The constant flow ventricular infusion test: a simple and useful study in the diagnosis of third ventriculostomy failure

Clinical article

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Object

The evaluation of third ventriculostomy function in hydrocephalic patients is challenging. The utility of the constant flow infusion test in predicting response to shunt insertion in normal-pressure hydrocephalus, as well as in identifying shunt malfunction, has been previously demonstrated. The object of this study was to evaluate its usefulness in determining whether a revision CSF diversion procedure was indicated in patients presenting with recurring symptoms and persisting ventriculomegaly after endoscopic third ventriculostomy (ETV).

Methods

The authors conducted a prospective study of all patients who, after undergoing ETV at their institution, presented postoperatively with recurring symptoms and persisting ventriculomegaly.

Results

Forty-six patients (mean age 40.7 years, including 11 patients younger than 18 years) underwent 56 constant flow ventricular infusion tests (VITs) at a mean of 24.7 months post-ETV. Thirty-three patients with resistance to CSF outflow (Rout) less than 13 mm Hg/ml/min underwent follow-up (median 17 months) and experienced resolution of symptoms. In 10 episodes Rout was greater than 13 mm Hg/ml/min; the patients in these cases underwent revisional CSF diversion. Two patients demonstrated high and frequent B (slow) waves despite a low Rout; these patients also underwent successful revisions. Patients who improved after surgery had increased B wave activity in the plateau phase of the VIT (p = 0.01). Thirty-four patients underwent MR imaging at the same time; 4 had high Rout despite evidence of flow across the stoma. These 4 patients underwent surgery and experienced resolution of symptoms. Of 9 patients without flow, Rout was less than 13 mm Hg/ml/min in 4; these patients were successfully treated conservatively.

Conclusions

The VIT is a useful and safe adjunct to clinical and MR imaging evaluation when ETV failure is suspected.

Abbreviations used in this paper: AMP = amplitude of the ICP waveform; ETV = endoscopic third ventriculostomy; ICP = intracranial pressure; LOVA = long-standing overt ventriculomegaly of adulthood; NPH = normal-pressure hydrocephalus; RAP = moving correlation coefficient between mean ICP and changes in AMP; Rout = resistance to CSF outflow; VAD = ventricular access device; VIT = ventricular infusion test; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Kristian Aquilina, F.R.C.S.(SN), Department of Neurosurgery, Frenchay Hospital, Bristol BS16 1LE, United Kingdom. email: K.Aquilina@bristol.ac.uk.

Please include this information when citing this paper: published online November 18, 2011; DOI: 10.3171/2011.10.JNS1140.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A and B: Midsagittal and axial T1-weighted MR images showing severe triventricular hydrocephalus related to long-standing aqueductal stenosis. C: Graph showing the ICP and amplitude of the ICP waveform against time, demonstrating a low baseline pressure during a prolonged baseline phase of the VIT. Both ICP and amplitude increase steeply during the infusion phase of the test, precluding completion to the plateau phase. D: Repeat VIT after shunt insertion demonstrating a low plateau pressure; Rout was 8.7 mm Hg/ml/min.

  • View in gallery

    Left: Still image from the cine phase-contrast MR imaging study demonstrating flow (arrow) across the stoma in the third ventricle floor. Right: Ventricular infusion test plot showing multiple high B waves in the plateau phase. The Rout was 16.7 mm Hg/ml/min.

  • View in gallery

    A and B: Midsagittal T1-weighted and axial T2-weighted MR images demonstrating enlarged third and lateral ventricles consistent with aqueductal stenosis. C: Ventricular infusion test plot showing B waves up to 45 mm Hg in the plateau phase; these were associated with typical headaches and nausea. The Rout was 10.1 mm Hg/ml/min.

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