Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients

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A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH.


The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded.


The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05).


The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

ABBREVIATIONS BBS = Berg Balance Scale; CSF-TT = CSF tap test; ELD = external lumbar drainage; HVLP = high-volume lumbar puncture; LD = lumbar drain; MMSE = Mini–Mental State Examination; NPH = normal pressure hydrocephalus; TUG = Timed Up and Go; VPS = ventriculoperitoneal shunting.

Article Information

Correspondence Jonathan A. White: UT Southwestern Medical Center, Dallas, TX.

INCLUDE WHEN CITING Published online January 4, 2019; DOI: 10.3171/2018.8.JNS181059.

Disclosures Dr. Olson reports being the editor of Journal of Neuroscience Nursing. Dr. Welch reports being a consultant for Medtronic, Inc.

© AANS, except where prohibited by US copyright law.




Adachi MKawanami TOhshima FKato T: Upper midbrain profile sign and cingulate sulcus sign: MRI findings on sagittal images in idiopathic normal-pressure hydrocephalus, Alzheimer’s disease, and progressive supranuclear palsy. Radiat Med 24:5685722006


Agren-Wilsson ALekman ASjöberg WRosengren LBlennow KBergenheim AT: CSF biomarkers in the evaluation of idiopathic normal pressure hydrocephalus. Acta Neurol Scand 116:3333392007


Bech-Azeddine RHøgh PJuhler MGjerris FWaldemar G: Idiopathic normal-pressure hydrocephalus: clinical comorbidity correlated with cerebral biopsy findings and outcome of cerebrospinal fluid shunting. J Neurol Neurosurg Psychiatry 78:1571612007


Boon AJTans JTDelwel EJEgeler-Peerdeman SMHanlo PWWurzer HA: Dutch normal-pressure hydrocephalus study: the role of cerebrovascular disease. J Neurosurg 90:2212261999


Bugalho PAlves L: Normal-pressure hydrocephalus: white matter lesions correlate negatively with gait improvement after lumbar puncture. Clin Neurol Neurosurg 109:7747782007


Caruso RCervoni LVitale AMSalvati M: Idiopathic normal-pressure hydrocephalus in adults: result of shunting correlated with clinical findings in 18 patients and review of the literature. Neurosurg Rev 20:1041071997


Chang SAgarwal SWilliams MARigamonti DHillis AE: Demographic factors influence cognitive recovery after shunt for normal-pressure hydrocephalus. Neurologist 12:39422006


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


Conradsson MLundin-Olsson LLindelof NLittbrand HMalmqvist LGustafson Y: Berg Balance Scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities. Phys Ther 87:115511632007


Delwel EJde Jong DAAvezaat CJJ: The prognostic value of clinical characteristics and parameters of cerebrospinal fluid hydrodynamics in shunting for idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 147:103710432005


Ekstedt J: CSF hydrodynamic studies in man. 2. Normal hydrodynamic variables related to CSF pressure and flow. J Neurol Neurosurg Psychiatry 41:3453531978


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


Greenberg JOShenkin HAAdam R: Idiopathic normal pressure hydrocephalus—a report of 73 patients. J Neurol Neurosurg Psychiatry 40:3363411977


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


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


Hughes CPSiegel BACoxe WSGado MHGrubb RLColeman RE: Adult idiopathic communicating hydrocephalus with and without shunting. J Neurol Neurosurg Psychiatry 41:9619711978


Ishikawa MHashimoto MKuwana NMori EMiyake HWachi A: Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 48 (Suppl):S1S232008


Ishikawa MHashimoto MMori EKuwana NKazui H: The value of the cerebrospinal fluid tap test for predicting shunt effectiveness in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 9:12012


Kahlon BSundbärg GRehncrona S: Lumbar infusion test in normal pressure hydrocephalus. Acta Neurol Scand 111:3793842005


Kang KYoon ULee JMLee HW: Idiopathic normal-pressure hydrocephalus, cortical thinning, and the cerebrospinal fluid tap test. J Neurol Sci 334:55622013


Kitagaki HMori EIshii KYamaji SHirono NImamura T: CSF spaces in idiopathic normal pressure hydrocephalus: morphology and volumetry. AJNR Am J Neuroradiol 19:127712841998


Kojoukhova MKoivisto AMKorhonen RRemes AMVanninen RSoininen H: Feasibility of radiological markers in idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 157:170917192015


Komotar RJZacharia BEMocco JKaiser MGFrucht SJMcKhann GM II: Cervical spine disease may result in a negative lumbar spinal drainage trial in normal pressure hydrocephalus: case report. Neurosurgery 63 (4 Suppl 2):315315 2008


Kubo YKazui HYoshida TKito YKimura NTokunaga H: Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus. Dement Geriatr Cogn Disord 25:37452008


Larsson AWikkelsö CBilting MStephensen H: Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta Neurol Scand 84:4754821991


Lee WJWang SJHsu LCLirng JFWu CHFuh JL: Brain MRI as a predictor of CSF tap test response in patients with idiopathic normal pressure hydrocephalus. J Neurol 257:167516812010


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


Malm JKristensen BKarlsson TFagerlund MElfverson JEkstedt J: The predictive value of cerebrospinal fluid dynamic tests in patients with the idiopathic adult hydrocephalus syndrome. Arch Neurol 52:7837891995


Marmarou ABergsneider MKlinge PRelkin NBlack PML: INPH guidelines, part III: the value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery 57:S2-17S2-282005


Meier UMiethke C: Predictors of outcome in patients with normal-pressure hydrocephalus. J Clin Neurosci 10:4534592003


Mori K: Management of idiopathic normal-pressure hydrocephalus: a multiinstitutional study conducted in Japan. J Neurosurg 95:9709732001


Ng SELow AMTang KKChan YHKwok RK: Value of quantitative MRI biomarkers (Evans’ index, aqueductal flow rate, and apparent diffusion coefficient) in idiopathic normal pressure hydrocephalus. J Magn Reson Imaging 30:7087152009


Podsiadlo DRichardson S: The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 39:1421481991


Razay GVreugdenhil ALiddell J: A prospective study of ventriculo-peritoneal shunting for idiopathic normal pressure hydrocephalus. J Clin Neurosci 16:118011832009


Relkin NMarmarou AKlinge PBergsneider MBlack PM: Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 57 (3 Suppl):S4S16ii–v 2005


Sasaki MHonda SYuasa TIwamura AShibata EOhba H: Narrow CSF space at high convexity and high midline areas in idiopathic normal pressure hydrocephalus detected by axial and coronal MRI. Neuroradiology 50:1171222008


Seo JGKang KJung JYPark SPLee MGLee HW: Idiopathic normal pressure hydrocephalus, quantitative EEG findings, and the cerebrospinal fluid tap test: a pilot study. J Clin Neurophysiol 31:5945992014


Stein JLuppa MMaier WWagner MWolfsgruber SScherer M: Assessing cognitive changes in the elderly: reliable change indices for the Mini-Mental State Examination. Acta Psychiatr Scand 126:2082182012


Virhammar JLaurell KCesarini KGLarsson EM: The callosal angle measured on MRI as a predictor of outcome in idiopathic normal-pressure hydrocephalus. J Neurosurg 120:1781842014


Virhammar JLaurell KCesarini KGLarsson EM: Preoperative prognostic value of MRI findings in 108 patients with idiopathic normal pressure hydrocephalus. AJNR Am J Neuroradiol 35:231123182014


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


Wikkelsö CAndersson HBlomstrand CLindqvist GSvendsen P: Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-test. Acta Neurol Scand 73:5665731986


Yamada SKimura TJingami NAtsuchi MHirai OTokuda T: Disability risk or unimproved symptoms following shunt surgery in patients with idiopathic normal-pressure hydrocephalus: post hoc analysis of SINPHONI-2. J Neurosurg 126:200220092017


Yang JDombrowski SMKrishnan CKrajcir NDeshpande AEl-Khoury S: Vascular endothelial growth factor in the CSF of elderly patients with ventriculomegaly: variability, periodicity and levels in drainage responders and non-responders. Clin Neurol Neurosurg 115:172917342013




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