The role of lumboperitoneal shunts in managing chronic hydrocephalus with slit ventricles

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OBJECTIVE

Lumboperitoneal (LP) shunts have a role not only in pseudotumor cerebri, but also in patients with slit-like ventricles who are treated with CSF shunting on a chronic basis. Hesitation to utilize LP shunts is based on previous conventional beliefs including the tendency for overdrainage, difficulties accessing the shunt to tap or revise, and risk of progressive cerebellar tonsillar herniation. The authors hypothesized that the use of horizontal-vertical (HV) valves may reduce the risk of these complications, particularly overdrainage and development of Chiari malformation.

METHODS

All pediatric cases involving patients treated with an LP shunt at the Children’s Hospital of Michigan were reviewed in this retrospective case series. A total of 143 patients with hydrocephalus were treated with LP shunts from 1997–2015 (follow-up range 8 months–8 years, median 4.2 years). Patients with pseudotumor cerebri underwent placement of an LP shunt as a primary procedure. In patients with slit ventricles from chronically treated hydrocephalus or repeated shunt malfunctions from proximal catheter obstruction, a lumbar drain was inserted to assess candidacy for conversion to an LP shunt. In patients who tolerated the lumbar drain and demonstrated communication of the ventricles with the spinal cisterns, treatment was converted to an LP shunt. All patients included in the series had undergone initial shunt placement between birth and age 16 years.

RESULTS

In 30% of patients (n = 43), LP shunts were placed as the initial shunt treatment; in 70% (n = 100), treatment was converted to LP shunts from ventriculoperitoneal (VP) shunts. The patients’ age at insertion of or conversion to an LP shunt ranged from 1 to 43 years (median 8.5 years). Of the patients with clear pre-LP and post-LP shunt follow-up imaging, none were found to develop an acquired Chiari malformation. In patients with pre-existing tonsillar ectopia, no progression was noted on follow-up MRIs of the brain in these patients after LP shunt insertion. In our LP shunt case series, no patient presented with acute deterioration from shunt malfunction.

CONCLUSIONS

Conversion to an LP shunt may minimize acute deterioration from shunt malfunction and decrease morbidity of repeated procedures in patients with chronically shunt-treated hydrocephalus and small ventricles. In comparison to previously published case series of LP shunt treatment, the use of LP shunts in conjunction with HV valves may decrease the overall risk of cerebellar tonsillar herniation. The use of an LP shunt may be an alternative in the management of slit ventricles when VP shunting repeatedly fails.

ABBREVIATIONS CSF = cerebrospinal fluid; EAM = external auditory meatus; EVD = external ventricular drain; HV = horizontal-vertical; IQR = interquartile range; LP = lumboperitoneal; VP = ventriculoperitoneal.

Article Information

Correspondence Sandeep Sood: Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, MI. ssood@med.wayne.edu.

INCLUDE WHEN CITING Published online September 21, 2018; DOI: 10.3171/2018.6.PEDS17642.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    CT ventriculogram, dye-injection study, confirming communication between ventricles and spinal subarachnoid space. Dye was administered via reservoir or catheter into the ventricle. A: Axial view of ventricular system with dye throughout the system. B: Axial view demonstrating dye at the foramen magnum and lower brainstem. C: Sagittal view demonstrating dye throughout ventricular system.

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    Radiographs for LP shunt series. Anterior-posterior view (A) and lateral view (B) radiographs demonstrating continuity of LP shunt system, including lumbar spinal catheter, HV valve, and peritoneal catheter.

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    MR images showing no progression of Chiari malformation in an LP shunt–treated patient. This 25-year-old woman had a history of hydrocephalus related to meningitis as infant. A VP shunt was placed at 9 months and converted to an LP shunt when the patient was 14-years-old due to small ventricles and multiple shunt revisions of the proximal ventricular catheter. A: Sagittal T2-weighted MR image obtained prior to LP shunt placement showing 8 mm cerebellar tonsillar descent. The patient had no Chiari-related symptoms at the time. B: Sagittal T2-weighted MR image obtained 3 years after LP shunt placement showing no change in tonsillar descent. The patient had no Chiari-related symptoms at the time of this MRI study. C: Sagittal T2 MR image obtained 11 years after LP shunt placement showing slight improvement in tonsillar descent to 6 mm. The patient remained free of any Chiari-related symptoms.

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