Complications of Ventriculoperitoneal Shunt for Idiopathic Intracranial Hypertension: A Single-Institution Study of 32 Patients

Abstract

Background: Because there are no head-to-head studies of the efficacy of surgical options in the treatment of medicallyintractable idiopathic intracranial hypertension (IIH), procedure selection is often based on expected complications. Cerebrospinal fluid (CSF) diversion by shunting has been reported to have a 23%-67% rate of shunt failure. But thesefigures derive from small cohorts or studies that do not separate the complication rates of the different shunt options-ventriculoperitoneal (VP), lumboperitoneal (LP), and ventriculoatrial (VA). The complication rate of LP shunts seems to be higher than that for VP shunts, the procedure currently in widest use. Our experience with VP shunts for IIH over the past decades suggests that the complication rate for that option is lower than reported series would suggest. Methods: Retrospective single-institutional study using a search engine that finds all text mentions of particular terms. We searched for the terms ("IIH" OR "Idiopathic intracranial hypertension" OR "PTC OR "pseudotumor") AND ("VP Shunt" OR "ventriculoperitoneal") over the period 1998 to 2018. From 490 "hits," only 32 patients met entry criteria: diagnosis of IIH confirmed at our institution, including examination in a neuro-ophthalmology clinic showing papilledema, elevated opening pressure on lumbar puncture or a consistently elevated intraparenchymal pressure on Codman intracranial pressure (ICP) monitoring, neuroimaging and CSF studies consistent with a diagnosis of IIH, and at least 1 year of follow-up in our neuroophthalmology or neurosurgery clinics. Results: Shunt failures occurred in 6 (18.7%) of 32 patients, which included elevated ICP due to obstruction or discontinuity of the shunt, over-drainage, infection of the shunt system, or intractable abdominal pain or infection. None of these failures caused permanent worsening of vision, neurologic morbidity, or death. But they entailed considerable medical care. Placement of VP shunts also aroused patient fear of complications, precipitating 38 emergency visits in 14 patients for "false alarms."Conclusions: In this series of 32 patients, the largest retrospective study of VP shunts for IIH, there was an 18.7% failure rate, lower than previously published smaller series have disclosed. But among patients who suffered complications, a saga of intensive medical care often occurred. Placement of the shunt also aroused patient fear of complications, leading to many medical encounters required to rule out complications.

Cerebrospinal fluid shunting protocol for idiopathic intracranial hypertension for an improved revision rate

“…14,15 The frequency of shunting for IIH, based on the literature, varies between 1.1 and 12.3 shunts per year, and our rate of 11.6 falls at the high end of the range. 9,20,21,[23][24][25][26][27][28]30,31 Nonetheless, the frequency is still less than 1 shunt per month and is even lower in most centers. In neurosurgery, most evidence on the positive impact of subspecialization comes from brain tumor surgery, but there has been an increasing trend toward concentrating expertise in many subspecialties.…”

Resolution of venous pressure gradient in a patient with idiopathic intracranial hypertension after ventriculoperitoneal shunt placement: A proof of secondary cerebral sinovenous stenosis

“…However, this modality can be complicated by the patients’ body habitus, slit-like ventricles, and high rates of shunt failure. [ 2 ] Endovascular treatment with VSS has recently emerged as an effective alternative to CSF diversion in patients with IIH and CSS with trans-stenosis gradient of (≥8 mmHg). [ 12 ] There are no clear cut guidelines on choosing between these two treatment modalities because of the ambiguity surrounding the pathophysiology of IIH.…”

What Is the Best Surgical Intervention for Patients With Idiopathic Intracranial Hypertension?

“…It should be noted that in study of Brune et al of 32 patients undergoing VPS, although the percentage of patients who experienced failure was 6 of 32 (18.7%), there were actually 12 failures among them, yielding a rate of 37.5%. 63 Furthermore, each failure was accompanied by complications that resulted in significant morbidity, including an iatrogenic enterotomy requiring intravenous antibiotics, 2 intracerebral hemorrhages (one with cerebral edema, reversible hemiparesis, and seizures), 1 patient with abdominal adhesions, a CSF–cutaneous fistula behind the ear and several bouts of meningitis (bacterial and fungal), and meningitis in 2 others. In the study by Huang et al, only 48% of VPS were still functioning without revision or replacement at 3 years.…”