British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20

Ventriculo-peritoneal shunting is a safe and

effective treatment for idiopathic intracranial
hypertension

Anna Bjornson, Ian Tapply, Eva Nabbanja, Afrodite-Despina Lalou, Marek

Czosnyka, Zofia Czosnyka, Brinda Muthusamy & Matthew Garnett

To cite this article: Anna Bjornson, Ian Tapply, Eva Nabbanja, Afrodite-Despina Lalou, Marek
Czosnyka, Zofia Czosnyka, Brinda Muthusamy & Matthew Garnett (2019): Ventriculo-peritoneal
shunting is a safe and effective treatment for idiopathic intracranial hypertension, British Journal of
Neurosurgery, DOI: 10.1080/02688697.2018.1538478

To link to this article: https://doi.org/10.1080/02688697.2018.1538478

Published online: 17 Jan 2019.

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BRITISH JOURNAL OF NEUROSURGERY
https://doi.org/10.1080/02688697.2018.1538478

ARTICLE

Ventriculo-peritoneal shunting is a safe and effective treatment for idiopathic

intracranial hypertension
Anna Bjornsona, Ian Tapplyb, Eva Nabbanjaa, Afrodite-Despina Lalouc, Marek Czosnykac, Zofia Czosnykac,
Brinda Muthusamyb and Matthew Garnetta
a
Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; bDepartment of Ophthalmology,
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; cBrain Physics Laboratory, Division of Neurosurgery, Department of
Clinical Neurosciences, Addenbrookes Hospital, Cambridge University, Cambridge, UK

ABSTRACT ARTICLE HISTORY

Purpose: To determine the outcome of ventriculo-peritoneal shunts as a treatment for idiopathic intracra- Received 2 November 2017
nial hypertension (IIH) Revised 21 June 2018
Materials and Methods: Retrospective case series of 28 patients with IIH and evidence of raised intracra- Accepted 15 October 2018
nial pressure (ICP) who underwent shunt insertion. Patients were identified from a prospectively updated
KEYWORDS
operative database. A case-notes review was performed and data on type of shunt, pre- and post-opera- Idiopathic intracranial
tive symptoms, ophthalmological findings and post-operative complications were recorded. hypertension; Ventriculo-
Results: All patients had symptoms of IIH that had failed medical management. Twelve patients had pre- peritoneal shunt; Orbis
vious lumbo-peritoneal shunts and 2 patients had previous venous sinus stents. All patients had evidence sigma valve
of raised ICP as papilloedema and raised CSF pressure on lumbar puncture. Twenty-seven patients
received a ventriculo-peritoneal shunt and 1 patient a ventriculo-atrial shunt. Twenty-six patients received
Orbis Sigma Valves and 2 patients Strata valves. At follow-up all patients (100%) had improvement/reso-
lution of papilloedema, 93% had improved visual acuity and 84% had improved headaches. Mean time to
last follow-up was 15 (range 4–96) months. Complications occurred in 3 patients (11%): 2 patients
required revision of their peritoneal catheters and 1 patient had an anti-siphon device inserted.
Conclusions: Previous literature reported a ventricular shunt revision rate of 22–42% in the management
of IIH. We demonstrate ventriculo-peritoneal shunts to be an effective treatment with a revision rate of
11% compared to the previously reported 22–42%.

GRAPHICAL ABSTRACT

28 patients

27 VP shunt 1 VA shunt

Symptomatic Ophthalmological
Surgical Outcomes
outcomes outcomes

• Papilloedema- 100%
• Headache- 84% improved/stable
improved • Visual acuity - 93% • 2 patients- revision
• Tinnitus - 80 % improved/stable peritonealcatheter
improved • Visual fields - 100% • 1 patient- anti-siphon
• Vision - 93% subjective improved/stable device inserted
improvement • Colour vision - 100%
improved/stable

CONTACT Anna Bjornson abjornson@nhs.net Department of Neurosurgery, Box 166, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation
Trust, Hills Rd, Cambridge, CB2 0QQ, UK.
ß 2019 The Neurosurgical Foundation
2 A. BJORNSON ET AL.
Background
Idiopathic intracranial hypertension (IIH), also known as pseudo-
tumour cerebri or benign intracranial hypertension, is a condi-
tion defined by raised intracranial pressure with no evidence of
intracranial pathology or other identifiable cause.1,2 The aetiology
is not fully understood, however risk factors include female sex,
obesity, endocrine disturbance and high levels of vitamin A.1–4
Patients present with symptoms of raised intracranial pressure:
chronic headaches, visual disturbances, tinnitus and changes in
cognition. If left untreated, IIH can progress to blindness.1
Examination will reveal papilloedema with or without 6th cranial
nerve palsy and loss of visual function. Imaging and cerebro-
spinal fluid (CSF) analysis is unremarkable except for signs of
raised intracranial pressure.1,3 The modified Dandy criteria can
be used for diagnosis (Figure 1).2,3
Treatment of IIH is aimed at reducing symptoms and pre-
venting loss of visual function. The majority of patients respond
to weight loss and medical management.1,4–6 However, for those
refractory to medical management or presenting with acute
vision loss, surgery can provide favourable outcomes.3–5
First line management of IIH includes weight loss in combin-
ation with acetazolomide or topirimate (carbonic anhydrase
inhibitors).3,4,6 These act on the choroid plexus to reduce CSF
production, with the additional side effect of appetite suppres-
sion.3 Studies have found a significant improvement in vision
and headaches following this treatment.4,5 Medications may be
tapered once CSF pressure has normalised and symptoms
have improved.
Surgical management of IIH includes optic nerve sheath
decompression (ONSD), CSF diversion and venous sinus stent-
ing.1,3,6 There remains much discussion over the most effective
surgical treatment, however ONSD is usually reserved for
patients presenting with acute severe vision loss,1 and cerebral
venous stenting for patients with evidence of venous sinus sten-
osis on imaging.3,4
CSF diversion by ventriculoperitoneal (VP) shunting or lum-
bar-peritoneal shunting can be used to reduce intracranial pres-
sure and improve headaches, vision and papilloedema. Lumbar
shunts have traditionally been preferred in the setting of IIH due
to the small sized ventricles, however numerous case series have
demonstrated similar or more favourable clinical outcomes
(improvement in symptoms and vision) and lower revision rate
with VP shunts in comparison.4,5 In addition, image guidance
has improved ventricular catheter placement (Figure 2).7
Nevertheless, there have been many case series demonstrating
a significant rate of shunt failure and complications with VP
shunts. Three comprehensive reviews have shown revision rates
of 22–60% for VP shunts.1,4,5
Modified Dandy Criteria for Idiopathic Intracranial Hypertension
Signs and symptoms of raised intracranial pressure
No focal neurological findings except 6th cranial nerve palsy
Evidence of raised CSF pressure of >25cm H20
No other cause for raised pressure identified on neuroimaging
Normal CSF composition
Figure 1. Modified Dandy Criteria. All patient in the study met this criteria for diagnosis of IIH.
We present a case series of 28 patients with a good clinical
outcome and a much lower rate of complications than previously
recorded in the literature.
Methods
We carried out a retrospective case review of IIH patients who
had undergone ventricular shunt insertion. Patients were identi-
fied from a prospectively updated surgical database at a single
centre over a 7 year period (2009–2016). Operative and clinical
notes were examined.
In this series, all patients met the Modified Dandy criteria for
IIH with documented evidence of raised intracranial pressure (as
papilloedema and either lumbar puncture with opening pressure
>25 cm H2O, raised pressure on ICP monitoring (above 20 mm
Hg), or raised baseline pressure on CSF infusion studies). All
patients received cranial imaging to exclude alternative pathology
and normal CSF composition. All patients who were operated on
in the single centre within the 7 year period and met the criteria
were included in the study.
Demographic details including age, sex and weight were
recorded. If only available as a measurement in kilograms, weight
was converted into BMI based on average body height for age.
Pre-operative symptoms, examination findings and any previous
medical or surgical intervention were recorded. All patients had
ophthalmological review pre-operatively and at 4–6 month fol-
low-up, however this data was not available for some patients
due to follow-up occurring at their local general hospital. All
patients received neurosurgical follow-up at 4–6 months which
included an assessment of papilloedema. Date of operation, type
of shunt inserted, urgency of operation, use of image guidance
and length of time to final follow-up were recorded. Post-opera-
tive symptoms and ophthalmological findings were recorded.
Any intra-operative, post-operative or re-referrals for symptom
progression were documented.
Ophthalmological findings, including visual acuity, colour
vision and visual fields, were recorded. Pre- and post-operative
retinal nerve fibre thickness was measured by ocular coherence
tomography (OCT) in only 2 patients and was therefore not
included. Visual acuity was measured as Snellen acuity. For the
purposes of this study, the results were converted to LogMAR
acuity and a sample standard deviation formula was used to cal-
culate average improvement.
Results
A total of 28 patients were included in this study. Two were
male, 26 were female (92%). The average age was 29.3 years

Figure 2. CT imaging of a patient with idiopathic intracranial hypertension with a ventriculo-peritoneal shunt and Orbis Sigma Valve in situ.
(range 6–48 years). Average BMI was 33.6 kg/m2 (range
19.5–58 kg/m2).
Two patients were admitted as an emergency with severe vis-
ual deterioration. After confirmation of raised intracranial pres-
sure and cranial imaging they underwent emergency VP shunt
insertion. The remaining 26 patients were referred from other
services due to failed medical management of their symptoms.
This included topirimate, acetazolamide and/or serial lumbar
punctures. Twelve of the 28 patients had had previous surgical
intervention - 9 had previous lumbar pleural/peritoneal shunts, 1
venous sinus stenting, 1 lumbar shunt and venous sinus stenting,
and 1 lumbar shunt and ventriculoatrial shunt. These were
removed either due to complications or failure to control the
raised intracranial pressure.
Image guidance with electromagnetic (EM) navigation was
used in all patients and the procedure was performed by a con-
sultant neurosurgeon in all cases. Standard operating procedures
were used. The majority of patients (21/28) received an antibiotic
impregnated catheter, 3 patients had been recruited into the
BASICS trial8 and were randomised to an antibiotic impregnated
or silver-lined catheter, and 3 patients had no record of type of
catheter. Twenty-six patients received an Orbis Sigma valve and
2 patients received a programmable Strata valve. 1 patient
received a ventriculoatrial shunt due to issues with the pleural
and peritoneal cavities, the other patients received a ventriculo-
peritoneal shunt. Right frontal ventricular access was used in
twenty-seven of the patients and one patient received a parietal
ventricular catheter. (Table 1)
BRITISH JOURNAL OF NEUROSURGERY 3
Symptomatic outcomes
Pre-operative signs and symptoms were recorded in all patients
either in clinic review or on admission in the emergency cases
(Table 2). Papilloedema and visual changes were present in all
patients pre-operatively (100%). Visual changes were reported as
blurring of vision, visual obscurations, subjective decrease in acu-
ity, and diplopia. Twenty-six patients (91%) suffered from head-
aches and 10 (36%) from tinnitus. Two patients had a 6th cranial
nerve palsy.
Post-operatively, improvement or resolution of papilloedema
occurred in 100% of patients. Subjective improvement or reso-
lution of visual symptoms occurred in 93% - two patients had
ongoing visual symptoms in the form of reduced acuity. Tinnitus
improved in 80% and headaches in 84%. Both patients with 6th
nerve palsies found their deficit resolved. The symptomatic
improvements were all self-reported by the patients during their
neurosurgical clinic follow-up and the papilloedema and 6th
nerve palsies were assessed during the clinic by a Consultant
Neurosurgeon.
Ophthalmological outcomes
Ophthalmological examination data was available for 14 of the
28 patients (Table 3). The remaining 14 were followed up in
their local hospital eye services.
Of the data available, outcomes including visual acuity, colour
vision and visual fields were reviewed. A significant change in
4 A. BJORNSON ET AL.

visual acuity was defined as a change of 3 lines or more on Discussion

Snellen assessment.9 Seven patients had improvement in their
visual acuity on assessment, and 6 remained stable. One patient
had slight deterioration in visual acuity of her left eye (a loss of 3
lines on the snellen chart). This patient had evidence of optic
atrophy and papilloedema preoperatively. Post-operatively the
papilloedema had resolved but the optic atrophy indicated dam-
age to the optic nerve which resulted in ongoing reduction in
visual acuity. Three patients had improvement in colour vision,
the remaining patients remained stable. Four patients had
improvement in their visual fields. The remaining patients had
stable visual fields.
LogMAR assessment demonstrated overall improvement in
visual acuity following shunt insertion (Table 4).
The visual symptoms and ophthalmological assessments pre-
and post-operatively are summarised in Table 5.
Surgical outcomes
All patients received follow up at 4–6 months. The mean time to
last follow up was 17 months (range 4–96 months).
Surgical complications intra-operatively or post-operatively
were reviewed (Table 6). No intra-operative complications
occurred. Two patients required revision procedures within the
early post-operative period (within 2 weeks), these were both to
re-site the peritoneal catheter. An additional patient was re-
referred 7 months post-operatively for over-drainage of the shunt
and an anti-siphon device was inserted. This gives a surgical
complication rate of 11%.
Table 1. Patient demographics and operative data.
Number of patients
Male/Female
Average age (yr)
Average weight (kg)
Previous surgical intervention
Operation: Emergency/Elective
Image guidance
Type of shunt
Peritoneal/atrial
Orbis sigma valve/strata valve
Frontal/parietal approach
The aim of treatment in IIH is to stabilise or improve visual
function and to manage symptoms related to raised intracra-
nial pressure.
This study demonstrates ventriculo-peritoneal shunting to be
an effective treatment. We have shown improvement in visual
function, papilloedema and symptoms including headache and
tinnitus in the majority of patients. These findings are similar to
previous studies published (Table 7), demonstrating that ven-
tricular shunting is effective in resolving symptoms and stabilis-
ing vision in the majority of patients.
It has previously been shown that ventricular shunting has a
relatively high complication rate and requires frequent revisions.
Reviews and case series have shown a revision rate for VP shunts
to be 11–71% (Table 7). The main complications identified
include infection, obstruction, migration of distal catheter, over-
drainage leading to low pressure headaches and chronic subdural
haematoma.7,10–20
We have demonstrated a lower complication or revision rate
compared to most previous research (Table 7).7,10–20 In our
patient group, 2 out of 28 (7%) required revision in the immedi-
ate post-op period, both due to catheter migration. In both cases
the operation notes demonstrate confidence that the catheter was
placed intra-peritoneal, however there is no imaging to confirm
this. It is possible that they were incorrectly placed intra-opera-
tively, or that post-operatively raised intra-abdominal pressure
secondary to obesity caused them to migrate into an extra-peri-
toneal location. One patient (3%) was referred back 7 months
later with symptoms of low pressure. An anti-siphon device was
inserted and the issue has now resolved.
We suggest several factors that may have contributed to a low
28 complication rate. Firstly, patients were only offered surgical
2/26 intervention if they had evidence of raised intracranial pressure
29.3 (þ/
23) with papilloedema and visual deterioration, and had failed all
87 (þ/
63) other medical management. Patients without evidence of papil-
12 (43%)
2/26 loedema and visual deterioration were not accepted for surgical
28 (100%) intervention. Operative intervention was not offered to manage
symptoms alone.
27/1 Secondly, all procedures were undertaken by a consultant
26/2
27/1 neurosurgeon using frameless EM guidance. A case series by
Herman et al which exclusively used EM navigation had a

Table 2. Pre-operative symptoms and improvement following ventriculoperitoneal shunt insertion.

Post-op improvement/ Percent improved/
Symptoms Pre-operatively resolution Post-op no change Post-op deterioration resolved
Headache 26 22 4 0 84
Tinnitus 8 6 2 0 80
6th CN palsy 2 2 0 0 100
Visual symptoms 28 26 2 1 93
Papilloedema 28 28 0 0 100

Table 3. Comparison of ophthalmological findings before shunt insertion and at last follow-up.
Examination finding Number improved Number remained stable Number deteriorated Improved/stabilised (%)
Visual acuity 7 6 1 93
Colour vision 3 4 0 100
Visual fields 4 5 0 100

Table 4. Average change in visual acuity at last follow-up after ventriculoperitoneal shunt insertion.
Pre-op visual acuity (mean LogMAR) Post-op visual acuity (mean LogMAR) Change in visual acuity (mean LogMAR)
Right eye 0.18 (SD 0.34) 0.07 (SD 0.33)
0.068 (SD 0.2)
Left eye 0.31 (SD 0.64) 0.08 (SD 0.27)
0.26 (SD 0.63)
 BRITISH JOURNAL OF NEUROSURGERY 5

Table 5. Pre-operative and post-operative visual symptoms and assessments for each patient (where available).
Pre-opertaive ophthalmological Post-opertaive ophthalmological
Patient Pre-operative visual symptoms assessment Post-operative visual symptoms assessment
1 Blurred vision Papilloedema Improved acuity Papilloedema resolved
Obscurations RVA - 6/9, LVA – CF Obscurations resolved RVA 6/6, LVA 6/6
R colour 13/14, L colour 6/14 R Colour 14/14, L colour 10/14
Bilateral enlarged blind spots Visual fields not recorded
2 Blurred vision Papilloedema Improved acuity Papilloedema resolved
Obscurations RVA 6/6, LVA 6/6 þ 2 Obscurations resolved RVA 6/5 þ 3, LVA 6/6 þ 2
R Colour 14/14, L colour 14/14 R colour 14/14, L colour 14/14
VF not recorded VF - left slight nasal defect
3 Blurred vision Papilloedema on assessment in clinic Improved acuity Papilloedema resolved on
Obscurations No formal ophthalmology assessment recorded Obscurations resolved assessment in clinic
No formal ophthalmology
assessment recorded
4 Blurred vision Papilloedema on assessment in clinic Visual acuity improved Papilloedema resolved on
No formal ophthalmology assessment assessment in clinic
recorded No formal ophthalmology
assessment recorded
5 Obscurations Papilloedema Obscurations resolved Papilloedema resolved on
Retro-orbital pain RVA 6/24 þ 1, LVA 6/24 Retro-orbital pain assessment in clinic
Tunnel vision Colour vision and VF not documented resolved No formal ophthalmology
Tunnel vision stable assessment recorded
6 Blurred vision Papilloedema Improved acuity Papilloedema resolved
Obscurations RVA 6/6, LVA CF Obscurations resolved RVA 6/5, LVA 6/38
R colour 10/14, L colour 0/14 R colour 10/14, L colour 1/10
VF not recorded VF not recorded
7 Blurred vision Papilloedema on assessment in clinic Improved acuity Papilloedema resolved on
Diplopia No formal ophthalmology assessment recorded Obscurations resolved assessment in clinic
No formal ophthalmology
assessment recorded
8 Obscurations Papilloedema Improved acuity Papilloedema resolved
Diplopia RVA 6/6, LVA 6/6 Obscurations resolved RVA 6/6, LVA 6/5 þ 2
R colour 13/14, Colour 12/14 R colour 14/14, L colour 14/14
VF - bilateral constriction VF normal
9 Obscurations Papilloedema Improved acuity Papilloedema improved
Retro-orbital pain RVA 6/9.5, LVA 6/7.5 Obscurations resolved RVA 6/5-3, LVA 6/6 þ 3
R colour 14/14, L colour 14/14 Retro-orbital pain resolved R colour 14/14, L colour 14/14
VF normal VF normal
10 Blurred vision Papilloedema Visual acuity subjectively stable Papilloedema resolved
RVA 6/5, LVA 6/5-3 RVA 6/4, LVA 6/9 þ 2
Colour vision not documented R colour 14/14, L colour 14/14
VF - enlarged blind spots VF - enlarged blind spots stable
11 Blurred vision Papilloedema Improved acuity Papilloedema resolved
Obscurations RVA 6/9, LVA 6/9 Obscurations resolved RVA 6/9, LVA 6/6
R colour 14/14, L colour 11/14 R colour 14/14, L colour 11/14
VF - R medial loss, L temporal loss VF - R medial loss, L temporal loss
12 Obscurations Papilloedema Visual acuity Papilloedema resolved
RVA 6/4, LVA 6/4 subjectively stable RVA 6/5, LVA 6/6
Colour vision not performed Obscurations resolved R colour 14/14, L colour 14/14
VF - bilateral enlarged blind spots VF - bilateral enlarged blind spots
13 Blurred vision Papilloedema Improved acuity Papilloedema resolved
Obscurations RVA 6/12, LVA 6/9.5 Obscurations resolved RVA 6/5, LVA 6/4-2
Colour vision not documented R colour 14/14, L colour 14/14
VF - bilateral constriction VF - normal
14 Obscurations Papilloedema Improved acuity Papilloedema resolved
Retro-orbital pain RVA 6/9 þ 2, LVA 6/9 Obscurations resolved RVA 6/5-2, LVA 6/5-1
R colour 14/14, L colour 14/14 Retro-orbital pain R colour 14/14, L colour 14/14
VF - enlarged blind spots, inferior resolved VF - Normal
scotomas
15 Blurred vision Papilloedema on assessment in clinic Visual acuity improved Papilloedema resolved on
No formal ophthalmology assessment recorded assessment in clinic
No formal ophthalmology
assessment recorded
16 Obscurations Papilloedema on assessment in clinic Obscurations resolved Papilloedema resolved on
No formal ophthalmology assessment recorded assessment in clinic
No formal ophthalmology
assessment recorded
17 Tunnel vision Papilloedema Tunnel vision improved Papilloedema resolved
Blurred vision RVA 6/5, LVA 6/18 Visual acuity improved RVA 6/6, LVA 6/9 þ 2
Colour vision not documented Colour vision not performed
VF- R moderate constriction, L severe constriction VF - R nasal defect, L restriction
18 Blurred vision Papilloedema Improved acuity Papilloedema resolved
Obscurations RVA 6/18, LVA 6/9 Obscurations resolved RVA 6/9, LVA 6/9
Colour vision not recorded R colour 12/14, L colour 14/14
VF not recorded VF - bilateral enlarged blind spots
(continued)
6 A. BJORNSON ET AL.

Table 5. Continued.
Pre-opertaive ophthalmological Post-opertaive ophthalmological
Patient Pre-operative visual symptoms assessment Post-operative visual symptoms assessment
19 Tunnel vision Papilloedema Tunnel vision stable Papilloedema resolved
Blurred vision RVA 6/4, LVA 6/4 Acuity improved RVA 6/4, LVA 6/4
Colour vision not documented R colour 14/14, L colour 14/14
VF normal VF normal
20 Visual change – Papilloedema on assessment in clinic Acuity stable Papilloedema resolved on
symptoms not No formal ophthalmology assessment recorded assessment in clinic
specified No formal ophthalmology
assessment recorded
21 Blurred vision Papilloedema on assessment in clinic Improved acuity Papilloedema resolved on
Obscurations No formal ophthalmology assessment recorded Obscurations resolved assessment in clinic
No formal ophthalmology
assessment recorded
22 Blurred vision Papilloedema Visual acuity improved Papilloedema resolved
RVA 6/60, LVA 6/6 RVA 6/60, LVA 6/5
Colour vision not documented Colour vision not documented
VF not recorded VF not documented
23 Diplopia Papilloedema on assessment in clinic Diplopia resolved Papilloedema resolved on
No formal ophthalmology assessment recorded assessment in clinic
No formal ophthalmology
assessment recorded
24 Visual change – Papilloedema on assessment in clinic Vision stable Papilloedema resolved on
symptoms not No formal ophthalmology assessment recorded Acuity normal assessment in clinic
specified No formal ophthalmology
assessment recorded
25 Visual change – Papilloedema on assessment in clinic Vision stable Papilloedema resolved on
symptoms not No formal ophthalmology assessment recorded Acuity normal assessment in clinic
specified No formal ophthalmology
assessment recorded
26 Blurred vision Papilloedema on assessment in clinic Improved acuity Papilloedema resolved on
No formal ophthalmology assessment recorded assessment in clinic
No formal ophthalmology
assessment recorded
27 Tunnel vision Papilloedema on assessment in clinic Obscurations resolved Papilloedema resolved on
Obscurations No formal ophthalmology assessment recorded Tunnel vision improved assessment in clinic
No formal ophthalmology
assessment recorded
28 Blurred vision Papilloedema on assessment in clinic Visual acuity improved Papilloedema resolved on
No formal ophthalmology assessment recorded assessment in clinic
No formal ophthalmology
assessment recorded

Table 6. Early and late complications of ventriculoperitoneal shunt insertion.
Complications Number
Early complication (within 2 weeks) - 2 (7%)
re-siting of peritoneal catheter
Late complication (>6 months) - 1 (3%)
Overdrainage requiring anti-siphon device
similarly low revision rate (11%) with all cases of revision due to
distal catheter migration.
Thirdly, choice of valve. Ninety-three percent of our patients
received an Orbis Sigma valve; this allows a rate of drainage
similar to the rate of CSF production, in preference to a pro-
grammable valve. The studies reviewed show a mix of program-
mable and fixed drainage valves, with little indication of which
provides better outcomes (Table 7). We suggest that as the Orbis
Sigma valve drains at a typical rate similar to physiological re-
absorption,21 it should avoid over or under drainage and also the
psychological uncertainty that may be associated with this. In
support of this we had only one patient re-referred due to over-
drainage, and no patients returning who needed increased CSF
drainage. In the studies reviewed, over-drainage was noted in
6–26% of patients (Table 7). There is currently insufficient
research on which valve provides the best outcomes in IIH spe-
cifically. Even when looking at hydrocephalus as a broad group,
there is inconclusive research determining which valve type is
preferable.21–24
Finally, the majority of our patients received a frontal ven-
tricular catheter, with only one receiving a parietally placed ven-
tricular catheter. This was due to surgeon preference - the
surgeon felt that a frontal approach was safer and easier for
patients with small ventricles in case of intra-operative failure of
stereotactic guidance. It is possible that the frontal approach may
have played a role in the low rate of complications by reducing
blockage of the catheter from choroid plexus ingrowth. There is
some evidence to support this,25–27 however these studies were in
paediatric hydrocephalus, not IIH. Further research is needed to
establish whether a frontally placed ventricular catheter is super-
ior to a parietal approach in IIH patients.
It should be noted that this study only looks at complications
which would require further neurosurgical intervention.
Complications such as superficial wound infection were not
included as these would be managed conservatively. This is also
apparent in the other studies included in the review (Table 7).
In our study all patients received follow-up at 4–6 months. If
there were no further issues, they were discharged from follow-
Table 7. Reviews and case series showing outcomes of ventriculoperitoneal shunt insertion for IIH.
Author Shunt type Insertion method Number patients Follow-up Symptom outcome Vision outcome Revision rate Complications
Hermann et al.7 VPS EM navigated 18 41.5 months Not reported Not reported 11% Distal
Type of valve catheter migration
not recorded
Matloob et al.10 LPS/VPS Not recorded 79 6.6 years (±4.2 years) Improvement in Not recorded 51.9% Shunt obstruction
Programmable symptoms in 29% (9.5%), shunt
Meithke valves migration (13.9 %)
shunt
infection (5.7 %)
Fonseca et al.11 VPS/VAS Not recorded 19 34 months (þ/
21) Not reported VA improved/ 42% - due to Shunt infection (5%)
Type of valve stabilised in 79%. persistent
not recorded Papilloedema papilloedema/
improved in 79%. symptoms
Huang et al.12 VPS Not recorded 19 21 months Not reported VA improved/ 20–52% - reasons Meningitis and
Type of valve stabilised in 82%. not recorded gangrenous
not recorded bowel (5%)
Sinclair et al.13 LPS/VPS (92% LPS) Not recorded 53 Not stated Headaches - 56% Papilloedema resolved 51% revision. 30% Shunt obstruction
Type of valve resolved. Tinnitus - in 86%. Visual multiple revisions (44.4%). Shunt
not recorded 33% resolved. deficit improved/ disconnection
resolved in 82% (18.5%). Shunt
migration (7.4%).
Low pressure
headache 26%
Tarnaris et al.14 25 (73.5%) LPS. 9 Not recorded 34 28.9 (±31.8) months Headaches - 71% VA improved/ 35% - for Shunt infection (2%).
(26.5%) VPS improved in LPS, remained stable complications as Shunt obstruction
Type of valve 60% improved VPS in 67–87.5% described and (2%). Overdrainage
not recorded symptomatic (6%). Malposition
recurrence of catheter (2%).
CSF leak (6%).
Abubaker et al.15 18 (72%) LPS, 7 (28%) EM navigated 25 Not stated 89% improvement in Papilloedema - 60% LPS, 30% VPS LPS - Catheter
VPS (further 3 LPS. 80% improved/resolved migration (36%),
patients had LPS improvement in 61% for LPS, shunt blockage
changed to VPS) in VPS 80% for VPS. (12%), low pressure
Type of valve headaches (8%),
not recorded shunt infection
(4%). VPS -
Catheter migration
(12%), chronic
subdural
haematoma (4%)
Abu-Serieh et al.16 VPS Frameless and frame- 9 44.3 months Headaches - 89% Visual function 50% at 12 months Shunt infection (55%),
Set pressure with based stereotactic improved/resolved improved 60%, and 71% at valve dysfunction
anti-siphon and stabilised 40% 24 months (22%), distal
programmable valves obstruction (11%),
ventricular shunt
malpositioning
(11%)
Woodworth et al.17 VPS/VAS Frameless 21 24 months 100% resolution Not recorded 20% by 6 months, Distal obstruction
22 - programmable of headaches 50% by 12 months, (67%),
8 - set pressure with 60% by 24 months overdrainage
anti-siphon (20%), distal
catheter migration
BRITISH JOURNAL OF NEUROSURGERY

or CSF leak (6.5%)

(continued)
7
 8 A. BJORNSON ET AL.

up at this point. Any symptom recurrence after this would result

41%, infection 11%,

overdrainage 14%,

3.5%, CSF leak 3%

Catheter malposition
in a re-referral via the GP, emergency department or neurologist.
Complications

shunt infection

Shunt obstruction
headache 23%
distal catheter
migration 5%,
Obstruction 48%
This explains why the mean follow-up time for our study is rela-

low pressure
tively short (17 months) compared to other studies (Table 7), as
patients who have made a good recovery would not receive fol-
low-up beyond 4–6 months.
LPS - 86%. VPS - 44%

Conclusion
Revision rate

Idiopathic intracranial hypertension is a difficult condition to

manage and many studies have commented on the cost, length
of stay and number of interventions for this patient group.
Contrary to other studies, we have demonstrated a low revision
41%

23%

and complication rate when using ventriculo-perotoneal shunts

as the main surgical intervention. We feel that strict patient
Papilloedema resolved

unchanged 100%

selection criteria, use of EM guidance and a flow-regulated valve

Vision outcome

Vision improved in

stable in 61.5%.
stabilised 100%

have contributed to the favourable outcomes.

38.5%. Vision
VA improved/
Not recorded

improved/
Visual fields
100%

Disclosure Statement
These authors declare no conflicts of interest
Headaches improved/
Symptom outcome

Headaches resolved
immediate relief,
56% at 3 years

resolved 100%
Headaches - 95%

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