS and those receiving an LPS in both headache and visual outcomes. The rate of complications was 20.5% and the need for revision was 35% for the whole group. Patients with LPS suffered more complications and first time revisions than patients with VPS. No factor recorded could predict the need for revision or final outcomes. The shunts of patients receiving a VPS tend to survive longer than those receiving primarily an LPS, however the difference is not statistically significant.

Conclusions

Predicting which patients will improve is not possible at present. The influence of site diversion is not critical but patients with VPS have less complications and revisions than those receiving a LPS.

Introduction

The incidence of idiopathic intracranial hypertension (IIH, benign intracranial hypertension, or pseudotumour cerebri) has been reported as 1–3 patients per 100,000 population per year [1], [2], [3]. However, only few studies have reported outcomes for surgically treated cases by cerebrospinal fluid diversion (CSFD) [4], [5], [6].

The shunt revision rates have been reported as high as 41–63% [4], [7]. The usual methods of diversion are that of lumboperitoneal (LPS) in earlier times and ventriculoperitoneal shunting (VPS) more recently. Revision rates have been reported lower in VPS than LPS [5]. Lack of papilloedema and symptoms more than 2 years were risk factors for treatment failure [5].

The aims of this study were to: (a) to assess outcomes of CSF diversion in IIH (b) to understand influence of the type of shunt in outcomes, and (c) to understand factors predisposing in shunt failure.

Section snippets

Materials and methods

The medical records of 34 patients who underwent CSFD between 1996 and 2007 were retrieved and data was collected. All patients included in the study satisfied the modified Dandy criteria [8]. Patient demographics, neurological status and ophthalmological examination at presentation and last follow-up, initial CSF dynamics, preoperative medication, as well as operative records were examined to document initial shunt placement and following revisions. Obesity as a clinical phenotype was

Demographics and symptom presentation

32 females and 2 males underwent CSFD procedure during the study period. The patients’ mean age was 35 (±7.9) years. There were 24 Caucasian patients, and 2 Asian patients. The race was not recorded in the remaining 8 cases. Only 2 patients (6%) were not obese. Mean preoperative symptom duration in 30 patients was 30.9 (±56.9) months. Five patients had optic nerve sheath fenestration (ONSF) prior to neurosurgical intervention. Mean CSF opening pressure during LP was 39.4 (±10.3) mm Hg. Sixteen

Discussion

A successful shunt will treat both papilloedema and headache and is the definitive treatment for IIH cases when medical management fails [9]. There is currently little evidence on best practice with regards to surgical management of patients with IIH. In a literature review comparing 4 different techniques improved or resolved vision deficit was noted in 39% of patients after VP shunt placement, 47% of patients after stent placement, 45% of patients after LP shunt placement, and 80% of eyes

Conclusion

Headaches improve more often when compared with visual disturbances in patients suffering from BIH. There was no difference in outcomes between VP and LP shunts. Patients undergo frequent shunt revisions which often require change of site insertion or occasionally an additional shunt component. VP shunting has fewer complications and they tend to last longer. A long follow-up of these patients is warranted with an associated standardised neuro opthalmological and headache assessment. A

Acknowledgement

Mr A. Tarnaris and Mr A. Toma have been supported by grants from B Braun/Aesculap.

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