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Lumboperitoneal shunt (LPS) has been an effective treatment of idiopathic normal pressure hydrocephalus (iNPH) but sometimes causes serious complications. Here we present the first reported case of cerebral venous thrombosis (CVT) after LPS. A 76-year-old man underwent LPS for iNPH and a week later developed weakness of the right arm and a generalized tonic-clonic seizure. Brain computed tomography and magnetic resonance imaging showed bilateral subdural hematoma (SDH) and left cortical vein thrombosis. Intravenous heparin was administered, followed by surgical evacuation of the SDH. The patient experienced gradual improvement and was subsequently discharged. It is conceivable that overdrainage of cerebrospinal fluid led to the development of both SDH and CVT. CVT is potentially fatal and should be recognized early as a possible complication after LPS to allow prompt treatment.

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Idiopathic intracranial hypertension (IIH) is a condition in which intracranial pressure (ICP) increases without an apparent cause. Typically, patients present with headaches, dizziness, pulsatile tinnitus, visual disturbances, blurred vision, diplopia, photophobia, visual field defects, and papilledema on fundoscopy. The association between IIH, spontaneous cerebrospinal fluid (CSF) rhinorrhea, and arachnoid cysts has been discussed in the literature; however, there is no clear explanation for this association. We aimed to present a series of four patients with a confirmed diagnosis of IIH with atypical presentations, discuss the management of each case, and provide an explanation for this association to alert clinicians to the atypical presentation of IIH and facilitate early diagnosis and proper treatment of this condition by CSF diversion. This was a retrospective case series of all patients who were diagnosed with IIH and showed improvement after ventriculoperitoneal shunt insertion after failure of at least one operative intervention resulting from primary radiological and clinical findings in 2001 to 2022. Data on demographics, clinical presentation, radiological findings, surgical management, and diagnostic criteria for IIH were recorded. We identified four patients with a confirmed diagnosis of IIH who presented with atypical presentations as follows: intracranial arachnoid cyst, cervical spine arachnoid cyst, giant Virchow perivascular space, and spontaneous CSF (CSF) rhinorrhea. All patients responded to CSF diversion after failure of surgical treatment targeting the primary pathology. IIH should be suspected after the failure of primary surgical treatment in cases of spontaneous CSF rhinorrhea, spinal and cranial arachnoid cysts, and symptomatic ventriculoperitoneal shunt. Treatment in such situations should be directed toward IIH with CSF diversion.

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BACKGROUND: Adjustable shunt valves that have been developed for managing hydrocephalus rely on intrinsically magnetic components ; thus, artifacts with these valves on magnetic resonance imaging (MRI) are inevitable. No studies on valve-induced artifacts in lumboperitoneal shunt (LPS) surgery have been published. Therefore, this study aimed to evaluate valve-induced artifacts in LPS. METHODS: We retrospectively reviewed all MRIs obtained between January 2023 and June 2023 in patients with an implanted Codman CERTAS Plus adjustable shunt valve (Integra Life Sciences, Princeton, New Jersey, USA). The valve was placed <1 cm subcutaneously on the paravertebral spinal muscle of the back, with its long axis perpendicular to the body axis. The scans were performed using a Toshiba Medical Systems 1.5 Tesla scanner. The in-plane artifact sizes were assessed as the maximum distance of the artifact from the expected region of the back. RESULTS: All spinal structures or spinal cords can be recognized, even with valve-induced artifacts. The median maximum valve-induced artifact distance on T1-weighted axial imaging was 25.63 mm (mean, 25.98 mm ; range, 22.24-30.94 mm). The median maximum valve-induced artifact distance on T2-weighted axial imaging was 25.56 mm (mean, 26.27 mm ; range, 21.83-29.53 mm). CONCLUSION: LPS surgery with adjustable valve implantation on paravertebral muscles did not cause valve-induced artifacts in the spine and spinal cord. We considered that LPS could simplify the postoperative care of these patients. J. Med. Invest. 71 : 154-157, February, 2024.

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Cerebrospinal fluid rhinorrhea associated with meningoencephalocele is usually treated surgically. During the perioperative period, cerebrospinal fluid diversion may be employed to control intracranial pressure, but there are few indications for this method. A 51-year-old female presented with cerebrospinal fluid rhinorrhea associated with meningoencephalocele and underwent surgical repair followed by the placement of a lumboperitoneal shunt. However, cerebrospinal fluid leakage recurred, requiring a second surgery. Lumbar drainage effectively controls intracranial pressure, but it does not cure bone defects. The use of these devices should be carefully considered based on the patient's condition.

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Objective: Chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) results in poor neurological outcomes and cognitive deficits. Currently, the main treatments for chronic hydrocephalus include ventriculoperitoneal shunt (VPS) and lumboperitoneal shunt (LPS); however, the optimal treatment for chronic hydrocephalus after aSAH remains controversial. Method: The records of 82 patients were retrospectively analyzed, and the patients were divided into VPS and LPS groups based on surgical methods. The efficacy, shunt successful rate and complications were compared. The assessments of treatment efficacy included the Evans index score (EIS), Keifer's hydrocephalus score (KHS), Mini-Mental State Examination (MMSE) score and functional independence measure (FIM). Patients were followed up for three months to observe the postoperative curative effects and complications. Results: The rate of shunt obstruction was significantly higher in the LPS group than that in the VPS group (p < 0.05), and the shunt successful rate was significantly higher in the VPS group than that in the LPS group (p < 0.05). The total rate of complications was 24.4% for LPS and 39% for VPS. The improvements in EIS, KHS, MMSE, and FIM within each group after the shunt were significantly different compared to those before shunt (p < 0.05). Compared to those in the LPS group, the improvements in EIS, KHS, MMSE, and FIM were significantly different in the VPS group after shunt (p < 0.05). Conclusion: Compared with LPS, VPS in the treatment for chronic hydrocephalus after aSAH had greater therapeutic efficacy, as indicated by improved radiological outcomes, improved shunt successful rate, improved clinical outcomes, and improved quality of life. Therefore, we believe that VPS is the preferred treatment option for chronic hydrocephalus after aSAH, while LPS should only be used as an alternative to VPS.

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Background: Despite the proven benefits of lumboperitoneal shunt (LPS) for idiopathic normal-pressure hydrocephalus, complications such as catheter migration remain a problem. Inguinal complications of the distal catheter are rare in adults, and their management is uncertain. Herein, we present two cases of distal catheter migration into the inguinal hernia sac after LPS in adults and recommend their management. Case Description: An 86-year-old man presented with inguinal swelling. In another 82-year-old man who did not show any improvement after LPS, shunt angiography revealed LPS dysfunction due to lumbar catheter occlusion and distal LPS catheter in the right inguinal hernia sac, and lumbar catheter reconstruction was performed. Both patients did not have any symptoms, except inguinal swelling, and were followed up. After 2 weeks and 4 days, the distal catheter moved into the peritoneal cavity. Conclusion: Inguinal complications due to the migration of the distal catheter into the inguinal hernia sac are rare in LPS because frequent movements of the distal catheter due to trunk rotation dislodge it from the inguinal hernia sac for a short period. Urgent surgery was not recommended because the catheter was moved in a short period and the patients did not wish to undergo hernia repair.

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We report a patient with idiopathic intracranial hypertension (IIH) with bilateral transverse sinus occlusion treated by a lumboperitoneal shunt. A 45-year-old woman presented with visual disturbance and chronic headache. Magnetic resonance (MR) venography and three-dimensional computed tomography angiography (3D-CTA) showed occlusion of both transverse sinuses. After the surgery, MR venography and 3D-CTA showed no blockages in both transverse sinuses. This phenomenon reveals that obstruction of the bilateral transverse sinus is a consequence of intracranial hypertension, not just a single cause. Since many patients have an obstruction or stenosis of the venous sinus, there are some reports of endovascular treatment. Sinus reconstruction is usually effective, but it is not effective in some cases. Reversal of sinus occlusion suggests that endovascular therapy for IIH is inadequate in some cases.

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Ventriculoperitoneal (VP) shunt infections are associated with increased risk of morbidity and mortality from complications such as meningitis, ventriculitis, shunt malfunction and in some cases, recurrence of infection. Brevibacterium and Corynebacterium are gram positive organisms that are rarely implicated in VP shunt infections but are more commonly associated with colonization of dialysis and central venous catheters. Typical microbiological isolates in VP shunt infections include Staphylococcus aureus, Staphylococcus epidermidis and gram-negative rods. Here, we describe the case of a young woman who had VP shunt placement for over a decade without any history of infection, and now presented with new-onset VP shunt co-infection with Brevibacterium and Corynebacterium organisms.

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Idiopathic normal pressure hydrocephalus (iNPH) with gait disturbance can be effectively treated with a cerebrospinal fluid shunt. Furthermore, balloon kyphoplasty (BKP) is a successful minimally invasive treatment for osteoporotic vertebral compression fractures (VCFs). This case report presents the surgical management of an elderly patient with iNPH who presented after a VCF due to a fall. A 77-year-old woman who had been experiencing progressive gait disturbance for five years reported experiencing back pain one month after a fall. Imaging revealed a recent L1 VCF that did not compromise the spinal canal. Furthermore, the Mini-Mental State Examination results and the timed up-and-go test were 20 points and 17.96 seconds, respectively. Magnetic resonance imaging revealed ventriculomegaly with an Evans' index of 0.35. Her symptoms improved temporarily after a tap test, and she was diagnosed with probable iNPH. BKP was performed for VCFs, followed by the lumboperitoneal (LP) shunt placement for iNPH one month later. Following the operation, her symptoms improved without complications. After one month of performing BKP, an LP shunt would be placed to prevent shunt complications, such as infection and catheter-related neurological symptoms. Screening for iNPH in the elderly who present after VCFs due to a fall may identify iNPH patients who may benefit more from surgical treatments.

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A 75-year-old man presented with bilateral lower limb weakness to our hospital from another clinic. Radiological examinations implied the possibilities of idiopathic normal pressure hydrocephalus (iNPH) and a suprasellar cyst, but both were observed conservatively at that time. Due to the progressive gait disturbance, a lumboperitoneal shunt was implanted 1 year later. The clinical symptoms improved, but the cyst had grown after another year, causing visual impairment. Transsphenoidal drainage of the cyst was performed, but delayed pneumocephalus occurred. Repair surgery was performed with temporary suspension of shunt function, but pneumocephalus relapsed two and a half months after the resumption of shunt flow. In the second repair surgery, the shunt was removed because it was assumed that it would prevent closure of the fistula by lowering intracranial pressure. Two and a half months later, after confirming involution of the cyst and no pneumocephalus, a ventriculoperitoneal shunt was implanted, and cerebrospinal fluid (CSF) leakage has not relapsed since then. The coexistence of idiopathic normal pressure hydrocephalus (iNPH) and Rathke's cleft cyst (RCC) is rare, but it can occur. RCC can be cured by simple drainage, but delayed pneumocephalus can occur in cases whose intracranial pressure decreases due to CSF shunting. When simple drainage without sellar reconstruction for RCC is attempted after CSF shunting for coexistent iNPH, attention should be paid to changes in intracranial pressure, and it is desirable to stop the flow of the shunt for a certain period.

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Since the publication of guidelines for managing idiopathic normal pressure hydrocephalus (iNPH) in 2004, an increasing number of patients with iNPH have been undergoing shunt surgery in Japan. However, shunt surgeries for iNPH can be challenging because the procedures are performed on elderly patients. General anesthesia-related risks, such as postoperative pneumonia or delirium, are higher in the elderly. To decrease these risks, we applied spinal anesthesia on a lumboperitoneal shunt (LPS). Herein, we analyzed our methods focusing on the postoperative outcomes. We retrospectively analyzed 79 patients who underwent LPS at our institution with more than one year of follow-up. The patients were divided into two groups based on the anesthetic approach, that is, 1) general anesthesia and 2) spinal anesthesia, and were examined in terms of postoperative complications, delirium, and postoperative hospital stay. In the general anesthesia group, two patients had respiratory complications after the surgery. The postoperative delirium score using the intensive care delirium screening checklist (ICDSC) was 0 (2) (median [interquartile range]), and the length of postoperative hospital stay was 11 (4) days. In the spinal anesthesia group, no patients had respiratory complications. The postoperative mean ICDSC was 0 (1), and the length of postoperative hospital stay was 10 (3) days. Although there was no significant difference regarding postoperative delirium existed, LPS under spinal anesthesia decreased respiratory complications and significantly shortened the postoperative hospital stay. LPS under spinal anesthesia could be an alternative to general anesthesia in elderly patients with iNPH and possibly lessen the general anesthesia-related risks.

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Blake's pouch cyst is a congenital disease in which the ventricle enlargement is a non-communicating hydrocephalus. Some elderly patients have a process of the idiopathic normal pressure hydrocephalus (communicating hydrocephalus). We report an elderly patient with Blake's pouch cyst. A 68-year-old man visited our hospital with a gait disturbance that had begun 2 years previously but had become aggravated. He did not have dementia or urinary disturbance. CT scan and MRI showed the hydrocephalus included an IV ventricle, and the cerebrocerebellar fluid space in the posterior fossa was large. A Tap test was positive, so we attempted lumboperitoneal shunt, and his gait disturbance improved.

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Objective: This study aimed to evaluate the functional outcomes of lumboperitoneal (LP) shunt for the treatment of non-obstructive hydrocephalus. Methods: We retrospectively studied the clinical surgical results of 172 adult patients with hydrocephalus who underwent LP shunt surgery between June 2014 and June 2019. Data regarding the following were collected: pre- and postoperative symptom status, third ventricle width changes, Evans index, and postoperative complications. Additionally, the baseline and follow-up Glasgow Coma Scale (GCS) score, Glasgow Outcome Scale (GOS), and Modified Rankin Scale (mRS) scores were investigated. All patients were followed up for ≥12 months using clinical interview and braining imaging using computed tomography (CT) scan or magnetic resonance imaging (MRI). Results: Majority of patients presented with normal pressure hydrocephalus as the etiology of their disease (48.8%), followed by cardiovascular accident (28.5%), trauma (19.7%), and brain tumor (3%). The mean GCS, GOS, and mRS improved postoperatively. The average period from symptomatic onset to surgery was 402 days. The average width of the third ventricle on CT scan or MRI was 11.43 mm preoperatively and 10.8 mm postoperatively (P<0.001). The Evans index improved from 0.258 to 0.222 after operation. The symptomatic improvement score was 7.0, with a complication rate of 7%. Conclusion: Significant improvement was observed in the functional score and brain image after LP shunt placement. Moreover, the satisfaction with symptomatic improvement after surgery remains high. LP shunt operation is a viable alternative in the treatment of non-obstructive hydrocephalus due to the low complication rate, fast recovery, and high satisfaction.

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[This corrects the article DOI: 10.3389/fneur.2022.1059316.].

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INTRODUCTION: The current standard surgical treatment for cerebrospinal fluid diversion is a ventriculoperitoneal shunt (VPS) implantation. Lumboperitoneal shunts (LPS) are an alternative treatment for communicating hydrocephalus. Prior studies comparing these two included a limited number of participants. METHODS: We performed a meta-analysis determined the treatment failure, complications and effectiveness of lumboperitoneal shunt for communicating hydrocephalus. We reviewed studies with clinical and imaging diagnoses of communicating hydrocephalus, all causes and subtypes of communicating hydrocephalus, and studies that analyzed the primary and secondary outcomes listed below. We included randomized controlled trials (RCTs), non-RCTs and retrospective studies. We performed the meta-analysis in R, using a random-effects model and reporting 95% confidence intervals. RESULTS: Data from 25 studies, including 3654 patients, were analyzed. The total complication rates were 12.98% (188/1448) for lumboperitoneal shunt and 23.80% (398/1672) for ventriculoperitoneal shunt. The odds ratio for lumboperitoneal shunt versus ventriculoperitoneal shunt complication rates was 0.29 (95% CI 0.19 to 0.45, p < 0.0001), and the I2 was 72%. The shunt obstruction/malfunction rate was 3.99% (48/1204) for lumboperitoneal shunt and 8.31% (115/1384) for ventriculoperitoneal shunt (Odds ratio 0.54, 95% CI 0.37 to 0.79, p = 0.002, I2  = 0%). Based on the Modified Rankin Scale score, there were no differences in effectiveness between lumboperitoneal shunt and ventriculoperitoneal shunt. Nevertheless, lumboperitoneal shunt improved radiological outcomes. CONCLUSIONS: This analysis demonstrated that lumboperitoneal shunt is a safe and equally effective choice for treating communicating hydrocephalus. More studies are needed to confirm the safety of lumboperitoneal shunt.

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Tonsillar herniation is a rare and seldom reported complication after lumboperitoneal (LP) shunting. There have been only few reports that have presented possible options for treatment with varying degrees of success. In this report, we describe a rare case of tonsillar herniation after LP shunting and review related literature.A 17-year-old girl with hydrocephalus related to a traumatic brain injury underwent implantation of an adjustable pressure shunt (valve setting2.5) and a small lumen peritoneal catheter via the L4-L5 interspinal space. One month later, she was admitted to the emergency room with a Glasgow Coma Scale score ofE1M1Vt and dilated pupil. Image studies demonstrated new-onset tonsillar herniation and a mild cervical syrinx. Emergent suboccipital decompressive craniectomy, C1 laminectomy, and duraplasty were performed. This was followed with ligation of the LP shunt and implantation of a ventriculoperitoneal (VP) shunt a few days later. The patient's Glasgow Coma Scale score gradually recovered to 6, which was her previous neurologic status.Tonsillar herniation as a complication after LP shunting is best treated with decompression, ligation or removal of the LP shunt, and a shift to a VP shunt. The tonsillar herniation should be rapidly addressed to avoid persistent symptoms or progression of the neurologic deficits.

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Background: Lumboperitoneal (LP) shunt placement is a good option for treating elderly patients with communicating normal pressure hydrocephalus (NPH) who are also on antiplatelet therapy following endovascular treatment of unruptured bilateral internal carotid artery aneurysms. Here, in an 80-year-old male with an LP shunt, the catheter was "pinched" between adjacent spinous processes, resulting in laceration of the catheter and intrathecal catheter migration. Case Description: An 80-year-old male was treated with a LP shunt for NPH 1 year after undergoing endovascular treatment of unruptured bilateral internal carotid artery aneurysms. The lumbar catheter was placed at the L2-3 level. Six months later, when he clinically deteriorated, the follow-up computed tomography showed recurrent ventricular enlargement. Further, studies additionally confirmed intrathecal migration of the lumbar catheter, warranting secondary ventriculoperitoneal shunt placement. Conclusion: Patients with LP shunts may develop lumbar catheter lacerations secondary to a "pinching" effect from adjacent spinous processes, resulting in intrathecal catheter migration.

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Background: Lumboperitoneal shunt (LPS) is an effective procedure for managing communicating hydrocephalus. LPS is performed as a one-stage procedure with the patient placed in the lateral position or as a two-stage procedure in which the patient's position is changed. Both methods can be bothersome to neurosurgeons. We designed a continuous two-stage LPS procedure in which the operative sites did not need to be sterilized again, and the surgical drapes did not have to be changed after changing the patient's position. In this study, we analyzed this procedure in terms of the technical features and outcomes. Methods: All patients from our institute who underwent LPS using the continuous two-stage procedure from October 2019 to August 2021 were reviewed retrospectively. The patient's demographic information, clinical features, operative data, and outcomes were analyzed. Results: A total of 46 consecutive patients who underwent LPS using the continuous two-stage procedure were enrolled. The mean operative duration was 70.6 ± 12.7 min. The 180-day revision rate for these patients was 2.2% (1/46). Moreover, 76.1% of the patients (35/46) experienced clinical improvement after LPS during the 180-day follow-up, and 70.0% of the patients (32/46) experienced an improvement in neuroimaging. Conclusion: We described a continuous two-stage LPS procedure. This method simplified the two-stage LPS procedure and maintained a low malfunction rate and shunt infection rate in our series.

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Background: Spinal catheter insertion in lumboperitoneal shunt (LPS) surgery for normal pressure hydrocephalus (NPH) can result in radiculopathy due to mechanical irritation of the nerve roots of the cauda equina. Here, we analyzed the position of LPS shunts placed without portable fluoroscopy in 72 patients, a subset of whom developed postoperative radiculopathy. Methods: We retrospectively analyzed how frequently 72 consecutive NPH patients experienced radiculopathy following LPS catheter placement performed without intraoperative fluoroscopy. Results: The rate of incorrect catheter placement was 15.3% (11/72 cases). We observed that is, downward placement in 6.9% (5/72 cases), hyperflexion in 6.9% (5/72 cases), and subcutaneous migration in 1.4% (1/72 cases) patients. One patient with initial correct LPS placement developed radicular pain 5-day postoperatively attributed to 1-cm of catheter movement; they recovered simply by utilizing oral analgesics for 1-month duration. Conclusion: LPS insertion without fluoroscopic guidance resulted in a 15.3% risk of spinal catheter displacement. We suggest, therefore, that intraoperative imaging guidance be utilized for the placement of LPS in patients with NPH and/or for other pathology to avoid the 15.3% risk of postoperative radiculopathy.

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Pseudomeningocele (PMC) is a rare complication of anterior cervical procedures resulting in pain, headaches, nerve root entrapment, and in rare cases, spinal cord compression. Here we present a 57-year-old male with increasing myelopathy due to late-onset PMC that developed two years following a 360-degree cervical surgery for ossification of the posterior longitudinal ligament (OPLL). In this case, the PMC was successfully treated with a lumboperitoneal shunt. A 57-year-old male presented with worsening symptoms and signs of cervical myelopathy. He had undergone a multilevel anterior corpectomy/fusion (ACCF), along with posterior fusion, two years earlier for severe ossification of the posterior longitudinal ligament (OPLL). Now presenting with increased myelopathy, his cervical spine MRI demonstrated a PMC in the perivertebral space, extending to and compressing the anterior cervical cord. Following a lumboperitoneal shunt insertion, the patient's myelopathy resolved.  Acute, subacute, or chronic postoperative cervical pseudomeningoceles (PMC) may be readily managed with a lumboperitoneal shunt insertion.