75. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie

Prof. Dr.

Vorsitz

Expectations of hydrocephalus treatment: A comparison between primary caregiver and surgeon

Hydrocephalus und pädiatrische Neurochirurgie 

Erwartungen an eine Hydrozephalus-Behandlung: Ein Vergleich zwischen Betreuungsperson und Chirurg

The outcome of surgical treatment depends strongly on patients" expectations. Although optimal management of idiopathic normal pressure hydrocephalus (iNPH) by central nervous system shunt placement is evident, symptom response rates are variable. The aim of this study was to investigate the expectations of patients' relatives and treating surgeons regarding the iNPH treatment outcome.Following ethics committee approval in December 2021, patients diagnosed with iNPH and selected for CNS shunt surgery were considered for inclusion in this prospective longitudinal clinical trial. iNPH symptoms were assessed using well-established grading scales (iNPH grading scale; Kiefer score) at baseline and follow-up. Similarly, primary caregivers, neurosurgical residents, and neurosurgeons recorded their expectations regarding the presumed outcome of surgical treatment. Expectations were correlated with outcome data, and statistical analyses were performed using the Pearson correlation test and Wilcoxon signed-rank test. Additionally, factors that might influence the accuracy of expectations, such as age, gender, education level, Charlson comorbidity index, duration of symptoms, and adverse events, were assessed.Since January 2022, 25 iNPH patients were screened, with 20 eligible for study participation (55% male, median age 73.1 years). All underwent ventriculoperitoneal shunt placement. Median follow-up at 57.1 days showed significant symptom improvement (p<0.001). Using the Pearson correlation test, the expectations of neurosurgeons and residents showed a strong correlation with postoperative outcomes (r=0.74; r=0.64), whereas the expectations of primary caregivers correlated less strongly (r=0.61). A Wilcoxon test revealed a significant difference between expectations of primary caregivers and actual postoperative outcomes (p=0.001). In contrast, neurosurgeons' and residents' expectations showed no significant difference compared to postoperative outcomes (p > 0.05), indicating an agreement between expectations and treatment outcomes.Our results underline that shunt placement improves symptoms in iNPH patients. Surgeons and patients' relatives have different expectations regarding the outcome following shunt surgery. The patients" relatives had much more optimistic expectations than the surgeons. These findings emphasize the importance of realistic expectations and aim to encourage better communication among surgeons and patients and their relatives.

Abstractvortrag | Abstract talk

Prof. Dr. med.

Enhancing shunt surgery outcomes and predicting shunt response in iNPH with AI: Promises and challenges of predictive models

Verbesserung der Ergebnisse von Shunt-Operationen und Vorhersage der Shunt-Reaktion bei iNPH mit KI: Versprechen und Herausforderungen prädiktiver Modelle

Idiopathic normal pressure hydrocephalus is a chronic neurological disorder and a known reversible cause of dementia. Shunt surgery remains the standard treatment, but its effectiveness is variable. Recent advancements in artificial intelligence (AI) offer the potential to refine shunt response prediction by analysing vast amounts of data. We aimed to assess the uses, methological rigour and performance of current models. This systematic review aimed to evaluate the efficacy of artificial intelligence in predicting shunt response (SR) in iNPH. A systematic search of the literature was conducted in MEDLINE, EMBASE and Web of Science to identify studies that employed AI or machine learning (ML) algorithms for shunt response prediction in iNPH. Original articles published from inception until September 2023 were included. Qualitative synthesis followed the Synthesis Without Meta-Analysis (SWiM) reporting guidelines.The initial search identified 3541 studies from which 33 were assessed for eligibility. 8 studies were included, featuring 479 patients. Sample size (with follow-up) ranged from 28 to 132 patients. Each model incorporated different input data, the most common being imaging/radiomics (62.5%), followed by demographic inputs (37.5%). The most used ML algorithm was the Support Vector Machine (87.5%). 2 articles (25%) implemented multiple machine learning algorithms with the aim of assessing their relative effectiveness. All studies employed cross-validation techniques as a validation method. Only half (4/8) of the articles reported AUC, which ranged from 0.80 to 0.94. However, the predefined outcome measures were not consistently reported in every article, highlighting the heterogeneity and the lack of quantitative data to compare each model, in addition to the high risk of bias and unclear applicability of some models.While AI holds significant promise for improving the diagnosis and management of iNPH, it requires standardized data and more extensive validation studies for each model, which in turn requires a homogenous approach of iNPH management. Besides coming to a field-wise consensus, to enhance clinical utility, future research should focus on developing more robust and generalizable AI models. The potential benefits for patients are clear, including improved diagnostic accuracy and personalized treatment strategies.

PD Dr. med.

Dr. med.

Prof Dr. med.

Prof Dr.

The impact of telemetric sensor implantations in complex hydrocephalus patients with chronic overdrainage or distorted ventricles

Der Einfluss telemetrischer Shuntsensoren auf die Behandlung komplexer Hydrocephlus-Patienten mit chronischer Überdrainage oder dysmorphen Ventrikelsystem.

Children with shunt dependency suffer the risk of overdrainage related complications in their future live. Neurosurgeons have to take care of patients from the pre-anti-syphon area. Those young adults can suffer from chronic overdrainage and slit ventricles. The implantation of telemetric sensor devices have been successfully established for the shunt therapy. We evaluated our results from those sensor in a cohort of young adults with dysmorphic ventriclesA retrospective analysis of the patient cohort with telemetric shunt sensor devices (n=145) in our department was performed. We included patients that received their first shunt as infants from 1973 to 1999. The inclusion criteria were distorted ventricles including slit ventricles and a change to adjustable valves and anti-syphon devices.We could identify 25 patients in total, six were lost to follow-up after less than 12 months. Main symptoms were unstable clinical course (n=14) and cephalgia (n=9). After sensor implantation and according valve adjustments 12 of 19 patients reached a stable course and significant reduced symptoms in the follow-up (mean 49 months). The amounts of MRIs could be reduced after the sensor implantations (35 vs. 91). Also, the frequency of appointments was reduced (312 vs 428).Telemetric shunt sensors are a versatile tool for the long term follow up and treatment of complex cases of hydrocephalus. The measurement can be performed quick and easy in the outpatient clinic and supports the decision making process and reduces the need for imaging controls.

Long-term follow-up in normal pressure hydrocephalus

Langzeit-Nachverfolgung beim Normaldruckhydrocephalus

Normal pressure hydrocephalus (iNPH) is characterized by a slowly progressive clinical triad of gait disorder, cognitive decline and urinary incontinence combined with ventricular dilation. Studies on short-term outcome after ventriculoperitoneal shunt implantation have shown a clinically significant improvement in 80 to 85% of patients after surgery. However, long-term results have rarely been published.A consecutive series of 165 patients (mean age 74.7 ± 7.4 years) treated by a single surgeon with a ventriculoperitoneal (VP) shunt between 2012 und February 2023 at the neurosurgical department of University Hospital Zurich with mean preoperative DESH score of 6.8 ± 2.7 were included in this retrospective study. They were followed without limit yearly or more frequently in case of need. Preoperative patient selection was based on clinical evaluation, radiological findings, and CSF dynamic supplemental tests. Outcomes were assessed using the Kiefer Scale and the NPH-Recovery Rate (NPH-RR). Secondarily, the number of steps needed for 180° turn as a measure of gait disturbance, the Montreal Cognitive Assessment (MoCA) score as a measure of cognitive decline and continence of patients were recorded preoperatively and at the last follow-up.The mean preoperative Kiefer Score was 7.3 ± 3.1, significantly higher than the Kiefer Score 6 months, 1, 2, 3, 4, 5 (p < 0.001) and 6 years (p = 0.006) after shunting procedure. The lowest Kiefer Score of 2.9 ± 2.7 was reached one year postoperatively with subsequent continuous slight increase to 4.1 ± 2.6 at the 6-year postoperative follow-up. The NPH-RR in the first 3 years after shunting procedure was greater than 5 and therefore representing a good clinical outcome. The number of steps for 180° turn decreased from 4.4 ± 1.9 preoperatively to 2.8 ± 1.6 postoperatively. 28 of 165 patients (17.0 %) underwent MoCA testing both pre- and postoperatively, with 9 patients (32.1 %) showing significant improvement. The proportion of urinary incontinent patients decreased from 70.4 % to 29.6 %.Patients with iNPH benefit significantly from shunt therapy up to 6 years postoperatively, with improvements noted among all components of the clinical triad.

A comparison of efficacy and safety of CSF shunting and diversion procedures in iNPH: A Meta-Analysis

Ein Vergleich der Wirksamkeit und Sicherheit von Liquor-Shunt- und -Umleitungsverfahren bei idiopathischem Normaldruckhydrozephalus (iNPH): Eine Meta-Analyse

Idiopathic normal pressure hydrocephalus (iNPH) is commonly treated using various cerebrospinal fluid (CSF) diversion procedure including ventriculo-peritoneal, ventriculo-atrial (VA), lumbo-peritoneal (LP) shunting, and endoscopic third ventriculostomy (ETV). Despite the prevalence of these interventions, there is limited comparative data on their efficacy and revision and complication rate over time.EMBASE, MEDLINE and Scopus were screened for studies investigating CSF shunting of iNPH patients. A meta-analysis and regression analyses were conducted with the primary outcome being shunt response, and secondary outcomes were complication rates and rate of surgical revisions between different shunt types.Out of the 1749 studies screened, 56 were included in this review. 5,624 patients were pooled in this meta-analysis. Overall, more than 70% of patients experienced improvement after surgical treatment (p<0.05). LP shunt demonstrated the highest efficacy at 74% (p<0.01), followed VP shunt at 72% (p<0.01). ETV exhibited the lowest success rate at 67%. Complication rates were however lowest for ETV (19%), but highest for VP (17%) and LP shunt (16%). Revision rates were lowest for VP shunt (12%), and highest for ETC (19%). The efficacy of CSF shunting was found to have significantly increased between 2005 and 2023 (p<0.05).This meta-analysis underscores the overall efficacy of CSF diversion procedures in managing iNPH, with a substantial majority of patients reporting symptomatic improvement. The comparative analysis reveals that while no CSF diversion technique significantly outperforms others in terms of outcomes, ETV is associated with a lower success rate. Moreover, the trend of increasing efficacy over the studied period suggests improvements in surgical techniques or patient selection. This study aids in informing clinical decisions in iNPH patients and highlights the benefit of continued refinement of iNPH treatment protocols.

Clinical long-term outcome in idiopathic normal pressure hydrocephalus (iNPH) after CSF shunt surgery: Is long-term improvement common or exceptional?

Klinisches Langzeitoutcome bei idiopathischem Normaldruckhydrocephalus (iNPH) nach Liquor-Shunt: Ist langfristige Besserung häufig oder außergewöhnlich?

Long-term efficacy of cerebrospinal fluid (CSF) shunt surgery in idiopathic normal pressure hydrocephalus (iNPH) patients is differently reported. The aim of this study was to assess responsiveness, symptom improvement and long-term outcome after shunt surgery.Altogether, 307 shunted patients with improved Hakim symptoms after preoperative test CSF diversion were retrospectively investigated. Ventriculo-atrial (in 26.1%) or ventriculo-peritoneal (in 73.9%) shunts and anti-siphon devices (in 22.8%) were used. Epidemiological data were retrospectively assessed using hospital records and telephone interviews (59.9 months mean follow up, FU).Patient age at the time of shunt surgery was 70.3 mean ± 9.0 years. 18 patients were lost to FU. Of the remaining 289 cases, 253 (87.5%) showed postoperative symptom improvement, and 36 patients (12.5%) did not respond to shunt surgery. Most frequent symptom prior to surgery was gait disturbance (99.4%) followed by cognitive impairment (80.6%) and urinary incontinence (69.3%). A complete Hakim's Triad was present in 60.2%. Postoperative symptom improvement was observed in 80.6%, 46.9%, and 40.8% for gait disturbance, cognitive impairment, and urinary incontinence respectively. Improvement of all three symptoms was seen in 25.6%. Average duration of symptom improvement was 51.5 months (4.3 yrs, from 0 to 21 yrs), 56% had continuing improvement of symptoms after 10 years of FU. Mean number of valve pressure changes was 2.36 ± 2.08. Older patients had significantly shorter duration of symptom improvement (p < .001). Neither comorbidity nor longer symptom duration were statistically significant negative shunt outcome predictors. Overall surgical complication rate was 17.3%, shunt infection rate was 3.3%, and shunt revision rate 14.9%, mostly due to shunt dislocation and/or dysfunction.Surgical CSF diversion by implanting shunt systems is an effective and long-lasting treatment method for iNPH, especially concerning the improvement of gait, with up to 21 years symptom improvement in our study. However, surgical complications are common and shunt revision surgery rate was found higher than commonly expected.

Gleis 3

Hydrocephalus – Various

Session 5

Hydrozephalus – Verschiedenes

Hydrocephalus und Pädiatrische Neurochirurgie | Hydrocephalus and Paediatric Neurosurgery

Session 5
Hydrozephalus – Verschiedenes

Appointment

Vorsitz

Topic

Programme

Session 5Hydrozephalus – Verschiedenes

Appointment

Vorsitz

Topic

Programme

Session 5
Hydrozephalus – Verschiedenes