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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OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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. nporfirio@unifi.it.

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.

References

1

Adams RDFisher CMHakim SOjemann RGSweet WH: Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure. A treatable syndrome. N Engl J Med 273:1171261965

2

Bergsneider MMiller CVespa PMHu X: Surgical management of adult hydrocephalus. Neurosurgery 62 (Suppl 2):6436602008

3

Burnett MGSonnad SSStein SC: Screening tests for normal-pressure hydrocephalus: sensitivity, specificity, and cost. J Neurosurg 105:8238292006

4

Chen IHHuang CILiu HCChen KK: Effectiveness of shunting in patients with normal pressure hydrocephalus predicted by temporary, controlled-resistance, continuous lumbar drainage: a pilot study. J Neurol Neurosurg Psychiatry 57:143014321994

5

Chotai SMedel RHerial NAMedhkour A: External lumbar drain: a pragmatic test for prediction of shunt outcomes in idiopathic normal pressure hydrocephalus. Surg Neurol Int 5:122014

6

Di Lauro LMearini MBollati A: The predictive value of 5 days CSF diversion for shunting in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 49:8428431986

7

Folstein MFFolstein SEMcHugh PR: “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:1891981975

8

Governale LSFein NLogsdon JBlack PM: Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Neurosurgery 63 (4 Suppl 2):3793842008

9

Greenberg BMWilliams MA: Infectious complications of temporary spinal catheter insertion for diagnosis of adult hydrocephalus and idiopathic intracranial hypertension. Neurosurgery 62:4314362008

10

Haan JThomeer RTWM: Predictive value of temporary external lumbar drainage in normal pressure hydrocephalus. Neurosurgery 22:3883911988

11

Halperin JJKurlan RSchwalb JMCusimano MDGronseth GGloss D: Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 85:206320712015

12

Kameda MYamada SAtsuchi MKimura TKazui HMiyajima M: Cost-effectiveness analysis of shunt surgery for idiopathic normal pressure hydrocephalus based on the SINPHONI and SINPHONI-2 trials. Acta Neurochir (Wien) 159:99510032017

13

Kunkel ECRay BSWolf HG: Experimental studies on headache. Analysis of the headache associated with changes in intracranial pressure. Arch Neurol Psychiatry 49:3233581943

14

Lenfeldt NHansson WLarsson ABirgander REklund AMalm J: Three-day CSF drainage barely reduces ventricular size in normal pressure hydrocephalus. Neurology 79:2372422012

15

Mahr CVDengl MNestler UReiss-Zimmermann MEichner GPreuß M: Idiopathic normal pressure hydrocephalus: diagnostic and predictive value of clinical testing, lumbar drainage, and CSF dynamics. J Neurosurg 125:5915972016

16

Marmarou ABergsneider MKlinge PRelkin NBlack PM: The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery 57 (3 Suppl):S17S28 ii–v2005

17

Marmarou AYoung HFAygok GASawauchi STsuji OYamamoto T: Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients. J Neurosurg 102:9879972005

18

Martín-Láez RCaballero-Arzapalo HLópez-Menéndez Arango-Lasprilla JCVázquez-Barquero A: Epidemiology of idiopathic normal pressure hydrocephalus: a systematic review of the literature. World Neurosurg 84:200220092015

19

Miyazawa KShiga YHasegawa TEndoh MOkita NHigano S: CSF hypovolemia vs intracranial hypotension in “spontaneous intracranial hypotension syndrome.” Neurology 60:9419472003

20

Mokri B: Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia—evolution of a concept. Mayo Clin Proc 74:111311231999

21

Panagiotopoulos VKonstantinou DKalogeropoulos AMaraziotis T: The predictive value of external continuous lumbar drainage, with cerebrospinal fluid outflow controlled by medium pressure valve, in normal pressure hydrocephalus. Acta Neurochir (Wien) 147:9539582005

22

Pleasure SJAbosch AFriedman JKo NUBarbaro NDillon W: Spontaneous intracranial hypotension resulting in stupor caused by diencephalic compression. Neurology 50:185418571998

23

Schade RPSchinkel JVisser LGVan Dijk JMCVoormolen JHCKuijper EJ: Bacterial meningitis caused by the use of ventricular or lumbar cerebrospinal fluid catheters. J Neurosurg 102:2292342005

24

Scollato AGallina PGautam BPellicanò GCavallini CTenenbaum R: Changes in aqueductal CSF stroke volume in shunted patients with idiopathic normal-pressure hydrocephalus. AJNR Am J Neuroradiol 30:158015862009

25

Silverberg GDHuhn SJaffe RAChang SDSaul THeit G: Downregulation of cerebrospinal fluid production in patients with chronic hydrocephalus. J Neurosurg 97:127112752002

26

Tullberg MPersson JPetersen JHellström PWikkelsø CLundgren-Nilsson A: Shunt surgery in idiopathic normal pressure hydrocephalus is cost-effective—a cost utility analysis. Acta Neurochir 160:5095182018

27

Walchenbach RGeiger EThomeer RTWMVanneste JAL: The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 72:5035062002

28

Wikkelsø CAndersson HBlomstrand CLindqvist G: The clinical effect of lumbar puncture in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 45:64691982

29

Williams MARazumovsky AYHanley DF: Comparison of Pcsf monitoring and controlled CSF drainage diagnose normal pressure hydrocephalus. Acta Neurochir Suppl 71:3283301998

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