Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 1187  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
   Ahead Of Print
    Search Pubmed for
 
    -  M de Oliveira AJ
    -  G Pinto FC
    -  Teixeira MJ
   Article in PDF
 
  In this Article
   Abstract
  Subjects and Methods
  Results
  Discussion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed44    
    PDF Downloaded3    

Recommend this journal

 

Previous Article   Table of Contents   Next Article  
ORIGINAL ARTICLE
Ahead of print schedule

Comparative Study of the Effectiveness of Lumboperitoneal and Ventriculoperitoneal Shunting with Neuronavigation in the Treatment of Idiopathic Intracranial Hypertension


1 Neurosurgery Division, Hospital Das Clinicas da Faculdade de Medicina da USP, São Paulo, Brazil; Neurosurgery Division, Clinica Girassol, Luanda, Angola
2 Neurosurgery Division, Hospital Das Clinicas da Faculdade de Medicina da USP, São Paulo, Brazil

Correspondence Address:
Adilson J M de Oliveira,
Alameda Santos, 663, Ap 34B, São Paulo

Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.294549

  Abstract 


Background: Idiopathic intracranial hypertension is an uncommon intracranial disorder in which intracranial pressure is increased without radiological evidence of lesions. Surgery is indicated when severe optic neuropathy is present or medical treatment fails.
Objective: To assess the comparative effectiveness of lumboperitoneal (LPS) and ventriculoperitoneal shunt (VPS) with neuronavigation.
Subjects and Methods: A retrospective study was performed based on our database. We analyzed demographics, pre and postoperative parameters, and follow-up data on patients who had undergone either LPS or VPS between January 2007 and December 2017.
Results: Group I consisted of 17 VPS patients, of which 16 were female, and group II consisted of 29 LPS patients, of which 26 were female. The number of surgeries performed in the LPS group was higher (due to recurrence) than that in the VPS group. Moreover, the rate of complications was higher in the LPS group.
Conclusions: VPS is safer and has a lower rate of complications and reinterventions compared to LPS.


Keywords: Idiopathic intracranial hypertension, lumboperitoneal shunt, neuronavigation, pseudotumor cerebri, ventricle-peritoneal shunt
Key Message: In this retrospective series, we show that neuronavigation is effective in improving the results of ventricular puncture and that it is cost beneficial; therefore, we recommend its use. Although there was no statistical significance in the number of complications between the two groups, we believe that VPS assisted by neuronavigation is a better choice than LPS, especially during reoperation. LPS showed to be superior in first surgeries being effective and with good cost-benefit so perhaps it should pass the first choice in these circumstances.



How to cite this URL:
M de Oliveira AJ, G Pinto FC, Teixeira MJ. Comparative Study of the Effectiveness of Lumboperitoneal and Ventriculoperitoneal Shunting with Neuronavigation in the Treatment of Idiopathic Intracranial Hypertension. Neurol India [Epub ahead of print] [cited 2020 Sep 18]. Available from: http://www.neurologyindia.com/preprintarticle.asp?id=294549




Idiopathic intracranial hypertension (IIH) is a disorder characterized by increased intracranial pressure with its associated signs and symptoms (mainly headache and visual loss) in alert and oriented patients with no lesions detected after neuroimaging and normal cerebrospinal fluid (CSF) analysis findings except for increased open pressure.[1]

The general incidence of IIH is 0.9 per 100, 000 inhabitants/year, and is higher in young females (15–44 years old) who have an incidence of 3 per 100, 000 inhabitants/year.[2]

The initial treatment of choice for IIH is conservative and includes weight loss and conservative treatment. Advanced cases with significant visual loss and/or progressive IIH may be refractory to conservative measures alone, with the drugs of choice in such cases being acetazolamide or topiramate. Such advanced cases occur in 10% to 20% of IIH patients and, if left untreated, may progress at highly variable rates (weeks–years) to permanent blindness via optic nerve atrophy. Therefore, timely referral to surgical subspecialists is recommended in the case of advanced IIH cases.[3]

Modern surgical treatments typically involve the placement of lumboperitoneal (LP), or ventriculoperitoneal (VP) shunts.[3],[4]

However, treatment of IIH using VP or LP shunts has been consistently associated with significant complication rates, which are more frequently related to proximal catheter infection and the need for frequent revision.[4]

Neuronavigation has been shown to improve the results of VP shunt in IIH by reducing the need for revisions due to wrong positioning of the proximal catheter.[5] The lumbar puncture (used in the LP shunt) is made blindly without the need for navigation systems.

There have been previous studies comparing both techniques with current recommendations indicating VPS as the preferred procedure but also recommending LP as an alternative,[5] some authors suggest that VPS has lower revision rates,[6] but there is no definition in the literature and it is important to publish the experience of large centers to help in future consensuses. In this study, we aimed to contribute to the current knowledge using a new series of cases comparing LP and VPS with neuronavigation, which has not been explored before by previous studies.


  Subjects and Methods Top


We obtained data from medical records of 46 patients who underwent VP and LP shunt between January 2007 and December 2017. All the patients included in the study satisfied the modified Dandy criteria,[1] listed below:

  1. Signs and symptoms of increased intracranial pressure
  2. Absence of localized findings on neurological examination
  3. Absence of deformity, displacement, or obstruction of the ventricular system in otherwise normal neurodiagnostic studies, except for evidence of increased cerebrospinal fluid pressure (greater than 200 mm water)
  4. Awake and alert
  5. No other cause of increased intracranial pressure present.


Patient demographics, neurological status, and ophthalmological examination at presentation and during hospitalization, as well as operative records, were examined to determine initial shunt placement and any following revisions. Patients operated by more than one surgeon were not separated during statistical analysis since the surgeons were found in the same center and formed a homogeneous group with a similar formation. The choice of diversion site BMI equal to or greater than 37 and the presence or suspected of Chiari syndrome and tonsillar ectopy were contraindicated to LPS, these patients always performed VPS, for all others the procedure of choice was LP as first procedure however sometimes the material was unavailable and in that case, it was done VPS.

The subjects were divided into two groups according to the initial procedure performed on them. Group I comprised 17 patients that had undergone VPS with neuronavigation as the initial procedure while group II comprised 29 patients who had undergone LPS as the initial procedure (conventionally LPS requires no navigation).

Inclusion criteria:

  • Adults patients with a diagnosis of IHH submitted to surgery
  • First surgical procedure VPS or LPS
  • The minimum period of follow-up 1 year.


Exclusion criteria:

  • The first surgical procedure other than VPS or LPS
  • The first surgical procedure in another hospital
  • VPS performed without navigation system
  • Lost to follow-up.


The minimum follow-up was 1 year (range 12 months to 60 months).

The differences between the two groups were compared using the Chi-square test. The variables in this study were the number of procedures (revision rates), hospitalization time, complications rates, and surgical and anesthetic time.

The patients cross over from one procedure to another, which depended on clinical conditions such as complication or failure of the shunt and other surgical complications, were identified.


  Results Top


A total of 46 patients were used as subjects. Group I comprised 17 patients that had undergone VPS with neuronavigation, 16 of whom were female. Group II comprised 29 patients that have undergone LPS, 26 of whom were female [Table 1]. In the LPS group, 4 patients (14%) underwent one procedure (no need for revision), 13 underwent two procedures (one revision), 3 underwent three procedures (two revisions), and 9 underwent four or more procedures (three or more revisions). In the VPS group 10 patients (59%) underwent one procedure (no need for revision), 4 underwent two procedures (one revision), 2 underwent three procedures (two revisions), and 1 underwent four or more procedures [Figure 1], [Figure 2], [Figure 3]. There was no statistically significant difference between the two groups (P = 0.85).
Table 1: Complications

Click here to view
Figure 1: Number of surgeries

Click here to view
Figure 2: Hospitalization time

Click here to view
Figure 3: Surgery time

Click here to view


Number values represent several patients.

Infection: ventriculitis or infection of any surgical site.

Wrong position: proximal or distal catheter poorly positioned on image examination.

Malfunction: hyper drainage or hypo drainage.


  Discussion Top


We reviewed a series of IIH cases to evaluate the efficacy complications of VPS with neuronavigation and LPS conducted in patients from January 2007 to December 2017.

We recruited a total of 46 patients, 27 of whom underwent LPS [Figure 4]a and [Figure 4]b while 17 underwent VPS with neuronavigation [Figure 5]a and [Figure 5]b. The number of reoperations was higher in LPS and the number of patients without reoperations was higher in VPS group (59% VPS and 14% LPS) but the rate of complication was similar between the two groups, at the in this study, the epidemiologic profile of the sample was similar to that of a previous study conducted in Sheffield, the UK that revealed a female/male proportion of 15/1.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] A study conducted in 1990 revealed a female/male proportion of 19/1.[2]
Figure 4: (a): Lumbar CT for surgical planning of LP shunting. (b): Well-positioned LP catheter (arrow)

Click here to view
Figure 5: (a) Head CT for surgical planning of VPS. (b) Well-positioned VPS catheter (arrow)

Click here to view


Surgical treatment is rarely necessary for IIH. The two main surgical options are VPS and LPS; however, they are often associated with complications mainly related to ventricular puncture difficulty for VPS. This has led to the need for means to guide the puncture process, in this case, neuronavigation, which improves the accuracy of the puncture, and thus reducing the complications. A previous series of cases with stereotactic placement reported that the rate of revision due to proximal malfunction was 2.9%, which is similar to our series.[10]

In currently the largest series comparing VPS and LPS, the revision rates were reported to be 3.7% and 7%, respectively.[11] An important factor that affected the results of this study was the greater training of the surgeons of this center in VPS than LPS, as well as the greater accuracy for identification and early resolution of complications in VPS. The same reason justifies the observed differences in the surgical time between the two procedures.[12] Although our study did not show a statistically significant difference between the two groups, we consider neuronavigation as important in improving the results and reducing the cost of hospitalization as demonstrate by previous retrospective studies.[5],[11]

Our results suggest that the choice of shunt procedure can change the patient's prognosis[13] and that VPS in our series was better. Other previous studies have suggested that the rates of complications in LPS are intolerable.[14],[20]

The main limitation of this study is that the patients were not randomized and that they were placed either group based on the preference of the surgeons, or in some cases, the availability of equipment.

From this study, we can see that LPS is suitable as an initial procedure; however, our results show that not an ideal choice in case of complications. Although several authors have shown that when adding ventricular puncture navigation or exteriotaxis systems, the performance of VPS was greatly improved, our results show that LPS is a more viable alternative with a greater chance of not having to reoperation.

We propose that LPS be used as an initial treatment after which VPS should be adopted in case of reoperations.[14],[19] This could be a new surgical approach model for IHH because some centers do VPS and other LPS but this combination of the two could optimize the results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abubaker K, Ali Z, Raza K, Bolger C, Rawluk D, O'Brien D. Idiopathic intracranial hypertension: Lumboperitoneal shunts versus ventriculoperitoneal shunts–case series and literature review. Br J Neurosurg 2011;25:94-9.  Back to cited text no. 1
    
2.
Abu-Serieh B, Ghassempour K, Duprez T, Raftopoulos C. Stereotactic ventriculoperitoneal shunting for refractory idiopathic intracranial hypertension. Neurosurgery 2007;60:1039-44.  Back to cited text no. 2
    
3.
Aoki N. Lumboperitoneal shunt: Clinical applications, complications, and comparison with ventriculoperitoneal shunt. Neurosurgery 1990;26:998-1004.  Back to cited text no. 3
    
4.
Burgett RA, Purvin VA, Kawasaki A. Lumboperitoneal shunting for pseudotumor cerebri. Neurology 1997;49:734-9.  Back to cited text no. 4
    
5.
Chumas PD, Kulkarni AV, Drake JM, Hoffman HJ, Humphreys RP, Rutka JT. Lumboperitoneal shunting: A retrospective study in the pediatric population. Neurosurgery 1993;32:376-83.  Back to cited text no. 5
    
6.
Eggenberger ER, Miller NR, Vitale S. Lumboperitoneal shunt for the treatment of pseudotumor cerebri. Neurology 1996;46:1524-30.  Back to cited text no. 6
    
7.
Kalyvas AV, Hughes M, Koutsarnakis C, Moris D, Liakos F, Sakas DE, et al. Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: A systematic review of the literature. Acta Neurochir (Wien) 2017;159:33-49.  Back to cited text no. 7
    
8.
Karabatsou K, Quigley G, Buxton N, Foy P, Mallucci C. Lumboperitoneal shunts: Are the complications acceptable? Acta Neurochir (Wien) 2004;146:1193-7.  Back to cited text no. 8
    
9.
Karsy M, Abou-Al-Shaar H, Bowers CA, Schmidt RH. Treatment of idiopathic intracranial hypertension via stereotactic placement of biventriculoperitoneal shunts. J Neurosurg 2018;130:136-44.  Back to cited text no. 9
    
10.
Maher CO, Garrity JA, Meyer FB. Refractory idiopathic intracranial hypertension treated with stereotactically planned ventriculoperitoneal shunt placement. Neurosurg Focus 2001;10:E1.  Back to cited text no. 10
    
11.
Markey KA, Mollan SP, Jensen RH, Sinclair AJ. Understanding idiopathic intracranial hypertension: Mechanisms, management, and future directions. Lancet Neurol 2016;15:78-91.  Back to cited text no. 11
    
12.
Menger RP, Connor DE, Thakur JD, Sonig A, Smith E, Guthikonda B, et al. A comparison of lumboperitoneal and ventriculoperitoneal shunting for idiopathic intracranial hypertension: An analysis of economic impact and complications using the Nationwide Inpatient Sample. Neurosurg Focus 2014;37:E4.  Back to cited text no. 12
    
13.
Mollan SP, Davies B, Silver NC, Shaw S, Mallucci CL, Wakerley BR, et al. Idiopathic intracranial hypertension: Consensus guidelines on management. J Neurol Neurosurg Psychiatry 2018;89:1088-100.  Back to cited text no. 13
    
14.
Radhakrishnan K, Ahlskog JE, Cross SA, Kurland LT, O'Fallon WM. Idiopathic intracranial hypertension (pseudotumor cerebri): Descriptive epidemiology in Rochester, Minn 1976 to 1990. Arch Neurol 1993;50:78-80.  Back to cited text no. 14
    
15.
Raoof N, Sharrack B, Pepper IM, Hickman SJ. The incidence and prevalence of idiopathic intracranial hypertension in Sheffield, UK. Eur J Neurol 2011;18:1266-8.  Back to cited text no. 15
    
16.
Satti SR, Leishangthem L, Chaudry MI. Meta-analysis of CSF diversion procedures and dural venous sinus stenting in the setting of medically refractory idiopathic intracranial hypertension. Am J Neuroradiol 2015;36:1899-904.  Back to cited text no. 16
    
17.
Tarnaris A, Williams MA. Idiopathic normal pressure hydrocephalus: Update and practical approach on diagnosis and management. Neurosurg Q 2011;21:72-81.  Back to cited text no. 17
    
18.
Wall M. Update on idiopathic intracranial hypertension. Neurol Clin 2017;35:45-57.  Back to cited text no. 18
    
19.
Yim B, Gooch MR, Dalfino JC, Adamo MA, Kenning TJ. Optimizing ventriculoperitoneal shunt placement in the treatment of idiopathic intracranial hypertension: An analysis of neuroendoscopy, frameless stereotaxy, and intraoperative CT. Neurosurg Focus 2016;40:E12.  Back to cited text no. 19
    
20.
Singh A, Vajpeyi IN. Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children. Neurol India 2013;61:513-6.  Back to cited text no. 20
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

Top
Print this article  Email this article
Previous Article    Next Article
Online since 20th March '04
Published by Wolters Kluwer - Medknow