Idiopathic normal pressure hydrocephalus: Validation of the DESH score as a prognostic tool for shunt surgery response.

OBJECTIVE: Several radiological markers have been linked to clinical improvement after shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). However, iNPH has no pathognomonic feature, and patients are still diagnosed as probable, possible, or unlikely cases based on clinical symptoms, imaging findings, and invasive supplementary tests. The predictive value of the disproportionately enlarged subarachnoid space hydrocephalus (DESH) score is not yet conclusively determined, but it might offer a more accurate diagnostic method. The aim of the present retrospective cohort study was to validate the predictive power of the DESH score for clinical improvement after shunt surgery in iNPH patients. METHODS: We retrospectively obtained presurgical MRI and/or CT scans from 71 patients with iNPH who underwent ventriculoperitoneal shunt surgery. Radiological images were evaluated for Evans index (EI), corpus callosal angle (CA), tight high convexity (THC), Sylvian fissure dilation, and focal sulci dilation. These markers were aggregated to determine the DESH score. Patient journal entries were used to subjectively determine the extent of improvement in gait function, urinary incontinence, and/or cognition as a measure of shunt surgery response. RESULTS: Multiple logistic regression analysis, controlling for age and sex (α = 0.05), showed that DESH score was significantly correlated (OR 1.77) with subjective shunt-surgery response at a minimum of 1-month follow-up. Patients with higher DESH scores were more likely to have a favorable response to shunt surgery. CONCLUSION: Aggregating radiological markers into the DESH score is useful for predicting shunt responders among iNPH patients and can aid the selection of patients for surgery. These findings provide further support for the DESH score as a diagnostic tool for iNPH.

Prognostic Factors in Idiopathic Normal Pressure Hydrocephalus Patients After Ventriculo-Peritoneal Shunt: Results from a Single-Institution Observational Cohort Study with Long Term Follow-Up.

OBJECTIVE: The aim of this study is to investigate long-term prognostic factors and clinical outcomes in patients with idiopathic normal pressure hydrocephalus (iNPH) treated with ventriculo-peritoneal shunt (VPS). METHODS: This single-center retrospective observational study of prospectively collected data included patients with probable iNPH treated with VPS surgery. All patients underwent complete preoperative assessment, including past medical history and neurological examination, dynamic cerebrospinal fluid (CSF) flow brain magnetic resonance imaging (MRI), and preoperative CSF samplings. NPH-consistent brain MRI findings and favorable responses to CSF subtraction tests were the main factors considered for VPS surgery eligibility. All patients were subsequently followed up every six to twelve months (mean follow-up time 40 months, minimum to maximum interval 6-150 months). RESULTS: A total of 238 patients with a diagnosis of probable iNPH treated with VPS were enrolled. Age, comorbidities, and response to CSF samplings were not significantly associated with a better long-term outcome after VPS surgery. The results of our retrospective analysis demonstrated a statistically significant association between the presence of preoperative aqueductal CSF flow acceleration on dynamic brain MRI and neurological outcomes at 12 and 18 months after VPS surgery. CONCLUSIONS: Long-term outcomes of iNPH patients treated with VPS surgery do not appear to be directly influenced by preoperative comorbidities, age, or responses to CSF samplings. Alterations in preoperative brain MRI CSF dynamics were found to be related to long-term outcomes following VPS surgery, highlighting the role of radiological assessment as a prognostic factor in patients deemed suitable candidates for VPS surgery.

Microscopic internal spermatic-inferior epigastric vein anastomosis for treating left varicocele.

OBJECTIVE: To evaluate the clinical efficacy of microscopic internal spermatic-inferior epigastric vein anastomosis in the treatment of left varicocele and compare it with microscopic spermatic vein ligation for the same condition. METHODS: A retrospective analysis of 74 patients with left varicocele between July 2020 and July 2022 was performed. The patients were divided into two groups based on the surgical method used. Group A consisted of 37 patients who underwent microscopic internal spermatic-inferior epigastric vein anastomosis, while Group B consisted of 37 patients who underwent microscopic spermatic vein ligation. Comparison of preoperative and postoperative semen quality, reproductive hormone levels, scrotal ultrasound results, duration of surgery, length of hospital stay, postoperative recurrence rate, and occurrence of complications with a follow-up time of 12 mo between two groups. RESULTS: Both groups showed significant improvements in semen quality and serum reproductive hormone levels. The Group A demonstrated significantly improved sperm forward motility compared to Group B, but had longer operation times and hospital stays (P < 0.05). After 1 year of follow-up, 8 partners in Group A and 6 partners in Group B achieved natural conception, with no significant difference between the two groups. There were no recurrences observed in either group during the follow-up period, and no significant statistical differences were found in other postoperative observation indicators. CONCLUSIONS: Both microscopic internal spermatic-inferior epigastric vein anastomosis and microscopic spermatic vein ligation are effective surgical methods for treating left varicocele. Anastomosis surgery provides greater improvement in sperm motility, although it is associated with longer operation times and hospital stays.

Comparing Outcomes of Tube Versus Trabeculectomy Among Patients With Angle-closure Glaucoma.

PURPOSE: Compare outcomes of tube shunt surgery (Tube) and trabeculectomy with mitomycin C (Trab-MMC) in patients with angle-closure glaucoma (ACG). DESIGN: Retrospective nonrandomized comparative study. PARTICIPANTS: A total of 80 eyes from 80 patients with ACG who underwent either Tube (N = 50) or Trab-MMC (N = 30) between January 2015 and January 2022 at Massachusetts Eye and Ear. METHODS: Reviewed and analyzed 390 visits from patient charts. MAIN OUTCOME MEASURES: Kaplan-Meier (KM) success rates, intraocular pressure (IOP), medication burden, best-corrected visual acuity (BCVA), adjusted hazard ratios (HRs), and complications. RESULTS: Baseline demographics were similar between both groups, except for a higher proportion of patients with pseudophakia and prior incisional ocular surgery in the Tube group. The Trab-MMC procedure had significantly higher KM complete success (CS) rates than the Tube procedure, but similar qualified success (QS) rates. Under QS, the cumulative probability of survival was 87% in the Tube group and 83% in the Trab-MMC group at year 1 (P = 0.77), and 75% in the Tube group and 58% in the Trab-MMC group at year 2 (P = 0.14). Under CS, the cumulative probability of survival was 13% in the Tube group and 59% in the Trab-MMC group at year 1 (P < 0.001), and 11% in the Tube group and 41% in the Trab-MMC group at year 2 (P < 0.001). Both Tube and Trab-MMC procedures resulted in significant patterns of IOP and medication reduction from baseline up to 2 years with mean IOP reduced to 12.6 ± 5.9 mmHg on 2.8 ± 1.4 medications after Tube and 12.1 ± 6.6 mmHg on 2.4 ± 1.7 medications after Trab-MMC. Patients who underwent Trab-MMC required less IOP-lowering medications at every follow-up visit up to year 1, but a similar number at year 2. No significant differences were found in IOP reduction, BCVA, or complication rates between groups. CONCLUSIONS: We demonstrate that Trab-MMC confers similar IOP reduction and QS rates to Tube placement in patients with ACG. Trab-MMC, however, demonstrated greater medication burden reduction up to 1 year, and more favorable CS rates up to 2 years, while still maintaining similar complication rates to Tube. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Optimization of number and range of shunt valve performance levels in infant hydrocephalus: a machine learning analysis.

Shunt surgery is the main treatment modality for hydrocephalus, the leading cause of brain surgery in children. The efficacy of shunt surgery, particularly in infant hydrocephalus, continues to present serious challenges in achieving improved outcomes. The crucial role of correct adjustments of valve performance levels in shunt outcomes has been underscored. However, there are discrepancies in the performance levels of valves from different companies. This study aims to address this concern by optimizing both the number and range of valve performance levels for infant hydrocephalus, aiming for improved shunt surgery outcomes. We conducted a single-center cohort study encompassing infant hydrocephalus cases that underwent initial shunt surgery without subsequent failure or unimproved outcomes. An unsupervised hierarchical machine learning method was utilized for clustering and reporting the valve drainage pressure values for all patients within each identified cluster. The optimal number of clusters corresponds to the number of valve performance levels, with the valve drainage pressure ranges within each cluster indicating the pressure range for each performance level. Comparisons based on the Silhouette coefficient between 3-7 clusters revealed that this coefficient for the 4-cluster (4-performance level) was at least 28.3% higher than that of other cluster formations in terms of intra-cluster similarity. The Davies-Bouldin index for the 4-performance level was at least 37.2% lower than that of other configurations in terms of inter-cluster dissimilarity. Cluster stability, indicated by a Jaccard index of 71% for the 4-performance level valve, validated the robustness, reliability, and repeatability of our findings. Our suggested optimized drainage pressure ranges for each performance level (1.5-5.0, 5.0-9.0, 9.0-15.0, and 15.0-18.0 cm H2O) may potentially assist neurosurgeons in improving clinical outcomes for patients with shunted infantile hydrocephalus.

Visual Field Outcomes in the Primary Tube Versus Trabeculectomy Study.

PURPOSE: To describe visual field outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. DESIGN: Cohort analysis. PARTICIPANTS: A total of 155 eyes (155 subjects) randomly assigned to treatment with tube shunt surgery (n = 84) or trabeculectomy with mitomycin C (n = 71). METHODS: The PTVT Study was a multicenter randomized clinical trial comparing the safety and efficacy of trabeculectomy and tube shunt surgery in eyes without previous intraocular surgery. Subjects underwent standard automated perimetry (SAP) at baseline and annually for 5 years. Standard automated perimetry tests were deemed reliable if the false-positive rate was ≤ 15%. Tests were excluded if visual acuity was ≤ 20/400 or loss of ≥ 2 Snellen lines from baseline because of a nonglaucomatous etiology. Linear mixed-effects models were used to compare rates of change in SAP mean deviation (MD) between the 2 groups. Intraocular pressure (IOP) control was assessed by percentage of visits with IOP < 18 mmHg and mean IOP. MAIN OUTCOME MEASURES: Rate of change in SAP MD during follow-up. RESULTS: A total of 730 SAP tests were evaluated (average of 4.7 tests per eye). The average SAP MD at baseline was -12.8 ± 8.3 decibels (dB) in the tube group and -12.0 ± 8.4 dB in the trabeculectomy group (P = 0.57). The mean rate of change in SAP MD was -0.32 ± 0.39 dB/year in the trabeculectomy group and -0.47 ± 0.43 dB/year in the tube group (P = 0.23). Eyes with mean IOP 14 to 17.5 mmHg had significantly faster rates of SAP MD loss compared with eyes with mean IOP < 14 mmHg (-0.59 ± 0.13 vs. -0.27 ± 0.08 dB/year; P = 0.012), and eyes with only 50% to 75% of visits with IOP < 18 mmHg had faster rates than those with 100% of visits with IOP < 18 mmHg (-0.90 ± 0.16 vs. -0.29 ± 0.08 dB/year; P < 0.001). Multivariable analysis identified older age and worse IOP control as risk factors for faster progression in both treatment groups. CONCLUSIONS: No statistically significant difference in mean rates of visual field change was observed between trabeculectomy and tube shunt surgery in the PTVT Study. Worse IOP control was significantly associated with faster rates of SAP MD loss during follow-up. Older patients were also at risk for faster progression.

Incidence and Outcomes of Hypertensive Phase After Glaucoma Drainage Device Surgery.

PURPOSE: To describe the incidence, risk factors, clinical characteristics, and long-term outcomes of a hypertensive phase (HP) after glaucoma drainage device (GDD) implantation. DESIGN: Retrospective cohort study. PARTICIPANTS: Eyes that underwent implantation of their first GDD from January 2010 to October 2020 at a tertiary care center. METHODS: Hypertensive phase was defined as intraocular pressure (IOP) >21 mmHg occurring at 2 consecutive visits in the first 90 days after the date of surgery for Ahmed Glaucoma Valve (AGV) or in the first 90 days after tube opening for Baerveldt Glaucoma Implant (BGI). Generalized estimating equations and Fisher exact tests were used to evaluate risk factors for HP and risk factors for failure of GDD surgery after occurrence of a HP. MAIN OUTCOME MEASURES: Incidence and risk factors for HP. Overall surgical success rates, defined as the absence of failure criteria: IOP >21 mmHg, ≤5 mmHg, or <20% reduction below baseline IOP after 3 months for 2 consecutive visits, with or without adjunctive ocular hypotensive therapy; additional glaucoma surgery; or loss of light perception. RESULTS: Among 419 eyes of 360 patients that underwent GDD implantation, 42 (10.0%) eyes developed HP. Onset of HP was 20.8 ± 10.5 days after AGV and 11.7 ± 20.3 days from the date of tube opening after BGI. Mean IOP during HP was 26.5 ± 3.2 mmHg with peak IOP of 30.0 ± 5.9 mmHg. Median follow-up duration was 21.5 months after onset of HP. Younger age and neovascular glaucoma were significant risk factors for HP occurrence in a multivariable model. Resolution of HP occurred in 32 eyes (76.2%) after a mean duration of 48.0 ± 53.0 days. Additional surgery with a second GDD or cyclophotocoagulation was performed for 12 eyes (28.6%). The overall success rate among eyes with a HP was 52.6% at 2 years, which was significantly lower than that observed among control eyes that did not experience HP (76.3%), P < 0.01. CONCLUSIONS: The incidence of HP was 10.0%. Younger age and neovascular glaucoma were significant risk factors for HP in the multivariable model. The risk of surgical failure after HP is significantly higher compared to eyes that did not experience HP. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Cerebrospinal fluid shunt surgery reduces the risk of developing dementia and Alzheimer's disease in patients with idiopathic normal pressure hydrocephalus: a nationwide population-based propensity-weighted cohort study.

BACKGROUND: Patients with idiopathic normal-pressure hydrocephalus (iNPH) are predisposed to developing dementing disorders. Cerebrospinal fluid (CSF) shunt implantation is a treatment used to improve the motor and cognitive disabilities of these patients; however, its effect on the risk of developing dementing disorders remains unclear. We conducted a population-based propensity-weighted cohort study to investigate whether CSF shunt surgery may reduce the risk of subsequently developing dementia, Alzheimer's disease (AD), and vascular dementia in iNPH patients. METHODS: Patients aged ≥ 60 years who were diagnosed with iNPH (n = 2053) between January 2001 and June 2018 were identified from the Taiwan National Health Insurance Research Database. Various demographic characteristics (age, sex, and monthly income) and clinical data (incidence year, comorbidities, and Charlson comorbidity index) were collected and divided into the shunt surgery group (SSG) and the non-shunt surgery group (NSSG). Stabilized inverse probability of treatment weighting by using the propensity score was performed to achieve a balanced distribution of confounders across the two study groups. The cumulative incidence rate and risk of dementing disorders were estimated during a 16-year follow-up period. RESULTS: After weighting, the data of 375.0 patients in SSG and 1677.4 patients in NSSG were analyzed. Kaplan-Meier curve analysis indicated that the cumulative incidence rate of AD (p = 0.009), but not dementia (p = 0.241) and vascular dementia (p = 0.761), in SSG was significantly lower than that in NSSG over the 16-year follow-up period. Cox proportional hazards regression analysis revealed that SSG had a reduced hazard ratio (HR) for developing AD [HR (95% CI) 0.17 (0.04-0.69)], but not for dementia [HR (95% CI) 0.83 (0.61-1.12)] and vascular dementia [HR (95% CI) 1.18 (0.44-3.16)], compared with NSSG. Further Fine-Gray hazard regression analysis with death as a competing event demonstrated that SSG had a reduced subdistribution HR (sHR) for developing dementia [sHR (95% CI) 0.74 (0.55-0.99)] and AD [sHR (95% CI) 0.15 (0.04-0.61)], but not for vascular dementia [sHR (95% CI) 1.07 (0.40-2.86)]. CONCLUSION: CSF shunt surgery is associated with reduced risks of the subsequent development of dementia and AD in iNPH patients. Our findings may provide valuable information for assessing the benefit-to-risk profile of CSF shunt surgery.

[Clinical features and effects of shunt surgery in patients with progressive supranuclear palsy and idiopathic normal pressure hydrocephalus].

This study aimed to retrospectively review the frequency and clinical features of 13 patients with progressive supranuclear palsy (PSP) and idiopathic normal pressure hydrocephalus (iNPH). All patients were found to have PSP-Richardson's syndrome (PSP-RS). Shunt surgery was effective in 5 of 11 patients (45.5%). A comparison of these 5 patients who responded to shunt surgery versus the remaining 6 patients revealed a significant difference in the reduction of frontal lobe blood flow on cerebral perfusion single-photon emission computed tomography (SPECT) (P = 0.018). These results suggest that PSP-RS is common in patients with PSP and iNPH and indicate the usefulness of cerebral perfusion SPECT in estimating the effect of shunt surgery.

Effect of Early Aqueous Suppression After Valved Tube Shunt Surgery for Uveitic Glaucoma.

PURPOSE: To compare outcomes of early aqueous suppression (EAS) and standard therapy (ST) after Ahmed Glaucoma Valve (AGV) implantation for uveitic glaucoma. DESIGN: Retrospective comparative cohort study. PARTICIPANTS: All patients with uveitic glaucoma underwent AGV implantation from January 2010 to October 2020 at Northwestern Medicine. METHODS: Excluding the first postoperative day 1 (POD1), only eyes with IOP 10-15 mmHg at their first visit with IOP ≥ 10 mmHg were included in the main analysis. Early aqueous suppression (EAS) was defined as initiation of ocular hypotensive therapy when IOP was first 10-15 mmHg. Standard therapy was initiation of therapy at any later time. Failure was defined as IOP > 21 mmHg, < 5 mmHg, or < 20% reduction in IOP from baseline after 3 months, for 2 consecutive study visits. Hypotony was defined as IOP ≤ 5 mmHg for ≥ 2 visits. Hypertensive phase was defined as IOP > 21 mmHg for 2 consecutive visits in the first 3 months. MAIN OUTCOME MEASURES: Proportion achieving overall success; incidence of hypotony and hypertensive phase. RESULTS: Twenty-eight eyes of 26 patients were in the EAS group and 20 eyes of 19 patients were in the ST group, with a mean follow-up of 17.7 and 28.2 months, respectively. Baseline IOP was similar in the EAS (31.2 ± 10.1 mmHg) and ST (34.6 ± 12.2 mmHg) groups; P = 0.18. Final IOP was lower in the EAS group (12.9 ± 4.6 mmHg) than the ST group (16.4 ± 5.7 mmHg; P = 0.02) on 2.6 ± 0.9 medications in the EAS group and 1.8 ± 1.5 in the ST group (P = 0.07). Overall success was achieved in 87% of EAS eyes and 74% of ST eyes (P = 0.43). There were no statistically significant differences in the occurrence of additional glaucoma surgery (4% for EAS, 20% for ST; P = 0.11), hypotony (7% for EAS, 0% for ST; P = 0.50), or hypertensive phase (4% for EAS, 21% for ST; P = 0.09). CONCLUSIONS: EAS was associated with a lower final IOP after AGV in uveitic glaucoma eyes; however, more medications were in use at the final visit. No statistically significant differences in overall success or the incidence of adverse events were observed. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Post-traumatic hydrocephalus: An overview of classification, diagnosis, treatment, and post-treatment imaging evaluation.

The syndrome of post-traumatic hydrocephalus (PTH) has been recognized since Dandy's report in 1914. The pathogenesis of PTH has not been fully clarified. At present, it is believed that the obstacles of cerebrospinal fluid (CSF) secretion, absorption and circulation pathways are the reasons for the development of PTH. However, recent studies have also suggested that the osmotic pressure load of CSF and the pathological changes of CSF dynamics are caused by the development of hydrocephalus. Therefore, a better understanding of the definition, classification, diagnostic criteria, treatment, and evaluation of post-treatment effects of PTH is critical for the effective prevention and treatment of PTH. In this paper, we reviewed the classification and diagnosis of PTH and focused on the treatment and the imaging evaluation of post-treatment effects of PTH. This review might provide a judgment criterion for diagnosis of PTH and a basis for the effective prevention and treatment of PTH in the future.

The necessity of gait evaluation on the 7th day after tap tests for the idiopathic normal pressure hydrocephalus patients.

BACKGROUND: A tap test is established as an evaluation method to indicate shunt surgery for hydrocephalus, especially idiopathic normal pressure hydrocephalus (iNPH). The timing of gait assessment after the test is still controversial, while some studies reported the effectiveness of the gait evaluation up to 2nd day after tap tests. Our study explored whether the gait evaluation on the 7th day after a tap test is necessary. METHODS: We retrospectively evaluated 129 consecutive cases with possible iNPH who performed gait assessment on all 1st, 3rd, and 7th days after tap tests between May 2020 and February 2022. We reviewed the following items of the patients: age, sex, modified Rankin scale, iNPH grading scale, Mini-Mental State Evaluation (MMSE), and neurological imaging. The number of probable iNPH patients who improved their gait each day after the test was analyzed. We also assessed the number of definite iNPH patients and revealed the background characteristics of the patients who showed gait improvement on the 7th day after the tests. RESULTS: Of the 129 patients who met our inclusion criteria, 57 were judged as probable iNPH on the 1st day, 28 were new on the 3rd, and 23 were new on the 7th. The number of probable iNPH patients up to the 7th day after tests was significantly more extensive than that of those up to the 3rd (108 [83.7%] vs. 85 [65.9%]; 95% confidence interval [CI], p < 0.0001). The number of definite iNPH patients was also significantly more prominent when the evaluation after the tests was performed on all of the 1st, the 3rd, and the 7th days than just on the 1st (72 vs. 42; 95% CI, p = 0.00016) or both of the 1st and the 3rd (72 vs. 61; 95% CI, p = 0.00074). No statistically significant difference existed in the patients' backgrounds except for the pre-tap test MMSE. CONCLUSION: Gait evaluation on the 7th day after tap tests, in addition to the first few days, may reduce the number of iNPH patients who miss the opportunity of getting beneficial treatment.

Gait Analysis in Idiopathic Normal Pressure Hydrocephalus: A Meta-Analysis.

Background: Gait analysis objectively quantifies gait impairment in idiopathic normal pressure hydrocephalus (iNPH), may improve diagnosis and evaluation for surgical candidacy. Objectives: This meta-analysis aims to understand which objective gait parameters improve after tap-test (TT) and CSF shunt surgery (CSS), also comparing responders (R) with non-responders (NR) and to assess if gait restores within the range of healthy controls after procedures. Methods: Studies enrolling iNPH with at least one instrumented gait measure were selected. Three time points of gait assessment were defined: PRE, POST-TT, and POST-CSS. Gait velocity, cadence, step length, stride length, and double limb support time were evaluated. Patients were categorized based on responsiveness to CSF diversion procedures. Results: Seventeen studies including 527 patients were selected. iNPH improved significantly in almost all gait parameters POST-TT, and to a greater extent POST-CSS. Gait parameters consistently discriminated iNPH from healthy controls. Despite the aforementioned improvements, iNPH's gait did not completely normalize after CSF diversion procedures. Meta-regression analysis also revealed that TT's effect on gait velocity plateaus after 24-48 hr and returns to baseline in 90-100 hr. Conclusions: Gait analysis is a reliable quantitative instrument to assess gait impairment in iNPH, demarking a net differentiation from healthy controls, according to the notion that the iNPH CSF dynamic alteration also leads to an irreversible damage. Specific gait parameters improve among TT-R, providing an opportunity to select patients that will respond to CSS. Future studies validating a standardized reporting method including criteria of responsiveness, specific gait parameters, and timeframe of assessment are needed.

Successful Treatment of Detachment of the Incision after Al-Ghorab Procedure: A Case Report and Review of Literature.

Al-Ghorab procedure is known as open distal shunt for the treatment of ischemic priapism. In the literature, no information in terms of complications is available in three of fourteen studies. In the remaining eleven studies, complications occurred in five studies only. Here we present a case report describing successful treatment of detachment of the incision after Al-Ghorab procedure.

Ahmed Glaucoma Valve Implantation to Reduce Intraocular Pressure: Updated Perspectives.

Trabeculectomy and glaucoma drainage device implantation are the most commonly performed glaucoma surgeries worldwide. Although trabeculectomy is the gold standard, at the present time there is an increase in the use of glaucoma drainage devices. The Ahmed glaucoma valve is one of the most widely used glaucoma drainage devices worldwide. Corneal endothelial cell loss and eventually corneal decompensation is one of the serious complication of glaucoma drainage device implantation. To avoid this, drainage tube can be inserted into the ciliary sulcus instead of the anterior chamber, especially in eyes with high risk for corneal decompensation. Tube/plate exposure, hypertensive phase, endophthalmitis, cataract formation, diplopia and ocular hypotony are the other potential complications that can develop after Ahmed glaucoma valve implantation.

Current research of idiopathic normal pressure hydrocephalus: Pathogenesis, diagnosis and treatment.

Idiopathic normal pressure hydrocephalus (iNPH) is caused by impaired cerebrospinal fluid absorption in the elderly; it is a surgically treatable form of dementia. Gait disturbance, dementia, and urinary incontinence are the triad of signs for iNPH. In addition to these clinical findings, imaging studies show characteristic ventricular enlargement. High Evans Index and 'disproportionately enlarged subarachnoid hydrocephalus' are other well-known imaging findings of iNPH. If the tap test shows improved symptoms, shunt surgery is performed. The disease was first described by Hakim and Adams in 1965, followed by the publication of the first, second, and third editions of the guidelines in 2004, 2012, and 2020, respectively. Recent studies signal the glymphatic system and classical cerebrospinal fluid (CSF) absorption from the dural lymphatics as aetiological mechanisms of CSF retention. Research is also underway on imaging test and biomarker developments for more precise diagnosis, shunting technique options with fewer sequelae and complications, and the influence of genetics. Particularly, the newly introduced 'suspected iNPH' in the third edition of the guidelines may be useful for earlier diagnosis. However, less well-studied areas remain, such as pharmacotherapy in non-operative indications and neurological findings other than the triadic signs. This review briefly presents previous research on these and future issues.

Open versus laparoscopic ventriculoperitoneal shunt placement in children: a systematic review and meta-analysis.

BACKGROUND: Ventriculoperitoneal shunt (VPS) surgery is the traditional method for treating hydrocephalus, remaining one of the most regularly used procedures in pediatric neurosurgery. The reported revision rate of VPS can reach up to 80% and significantly reduces the quality of life in the affected children and has a high socioeconomic burden. Traditionally, distal VPS placement has been achieved open via a small laparotomy. However, in adults several studies have shown a lower rate of distal dysfunction using laparoscopic insertion. As the data in children are scarce, the aim of this systematic review and meta-analysis was to compare open and laparoscopic VPS placement in children regarding complications. METHODS: PubMed and Embase databases were searched using a systematic search strategy to identify studies comparing open and laparoscopic VPS placement up to July 2022. Two independent researchers assessed the studies for inclusion and quality. Primary outcome measure was distal revision rate. A fixed effects model was used if low heterogeneity (I2 < 50%) was present, otherwise a random effects model was applied. RESULTS: Out of 115 screened studies we included 8 studies in our qualitative assessment and three of them in our quantitative meta-analysis. All studies were retrospective cohort studies with 590 analyzed children, of which 231 children (39.2%) received laparoscopic, and 359 children (60.8%) open shunt placement. Similar distal revision rates were observed between the laparoscopic and open group (3.75% vs. 4.3%, RR 1.16, [ 95% CI 0.48 to 2.79], I2 = 50%, z = 0.32, p = 0.74). There was no significant difference in postoperative infection rate between the two groups (laparoscopic 5.6% vs. open 7.5%, RR 0.99, (95% CI [0.53 to 1.85]), I2=0%, z = -0.03, p= 0.97). The meta-analysis showed a significantly shorter surgery time in the laparoscopic group (49.22 (±21.46) vs. 64.13 (±8.99) minutes, SMD-3.6, [95% CI -6.9 to -0.28], I2=99%m z= -2.12, p= 0.03) compared to open distal VPS placement. CONCLUSION: Few studies are available comparing open and laparoscopic shunt placement in children. Our meta-analysis showed no difference in distal revision rate between laparoscopic and open shunt insertion; however, laparoscopic placement was associated with a significantly shorter surgery time. Further prospective trials are needed to assess possible superiority of one of the techniques.

Cerebrospinal fluid transcripts may predict shunt surgery responses in normal pressure hydrocephalus.

Molecular biomarkers for neurodegenerative diseases are critical for advancing diagnosis and therapy. Normal pressure hydrocephalus (NPH) is a neurological disorder characterized by progressive neurodegeneration, gait impairment, urinary incontinence and cognitive decline. In contrast to most other neurodegenerative disorders, NPH symptoms can be improved by the placement of a ventricular shunt that drains excess CSF. A major challenge in NPH management is the identification of patients who benefit from shunt surgery. Here, we perform genome-wide RNA sequencing of extracellular vesicles in CSF of 42 NPH patients, and we identify genes and pathways whose expression levels correlate with gait, urinary or cognitive symptom improvement after shunt surgery. We describe a machine learning algorithm trained on these gene expression profiles to predict shunt surgery response with high accuracy. The transcriptomic signatures we identified may have important implications for improving NPH diagnosis and treatment and for understanding disease aetiology.

Optic disc vessel density changes after shunt surgery in idiopathic intracranial hypertension.

AIM: To detect the change in optic disc vessel density in patients with idiopathic intracranial hypertension (IIH) after shunt surgery. PATIENTS AND METHOD: Twenty-one patients with IIH underwent shunt surgery. Patients were subjected to full ophthalmic and neurological examinations. Optic disc vessel density was measured using optical coherence tomography angiography (OCT-A) before and two months after surgery. RESULTS: The age of patients ranged from 27 to 48 years old, with a mean of (34.85 ± 6.87). Visual acuity ranged between 0.2 and 0.9 by log Mar, with a mean of (0.64±o.20). The mean deviation (MD) of the perimeter ranged from -22.9 to 0 dB, with a mean of (-9.77 ± 7.23 dB). With respect to the grade of papilledema, 15 eyes (35.7%) were of grade II, 21 eyes (50.0%) were of grade III, and 6 eyes (14.3%) were grade IV. Intracranial pressure measured by lumbar puncture (LP) prior to surgery ranged from 30 to 40 cm, with a mean of 35.43 cm. Except for right transverse sinus hypoplasia in 6 patients (28.6%), MRV was normal. In 15 patients (71.4%), lumboperitoneal shunt was performed, while ventriculoperitoneal shunt was performed in 6 patients (28.6%). After surgery, the optical disc vessel density was decreased in all patients. This decrease was highly significant for the whole image, the inner disc, the peripapillary, superior, and inferior hemispheres. Moreover, this reduction affected both optic disc microvasculature (referred to as capillary vessel density) and macro vasculature (also known as all vessel density). There were positive correlations between the CSF opening pressures and the preoperative optic disc vessel density of the whole image and inside disc with a P-value (0.002, 0.009), respectively. In addition, there was a positive correlation between the opening CSF pressures and the reduction in whole image vessel density after surgery with a P-value of 0.000. CONCLUSION: Optic disc vessel density decreased after shunt surgery in patients with IIH. Consequently, optic disc vessel density can be used as a biomarker for the reduction of CSF opening pressure.