Progressive Functional Underdrainage in Cerebrospinal Fluid Shunt-Dependent Women During Pregnancy: Case Report and Review of the Literature

Krauss, Philipp; Fritz-Naville, Marco; Regli, Luca; Stieglitz, Lennart

doi:10.1016/j.wneu.2017.09.108

Cited by 8 publications

(3 citation statements)

References 28 publications

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“…The cause of non-mechanical shunt Malfunctions is mainly due to the increase in intra-abdominal pressure with weight gain, which results in an increase in intracranial pressure outside the appropriate therapeutic window (in print). Similar shunt malfunctions have been reported rarely in pregnant women ( 30 ). However, its high frequency in iNPH patients may be due to the narrow therapeutic window for valve setting pressure in iNPH patients.…”

Section: Discussionsupporting

confidence: 85%

Impact of Early Intervention for Idiopathic Normal Pressure Hydrocephalus on Long-Term Prognosis in Prodromal Phase

et al. 2022

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ObjectivesBecause the progression of idiopathic normal pressure hydrocephalus (iNPH) is partially irreversible, we hypothesized that early intervention would markedly improve its prognosis. To test this hypothesis, we retrospectively investigated the long-term prognosis of patients with early intervention in the prodromal phase of iNPH.MethodsWe defined the prodromal phase of iNPH as a 3m Timed Up and Go (TUG) of 13.5 s or less and a Mini-Mental State Examination (MMSE) of 24 or more. Of the 83 iNPH patients who underwent shunt surgery at Osaka Medical and Pharmaceutical University Hospital over 3 years from January 2015, 12 prodromal phase cases (73.3 ± 6.2 years, 10 males and 2 females) were included in the study. The iNPH grading scale (INPHGS), MMSE, Frontal Assessment Battery (FAB), intermittent gait disturbance (IGD), social participation status, and development of comorbidities were evaluated over 4 years.ResultsPreoperative MMSE was 27.2 ± 1.5, FAB was 14.1 ± 1.8, TUG was 10.7 ± 1.4 s, and total iNPHGS was 2.8 ± 1.4. At 1, 2, 3, and 4 years postoperatively, total INPHGS improved to 0.8, 0.9, 1.5, and 1.7, respectively, and remained significantly better than preoperatively except at 4 years postoperatively. The MMSE improved slightly to 27.5 after 1 year and then declined by 0.35 per year. After 4 years, the mean MMSE was 26.1, and only one patient had an MMSE below 23. FAB improved to 15.2 after 1 year and then declined slowly at 0.85/year. Ten patients (83%) maintained a high capacity for social participation postoperatively. The preoperative tendency to fall and IGD in 9 (75%) and 8 (67%) patients, respectively, completely disappeared postoperatively, resulting in improved mobility. Shunt malfunction associated with four weight fluctuations and one catheter rupture caused temporary worsening of symptoms, which were recovered by valve re-setting and catheter revision, respectively.ConclusionEarly intervention in the prodromal phase of iNPH patients maintained good cognitive and mobility function and social participation ability in the long term. The maintenance of long-term cognitive function suggests its preventive effect on dementia. To realize early intervention for iNPH, it is desirable to establish an early diagnosis system for iNPH.

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Section: Discussionsupporting

confidence: 85%

Impact of Early Intervention for Idiopathic Normal Pressure Hydrocephalus on Long-Term Prognosis in Prodromal Phase

et al. 2022

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“…On the other hand, as the abdominal volume of a pregnant woman increases, the IAP increases ( 1 ). Therefore, the true cause of underdrainage in pregnancy is not the position of the peritoneal catheter, but the elevated IAP ( 7 ). Thus, the mechanism for underdrainage due to weight gain and underdrainage in pregnant women is almost the same.…”

Section: Discussionmentioning

confidence: 99%

“…We can easily explain this hypothesis from QRT, which shows that a 5 kg change in the body weight can change the optimal valve pressure ( Figure 1 ). However, such shunt malfunctions associated with weight gain and weight loss have not been detected so far, except for those associated with pregnancy ( 7 ).…”

Section: Introductionmentioning

confidence: 99%

Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System

et al. 2022

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ObjectivesWe identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment.MethodsThe total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from −8 to −13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM.ResultsIn four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to −6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to −18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month.ConclusionIn patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.

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Pregnancy and Neuroanesthesia

Tandon

Dhingra

2019

Textbook of Neuroanesthesia and Neurocritical Care

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Progressive Functional Underdrainage in Cerebrospinal Fluid Shunt-Dependent Women During Pregnancy: Case Report and Review of the Literature

Abstract: Conservative treatment of pregnancy-related functional underdrainage by consecutive valve pressure adjustment is possible, easy, and safe.

Cited by 8 publications

References 28 publications

Impact of Early Intervention for Idiopathic Normal Pressure Hydrocephalus on Long-Term Prognosis in Prodromal Phase

Impact of Early Intervention for Idiopathic Normal Pressure Hydrocephalus on Long-Term Prognosis in Prodromal Phase

Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System

Pregnancy and Neuroanesthesia

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