Claudia Craven

Idiopathic intracranial hypertension: 120-day clinical, radiological, and manometric outcomes after stent insertion into the dural venous sinus

OBJECTIVE Idiopathic intracranial hypertension (IIH) is commonly associated with venous sinus stenosis. In recent years, transvenous dural venous sinus stent (DVSS) insertion has emerged as a potential therapy for resistant cases. However, there remains considerable uncertainty over the safety and efficacy of this procedure, in particular the incidence of intraprocedural and delayed complications and in the longevity of sinus patency, pressure gradient obliteration, and therapeutic clinical outcome. The aim of this study was to determine clinical, radiological, and manometric outcomes at 3-4 months after DVSS in this treated IIH cohort. METHODS Clinical, radiographic, and manometric data before and 3-4 months after DVSS were reviewed in this single-center case series. All venographic and manometric procedures were performed under local anesthesia with the patient supine. RESULTS Forty-one patients underwent DVSS venography/manometry within 120 days. Sinus pressure reduction of between 11 and 15 mm Hg was achieved 3-4 months after DVSS compared with pre-stent baseline, regardless of whether the procedure was primary or secondary (after shunt surgery). Radiographic obliteration of anatomical stenosis correlating with reduction in pressure gradients was observed. The complication rate after DVSS was 4.9% and stent survival was 87.8% at 120 days. At least 20% of patients developed restenosis following DVSS and only 63.3% demonstrated an improvement or resolution of papilledema. CONCLUSIONS Reduced venous sinus pressures were observed at 120 days after the procedure. DVSS showed lower complication rates than shunts, but the clinical outcome data were less convincing. To definitively compare the outcomes between DVSS and shunts in IIH, a randomized prospective study is needed.

DESH negative normal pressure hydrocephalus: can patients still benefit from shunt insertion?

Selecting probable idiopathic normal pressure hydrocephalus (INPH) patients for shunt insertion presents a challenge because of coexisting comorbidities and other conditions that could mimic NPH. The characteristic appearance of DESH (Disproportionately Enlarged Subarachnoid Space Hydrocephalus) on brain imaging has been shown to have a high positive predictive value in identifying shunt responsive INPH patients (SINPHONI trial). However, the negative predictive value of this radiological sign was not clearly demonstrated.

Three-hundred cases of Spiegelberg ICP monitoring for hydrocephalus and CSF disorders: the Queen Square experience

Results ICPM was undertaken for a number of different conditions including undiagnosed headache (20.4%), IIH (28.7%), NPH (5.3%), high-pressure hydrocephalus (eg congenital/ post-traumatic/post-SAH) (17.2%) and Chiari malformations/syringomyelia (13.6%). Indications for ICPM included headache (74.0%), visual disturbance (6.2%), gait disturbance (6.2%) and cognitive disturbance (5.0%). Mean monitoring time was 37.3 hrs (range 12-154 hrs). Monitoring was conducted in the presence of a CSF shunt (50.6%), venous stent (3.7%) and previous cranial decompression (6.5%). Dynamic monitoring (eg with different shunt settings or pre/post venous stent insertion) was undertaken in 12.4%. Outcomes from ICPM included insertion of new CSF shunt (21.0%), revision of CSF shunt (13.0%), insertion of venous stent (6.5%), insertion of and lumbar drains for infusion studies (3.6%); importantly, non-operative treatment was pursued in a number of cases including shunt valve adjustment (7.7%) and conservative management (29.9%). Complications included superficial infection (4 patients, 1.2%), symptomatic intracerebral haematoma (1 patient, 0.3%) and misplacement (3 patients, 0.9%); importantly, there were no cases of deep intracranial infection and the only case of seizures was in the patient with the intracerebral haematoma. Conclusion This is the largest known series of ICPM for CSF disorders. It shows that ICP monitoring is a safe procedure and may be undertaken as part of routine protocol in the management of complex hydrocephalus patients. The number of cases that were subsequently managed conservatively or with a simple valve adjustment (37.6%) indicates the utility in terms of reducing operative interventions. Further evaluation of positive and negative predictive values based on the results of ICP monitoring and health-economic analyses will push the case for routine ICP monitoring prior to definitive management of all hydrocephalus patients.

The predictive value of DESH for shunt responsiveness in idiopathic normal pressure hydrocephalus

OBJECTIVE Selecting probable idiopathic normal pressure hydrocephalus (INPH) patients for shunt insertion presents a challenge because of coexisting comorbidities and other conditions that could mimic NPH. The characteristic appearance of DESH (Disproportionately Enlarged Subarachnoid Space Hydrocephalus) on brain imaging has been shown to have a high positive predictive value in identifying shunt responsive INPH patients (SINPHONI trial). However, the negative predictive value of this radiological sign was not clearly demonstrated. The aim of the present study was to calculate the negative predictive value of the DESH sign. METHODS A single centre study of probable INPH patients, who underwent ventriculoperitoneal (VP) shunt insertion. Shunt responsive INPH patients were identified as those having improvement in their walking speed, neuropsychological assessment and continence one year post operatively. Preoperative images were reviewed for DESH sign. Negative and Positive Predictive Values (NPV and PPV) of DESH sign were determined post analysis. RESULTS A total of 103 probable INPH patients were included (31 were DESH positive (30%) and 72 were DESH negative (70%)). A total of 78 patients showed measurable improvement one year post shunt insertion (76%); 24 (31%) of these patients were DESH positive and 54 (69%) were DESH negative (p=<0.001). Therefore, the DESH sign had an estimated PPV of 77% and NPV of 25%. CONCLUSION DESH sign demonstrates a low negative predictive value. We conclude that DESH negative patients should still undergo prognostic tests for iNPH, such as an extended lumbar drainage protocol, and should not be excluded from shunt insertion.

Venous sinus stenting immediately reduces intracranial pressure in Idiopathic Intracranial Hypertension patients with venous sinus stenosis

Idiopathic Intracranial Hypertension (IIH) is characterised by an increased intracranial pressure (ICP) in the absence of any central nervous system disease or structural abnormality, and normal CSF composition. Management becomes complicated once surgical intervention is required. Venous sinus stenosis has been suggested as a possible aetiology for IIH. Venous sinus stenting has emerged as a possible interventional option. Evidence for venous sinus stenting is based on elimination of the venous pressure gradient and clinical response. There have been no studies demonstrating the immediate effect of venous stenting on ICP.

The predictive value of T-tau and AB1-42 levels in idiopathic normal pressure hydrocephalus

BackgroundIdiopathic normal pressure hydrocephalus (INPH) has no reliable biomarker to assist in the selection of patients who could benefit from ventriculo-peritoneal (VP) shunt insertion. The neurodegenerative markers T-tau and Aβ1-42 have been found to successfully differentiate between Alzheimer’s disease (AD) and INPH and therefore are candidate biomarkers for prognosis and shunt response in INPH. The aim of this study was to test the predictive value of cerebrospinal fluid (CSF) T-tau and Aβ1-42 for shunt responsiveness. In particular, we pay attention to the subset of INPH patients with raised T-tau, who are often expected to be poor surgical candidates.MethodsSingle-centre retrospective analysis of probable INPH patients with CSF samples collected from 2006 to 2016. Index test: CSF levels of T-tau and Aβ1-42. Reference standard: postoperative outcome. ROC analysis assessed the predictive value.ResultsA total of 144 CSF samples from INPH patients were analysed. Lumbar T-tau was a good predictor of post-operative mobility (AUROC 0.80). The majority of patients with a co-existing neurodegenerative disease responded well, including those with high T-tau levels.ConclusionINPH patients tended to exhibit low levels of CSF T-tau, and this can be a good predictor outcome. However levels are highly variable between individuals. Raised T-tau and being shunt-responsive are not mutually exclusive, and such patients ought not necessarily be excluded from having a VP shunt. A combined panel of markers may be a more specific method for aiding selection of patients for VP shunt insertion. This is the most comprehensive presentation of CSF samples from INPH patients to date, thus providing further reference values to the current literature.

Case series of ventriculopleural shunts in adults: a single-center experience

OBJECTIVE The peritoneal cavity is widely used as the destination of choice for cerebrospinal fluid shunts. Various alternative sites have been used, particularly in the presence of certain contraindications. The pleural cavity has been used; however, a paucity of evidence details ventriculopleural (VPL) shunt survival, complication, and revision rates in adults. The aim of this study was to present a single centers experience with VPL shunts, identifying complication, revision, and survival rates. METHODS A single-center, retrospective case series analysis was conducted for VPL shunt insertions and revisions over a period of 5 years. Demographic as well as clinical data were collected. Ventriculopleural shunt survival was assessed using Kaplan-Meier curves and the log rank (Cox-Mantel) test. RESULTS Twenty-two VPL shunts were inserted in 19 patients. Median survival of the VPL shunts was 14 months. Pathological indication for the VPL shunt did not significantly affect survival. A total of 10 complications was observed: 2 infections, 2 cases of overdrainage, 2 obstructions, 1 distal catheter retraction, 2 symptomatic pleural effusions, and 1 asymptomatic pleural effusion. CONCLUSIONS Ventriculopleural shunting is a safe and viable second-line procedure for cases in which ventriculoperitoneal shunts are unsuitable. While VPL shunts have a high revision rate, their complication rate is comparable to that of VP shunts. Ventriculopleural shunt survival can be improved by careful patient selection and the implementation of a combination of valves with antisiphon devices.

Comorbidites in NPH - local introspective - ‘Shunt them all’!.

In response to the 2013 ISH-CSF task force review on comorbidities in NPH we assessed 73 patients who were diagnosed with NPH and underwent shunt surgery at our tertiary neurosurgical unit between August 2008 and August 2012.

Intracranial pressure and venous sinus pressure gradients: what happens 3 months after stenting?

Benign Intracranial hypertension (BIH) is commonly associated with venous sinus stenosis. Increasingly, this is treated endovascularly with stent insertion. However, this treatment modality is still controversial. Clinical improvement post stent insertion has been described. Little is known about long-term control of intracranial pressure (ICP). In our unit, catheter cerebral venogram with pressure measurements is routinely performed 3 months post stent insertion in BIH patients. We aim to quantify the degree of venous pressure changes in stenosis patients treated with sinus stenting and how the changes correlate with radiographic improvements.

Superficial and Deep Skin Preparation with Povidone-Iodine for Ventriculoperitoneal Shunt Surgery : A Technical Note

Objective Ventriculoperitoneal (VP) shunt surgery is a common and effective treatment for hydrocephalus and cerebrospinal fluid disorders. Infection remains a major cause of morbidity and mortality after a VP shunt. There is evidence that a deep skin flora microbiome may have a role to play in post-operative infections. In this technical note, we present a skin preparation technique that addresses the issue of the skin flora beyond the initial incision. Methods The patient is initially prepped, as standard, with. a single layer of 2% CHG+70% isopropyl alcohol. The novel stage is the ‘double incision’ whereby an initial superficial incision receives a further application of povidone-iodine prior to completing the full depth incision. Results Of the 84 shunts inserted using the double-incision method (September 2015 to September 2016), only one developed a shunt infection. Conclusion The double incision approach to skin preparation is a unique operative stage in VP shunt surgery that may have a role to play in reducing acute shunt infection.