Migration complications of lumboperitoneal shunts

Background

Lumboperitoneal (LP) shunts have been described as a safe and effective option for idiopathic intracranial hypertension (IIH). However, it had many complications, including migration. Herein, we report our experience regarding the incidence, different sites, presentation, and management of LP shunt migration in patients with IIH.

Patients and methods

This retrospective series reviewed the data of IIH patients who had migration after LP shunt during the period between January 2018 and June 2021.

Results

From 67 patients who had LP shunt, 12 patients developed shunt migration. Two cases had intrathecal migration, while three cases had intraperitoneal migration. In four cases, the distal tube migrated to the subcutaneous location at the abdomen, whereas the other two cases had the proximal tube migrated outside the thecal sac to the subcutaneous location in the back. In one case, the distal tube migrated from the abdomen to the back subcutaneously.

Conclusion

The insertion of LP shunts appears to be a relatively safe technique. Shunt migration, on the other hand, is a common side effect. While various theories have been proposed to explain shunt migration, good shunt fixation remains the most critical component in preventing shunt migration.

Creating of “fascial sheath” around subcutaneous lumboperitoneal shunt catheters largely prevents postoperative subcutaneous shunt catheter migration

Background:

Spinal catheter migration into the subcutaneous tissue is common after lumboperitoneal shunt (LPS) placement. This study proposed a new method (i.e., wrapping fascia around the catheter like a sheath) to prevent LPS spinal catheter migration.

Methods:

After a LPS spinal catheter was inserted under routine fluoroscopic guidance, and the paravertebral muscle fascia was closed, the fascia was sutured to wrap the catheter like a sheath using intermittent sutures.

Results:

Before the introduction of this technique, the rate of LPS spinal catheter subcutaneous migration was 4.6%. In this study, following LPS shunt placement in 18 consecutive patients with normal pressure hydrocephalus, no further spinal catheter migrations were observed.

Conclusion:

This novel method of “wrapping the LPS catheter with intermittent suture like a sheath” was found to be safe and effective for preventing further spinal catheter subcutaneous migration.

Dural sac shrinkage signs on spinal magnetic resonance imaging indicate overdrainage after lumboperitoneal shunt for idiopathic normal pressure hydrocephalus

Background:

We previously found the usefulness of dural sac shrinkage signs (DSSSs), which are the anterior shift of the spinal cord and dura mater behind the cord, detected by magnetic resonance imaging (MRI) at the thoracic level for the diagnosis of spontaneous intracranial hypotension (IH). This is a retrospective survey on the usefulness of DSSSs for the early detection of iatrogenic IH caused by overdrainage through a lumboperitoneal shunt (LPS) for patients with idiopathic normal pressure hydrocephalus (INPH).

Methods:

Forty-five INPH patients had an LPS using a pressure programmable valve equipped with an anti-siphon device.

Results:

Nine patients complained of orthostatic headache after the LPS, indicating IH due to overdrainage, which persisted for more than a week in three patients and 2–7days in six patients. The headache was transient/ nonorthostatic in ten patients and absent in 26 patients. The DSSSs and accompanying enlargement of the venous plexus were observed in all three patients with prolonged orthostatic headaches. Only the anterior shift of the dura mater was observed in 1 (4%) among 25 patients who had short-term orthostatic headache, transient/ nonorthostatic headache, or absent headache, and underwent spinal MRI. A patient with prolonged severe orthostatic headache with both DSSSs eventually developed intracranial subdural effusion and underwent tandem valve surgery, which provided a quick improvement of symptoms. The DSSSs on thoracic MRI also disappeared promptly.

Conclusion:

DSSSs may serve as objective signs for the diagnosis of IH due to overdrainage through an LPS for INPH.

Transversus abdominis plane block for lumboperitoneal shunt surgery in idiopathic normal pressure hydrocephalus: a case report

The transversus abdominis plane (TAP) block is an ideal pain control method used in surgeries that require abdominal wall incisions through the injection of an anesthetic solution into the plane between the internal oblique muscle and transversus abdominis muscle. Herein, we report an 83-year-old man who was diagnosed with idiopathic normal pressure hydrocephalus (iNPH) and underwent lumboperitoneal shunt surgery (LPS). The TAP block was performed before LPS, and the numerical rating scale for pain was 0 at day 1 after the surgery. The patient was discharged early at day 3 after surgery despite the patient being extremely old, as he reported quick relief from the postoperative abdominal pain. The TAP block can hence be considered for use before LPS in elderly patients with iNPH.

Outcome of idiopathic intracranial hypertension after laparoscopic sleeve gastrectomy

BACKGROUND

Idiopathic intracranial hypertension (IIH) predominantly affects young, obese women and presents with signs and symptoms of increased intracranial pressure, such as headaches and visual impairment.

OBJECTIVE

We aim to present our experience in the management of IIH.

SETTING

University Hospital.

METHODS

Obese IIH patients who had a laparoscopic sleeve gastrectomy during the study period (2 years) were included. Data were retrieved from prospectively collected database. Headaches, visual alterations, and medications or interventions used to treat are discussed.

RESULTS

The study included 16 obese women with IIH. Mean age was 31 ± 2 years (range, 25-44 yr) and mean body mass index was 46 ± 4 kg/m² (range, 42-53 kg/m²). Main symptoms and signs were chronic headaches (14), impaired vision (15), vision loss (1), papilledema (6), and field defects in 4 patients. Symptoms were present for a mean of 5 years (4-11). History of medical treatment with carbonic anhydrase inhibitor (acetazolamide) and thecoperitoneal shunting was present in 12 and 9 patients, respectively. Mean lumbar puncture opening pressure was 41.2 ± 21- (range, 30-64) cm water. At 12 months after laparoscopic sleeve gastrectomy, body mass index and percentage excess weight loss were 27.8 ± 1 kg/m² and 75.2 ± 2%, respectively. Symptoms gradually improved with complete resolution in all but 2 patients (87.5%).

CONCLUSION

The present work emphasizes the role of bariatric surgery in the management of obese patients with IIH. Larger, prospective, controlled studies are needed.

One-year outcome in patients with idiopathic normal-pressure hydrocephalus: comparison of lumboperitoneal shunt to ventriculoperitoneal shunt

OBJECTIVE

Idiopathic normal pressure hydrocephalus (iNPH) is treated with cerebrospinal fluid shunting, and implantation of a ventriculoperitoneal shunt (VPS) is the current standard treatment. The objective of this study was to compare the efficacy and safety of VPSs and lumboperitoneal shunts (LPSs) for patients with iNPH.

METHODS

The authors conducted a prospective multicenter study of LPS use for patients with iNPH. Eighty-three patients with iNPH (age 60 to 85 years) who presented with ventriculomegaly and high-convexity and medial subarachnoid space tightness on MR images were recruited from 20 neurological or neurosurgical centers in Japan between March 1, 2010, and October 19, 2011. The primary outcome was the modified Rankin Scale (mRS) score 1 year after surgery, and the secondary outcome included scores on the iNPH grading scale (iNPHGS). A previously conducted VPS cohort study with the same inclusion criteria and primary and secondary end points was used as a historical control.

RESULTS

The proportion of patients who achieved a favorable outcome (i.e., improvement of at least 1 point in their mRS score) was 63% (95% CI 51%–73%) and was comparable to values reported with VPS implantation (69%, 95% CI 59%–78%). Using the iNPHGS, the 1-year improvement rate was 75% (95% CI 64%–84%) and was comparable to the rate found in the VPS study (77%, 95% CI 68%–84%). The proportion of patients experiencing serious adverse events (SAEs) and non-SAEs did not differ significantly between the groups at 1 year after surgery (SAEs: 19 [22%] of 87 LPS patients vs 15 [15%] of 100 VPS patients, p = 0.226; non-SAEs: 24 [27.6%] LPS patients vs 20 [20%] VPS patients, p = 0.223). However, shunt revisions were more common in LPS-treated patients than in VPS-treated patients (6 [7%] vs 1 [1%]).

CONCLUSIONS

The efficacy and safety rates for LPSs with programmable valves are comparable to those for VPSs for the treatment of patients with iNPH. Despite the relatively high shunt failure rate, an LPS can be the treatment of choice because of its minimal invasiveness and avoidance of brain injury.