Shunt surgery in patients with hydrocephalus and white matter changes

Clinical article

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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.


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.


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.


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:

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.



  • 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.


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