Hebb A O, Cusimano M D
Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.
Neurosurgery. 2001 Nov;49(5):1166-84; discussion 1184-6. doi: 10.1097/00006123-200111000-00028.
Patient selection for cerebrospinal fluid diversion is difficult, because idiopathic normal pressure hydrocephalus (INPH) mimics other neurodegenerative disorders and no findings reliably predict outcome. The literature was reviewed to identify diagnostic criteria that predict shunt response and to formulate prognostic expectations.
MEDLINE was searched, and 44 articles meeting predetermined criteria were included.
Clinical series were frequently retrospective with small patient numbers and unstandardized outcome evaluation. Clinical findings suggestive of shunt responsiveness were the complete triad (gait disturbance, urinary incontinence, and dementia) with early gait disturbance. Degree of hydrocephalus was not correlated with clinical improvement. Reduction of the subcortical low-blood flow area was correlated with improvement in three small studies. Clinical response to prolonged cerebrospinal fluid drainage predicted shunt outcome in all cases in two small series. Overall, 59% (range, 24-100%) of patients improved after shunting, and 29% (range, 10-100%) of patients experienced prolonged improvement. Complications occurred in 38% (range, 5-100%) of patients, additional surgery was required in 22% (range, 0-47%) of patients, and there was a 6% (range, 0-35%) combined rate of permanent neurological deficit and death.
Shunting INPH is associated with an approximately 29% rate of significant improvement and a 6% significant complication rate. Enlargement of the subcortical low-flow area and clinical improvement secondary to prolonged lumbar drainage may provide additive predictive value above clinical and computed tomographic criteria. A multicenter clinical trial that focuses on the value of ancillary tests, defines the clinical course of a patient with a ventriculoperitoneal shunt, and evaluates the cost effectiveness of shunting INPH is needed to better describe outcome from shunting in INPH.
脑脊液分流术的患者选择较为困难，因为特发性正常压力脑积水（INPH）会模仿其他神经退行性疾病，且没有任何发现能够可靠地预测治疗结果。对相关文献进行综述，以确定可预测分流反应的诊断标准，并制定预后预期。
检索MEDLINE，纳入44篇符合预定标准的文章。
临床系列研究多为回顾性研究，患者数量少且结局评估未标准化。提示分流反应性的临床发现为具有早期步态障碍的完整三联征（步态障碍、尿失禁和痴呆）。脑积水程度与临床改善无关。在三项小型研究中，皮质下低血流区域的缩小与改善相关。在两项小型系列研究中，延长脑脊液引流的临床反应在所有病例中均能预测分流结果。总体而言，59%（范围24%-100%）的患者分流后病情改善，29%（范围10%-100%）的患者病情得到长期改善。38%（范围5%-100%）的患者出现并发症，22%（范围0%-47%）的患者需要再次手术，永久性神经功能缺损和死亡的综合发生率为6%（范围0%-35%）。
INPH分流术约有29%的显著改善率和6%的显著并发症发生率。皮质下低血流区域扩大以及延长腰段引流后临床改善可能比临床和计算机断层扫描标准具有更大的预测价值。需要开展一项多中心临床试验，重点关注辅助检查的价值，明确脑室腹腔分流患者的临床病程，并评估INPH分流术的成本效益，以更好地描述INPH分流术的治疗结果。
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