87

Endoscopic Ventriculostomy versus Shunt Operation

in Normal Pressure Hydrocephalus: Diagnostics and Indication
U. Meier, F. S. Zeilinger, B. Schönherr
Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany

nnnnnn In contrast to the shunt operation the indication for cephalus was obtained by the intrathecal infusion test on
an endoscopic ventriculostomy in patients diagnosed for a lumbar and/or ventricular route, the cerebrospinal fluid
normal pressure hydrocephalus is not scientifically estab- tap test, and MRI cerebrospinal fluid flow studies pre- and
lished. Between September 1997 and December 1999 we postoperatively. The signs of each patient were registered,
operated on 48 patients diagnosed for normal pressure hy- according to the clinical grading for normal pressure
drocephalus. The diagnosis was established by means of the hydrocephalus by Kiefer and Steudel. We then compared
intrathecal lumbar or ventricular infusion test, the cere- the course of disease at a mean time interval of 7 months
brospinal fluid tap test and MRI-CSF flow studies pre- and while using our created NPH recovery rate [12]:

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postoperatively. In 37 patients (77 %) we have implanted a
ventriculo-peritoneal shunt, and in 11 patients (23 %) we
performed the endoscopic assisted third ventriculostomy.
With our created NPH recovery rate and use of the clinical
grading for normal pressure hydrocephalus created by Kie- The indication for shunt operation or endoscopic ventricu-
fer and Steudel we compared the operative results of both lostomy was assessed by evaluating the clinical signs and
groups of patients. In patients with a pathologically in- the results of the intrathecal infusion test [8]. The outflow
creased resistance to CSF outflow in the lumbar infusion resistance is the main criterion for grouping patients into
test a shunt implantation is indicated. Patients whose out- those with NPH and into those with cerebral atrophy. A
flow resistance is increased in the ventricular infusion test pathological increased outflow resistance in the intrathe-
but with a physiological lumbar infusion test are suspected cal infusion test represents an indication for an operative
for a functional aqueduct stenosis and should be treated by intervention. Patients with a physiological outflow resis-
means of endoscopic assisted ventriculostomy. tance and increased compliance were diagnosed for
cerebral atrophy and not treated operatively [8]. The
n Key words: Endoscopic Ventriculostomy ± Normal Pres- mathematical fundamentals and standardized investiga-
sure Hydrocephalus ± Aqueduct Stenosis ± Phase Contrast tion procedures as well as the indications for the computer
MRI assisted intrathecal infusion test and pathophysiological
basics we have already described previously [6 ± 12].
Introduction
Results
In contrast to insertion of a ventriculo-peritoneal shunt
the indication for an endoscopic ventriculostomy in In 37 patients (77 %) a ventriculo-peritoneal shunt with a
patients diagnosed for normal pressure hydrocephalus Miethke Dual-Switch valve [13] was inserted, and in 11
(NPH) is not scientifically established. Our prospective patients (23 %) we performed an endoscopic assisted third
clinical study was designed in order to find predictors for ventriculostomy. After evaluation of the clinical signs
each operative method and to evaluate the long-term according to the clinical grading for normal pressure
results. hydrocephalus the lumbar infusion test was accomplished
[12]. The indication for shunt operation was assessed by
Material and Method means of measuring the intracranial pressure and a base-
line pressure within physiological limits, a hydrocephalus
48 patients with normal pressure hydrocephalus were of all ventricles visualised in CT scan or MRI and a
operatively treated in the Department of Neurosurgery of pathological increased outflow resistance in the lumbar
the Unfallkrankenhaus Berlin between September 1997 infusion test.
and December 1999. Diagnosis of normal pressure hydro-

Minim Invas Neurosurg 2000; 43: 87 ± 90

 Georg Thieme Verlag Stuttgart New York
·

ISSN 0946-7211
88 Minim Invas Neurosurg 2000; 43 Meier U et al

Table 1 Complications in shunt surgery and endoscopic ventri-

culostomy

shunt surgery 3rd ventriculostomy

morbidity 24 % 18 %
infection 3 0
malfunction of valve 3 0
dislocation 1 0
SDH 2 0
pneumatocephalus 0 1
lesion of thalamus 0 1
2nd look surgery 8 0
Fig. 1 NPH recovery rate according to clinical grading for NPH of
Kiefer. lethality
due to surgery 0 0
independent 2 1
Indication for shunt operation in NPH
MRI/CT: hydrocephalus internus of all ventricles
Baseline ICP: within physiological limits combination of neuronavigation and endoscopic techni-

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Lumbar infusion test: pathological resistance ques for an intraoperative quality assessment. The type of
Ventricular infusion test: pathological resistance normal pressure hydrocephalus described as functional
aqueduct stenosis by our own workgroup is established
In cases with a suspicion for an aqueduct stenosis due to while measuring a normal baseline ICP value in the
the MRI examinations and/or physiological outflow resis- horizontal position but an increased outflow resistance in
tance in the lumbar infusion test a ventricular infusion the ventricular infusion test. The reason for this phenom-
test was indicated. With a pathological outflow resistance enon is, in our opinion, a valve like mechanism in the
in the ventricular infusion test but physiological resistance region of the stenosis, which causes a pathologically
in the lumbar infusion test we favor the third ventriculos- increased resistance, mostly at ICP values between 15 and
tomy (Fig. 2). 30 Torr, which decreases gradually at higher ICP values, to
normal range, due to the intrathecal infusion (volume-
Indication for third ventriculostomy in NPH pressure-load) (Fig. 2). Pathophysiologically a reduced
bulk flow of cerebrospinal fluid between third and forth
MRI/CT: suspicion for aqueduct stenosis ventricles must be considered. This induces a dilatation of
Baseline ICP: within physiological limits the lateral and third ventricle and when the intraventri-
Lumbar infusion test: physiological resistance cular pressure exceeds the resistance of the stenosis CSF
Ventricular infusion test: pathological resistance can flow. The physiological examination results in the
lumbar infusion test prove that these patients have no
Patients with an elevated baseline ICP in the horizontal disturbances in the extraventricular cerebrospinal fluid
position were classified as pressure hydrocephalus and bulk flow.
excluded from this study. The complications of both
operative methods were analyzed regarding re-operation According to Barlow and Ching [1] the ratio between
rate, operation related morbidity and lethality (Table 1). patients with shunt operation and endoscopic ventricu-
The comparison of the course of disease postoperative and lostomy (150 : 23) is at about 15 % and this is in accordance
katamnestic at a mean time interval of 7 months while with our results (23 %). These authors [1] conclude on the
using our own NPH recovery rate allows no statistical basis of their excellent clinical results after an endoscopic
evaluation due to the small number of patients where we third ventriculostomy that ventriculostomy has the advan-
have performed a third ventriculostomy (Fig. 1). Our tage of a reduced revision rate and reduced length of the
experiences with shunt therapy and different valve types hospital stay, which is a relevant economic factor. Due to
were published elsewhere [8, 9,11]. From 1997 onwards the small number of patients in our study we cannot make
we inserted the Miethke Dual Switch valve [13,14] in an assumption about that. Regarding the complications in
patients with NPH exclusively. our patients we could not find significant differences with
24 % after shunt insertion and 18 % after third ventriculos-
Discussion tomy. De Divitiis [2] reported about complications in 11 %,
which were mostly a temporary bleeding out of an
Indications for an intracranial endoscopy are, as stated by external drainage after endoscopic ventriculostomy. In
different authors [1, 4, 5,17], the obstructive hydrocephalus contrast to Mohanty et al. [15] who reported about acute
internus caused by intraventricular cysts and tumors. subdural hematomas after endoscopic ventriculostomy
According to the Aachener workgroup [16] we favor the this complication did not occur in our patients. The
Endoscopic Ventriculostomy versus Shunt Operation in Normal Pressure Hydrocephalus Minim Invas Neurosurg 2000; 43 89

Fig. 2 Example of a patient with a NPH in

an early stage. Examination protocol of
ventricular infusion test (above) with an
elevated ICP time-curve; pathological in-
creased outflow resistance (above left);
physiological compliance (above right). Ex-
amination protocol of lumbar infusion test
(below) with a flat ICP time-curve; outflow
resistance in the physiological range (below
left); physiological compliance (below right).

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operation related morbidity due to shunt operation has normal pressure hydrocephalus in a chronic state because
been discussed extensively on other occasions [13]. The the bioplastic deformation has induced a decrease of
lethality due to the operations was as in other workgroups parenchymatous tissue. Therefore the determining factors
[2, 4] with 0 % in both groups of patients fortunately low. for a restitution are accomplished by the intracranial
compensating mechanisms and the quantity of unda-
Foroutan et al. [3] points out that aside from the improved maged structures [13]. Bearing this in mind normal
clinical symptoms the postoperative functional MRI con- pressure hydrocephalus should be diagnosed at an early
firms the right indication and operative therapy of the stage because disturbances of the cerebral autoregulation
endoscopic ventriculostomy. We can thoroughly empha- take place in the late stage and therefore the therapeutic
size this statement. In contrast to Schwartz et al. [17] we results are worse after valve implantation or endoscopic
did not recognize a marked reduction in ventricular width ventriculostomy. Thus a delay in the diagnostic process
from patients with NPH. Contrary to pressure hydrocepha- reduces the rehabilitation potential of the patients due to
lus a reduction of ventricle width cannot be expected in an irreversible disturbance of their cognitive potential.
90 Minim Invas Neurosurg 2000; 43 Meier U et al

17
We conclude that for patients diagnosed for NPH with Schwartz TH, Yoon SS, Cutruzzola FW, Goodman RR. Third
findings of a pathological outflow resistance in the lumbar ventriculostomy: post-operative ventricular size and outcome.
infusion test the shunt operation is indicated. Patients Minim Invasive Neurosurg 1996; 39: 122 ± 129
whose outflow resistance is pathologically increased in
the ventricular infusion test as well as with physiological
Corresponding Author:
results in the lumbar infusion test and signs of an
aqueduct stenosis in MRI an endoscopic assisted third Privatdozent Dr. med. U. Meier
ventriculostomy is indicated. Postoperative a functional
MRI with phase-contrast imaging supports the visualiza- Head of Department
tion of operative result. Follow up examinations, which Department of Neurosurgery
Unfallkrankenhaus Berlin
are important for the evaluation of this method and for a
Warener Straûe 7
quality assessment of this endoscopic operation method 12683 Berlin
are still in progress. Germany

Phone: +49 30 5681-2701

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