Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany.
Department of Neurosurgery, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany.
Fluids Barriers CNS. 2020 Mar 4;17(1):18. doi: 10.1186/s12987-020-00180-w.
After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this group of patients with secondary deterioration and to evaluate the performed shunt management.
For this investigation, we retrospectively reviewed our NPH registry for patients included between 1999 and 2013 with a decrease by a minimum of two points in the Kiefer score in the first year of follow up and an increase of two points in the Kiefer score between the second and the fifth year after shunt surgery (secondary deterioration). Then, we analyzed the patient's shunt management (adapting the valve pressure setting, shuntography, valve replacement, catheter replacement, implant an adjustable gravitational unit). Additionally, we searched for risk factors for secondary deterioration.
Out of 259 iNPH patients, 53 (20%) patients showed secondary deterioration on an average of 2.7 (2-4 years) years after shunt surgery. Fourteen (26%) patients with secondary deterioration improved after shunt or valve management and 58% remained without clinical benefit after management. We had a drop-out rate of 15% due to incomplete datasets. Our shunt management reduced the rate of secondary deterioration from 20 to 15%. On the basis of our findings, we developed an algorithm for shunt management. Risk factors for secondary deterioration are the age of the patient at the time of shunting, newly diagnosed neurodegenerative diseases, and overdrainage requiring adjusting the valve to higher-pressure levels.
Twenty percent of patients with iNPH were at risk for secondary clinical worsening about 3 years after shunt surgery. About one-fourth of these patients benefited for additional years from pressure level management and/or shunt valve revision. Our findings underline the need for long-term follow-ups and intensive shunt management to achieve a favorable long-term outcome for patients with iNPH and VPS.
特发性正常压力脑积水（iNPH）患者在接受可调压重力阀脑室-腹腔分流术后，有一定比例的患者在初始临床症状改善后出现继发性临床恶化。本研究旨在分析这组继发性恶化患者，并评估已行的分流管管理。
为了进行这项研究，我们回顾性地审查了我们的 NPH 登记处，纳入了 1999 年至 2013 年期间的患者，这些患者在随访的第一年中，Kiefer 评分至少降低 2 分，在分流手术后的第 2 年至第 5 年期间，Kiefer 评分增加 2 分（继发性恶化）。然后，我们分析了患者的分流管管理（调整阀门压力设定、分流管造影、更换阀门、更换导管、植入可调压重力单位）。此外，我们还寻找了继发性恶化的危险因素。
在 259 例 iNPH 患者中，53 例（20%）患者在分流手术后平均 2.7 年（2-4 年）出现继发性恶化。14 例（26%）继发性恶化患者在分流管或阀门管理后得到改善，58%的患者在管理后仍无临床获益。由于数据集不完整，我们的失访率为 15%。我们的分流管管理将继发性恶化的发生率从 20%降低到 15%。基于我们的发现，我们制定了一个分流管管理的算法。继发性恶化的危险因素包括分流时患者的年龄、新诊断的神经退行性疾病以及需要将阀门调整到更高压力水平的过度引流。
iNPH 患者在分流手术后约 3 年有 20%的风险出现继发性临床恶化。这些患者中有四分之一左右通过压力水平管理和/或分流阀修正获得了额外数年的获益。我们的发现强调了需要对患者进行长期随访和强化分流管管理，以实现 iNPH 和 VPS 患者的良好长期预后。
