Dutch Normal-Pressure Hydrocephalus Study: randomized comparison of low- and medium-pressure shunts

Restricted access

Object. The goal of this prospective study was to compare outcome after placement of a low- or medium-pressure shunt in patients with normal-pressure hydrocephalus (NPH).

Methods. Ninety-six patients with NPH were randomized to receive a low-pressure ventriculoperitoneal shunt (LPV; 40 ± 10 mm H2O) or medium high—pressure ventriculoperitoneal shunt (MPV; 100 ± 10 mm H2O). The patients' gait disturbance and dementia were quantified by applying an NPH scale, and their level of disability was evaluated by using the modified Rankin scale (mRS). Patients were examined prior to and 1, 3, 6, 9, and 12 months after surgery. Primary outcome measures were determined by differences between preoperative and last NPH scale scores and mRS grades. The LPV and MPV shunt groups were compared by calculating both the differences between mean improvements and the proportions of patients showing improvement.

Intention-to-treat analysis of mRS grades yielded a mean improvement of 1.27 ± 1.41 for patients with LPV shunts and 0.68 ± 1.58 for patients with MPV shunts (p = 0.06). Improvement was found in 74% of patients with LPV shunts and in 53% of patients with MPV shunts (p = 0.06) and a marked-to-excellent improvement in 45% of patients with LPV shunts and 28% of patients with MPV shunts (p = 0.12). All outcome measures indicated trends in favor of the LPV shunt group, with only the dementia scale reaching significance. After exclusion of serious events and deaths unrelated to NPH, efficacy analysis showed the advantage of LPV shunts to be diminished. Reduction in ventricular size was also significantly greater for patients in the LPV shunt group (p = 0.009). Subdural effusions occurred in 71% of patients with an LPV shunt and in 34% with an MPV shunt; however, their influence on patient outcome was limited.

Conclusions. Outcome was better for patients who had an LPV shunt than for those with an MPV shunt, although most differences were not statistically significant. The authors advise that patients with NPH be treated with an LPV shunt.

Article Information

Current address for Dr. Boon: University Hospital, Rotterdam, The Netherlands.Address reprint requests to: Joseph T. J. Tans, M.D., Department of Neurology, Westeinde Hospital, Lijnbaan 32, Post Box 432, 2501 CK, The Hague, The Netherlands.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1.

    Adams RDFisher CMHakim Set al: Symptomatic occult hydrocephalus with “normal” cerebrospinal fluid pressure. A treatable syndrome. N Engl J Med 273:1171261965Adams RD Fisher CM Hakim S et al: Symptomatic occult hydrocephalus with “normal” cerebrospinal fluid pressure. A treatable syndrome. N Engl J Med 273:117–126 1965

  • 2.

    Benzel ECPelletier ALLevy PG: Communicating hydrocephalus in adults: prediction of outcome after ventricular shunting procedures. Neurosurgery 26:6556601990Benzel EC Pelletier AL Levy PG: Communicating hydrocephalus in adults: prediction of outcome after ventricular shunting procedures. Neurosurgery 26:655–660 1990

  • 3.

    Black PML: Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg 52:3713771980Black PML: Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg 52:371–377 1980

  • 4.

    Black PMLHakim RBailey NO: The use of the Codman-Medos programmable Hakim valve in the management of patients with hydrocephalus: illustrative cases. Neurosurgery 34:111011131994Black PML Hakim R Bailey NO: The use of the Codman-Medos programmable Hakim valve in the management of patients with hydrocephalus: illustrative cases. Neurosurgery 34:1110–1113 1994

  • 5.

    Boon AJWTans JTJDelwel EJet al: Dutch normal pressure hydrocephalus study: baseline characteristics with emphasis on clinical findings. Eur J Neurol 4:39471997Boon AJW Tans JTJ Delwel EJ et al: Dutch normal pressure hydrocephalus study: baseline characteristics with emphasis on clinical findings. Eur J Neurol 4:39–47 1997

  • 6.

    Boon AJWTans JTJDelwel EJet al: Dutch Normal-Pressure Hydrocephalus Study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg 87:6876931997Boon AJW Tans JTJ Delwel EJ et al: Dutch Normal-Pressure Hydrocephalus Study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg 87:687–693 1997

  • 7.

    Børgesen SE: Conductance to outflow of CSF in normal pressure hydrocephalus. Acta Neurochir 71:1451984Børgesen SE: Conductance to outflow of CSF in normal pressure hydrocephalus. Acta Neurochir 71:1–45 1984

  • 8.

    Graff-Radford NRGodersky JCJones MP: Variables predicting surgical outcome in symptomatic hydrocephalus in the elderly. Neurology 39:160116041989Graff-Radford NR Godersky JC Jones MP: Variables predicting surgical outcome in symptomatic hydrocephalus in the elderly. Neurology 39:1601–1604 1989

  • 9.

    Greenberg JOShenkin HAAdam R: Idiopathic normal pressure hydrocephalus—a report of 73 patients. J Neurol Neurosurg Psychiatry 40:3363411977Greenberg JO Shenkin HA Adam R: Idiopathic normal pressure hydrocephalus—a report of 73 patients. J Neurol Neurosurg Psychiatry 40:336–341 1977

  • 10.

    Hakim SAdams RD: The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 2:3073271965Hakim S Adams RD: The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 2:307–327 1965

  • 11.

    Hakim SHakim C: A biomechanical model of hydrocephalus and its relationship to treatment in Shapiro KMarmarou APortnoy H (eds): Hydrocephalus. New York: Raven Press1984 pp 143160Hakim S Hakim C: A biomechanical model of hydrocephalus and its relationship to treatment in Shapiro K Marmarou A Portnoy H (eds): Hydrocephalus. New York: Raven Press 1984 pp 143–160

  • 12.

    Hughes CPSiegel BACoxe WSet al: Adult idiopathic communicating hydrocephalus with and without shunting. J Neurol Neurosurg Psychiatry 41:9619711978Hughes CP Siegel BA Coxe WS et al: Adult idiopathic communicating hydrocephalus with and without shunting. J Neurol Neurosurg Psychiatry 41:961–971 1978

  • 13.

    Janny PColnet GVeyre Aet al: Hydrocéphalie à pression normale. Etude pré- et postopératoire de 56 cas. Neurochirurgie 27:89961981Janny P Colnet G Veyre A et al: Hydrocéphalie à pression normale. Etude pré- et postopératoire de 56 cas. Neurochirurgie 27:89–96 1981

  • 14.

    Katzman RHussey F: A simple constant-infusion manometric test for measurement of CSF absorption. 1. Rationale and method. Neurology 20:5345441970Katzman R Hussey F: A simple constant-infusion manometric test for measurement of CSF absorption. 1. Rationale and method. Neurology 20:534–544 1970

  • 15.

    Larsson AJensen CBilting Met al: Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus? Acta Neurochirur 117:15221992Larsson A Jensen C Bilting M et al: Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus? Acta Neurochirur 117:15–22 1992

  • 16.

    Larsson AWikkelsö CBilting Met al: Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta Neurol Scand 84:4754821991Larsson A Wikkelsö C Bilting M et al: Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta Neurol Scand 84:475–482 1991

  • 17.

    Magnaes B: Communicating hydrocephalus in adults. Diagnostic tests and results of treatment with medium pressure shunts. Neurology 28:4784841978Magnaes B: Communicating hydrocephalus in adults. Diagnostic tests and results of treatment with medium pressure shunts. Neurology 28:478–484 1978

  • 18.

    McQuarrie IGSaint-Louis LScherer PB: Treatment of normal pressure hydrocephalus with low versus medium pressure cerebrospinal fluid shunts. Neurosurgery 15:4844881984McQuarrie IG Saint-Louis L Scherer PB: Treatment of normal pressure hydrocephalus with low versus medium pressure cerebrospinal fluid shunts. Neurosurgery 15:484–488 1984

  • 19.

    McQuarrie IGScherer PB: Treatment of adult-onset obstructive hydrocephalus with low- or medium-pressure CSF shunts. Neurology 32:105710611982McQuarrie IG Scherer PB: Treatment of adult-onset obstructive hydrocephalus with low- or medium-pressure CSF shunts. Neurology 32:1057–1061 1982

  • 20.

    Pang DAltschuler E: Low-pressure hydrocephalic state and viscoelastic alterations in the brain. Neurosurgery 35:6436561994Pang D Altschuler E: Low-pressure hydrocephalic state and viscoelastic alterations in the brain. Neurosurgery 35:643–656 1994

  • 21.

    Petersen RCMokri BLaws ER Jr: Surgical treatment of idiopathic hydrocephalus in elderly patients. Neurology 35:3073111985Petersen RC Mokri B Laws ER Jr: Surgical treatment of idiopathic hydrocephalus in elderly patients. Neurology 35:307–311 1985

  • 22.

    Sahuquillo JRubio ECodina Aet al: Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “normal pressure hydrocephalus” syndrome. Acta Neurochir 112:50611991Sahuquillo J Rubio E Codina A et al: Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “normal pressure hydrocephalus” syndrome. Acta Neurochir 112:50–61 1991

  • 23.

    Sainte-Rose CHooven MDHirsch JF: A new approach in the treatment of hydrocephalus. J Neurosurg 66:2132261987Sainte-Rose C Hooven MD Hirsch JF: A new approach in the treatment of hydrocephalus. J Neurosurg 66:213–226 1987

  • 24.

    Samuelson SLong DMChou SN: Subdural hematoma as a complication of shunting procedures for normal pressure hydrocephalus. J Neurosurg 37:5485511972Samuelson S Long DM Chou SN: Subdural hematoma as a complication of shunting procedures for normal pressure hydrocephalus. J Neurosurg 37:548–551 1972

  • 25.

    Spanu GSangiovanni GLocatelli D: Normal pressure hydrocephalus: twelve years experience. Neurochirurgia 29:15191986Spanu G Sangiovanni G Locatelli D: Normal pressure hydrocephalus: twelve years experience. Neurochirurgia 29:15–19 1986

  • 26.

    Tanaka K: The implications of shunt surgery in the intracranial hydrodynamics of normal pressure hydrocephalus (NPH) in Matsumoto STamaki N (eds): Hydrocephalus. Pathogenesis and Treatment. Tokyo: Springer-Verlag1991 pp 611618Tanaka K: The implications of shunt surgery in the intracranial hydrodynamics of normal pressure hydrocephalus (NPH) in Matsumoto S Tamaki N (eds): Hydrocephalus. Pathogenesis and Treatment. Tokyo: Springer-Verlag 1991 pp 611–618

  • 27.

    Tokoro KChiba YAbe H: Pitfalls of the Sophy programmable pressure value: is it really better than a conventional valve and an anti siphon device? in Matsumoto STamaki N (eds): Hydrocephalus. Pathogenesis and Treatment. Tokyo: Springer-Verlag1991 pp 405421Tokoro K Chiba Y Abe H: Pitfalls of the Sophy programmable pressure value: is it really better than a conventional valve and an anti siphon device? in Matsumoto S Tamaki N (eds): Hydrocephalus. Pathogenesis and Treatment. Tokyo: Springer-Verlag 1991 pp 405–421

  • 28.

    Trost HAHeissler HEClaussen Get al: Testing the hydrocephalus shunt valve: long-term bench test results of various new and explanted valves. The need for model for testing valves under physiological conditions. Eur J Pediatr Surg 1 (Suppl 1):38401991Trost HA Heissler HE Claussen G et al: Testing the hydrocephalus shunt valve: long-term bench test results of various new and explanted valves. The need for model for testing valves under physiological conditions. Eur J Pediatr Surg 1 (Suppl 1):38–40 1991

  • 29.

    Udvarhelyi GBWood JHJames AE Jret al: Results and complications in 55 shunted patients with normal pressure hydrocephalus. Surg Neurol 3:2712751975Udvarhelyi GB Wood JH James AE Jr et al: Results and complications in 55 shunted patients with normal pressure hydrocephalus. Surg Neurol 3:271–275 1975

  • 30.

    Vanneste JAugustijn PDirven Cet al: Shunting normal pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology 42:54591992Vanneste J Augustijn P Dirven C et al: Shunting normal pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology 42:54–59 1992

  • 31.

    Weiner HLConstantini SCohen Het al: Current treatment of normal-pressure hydrocephalus: comparison of flow-regulated and differential-pressure shunt valves. Neurosurgery 37:8778841995Weiner HL Constantini S Cohen H et al: Current treatment of normal-pressure hydrocephalus: comparison of flow-regulated and differential-pressure shunt valves. Neurosurgery 37:877–884 1995

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 153 153 5
Full Text Views 162 162 3
PDF Downloads 116 116 2
EPUB Downloads 0 0 0

PubMed

Google Scholar