Shunt surgery in patients with hydrocephalus and white matter changes

Clinical article

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Object

Patients with idiopathic normal pressure hydrocephalus (iNPH) often present with impaired gait and cognition together with ventricular enlargement and normal intracranial pressure. Many have vascular risk factors as well as periventricular and deep white matter changes on MR imaging. Abnormal CSF dynamics, that is, high resistance to outflow or improvement after CSF drainage, indicate good effects of shunt surgery.

The authors examined whether the worst-case iNPH patients with extensive vascular white matter disease and normal CSF dynamics would benefit from shunt surgery. These patients also fulfilled the criteria for Binswanger disease. Therefore, a randomized controlled double-blind study was performed.

Methods

Fourteen consecutive patients fulfilling the above criteria were randomized to receive either open or closed shunts. At 3 months after surgery, the patients with initially ligated shunts had their shunts opened. Clinical evaluation consisting of 7 quantitative psychometric and 6 continuous gait tests was performed preoperatively and 3 and 6 months after surgery.

Results

Patients randomized to receive open shunts had improved motor (30% increase) and psychometric (23% increase) scores 3 months after shunt placement. There were no significant changes between the 3- and 6-month follow-up in these same patients. Conversely, those with initially ligated shunts were unchanged during the first 3-month period, although they improved in both motor (28%) and cognitive (18%) functions following removal of the ligature.

Conclusions

Patients with enlarged ventricles, hydrocephalic symptoms, and extensive vascular white matter changes benefit from shunt surgery.

Abbreviations used in this paper: BD = Binswanger disease; FOV = field of view; iNPH = idiopathic normal pressure hydrocephalus; Rout = resistance outflow.

Article Information

Address correspondence to: Magnus Tisell, M.D., Ph.D., Department of Neurosurgery, Vån 5, Blå stråket 7, Sahlgrenska University Hospital, 413 45 Göteborg, Sweden. email: magnus.tisell@vgregion.se.

Please include this information when citing this paper: published online January 14, 2011; DOI: 10.3171/2010.11.JNS10967.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Two FLAIR MR images showing white matter disease (Wahlund Score 3) and ventriculomegaly.

  • View in gallery

    Graphs displaying individual treatment effect trajectories from the preoperative period to the 2 follow-up examinations. Left: Patients randomized to treatment with continuously open shunts. Right: Patients whose shunts were ligated during the first 3 months after surgery and then opened. mts = months.

References

  • 1

    Akai KUchigasaki STanaka UKomatsu A: Normal pressure hydrocephalus. Neuropathological study. Acta Pathol Jpn 37:971101987

  • 2

    Akiguchi ITomimoto HSuenaga TWakita HBudka H: Alterations in glia and axons in the brains of Binswanger's disease patients. Stroke 28:142314291997

  • 3

    Bennett DAGilley DWLee SCochran EJ: White matter changes: neurobehavioral manifestations of Binswanger's disease and clinical correlates in Alzheimer's disease. Dementia 5:1481521994

  • 4

    Bennett DAWilson RSGilley DWFox JH: Clinical diagnosis of Binswanger's disease. J Neurol Neurosurg Psychiatry 53:9619651990

  • 5

    Blomsterwall EBilting MStephensen HWikkelsö C: Gait abnormality is not the only motor disturbance in normal pressure hydrocephalus. Scand J Rehabil Med 27:2052091995

  • 6

    Blomsterwall ESvantesson UCarlsson UTullberg MWikkelsö C: Postural disturbance in patients with normal pressure hydrocephalus. Acta Neurol Scand 102:2842912000

  • 7

    Boon AJTans JTDelwel EJEgeler-Peerdeman SMHanlo PWWurzer HA: Dutch normal-pressure hydrocephalus study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg 87:6876931997

  • 8

    Boon AJTans JTDelwel EJEgeler-Peerdeman SMHanlo PWWurzer HA: Dutch Normal-Pressure Hydrocephalus Study: the role of cerebrovascular disease. J Neurosurg 90:2212261999

  • 9

    Czosnyka MBatorski LLaniewski PMaksymowicz WKoszewski WZaworski W: A computer system for the identification of the cerebrospinal compensatory model. Acta Neurochir (Wien) 105:1121161990

  • 10

    Czosnyka MWhitehouse HSmielewski PSimac SPickard JD: Testing of cerebrospinal compensatory reserve in shunted and non-shunted patients: a guide to interpretation based on an observational study. J Neurol Neurosurg Psychiatry 60:5495581996

  • 11

    Eide PKSorteberg W: Diagnostic intracranial pressure monitoring and surgical management in idiopathic normal pressure hydrocephalus: a 6-year review of 214 patients. Neurosurgery 66:80912010

  • 12

    Eklund ALundkvist BKoskinen LOMalm J: Infusion technique can be used to distinguish between dysfunction of a hydrocephalus shunt system and a progressive dementia. Med Biol Eng Comput 42:6446492004

  • 13

    Eklund ASmielewski PChambers IAlperin NMalm JCzosnyka M: Assessment of cerebrospinal fluid outflow resistance. Med Biol Eng Comput 45:7197352007

  • 14

    Esmonde TCooke S: Shunting for normal pressure hydrocephalus (NPH). Cochrane Database Syst Rev 3CD0031572002

  • 15

    Hebb AOCusimano MD: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:116611862001

  • 16

    Hellström PEdsbagge MBlomsterwall EArcher TTisell MTullberg M: Neuropsychological effects of shunt treatment in idiopathic normal pressure hydrocephalus. Neurosurgery 63:5275362008

  • 17

    Kahlon BSundbärg GRehncrona S: Comparison between the lumbar infusion and CSF tap tests to predict outcome after shunt surgery in suspected normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 73:7217262002

  • 18

    Krauss JKDroste DWVach WRegel JPOrszagh MBorremans JJ: Cerebrospinal fluid shunting in idiopathic normal-pressure hydrocephalus of the elderly: effect of periventricular and deep white matter lesions. Neurosurgery 39:2923001996

  • 19

    Krauss JKRegel JPVach WOrszagh MJüngling FDBohus M: White matter lesions in patients with idiopathic normal pressure hydrocephalus and in an age-matched control group: a comparative study. Neurosurgery 40:4914961997

  • 20

    Lundkvist BEklund AKoskinen LOMalm J: An adjustable CSF shunt: advices for clinical use. Acta Neurol Scand 108:38422003

  • 21

    Malm JKristensen BKarlsson TFagerlund MElfverson JEkstedt J: The predictive value of cerebrospinal fluid dynamic tests in patients with th idiopathic adult hydrocephalus syndrome. Arch Neurol 52:7837891995

  • 22

    Malm JKristensen BStegmayr BFagerlund MKoskinen LO: Three-year survival and functional outcome of patients with idiopathic adult hydrocephalus syndrome. Neurology 55:5765782000

  • 23

    Marmarou ABlack PBergsneider MKlinge PRelkin N: Guidelines for management of idiopathic normal pressure hydrocephalus: progress to date. Acta Neurochir Suppl (Wien) 95:2372402005

  • 24

    Tarkowski ETullberg MFredman PWikkelsö C: Normal pressure hydrocephalus triggers intrathecal production of TNF-alpha. Neurobiol Aging 24:7077142003

  • 25

    Tisell MHellström PAhl-Börjesson GBarrows GBlomsterwall ETullberg M: Long-term outcome in 109 adult patients operated on for hydrocephalus. Br J Neurosurg 20:2142212006

  • 26

    Tullberg MHultin LEkholm SMånsson JEFredman PWikkelsø C: White matter changes in normal pressure hydrocephalus and Binswanger disease: specificity, predictive value and correlations to axonal degeneration and demyelination. Acta Neurol Scand 105:4174262002

  • 27

    Tullberg MJensen CEkholm SWikkelsø C: Normal pressure hydrocephalus: vascular white matter changes on MR images must not exclude patients from shunt surgery. AJNR Am J Neuroradiol 22:166516732001

  • 28

    Vanneste JA: Diagnosis and management of normal-pressure hydrocephalus. J Neurol 247:5142000

  • 29

    Wahlund LOBarkhof FFazekas FBronge LAugustin MSjögren M: A new rating scale for age-related white matter changes applicable to MRI and CT. Stroke 32:131813222001

  • 30

    Wikkelsø CAndersson HBlomstrand CLindqvist G: The clinical effect of lumbar puncture in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 45:64691982

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