L’IDROCEFALO NORMOTESO

Il Trattamento Chirurgico

Francesco Lupidi

ENTE OSPEDALIERO “OSPEDALI GALLIERA” - GENOVA

S.C. NEUROCHIRURGIA

Direttore: Dr. Paolo Severi

OUTLINE

DISCLOSURE

History

Procedures

Devices

Guidelines

Conflict of interest: none

…a reversible dementia [www.idrocefaloidiopatico.it]

SURGICAL TREATMENT

- Clinic

- Imaging

- Invasive tests: at least one CSF tap test

- Risk-benefit assessment > Comorbidity Index

GOAL

INDICATION

Clinical improvement through unidirectional

diversion of CSF to absorption cavity

effective outflow / pulse-synchronous transient outplacement

HISTORY

Mikulicz-Radecki (1893): cortectomy

Pair (1908): saphenous vein transplantation

Torkildsen (1947): first ventriculocisternostomy

Pudenz (1955): Teflon valve with slit mechanism

Hakim (1964): unidirectional pressure-regulated valve for NPH

…more than 200 shunt designs…

SURGICAL PROCEDURES

SHUNT INSERTION: standard of surgical care

diversion of CSF regulated by one-way flow valve

• Ventriculoperitoneal (lateral ventricles: frontal / occipital)

• Ventriculoatrial

• Ventricolopleural

• Lumboperitoneal (SINPHONI-2 trial)

ENDOSCOPIC THIRD VENTRICULOSTOMY (ETV)

VALVES

SVASONA trial:

gravitational valve reduce the risk

of overdrainage complications

Lemke JNNP 2013

DEVICES

Siphonguard ®

Ventricular Catheter

Reservoir Adjustable valve Gravitational unit

PHYSICS OF VP SHUNTS

Opening Pressure

Boon (Dutch), JNS 1998: 100 vs 40 mm H2O

Lemke (SVASONA), JNNP 2013: 100 > 70 mm H2O

Delwel JNNP 2013 (DEPSS): optimal setting controversial

> highest opening pressure (140 mm H2O)

Pressure at the outlet

Hydrostatic Pressure

Siphoning

Frontal VP SHUNT: SURGICAL PROCEDURE

- General anaesthesia

- Curvilinear frontal skin incision, right precoronal burr hole

- Paraumbilical skin incision

- Subcutaneous tunnelling through shunt-passer (intermediate incisions)

- Ventricular puncture (5.5 cm)

- Connection ventricular catether - valve

- Valve placed in the subgaleal plane (pouch)

- Peritoneum opening - placement of the

distal catheter in the peritoneal cavity

Frontal VP SHUNT: SURGICAL PROCEDURE

Frontal skin incision

Right precoronal burr hole

Subcutaneous tunnelling

Ventricular puncture

TIPS & TRICKS

- Sterility: first case, limited number of personnel,

clippers, drapes, anti-microbial impregnated

catheter, etc.

- Time: straight-forward procedure (1 hour or less),

minimal amount of time for cranial incision

- Minimal intraoperative CSF leakage

OUTCOME: improvement

Toma Acta Neurochir 2013

71%

E iNPH MS 2013 69 / 84%

OUTCOME: complications

Toma Acta Neurochir 2013

16%6.3%

PREDICTORS

Halperin Neurology 2015

- elevated Ro (1 Class I, multiple Class II, level B)

- impaired cerebral blood flow reactivity to acetazolamide

(by SPECT) (1 Class I, level C)

- positive response to either external lumbar drainage (1

Class III) or repeated lumbar punctures (level C)

- Age may not be a prognostic factor (1 Class II, level C).

GUIDELINES

AAN 2015 (AANS and CNS)

Shunting is possibly effective in patients with iNPH

GUIDELINES

Mori Neurol Med Chir (Tokio) 2012

ENDOSCOPIC THIRD VENTRICULOSTOMY (ETV)

• secondary NPH: acquired / developmental etiologies

- Late-onset Idiopathic Aqueductal Stenosis (LIAS)

- Longstanding Overt Ventriculomegaly (LOVA)

• alternative to shunt revision

Selected INDICATIONS:

ETV: SURGICAL PROCEDURE

- standard frontal burr hole

- endoscope advanced through the foramen

of Monro into the third ventricle

-perforation of the floor of the third ventricle

between the infundibular recess and the

anterior border of the mammillary bodies

to enter the prepontine cistern

ETV: OUTCOME

Kandasamy WN 2013

COCHRANE Database

“no randomized controlled trials of shunt placement versus no shunt were found”

> “no evidence to indicate whether placement of a shunt is effective in the management of NPH”

“no randomised clinical trials were found”

> “no evidence…that shunt valves differ with regard to clinical outcome,

shunt failure, or intervention risks.”

“the only randomised trial of ETV for iNPH compares it to an intervention which is not a

standard practice . The evidence from this study is inconclusive and of very low quality.”

2002

2015

2015

but…lack of evidence does not mean evidence of absence

Incidence of hydrocephalus surgery increased significantly during 2004 - 2011,

specifically in elderly patients

BJN 2017

Incidence iNPH surgery: 0.91/100,000/year

3-month FU in 704 patients:

the mean score of the modified iNPH scale increased from 53.7 ±

23.1 preoperatively to 63.0 ± 24.8 postoperatively (p < .0001)

Proportion improved vs. those who did not improve was not dependent on age

when using the modified iNPH scale or the MMSE,

but the oldest patient group had significantly worse outcome than the younger group

when assessed by the mRS scale

PREOPERATIVE Video

POSTOPERATIVE Video: 6 months

DISCUSSION / CONCLUSIONS

- Safe ed effective management (proper selection)

- Long lasting improvement (even after shunt revision)

- Aging: older patient increasingly operated improved QOL

- Role of physiotherapy

- Need for randomized controlled trials

GRAZIE PER

L’ATTENZIONE!