Cerebrospinal Fluid Shunting for Idiopathic Intracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol

Abstract

BACKGROUND: Cerebrospinal fluid (CSF) shunting is widely used in refractory idiopathic intracranial hypotension (IIH). Although multiple reviews have assessed its efficacy compared with other surgical treatments, there is no detailed analysis that evaluates the clinical outcomes after CSF shunting. OBJECTIVE: To conduct a meta-analysis of the clinical impact of CSF shunting for refractory IIH and use this in conjunction with existing information on other treatment modalities to develop a modern management protocol. METHODS: PubMed and Embase were systematically searched for studies describing CSF shunting for medically refractory IIH. Relevant information including study characteristics, patient demographics, clinical outcomes, periprocedural complications, and long-term outcomes were subjected to meta-analysis. RESULTS: Fifteen studies published between 1988 and 2019 met our inclusion and exclusion criteria, providing 372 patients for analysis. The mean age was 31.2 years (range 0.5-71) with 83.6% being female. The average follow-up was 33.9 months (range 0-278 months). The overall rate of improvement in headache, papilledema, and visual impairment was 91% (95% CI 84%-97%), 96% (95% CI 85%-100%), and 85% (95% CI 72%-95%), respectively. Of 372 patients, 155 had 436 revisions; the overall revision rate was 42% (95% CI 26%-59%). There was no significant correlation between average follow-up duration and revision rates in studies (P = .627). Periprocedural low-pressure headaches were noted in 74 patients (20%; 95% CI 11%-32%). CONCLUSION: CSF shunting for IIH is associated with significant improvement in clinical symptoms. Shunting rarely causes periprocedural complications except overdrainagerelated low-pressure headache. However, CSF shunting has a relatively high revision rate.

Literature Commentary

“…Many conditions in neuro-ophthalmology are uncommon, so a meta-analysis may help increase the sample size and statistical power to determine a treatment effect, but meta-analysis is subject to publication bias and limited by the heterogeneity and quality of published studies (4). I invite you to read the meta-analyses of stenting, optic nerve sheath fenestration, stenting, and bariatric surgery that are based on the published literature (5–8). Take a look at the denominators in the tables—you may be surprised by the relatively small numbers of patients compared with the number of procedures performed, with only 2 randomized trials.…”

Cerebrospinal Fluid Shunting for IdiopathicIntracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol: Corrigendum

“…In the article appearing in volume 91, pages 529-540 of Neurosurgery , entitled “Cerebrospinal Fluid Shunting for Idiopathic Intracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol,” there was an error. 1…”

Letter: Cerebrospinal Fluid Shunting for Idiopathic Intracranial Hypertension: A Systematic Review, Meta-Analysis, and Implications for a Modern Management Protocol

“…Salih et al 1 recently published a meta-analysis on cerebrospinal fluid (CSF) shunting in idiopathic intracranial hypertension (IIH). This publication among others 2 is important in highlighting the lack of detail provided in common data points and the need for uniformity in reporting outcome measures when assessing the success of any intervention.…”

“…We are encouraged by the reducing complication rate reported. 1 This too has been our local experience which we believe is due to a dedicated CSF shunt pathway, CSF specialist surgeons, and a standardized protocol: where there is a preference for a frontal ventriculoperitoneal shunt, use of adjustable gravitational valves, an implantable ICP monitoring device in line with the shunt to optimize CSF drainage and identify possible future malfunction, frameless stereotactic image guidance for insertion of the ventricular catheter, and laparoscopic placement of the peritoneal end in patients with high body mass index. 9,10 Horizon scanning in IIH reveals an avenue where the need for surgical intervention could be reduced.…”