Accuracy and safety of 1-day external lumbar drainage of CSF for shunt selection in patients with idiopathic normal pressure hydrocephalus

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Three to five days of external lumbar drainage (ELD) of CSF is a test for ventriculoperitoneal shunt (VPS) selection in idiopathic normal pressure hydrocephalus (iNPH). The accuracy and complication rates of a shorter (1-day) ELD procedure were analyzed.


Data of patients with iNPH who underwent 1-day ELD to be selected to undergo VPS placement with a programmable valve in the period from 2005 to 2015 were reviewed. Patients experiencing VPS complications, valve malfunctioning, or with less than 1 year of follow-up were excluded. The ability of 1-day ELD to predict VPS outcome at 1- and 12-month follow-up was assessed by calculating sensitivity, specificity, and positive and negative predictive values.


Of 93 patients who underwent 1-day ELD, 3 did not complete the procedure. Of the remaining 90 patients, 2 experienced transient nerve root irritation. Twenty-four patients had negative test outcomes and 66 had positive test outcomes. Nine negative-outcome patients had intraprocedural headache, which showed 37.5% sensitivity (95% confidence interval [CI] 19.5%–59.2%) and 100% specificity (95% CI 93.1%–100%) as predictors of negative 1-day ELD outcome. Sixty-eight patients (6 with negative and 62 with positive outcomes) underwent VPS insertion, which was successful in 0 and 58 patients, respectively, at 1-month follow-up. Test sensitivity and specificity in predicting surgical outcome at 1-month follow-up were 100% (95% CI 92.3%–100%) and 60% (95% CI 27.4%–86.3%), respectively, with 94.1% accuracy (95% CI 85.6–98.4%). Among the 1-day ELD–positive patients, 2 showed no clinical benefit at 12 months follow-up. Test sensitivity and specificity in predicting surgical outcome at 12-month follow-up was 100% (95% CI 92.5%–100%) and 75.0% (95% CI 35.6%–95.5%), respectively, with 97.1% (95% CI 89.8%–99.6%) accuracy.


One-day ELD is a reliable tool in iNPH management, with low complication risk and short trial duration. The test is very consistent in predicting who will have a positive outcome with VPS placement, given the high chance of successful outcome at 1- and 12-month follow-up; negative-outcome patients have a high risk of unsuccessful surgery. Intraprocedural headache is prognostic of 1-day ELD negative outcome.

ABBREVIATIONS ELD = external lumbar drainage; iNPH = idiopathic normal pressure hydrocephalus; MMSE = Mini-Mental State Examination; VPS = ventriculoperitoneal shunt.

Article Information

Correspondence Berardino Porfirio: University of Florence, Italy.

INCLUDE WHEN CITING Published online November 16, 2018; DOI: 10.3171/2018.6.JNS18400.

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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    Stratification of 93 patients with iNPH who underwent 1-day ELD as a test for VPS selection: accuracy of headache occurrence during the procedure as a predictor of test outcome, and accuracy of the test as a predictor of shunt surgery outcome. (a)One of these patients received downward opening pressure valve adjustment between shunt surgery and 1-month follow-up. (b)One of these patients received upward valve resetting between shunt surgery and 1-month follow-up of headache. (c)Between 1- and 12-month follow-up, 5 of these patients received downward opening pressure valve resetting, while in 1 patient the valve was reset at the implantation value after downward adjustments because of subdural fluid collection. (d)Both of these patients received downward opening pressure valve adjustment between 1- and 12-month follow-up. (e)Between 1- and 12-month follow-up, 28 patients received downward opening pressure valve adjustment. Because of the occurrence of symptoms of overdrainage, 4 patients (in addition to one who already had received valve adjustment to a higher value than that at implantation [see note (b)]) received upward opening pressure valve adjustments. NPV = negative predictive value; PPV = positive predictive value; sens = sensitivity; spec = specificity.



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