A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus

Farahmand, Dan; Sæhle, Terje; Eide, Per Kristian; Tisell, Magnus; Hellström, Per; Wikkelsø, Carsten

doi:10.3171/2015.1.jns141301

Cited by 21 publications

(20 citation statements)

References 28 publications

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“…Of note, this latter group also improved after opening the shunts, although with less benefit (28 and 18%, respectively) [39].This rate of benefit is in line with the results of a systematic review, which reported a long-term response of 29% [40]. A double-blind randomized trial on the clinical effect of different shunt valve settings was also performed [41]; improvement after shunt surgery was evident within 3 months, irrespective of valve setting.…”

Section: Managementsupporting

confidence: 79%

Clinical and Cognitive Features of Idiopathic Normal Pressure Hydrocephalus

Sinforiani¹,

Pacchetti²,

Picascia³

et al. 2018

Hydrocephalus - Water on the Brain

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Introduction: Idiopathic normal pressure hydrocephalus (iNPH) is characterized by dilated cerebral ventricles with progressive impaired gait, cognition, and urinary control. Firstly described in 1965 by Hakim and Adam, it remains largely under-diagnosed. The diagnosis is based on clinical and imaging (CT or MRI) investigations; a timely diagnosis and cerebrospinal fluid (CSF) shunt surgery has reported to be beneficial in 60 up to 80% of the cases. Body: The severity of motor and cognitive disturbances varies widely and it can be difficult to distinguish iNPH from other neurodegenerative disorders. The cognitive and behavioral disturbances have been commonly described as "fronto-subcortical dysfunction". However, this definition is reductive not encompassing the entire cognitive spectrum of iNPH deficits. In our sample we found an impairment in respect to healthy controls in all the neuropsychological tests, but verbal memory. We could also find a positive correlation between the severity of cognition deficit and disease progression, suggesting a common pathological mechanism. Conclusions: iNPH can be reliably diagnosed with an organized approach. Neurologists play an essential role in the care of patients and a multidisciplinary team can improve this process. An early shunt surgery might contain the progression of the disturbances and also possibly prevent their development.

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Section: Managementsupporting

confidence: 79%

Clinical and Cognitive Features of Idiopathic Normal Pressure Hydrocephalus

Sinforiani¹,

Pacchetti²,

Picascia³

et al. 2018

Hydrocephalus - Water on the Brain

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“…However in a previous study where participants had low MMSE of 18 at baseline there was also no improvement in cognition after shunt placement [ 14 ]. This raises the possibility of MMSE not being a sensitive measure and perhaps more detailed cognitive testing should be performed similar to a small study of 37 participants [ 18 ] and another clinical trial of 68 participants [ 38 ] where a larger neuropsychological battery was able to capture differences. Additionally, the relatively short follow-up time (104 days) may not be sufficient to capture changes in clinical outcome measures.…”

Section: Discussionmentioning

confidence: 99%

Alzheimer’s disease pathology and shunt surgery outcome in normal pressure hydrocephalus

Yaşar

Jusué-Torres²,

et al. 2017

PLoS ONE

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We aimed to determine whether presence of AD neuropathology predicted cognitive, gait and balance measures in patients with idiopathic normal pressure hydrocephalus (iNPH) after shunt surgery. This is a prospective study of gait and balance measured by Timed Up and Go (TUG) and Tinetti tests, and cognitive function measured by Mini Mental Status Exam (MMSE), before and after shunt surgery in participants 65 years and older with iNPH at the Johns Hopkins University. Random effects models were used and adjusted for confounders. 88 participants were included in the analysis with a median (IQR) time of 104 (57–213) days between surgery and follow-up. 23 (25%) participants had neuritic plaques present (NP+) and were significantly older [76.4 (6.0) years], but were otherwise similar in all demographics and outcome measures, when compared to the group without neuritic plaques (NP-). NP- and NP+ participants equally improved on measures of TUG (β = -3.27, 95% CI -6.24, -0.30, p = 0.03; β = -2.37, 95% CI -3.90, -0.86, p = 0.02, respectively), Tinetti-total (β = 1.95, 95% CI 1.11, 2.78, p<0.001; β = 1.72, 95% CI 0.90, 2.53, p<0.001, respectively), -balance (β = 0.81, 95% CI 0.23, 1.38, p = 0.006; β = 0.87, 95% CI 0.40, 1.34, p<0.001, respectively) and -gait (β = 1.03, 95% CI 0.61, 1.45, p<0.001; β = 0.84, 95% CI 0.16, 1.53, p = 0.02, respectively), while neither NP- nor NP+ showed significant improvement on MMSE (β = 0.10, 95% CI -0.27, 0.46, p = 0.61, β = 0.41, 95% CI -0.27, 1.09, p = 0.24, respectively). In summary, 26% of participants with iNPH had coexisting AD pathology, which does not significantly influence the clinical response to shunt surgery.

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“…8 They observed that programmable pressure valves were associated with fewer revision surgeries at 1 year; however, this effect was only substantiated in patients younger than 18 years. In that report, only 3 of the 11 studies evaluated included adult patients 6,7,14 and only one of the studies included adult hydrocephalus etiologies other than NPH. 14 A prospective study by Farahmand et al reported that nonprogrammable pressure valves were a risk factor for shunt revision within 6 months of initial implantation with an HR of 1.86 (95% CI 1.18-2.93).…”

Section: Discussionmentioning

confidence: 99%

Comparative durability and costs analysis of ventricular shunts

Agarwal

Kashkoush

McDowell

et al. 2019

Journal of Neurosurgery

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OBJECTIVEVentricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type—fixed versus programmable—on shunt durability and cost for placement of shunts in adult patients.METHODSThe authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.RESULTSA total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6–1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938–$3876) and $1504 (interquartile range $753–$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2–3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2–2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.CONCLUSIONSLong-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.

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A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus

Cited by 21 publications

References 28 publications

Clinical and Cognitive Features of Idiopathic Normal Pressure Hydrocephalus

Clinical and Cognitive Features of Idiopathic Normal Pressure Hydrocephalus

Alzheimer’s disease pathology and shunt surgery outcome in normal pressure hydrocephalus

Comparative durability and costs analysis of ventricular shunts

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