Is there a difference in outcomes of patients with idiopathic intracranial hypertension with the choice of cerebrospinal fluid diversion site: A single centre experience
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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2022, World NeurosurgeryCitation Excerpt :The most common types of shunt for IIH are ventriculoperitoneal and lumboperitoneal shunts.7 The protocol recommends the former because they are associated with lower revision rates and can be fitted with advanced valves and sensors.8,9 A frontal trajectory has been associated with lower revisions.10
Lumbo-peritoneal shunt as treatment modality for visual symptoms in idiopathic intracranial hypertension: A single institution experience
2021, NeurocirugiaCitation Excerpt :VPS are suggested to have lower revision rates, but the number of true revisions could be distorted by the fact that far fewer VPS are performed than LPS. VPS also carry the much greater feared intracranial complications, as well as increased difficulty with shunt placement within the small ventricles of IIH patients.44 In multiple series, headaches have been shown to improve more than visual disturbance, and LPS appear to perform better in both outcomes, even though the difference is not statistically significant, a result that this is not supported by the findings of Wall and George.
Effect of Shunting on Visual Outcomes and Headache in Patients with Idiopathic Intracranial Hypertension
2020, World NeurosurgeryCitation Excerpt :Previous studies that compared the 2 shunting procedures did not find any differences in outcome. Tarnaris et al16 reported that there was no significant difference between the groups that received a VPS and those receiving an LPS in both headache and visual outcomes, although LPS appeared to perform better in both outcomes. In our study, VPS resulted in a significantly higher rate of headache resolution as compared with LPS, but with a similar rate of visual acuity improvement, visual field improvement and improvement of other symptoms including transient visual obscurations, diplopia, tinnitus, blackouts, and photopsia.