Introduction
Methods
1. Clinical symptoms of hydrocephalus developing in adulthood—e.g. headaches, cognitive decline, imbalance, gait disturbance, psychological disturbance, visual deterioration/diplopia |
3. Overt tri-ventriculomegaly (lateral and third ventricles) on neuroimaging, with cortical sulcal effacement and/or destruction of the sella turcica as evidence of long-standing ventriculomegaly |
4. Absence of a secondary cause for aqueductal stenosis in adulthood (e.g. previous meningitis, subarachnoid haemorrhage) |
Authors (year) | No. of LOVA patients (total in cohort) | Primary interventions (n) | Outcomes | Complications | Caveats |
---|---|---|---|---|---|
Oi et al. (2000) [1] | 18 (18) | ETV (8); VP shunt (9) (DPV 7; PPV 2) | Clinical improvement and radiological arrest of hydrocephalus in all patients after primary ETV and PPV | SDH in all 7 patients receiving DPV shunts, requiring shunt revision to PPV or ETV Two intra-axial haemorrhages after ETV. One case of transient visual field deficit after ETV | Relatively small cohort |
Keifer et al. (2002) | 23 (23) | Gravitational-shunt (23) | 82 % (19) patients reporting symptomatic improvement | 2 SDH—one necessitating operative drainage | Non-comparative study; potential selection bias; relatively small cohort |
Keifer et al. (Jan 2005) | 30 (30) | Gravitational shunt (30) | 87 % (26) patients reported improvement in pre-operative symptoms | 2 post-operative hygromas—one requiring shunt revision; limited or transient improvement in pre-operative symptoms in 3 (10 %) patients | Non-comparative study; follow-up of up to 12 months only, therefore late shunt infections or failures potentially not captured; potential selection bias; relatively small cohort |
Keifer et al. (July 2005) | 26 (26) | Gravitational shunt (26) | 87 % (22) of patients reporting clinical improvement | 2 SDH; 4 cases with symptoms of over-drainage, 2 requiring shunt revision; one case of severe weight gain (due to underdrainage) requiring replacement of the shuntAssistant® portion of the shunt; one case with recurrence of symptoms | Non-comparative study; patient selection potentially affected by suboptimal ETV equipment; relatively small cohort |
Canu et al. (2005) [7] | 1 (1) | N/A | Identification of preserved language and praxis functions despite severe ventriculomegaly | N/A | Single case report; no therapeutic interventions performed |
Rekate H. (2007) [13] | 6 (6) | ETV (6) | CSF flow through ETV confirmed radiologically in all cases post-operatively | Persistent symptoms in 5 cases (83 %) necessitating VP shunt or venous stenting. Mild short-term memory deficits in 1 patient | Small cohort; heterogeneous patient population, including three (50 %) patients <30 and one <20 (age 16). ETVs within the study cohort performed at two different institutions |
Hamanda et al. (2009) [8] | 1 (1) | ETV (1) | Improvement in headaches, memory, cognitive and constructional abilities | None | Single case report; patient had a history of operated myeloschisis and aqueductal stenosis as a child (potentially not a true case of LOVA) |
Jenkinson et al. (2009) [6] | 24 (190) | ETV (24) | 88 % (21) reporting improved symptoms after ETV | 9 post-ETV complications in the total cohort (5 %): 2 minor SDHs; 2 transient focal neurological deficits; 2 CSF leaks; 3 ICHs (2 necessitating EVD placement) | Heterogeneity of indications for ETV; small numbers of patients in each subgroup; outcomes defined by clinical assessment in outpatient clinic |
Al Jumaily et al. (2012) [4] | 20 (20) | ETV (20) | Improvement in headache (18; 90 %); improved balance (12; 80 %) | Persistent headaches in 2 patients (10 %), requiring repeat ETV and gravitational shunt insertion, with persistence of symptoms despite shunt insertion in one patient. Two short seizures immediately post-operatively; poor cognitive performances persisted across the cohort post-ETV | Patients failing to respond to ETV may have been suffering from non-ICP-related chronic daily headaches—however ICP monitoring was not performed to confirm this |
Ono et al. (2012) [10] | 1 (1) | Pressure programmable valve VP shunt (1) | Improvement in memory | SDH requiring drainage and second shunt insertion | Single case report |
Issacs et al. (2016) | 97 (163) | ETV (163) | 130 (87 %) of total patient cohort reported improvement in symptoms at 3 months post-ETV | 10 (6 %): meningitis (4); SDH (2); focal neurological deficit (1); memory deficit (1); weight gain (2). No long-term disability | Data not specific to LOVA (cohort includes ETVs for failed VP shunts, secondary hydrocephalus and NPH) |
Ved et al. (2016) | 14 (14) | ETV (14) | 14 patients (100 %) reported improvement or halt of progression in presenting symptoms 3 months post-operatively; 97 % (13) | One (7 %) post-operative seizure with no long-term disability; one (7 %) patient requiring a second procedure (VP shunt) due to symptom recurrence | Relatively small cohort. Outcomes defined by clinical assessment in outpatient clinic |
Results
Case number | Sex | Presenting symptoms | Age at presentation | Head circumference | Operative complications | Outcome at 3 months | Outcome beyond 3 months |
---|---|---|---|---|---|---|---|
1 | M | Leg weakness, falls, Headaches | 43 | 55 cm | No | Reduced headache frequency, “80 % better” | 5 years: no deterioration; “100 % better” |
2 | M | Unsteadiness | 38 | 58 cm | No | No deterioration in balance | 5 years: no deterioration |
3 | M | Dizzy spells, mood swings and headaches | 53 | 62 cm | No | Improved memory and headaches; no deterioration in mood swings | 5 years: mild headaches and dizziness returned |
4 | F | Poor mobility and headaches | 68 | 59 cm | No | Improved mobility and headaches absent | 5 years: improved mobility and headaches |
5 | M | Ataxia, seizures, and poor memory | 34 | 54 cm | Yes (Generalised tonic clonic seizure) | Improved ataxia and seizure frequency; no deterioration of memory | 5 years: no further deterioration |
6 | F | Poor mobility and headaches | 57 | 59 cm | No | Improved mobility and headaches | 4 years: return of headaches; awaiting outpatient review |
7 | M | Unsteadiness | 63 | 60 cm | No | Balance improved | 3 years: “balance back to normal” |
8 | M | Diplopia | 59 | 60 cm | No | Diplopia resolved | 36 months: return of diplopia and onset of leg weakness: VP shunt inserted |
9 | F | Imbalance | 75 | 57 cm | No | Improved balance and mobility | 2 years: no further deterioration |
10 | M | Headaches and imbalance | 22 | 58 cm | No | Improved headaches and balance | 2 years: balance further improved |
11 | M | Headaches and cognitive decline | 55 | 59 cm | No | Improved headaches and cognition | 1 year: cognition further improved |
12 | F | Headaches | 41 | 59 cm | No | Improved headaches | 1 year: no further deterioration |
13 | F | Headaches | 17 | 57 cm | No | Headaches absent | 1 year: no further deterioration |
14 | F | Memory disturbance, disinhibition, and unsteadiness | 81 | 58 cm | No | Socially and cognitively much improved at 4 months | 6 months: continued cognitive and social improvement |