Shunt options for normal pressure hydrocephalus: a comparison of complications, overdrainage rates and neurological outcomes between integra low flow regulated and Codman Hakim programmable shunts

Year 2024, , 261 - 266, 29.07.2024

Alper Türkkan , Ahmet Bekar

https://doi.org/10.38053/acmj.1494578

Abstract

Aims: Shunt surgery is the most commonly performed treatment for idiopathic normal pressure hydrocephalus, and shunt systems with different operating principles are employed. This study aimed to retrospectively compare programmable ventriculoperitoneal shunts and flow-regulated shunts in terms of complications, overdrainage rates, and neurological outcomes.
Methods: Between January 2020 and May 2022, 44 patients who underwent shunt operation with a diagnosis of idiopathic normal pressure hydrocephalus at our clinic were retrospectively analyzed. Patients were categorized into two groups: the programmable ventriculoperitoneal shunt and the flow-regulated shunt group. Demographic characteristics, complications, rates of insufficient drainage/overdrainage, and surgical outcomes were compared.
Results: There were 26 patients in the programmable ventriculoperitoneal shunt group and 18 patients in the flow-regulated shunt group. In the programmable ventriculoperitoneal shunt group, 14 patients (53.8%) required 27 shunt setting adjustments owing to excessive or inadequate drainage. Subdural effusion was observed in five patients (19.2%), and shunt revision was performed in one patient (3.8%). Subdural effusion was observed in two (11.1%) patients in the flow-regulated shunt group. One of these patients (5.5%) underwent shunt revision. There was no significant difference between the groups in terms of the development of subdural effusion and need for shunt revision (p>0.05). The rate of improvement in at least one of the symptoms was 53.8% in the programmable ventriculoperitoneal shunt group at the 1st-month postoperative outpatient follow-up. In the flow-regulated shunt group, this rate was 72.2% and there was no statistically significant difference. Both groups showed similar clinical improvement at the 1-year follow-up.
Conclusion: There was no difference between the groups in terms of neurological outcomes and the need for shunt revision. However, the use of flow-regulated shunts has demonstrated earlier rates of clinical improvement without the need for reprogramming.

Keywords

Idiopathic normal pressure hydrocephalus, Overdrainage, Flow-regulated valve, Programmable valve

Thanks

We thank Prof. Dr. Kazım Yiğitkanlı (Bursa Medicana Hospital, Neurosurgery Clinic, Turkey) for statistical analysis.

References

• Shprecher, David, Jason Schwalb, and Roger Kurlan. “Normal pressure hydrocephalus: diagnosis and treatment.” Curr Neurol Neurosci Rep. 2008;8(5):371-376.
• Salomón H, Raymond D. “The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure: observations on cerebrospinal fluid hydrodynamics.” J Neurol Sci. 1965;(24):307-327.
• Etsuro M. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir. 2012;52(11):775-809.
• Nakajima M, Yamada S, Miyajima M et al. Tap test can predict cognitive improvement in patients with iNPH-results from the multicenter prospective studies SINPHONI-1 and–2. Front Neurol. 2021;12:769216.
• Li Min. Efficacy and safety of programmable shunt valves for hydrocephalus: a meta-analysis. Int J Surg. 2017;44:139-146.
• Zemack G, Romner B. Seven years of clinical experience with the programmable Codman Hakim valve: a retrospective study of 583 patients. J Neurosurg. 2000;92(6):941-948.
• Xu H, Wang ZX, Liu F. Programmable shunt valves for the treatment of hydrocephalus: a systematic review. Eur J Paediatr Neurol. 2013;17(5):454-461.
• Ortler M, Kostron H, Felber S. Transcutaneous pressure-adjustable valves and magnetic resonance imaging: an ex vivo examination of the Codman-Medos programmable valve and the Sophy adjustable pressure valve. Neurosurgery. 1997;40(5): 1050-1058.
• Capitanio JF, Venier A, Mazzeo LA, et al. Prospective study to evaluate rate and frequency of perturbations of implanted programmable hakim codman valve after 1.5-Tesla magnetic resonance imaging. World Neurosurg. 2016;88:297-299.
• Strahle J, Selzer BJ, Muraszko KM, et al. Programmable shunt valve affected by exposure to a tablet computer. J Neurosurg Pediatr. 2012;10(2):118-120.
• Zuzak TJ, Balmer B, Schmidig D, et al. Magnetic toys: forbidden for pediatric patients with certain programmable shunt valves? Child’s Nervous System. 2009;5(2):161-164. https://doi.org/10.1007/s00381-008-0770-x
• Duplessis E, Decq P, Barat JL, et al. Treatment of chronic hydrocephalus in adults by flow-regulated shunt. Apropos of a series of 46 patients. Neurochirurgie. 1991;37(1):40-43
• Weiner HL, Constantini S, Cohen H, et al. Current treatment of normal-pressure hydrocephalus: comparison of flow-regulated and differential-pressure shunt valves. Neurosurgery. 1995;37(5): 877-884.
• Wetzel C, Goertz L, Noé P, et al. Flow-regulated versus differential pressure valves for idiopathic normal pressure hydrocephalus: comparison of overdrainage rates and neurological outcome. Acta Neurochir. 2020;62(1):15-21.
• Wetzel C, Goertz L, Schulte AP, et al. Minimizing overdrainage with flow-regulated valves - Initial results of a prospective study on idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg. 2018;173:31-37.
• Bozhkov Y, Roessler K, Hore N, et al. Neurological outcome and frequency of overdrainage in normal pressure hydrocephalus directly correlates with implanted ventriculo-peritoneal shunt valve type. Neurol Resul. 2017;39(7):601-605.
• Ziebell M, Wetterslev J, Tisell M et, al. Flow-regulated versus differential pressure-regulated shunt valves for adult patients with normal pressure hydrocephalus. Cochrane Database Syst Rev. 2013;5:1-21.
• Katiyar V, Sharma R, Tandon V, et al. Comparison of programmable and non-programmable shunts for normal pressure hydrocephalus: a meta-analysis and trial sequential analysis. Neurol India. 2021;69:399-405.
• Jain H, Sgouros S, Walsh AR et al. The treatment of infantile hydrocephalus: ‘differential-pressure’ or ‘flow-control’ valves. A pilot study. Childs Nerv Syst. 2000;16(4):242-246.
• Lund-Johansen M, Svendsen F, Wester K. Shunt failures and complications in adults as related to shunt type, diagnosis, and the experience of the surgeon. Neurosurgery. 1994;35(5):839-844.
• Feletti A, D’Avella D, Wikkelsø C et.al. Ventriculoperitoneal shunt complications in the european idiopathic normal pressure hydrocephalus multicenter study. Oper Neurosurg. 2019;17(1):97-101.
• Giordan E, Palandri G, Lanzino G, et al. Outcomes and complications of different surgical treatments for idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. J Neurosurg. 2018;131(4):1024-1036. https://doi.org/ 10.3171/2018.5.JNS1875
• Nakajima M, Yamada S, Miyajima M, et al. Guidelines for management of idiopathic normal pressure hydrocephalus (third edition): endorsed by the japanese society of normal pressure hydrocephalus. Neurol Med Chir. 2021;61(2):63-97.
• Klinge P, Hellström P, Tans J, et al. One-year outcome in the european multicentre study on iNPH. Acta Neurol Scand. 2012;126(3):145-153.
• Larsson A, Jensen C, Bilting M, et al. Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus? Acta Neurochir (Wien). 1992;117(1-2):15-22. https://doi.org/10.1007/BF01400629
• Farahmand D, Sæhle T, Eide PK, et al. A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus. J Neurosurg. 2016; 124(2):359-367.
• Nadel JL, Wilkinson DA, Linzey JR, et al. Thirty-day hospital readmission and surgical complication rates for shunting in normal pressure hydrocephalus: a large national database analysis. Neurosurgery. 2020;86(6):843-850.
• Schenker P, Stieglitz LH, Sick B, et al. Patients with a normal pressure hydrocephalus shunt have fewer complications than do patients with other shunts. World Neurosurg. 2018;110: 249-e257.
• Scholz R, Lemcke J, Meier U, et al. Efficacy and safety of programmable compared with fixed anti-siphon devices for treating idiopathic normal-pressure hydrocephalus (iNPH) in adults - SYGRAVA: study protocol for a randomized trial. Trials. 2018;19(1):566-576.