lumboperitoneal_shunt_overdrainage [Neurosurgery Wiki]

Cerebrospinal fluid overdrainage after lumboperitoneal shunt placement for the patients with idiopathic normal pressure hydrocephalus (iNPH) is mainly caused by insufficient management of pressure settings of the shunt valve and/or siphon effect of shunt systems induced by the patient's postural changes. ¹⁾ ²⁾. Some cases of IH due to CSF leakage with other mechanisms have been reported ³⁾) ⁴⁾.

Headache is commonly attributed to intracranial hypotension (IH) due to shunt overdrainage ⁵⁾.

In a retrospective survey on the usefulness of Dural sac shrinkage sign for the early detection of iatrogenic intracranial hypotension caused by lumboperitoneal shunt overdrainage for patients with idiopathic normal pressure hydrocephalus (INPH).

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

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.

DSSSs may serve as objective signs for the diagnosis of IH due to overdrainage through an LPS for INPH ⁶⁾.

Likhterman et al. describe a case of paradoxical lumboperitoneal overdrain of cerebrospinal fluid (CSF) with severe CSF hypotension syndrome in horizontal position of the patient and immediate cessation in vertical position. Ligation and then removal of lumboperitoneal shunt lead to rapid and stable disappearance of overdrain syndrome as well as concurrent left-side radicular pain syndrome in the leg ⁷⁾.

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Wang VY, Barbaro NM, Lawton MT, Pitts L, Kunwar S, Parsa AT, Gupta N, McDermott MW: Complications of lumboperitoneal shunts. Neurosurgery 60: 1045–1048; discussion 1049, 2007

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Eggenberger ER, Miller NR, Vitale S: Lumboperitoneal shunt for the treatment of pseudotumor cerebri. Neurology 46: 1524–1530, 1996

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Kaijima M, Fukuda H, Yamamoto K: [Post-operative complications peculiar to lumboperitoneal shunt: possible consequences due to side leakage of CSF from around the inserted spinal tube into the lumbar epidural space]. No Shinkei Geka 39: 497–504, 2011 (Japanese

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Liao YJ, Dillon WP, Chin CT, McDermott MW, Horton JC: Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report. J Neurosurg 107: 173–177, 2007

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Kawahara T, Atsuchi M, Arita K, Fujio S, Higa N, Moinuddin FM, Yoshimoto K, Hanaya R. Dural sac shrinkage signs on spinal magnetic resonance imaging indicate overdrainage after lumboperitoneal shunt for idiopathic normal pressure hydrocephalus. Surg Neurol Int. 2022 Jun 23;13:269. doi: 10.25259/SNI_291_2022. PMID: 35855156; PMCID: PMC9282775.

⁷⁾

Likhterman LB, Okhlopkov VA, Shukhraĭ VA. [Case report of paradoxical overdrainage of cerebrospinal fluid]. Zh Vopr Neirokhir Im N N Burdenko. 2009 Jul-Sep;(3):34-6; discussion 36. Russian. PubMed PMID: 20088447.