Salih Ahmed, Arif Aksaan, Varadpande Madhur, Fernandes Rafael Tiza, Jankovic Dragan, Kalasauskas Darius, Ottenhausen Malte, Kramer Andreas, Ringel Florian, Thavarajasingam Santhosh G
School of Medicine, Imperial College London, London, United Kingdom.
Imperial Brain and Spine Initiative, Imperial College London, London, United Kingdom.
EClinicalMedicine. 2024 Oct 30;77:102891. doi: 10.1016/j.eclinm.2024.102891. eCollection 2024 Nov.
Idiopathic normal pressure hydrocephalus (iNPH) is commonly treated using cerebrospinal fluid (CSF) diversion procedures, most commonly ventriculoperitoneal (VP) but also lumboperitoneal (LP), ventriculoatrial (VA) shunting, and endoscopic third-ventriculostomy (ETV). Despite the prevalence of these interventions and recent advancements in iNPH diagnostic processes, there is limited up-to-date evidence regarding surgical outcomes.
A systematic review and meta-analysis were conducted to analyse the effects of CSF diversion surgeries among iNPH patients. The primary outcome was efficacy of the CSF diversion procedure, defined as symptomatic improvement, and secondary outcomes included surgical complications. Several major databases were searched for original studies from inception up to June 4, 2024, which were evaluated using random-effects meta-analyses, meta-regression, and influence analyses. This study was registered with PROSPERO: CRD42023458526.
Out of the 1963 studies screened, 54 were included in this review, and 4811 patients were pooled. Overall, more than 74% of patients experienced improvement after surgical treatment (95% CI: 70-78%). VP shunting demonstrated an efficacy of 75% (95% CI 70-79%), VA shunting at 75% (95% CI: 70-80%), and LP shunting at 70% (95% CI: 52-83%). ETV had a success rate of 69% (95% CI: 58-78%). Gait improvement was high at 72% (95% CI: 67-77%), while urinary and cognitive dysfunction each improved in approximately 50% of patients. The efficacy of surgery did not increase between 2005 and 2024 (p = 0.54). Complications occurred in 20.6% of cases, with a surgery revision rate of 15.1%.
This meta-analysis found that the overall efficacy of CSF diversion procedures for iNPH remained unchanged from 2005 to 2024, with 74% of cases showing improvement. No procedure was found to be clearly superior, and only half of the patients saw improvements in urinary and cognitive dysfunction. The stagnant efficacy over time and frequent complications highlight the need for improved patient selection criteria to best identify those most likely to benefit from CSF shunting.
None for this study.
特发性正常压力脑积水（iNPH）通常采用脑脊液（CSF）分流术进行治疗，最常见的是脑室腹腔（VP）分流术，但也包括腰大池腹腔（LP）分流术、脑室心房（VA）分流术和内镜下第三脑室造瘘术（ETV）。尽管这些干预措施很普遍，且iNPH诊断方法最近也有进展，但关于手术结果的最新证据有限。
进行了一项系统评价和荟萃分析，以分析CSF分流手术对iNPH患者的影响。主要结局是CSF分流手术的疗效，定义为症状改善，次要结局包括手术并发症。检索了几个主要数据库，以查找从数据库建立到2024年6月4日的原始研究，使用随机效应荟萃分析、荟萃回归和影响分析对这些研究进行评估。本研究已在国际前瞻性系统评价注册库（PROSPERO）注册：CRD42023458526。
在筛选的1963项研究中，本评价纳入了54项研究，共汇总了4811例患者。总体而言，超过74%的患者在手术治疗后症状改善（95%置信区间：70%-78%）。VP分流术的疗效为75%（95%置信区间70%-79%），VA分流术为75%（95%置信区间：70%-80%），LP分流术为70%（95%置信区间：52%-83%）。ETV的成功率为69%（95%置信区间：58%-78%）。步态改善率较高，为72%（95%置信区间：67%-77%），而尿失禁和认知功能障碍患者各有大约50%得到改善。2005年至2024年期间手术疗效未增加（p = 0.54）。20.6%的病例发生并发症，手术翻修率为15.1%。
这项荟萃分析发现，2005年至2024年期间，CSF分流术治疗iNPH的总体疗效保持不变，74%的病例症状改善。未发现哪种手术明显更优，只有一半的患者尿失禁和认知功能障碍得到改善。随着时间推移疗效停滞不前以及并发症频发，凸显了需要改进患者选择标准，以更好地识别最可能从CSF分流术中获益的患者。
本研究无资金支持。
