Giordan Enrico, Palandri Giorgio, Lanzino Giuseppe, Murad Mohammad Hassan, Elder Benjamin D
1Department of Neurologic Surgery and.
2IRCCS Institute of Neurological Sciences of Bologna, Division of Neurosurgery, Bellaria Hospital, Bologna, Italy.
J Neurosurg. 2018 Nov 23;131(4):1024-1036. doi: 10.3171/2018.5.JNS1875. Print 2019 Oct 1.
Different CSF diversion procedures (ventriculoperitoneal, ventriculoatrial, and lumboperitoneal shunting) have been utilized for the treatment of idiopathic normal pressure hydrocephalus. More recently, endoscopic third ventriculostomy has been suggested as a reasonable alternative in some studies. The purpose of this study was to perform a systematic review and meta-analysis to assess overall rates of favorable outcomes and adverse events for each of these treatments. An additional objective was to determine the outcomes and complication rates in relation to the type of valve utilized (fixed vs programmable).
Multiple databases (PubMed, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) were searched for studies involving patients with idiopathic ventriculomegaly, no secondary cause of hydrocephalus, opening pressure < 25 mm Hg on high-volume tap or drainage trial, and age > 60 years. Outcomes included the proportion of patients who showed improvement in gait, cognition, and bladder function. Adverse events considered in the analysis included postoperative ischemic/hemorrhagic complications, subdural fluid collections, seizures, need for revision surgery, and infection.
A total of 33 studies, encompassing 2461 patients, were identified. More than 75% of patients experienced improvement after shunting, without significant differences among the different techniques utilized. Overall, gait improvement was observed in 75% of patients, cognitive function improvement in more than 60%, and improvement of incontinence in 55%. Adjustable valves were associated with a reduction in revisions (12% vs 32%) and subdural collections (9% vs 22%) as compared to fixed valves.
Outcomes did not differ significantly among different CSF diversion techniques, and overall improvement was reported in more than 75% of patients. The use of programmable valves decreased the incidence of revision surgery and of subdural collections after surgery, potentially justifying the higher initial cost associated with these valves.
不同的脑脊液分流术（脑室腹腔分流术、脑室心房分流术和腰大池腹腔分流术）已被用于治疗特发性正常压力脑积水。最近，在一些研究中，内镜下第三脑室造瘘术被认为是一种合理的替代方法。本研究的目的是进行系统评价和荟萃分析，以评估这些治疗方法各自的总体良好结局率和不良事件发生率。另一个目的是确定与所用瓣膜类型（固定型与可调节型）相关的结局和并发症发生率。
检索了多个数据库（PubMed、Ovid MEDLINE在研及其他未索引引文、Ovid MEDLINE、Ovid Embase、Ovid Cochrane对照试验中央注册库、Ovid Cochrane系统评价数据库和Scopus），以查找涉及特发性脑室扩大、无继发性脑积水病因、在大量引流或引流试验中开放压力<25mmHg且年龄>60岁的患者的研究。结局包括步态、认知和膀胱功能改善的患者比例。分析中考虑的不良事件包括术后缺血性/出血性并发症、硬膜下积液、癫痫发作、翻修手术需求和感染。
共确定了33项研究，涉及2461例患者。超过75%的患者在分流术后病情改善，不同技术之间无显著差异。总体而言，75%的患者步态改善，超过60%的患者认知功能改善，55%的患者失禁改善。与固定瓣膜相比，可调节瓣膜与翻修手术（12%对32%）和硬膜下积液（9%对22%）的减少相关。
不同脑脊液分流技术的结局无显著差异，超过75%的患者报告有总体改善。使用可调节瓣膜降低了翻修手术的发生率和术后硬膜下积液的发生率，这可能证明这些瓣膜较高的初始成本是合理的。
