Marupudi Neena I, Harris Carolyn, Pavri Tanya, Mell Brenna, Singh Rasanjeet, Ham Steven D, Sood Sandeep
1Departments of Neurosurgery and Pediatric Neurosurgery, Wayne State University School of Medicine and Children's Hospital of Michigan, Detroit; and.
2Department of Chemical Engineering and Materials Science, Wayne State University College of Engineering, Detroit, Michigan.
J Neurosurg Pediatr. 2018 Dec 1;22(6):632-637. doi: 10.3171/2018.6.PEDS17642. Epub 2018 Sep 21.
OBJECTIVELumboperitoneal (LP) shunts have a role not only in pseudotumor cerebri, but also in patients with slit-like ventricles who are treated with CSF shunting on a chronic basis. Hesitation to utilize LP shunts is based on previous conventional beliefs including the tendency for overdrainage, difficulties accessing the shunt to tap or revise, and risk of progressive cerebellar tonsillar herniation. The authors hypothesized that the use of horizontal-vertical (HV) valves may reduce the risk of these complications, particularly overdrainage and development of Chiari malformation.METHODSAll pediatric cases involving patients treated with an LP shunt at the Children's Hospital of Michigan were reviewed in this retrospective case series. A total of 143 patients with hydrocephalus were treated with LP shunts from 1997-2015 (follow-up range 8 months-8 years, median 4.2 years). Patients with pseudotumor cerebri underwent placement of an LP shunt as a primary procedure. In patients with slit ventricles from chronically treated hydrocephalus or repeated shunt malfunctions from proximal catheter obstruction, a lumbar drain was inserted to assess candidacy for conversion to an LP shunt. In patients who tolerated the lumbar drain and demonstrated communication of the ventricles with the spinal cisterns, treatment was converted to an LP shunt. All patients included in the series had undergone initial shunt placement between birth and age 16 years.RESULTSIn 30% of patients (n = 43), LP shunts were placed as the initial shunt treatment; in 70% (n = 100), treatment was converted to LP shunts from ventriculoperitoneal (VP) shunts. The patients' age at insertion of or conversion to an LP shunt ranged from 1 to 43 years (median 8.5 years). Of the patients with clear pre-LP and post-LP shunt follow-up imaging, none were found to develop an acquired Chiari malformation. In patients with pre-existing tonsillar ectopia, no progression was noted on follow-up MRIs of the brain in these patients after LP shunt insertion. In our LP shunt case series, no patient presented with acute deterioration from shunt malfunction.CONCLUSIONSConversion to an LP shunt may minimize acute deterioration from shunt malfunction and decrease morbidity of repeated procedures in patients with chronically shunt-treated hydrocephalus and small ventricles. In comparison to previously published case series of LP shunt treatment, the use of LP shunts in conjunction with HV valves may decrease the overall risk of cerebellar tonsillar herniation. The use of an LP shunt may be an alternative in the management of slit ventricles when VP shunting repeatedly fails.
目的
腰大池-腹腔（LP）分流术不仅在假性脑瘤中发挥作用，对于裂隙样脑室且长期接受脑脊液分流治疗的患者也有作用。以往人们对使用LP分流术有所犹豫，是基于一些传统观念，包括存在过度引流的倾向、难以接近分流装置进行穿刺或修正，以及有发生进行性小脑扁桃体疝的风险。作者推测使用水平-垂直（HV）瓣膜可能会降低这些并发症的风险，尤其是过度引流和Chiari畸形的发生。
方法
在这个回顾性病例系列中，对密歇根儿童医院所有接受LP分流术治疗的儿科病例进行了回顾。1997年至2015年期间，共有143例脑积水患者接受了LP分流术（随访时间为8个月至8年，中位时间为4.2年）。假性脑瘤患者将LP分流术作为主要治疗手段。对于因慢性脑积水导致裂隙样脑室或近端导管阻塞引起反复分流故障的患者，插入腰大池引流管以评估是否适合转换为LP分流术。对于能够耐受腰大池引流管且脑室与脊髓池相通的患者，治疗转换为LP分流术。该系列纳入的所有患者均在出生至16岁之间接受了初次分流术。
结果
30%的患者（n = 43）将LP分流术作为初次分流治疗；70%（n = 100）的患者是从脑室-腹腔（VP）分流术转换为LP分流术。接受LP分流术或转换为LP分流术时患者的年龄范围为1至43岁（中位年龄8.5岁）。在有明确的LP分流术前和术后随访影像学资料的患者中，未发现有发生后天性Chiari畸形的情况。在术前就存在扁桃体异位的患者中，LP分流术插入后脑部的随访磁共振成像未发现病情进展。在我们的LP分流术病例系列中，没有患者因分流故障出现急性病情恶化。
结论
对于长期接受分流治疗且脑室较小的脑积水患者，转换为LP分流术可将分流故障导致的急性病情恶化降至最低，并降低重复手术的发病率。与先前发表的LP分流术治疗病例系列相比，使用LP分流术结合HV瓣膜可能会降低小脑扁桃体疝的总体风险。当VP分流术反复失败时，使用LP分流术可能是处理裂隙样脑室的一种替代方法。
