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Ventriculo-Peritoneal Shunting Is A Safe and Effective Treatment For Idiopathic Intracranial Hypertension
Ventriculo-Peritoneal Shunting Is A Safe and Effective Treatment For Idiopathic Intracranial Hypertension
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
ARTICLE
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.
Figure 1. Modified Dandy Criteria. All patient in the study met this criteria for diagnosis of IIH.
BRITISH JOURNAL OF NEUROSURGERY 3
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 Symptomatic outcomes
19.5–58 kg/m2).
Two patients were admitted as an emergency with severe vis- Pre-operative signs and symptoms were recorded in all patients
ual deterioration. After confirmation of raised intracranial pres- either in clinic review or on admission in the emergency cases
sure and cranial imaging they underwent emergency VP shunt (Table 2). Papilloedema and visual changes were present in all
insertion. The remaining 26 patients were referred from other patients pre-operatively (100%). Visual changes were reported as
services due to failed medical management of their symptoms. blurring of vision, visual obscurations, subjective decrease in acu-
This included topirimate, acetazolamide and/or serial lumbar ity, and diplopia. Twenty-six patients (91%) suffered from head-
punctures. Twelve of the 28 patients had had previous surgical aches and 10 (36%) from tinnitus. Two patients had a 6th cranial
intervention - 9 had previous lumbar pleural/peritoneal shunts, 1 nerve palsy.
venous sinus stenting, 1 lumbar shunt and venous sinus stenting, Post-operatively, improvement or resolution of papilloedema
and 1 lumbar shunt and ventriculoatrial shunt. These were occurred in 100% of patients. Subjective improvement or reso-
removed either due to complications or failure to control the lution of visual symptoms occurred in 93% - two patients had
raised intracranial pressure. ongoing visual symptoms in the form of reduced acuity. Tinnitus
Image guidance with electromagnetic (EM) navigation was improved in 80% and headaches in 84%. Both patients with 6th
used in all patients and the procedure was performed by a con- nerve palsies found their deficit resolved. The symptomatic
sultant neurosurgeon in all cases. Standard operating procedures improvements were all self-reported by the patients during their
were used. The majority of patients (21/28) received an antibiotic neurosurgical clinic follow-up and the papilloedema and 6th
impregnated catheter, 3 patients had been recruited into the nerve palsies were assessed during the clinic by a Consultant
BASICS trial8 and were randomised to an antibiotic impregnated Neurosurgeon.
or silver-lined catheter, and 3 patients had no record of type of
catheter. Twenty-six patients received an Orbis Sigma valve and
Ophthalmological outcomes
2 patients received a programmable Strata valve. 1 patient
received a ventriculoatrial shunt due to issues with the pleural Ophthalmological examination data was available for 14 of the
and peritoneal cavities, the other patients received a ventriculo- 28 patients (Table 3). The remaining 14 were followed up in
peritoneal shunt. Right frontal ventricular access was used in their local hospital eye services.
twenty-seven of the patients and one patient received a parietal Of the data available, outcomes including visual acuity, colour
ventricular catheter. (Table 1) vision and visual fields were reviewed. A significant change in
4 A. BJORNSON ET AL.
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. research on which valve provides the best outcomes in IIH spe-
Complications Number cifically. Even when looking at hydrocephalus as a broad group,
Early complication (within 2 weeks) - 2 (7%) there is inconclusive research determining which valve type is
re-siting of peritoneal catheter preferable.21–24
Late complication (>6 months) - 1 (3%) Finally, the majority of our patients received a frontal ven-
Overdrainage requiring anti-siphon device
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
similarly low revision rate (11%) with all cases of revision due to patients with small ventricles in case of intra-operative failure of
distal catheter migration. stereotactic guidance. It is possible that the frontal approach may
Thirdly, choice of valve. Ninety-three percent of our patients have played a role in the low rate of complications by reducing
received an Orbis Sigma valve; this allows a rate of drainage blockage of the catheter from choroid plexus ingrowth. There is
similar to the rate of CSF production, in preference to a pro- some evidence to support this,25–27 however these studies were in
grammable valve. The studies reviewed show a mix of program- paediatric hydrocephalus, not IIH. Further research is needed to
mable and fixed drainage valves, with little indication of which establish whether a frontally placed ventricular catheter is super-
provides better outcomes (Table 7). We suggest that as the Orbis ior to a parietal approach in IIH patients.
Sigma valve drains at a typical rate similar to physiological re- It should be noted that this study only looks at complications
absorption,21 it should avoid over or under drainage and also the which would require further neurosurgical intervention.
psychological uncertainty that may be associated with this. In Complications such as superficial wound infection were not
support of this we had only one patient re-referred due to over- included as these would be managed conservatively. This is also
drainage, and no patients returning who needed increased CSF apparent in the other studies included in the review (Table 7).
drainage. In the studies reviewed, over-drainage was noted in In our study all patients received follow-up at 4–6 months. If
6–26% of patients (Table 7). There is currently insufficient 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
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
23%
unchanged 100%
Vision improved in
stable in 61.5%.
stabilised 100%
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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