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New Look at a Controversial Shunting Method for Hydrocephalus

Dr. Guy McKhannDr. Guy McKhann from the Movement Disorders Center is senior author* of a paper about a rarely used method of treatment for hydrocephalus that, he says, warrants a second look.

Hydrocephalus, sometimes called “water on the brain,” is a condition characterized by too much cerebrospinal fluid (CSF) in and around the brain. This fluid is produced in cavities called ventricles deep in the brain. CSF nourishes and protects the brain and spinal cord and is then reabsorbed by the body to maintain a healthy level of fluid in the brain at all times.

There are a number of types of hydrocephalus depending on the cause. The kind that most often effects adults is called Normal-Pressure Hydrocephalus (NPH), or Adult Communicating Hydrocephalus.

NPH is a result of an imbalance between how much CSF is produced by the brain and how much is reabsorbed. When too much fluid is produced and/or not enough fluid is reabsorbed, fluid backs up inside the skull and can damage the brain.

The most common symptoms that result are problems with walking, urinary incontinence, and cognitive slowing such as short term memory loss and dementia. These symptoms often indicate the need for surgery

The surgical treatment for NPH involves the placement of a one-way valve, called a shunt, to remove excess fluid from the brain. The most common type of shunt drains fluid from its source inside the brain’s ventricles directly into the abdomen. This is called a ventriculoperitoneal (VP) shunt.

Another method (and the subject of this paper) uses a ventriculoatrial (VA) shunt. Here, the excess fluid is drained out of the ventricles of the brain directly into the heart. This type of shunting is rarely used, however, due to reports in the pediatric literature that indicate it may be associated with cardiopulmonary (heart and lung) complications.

Dr. Guy McKhann and co-authors*, including neurosurgery resident Dr. Robert McGovern, have taken a second look at this claim in their paper, Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus?. They published their findings last month in the Journal of Neurosurgery.

“These complications have typically been limited to adults in whom VA shunts had been placed when they were children,” they said. “Few studies have directly compared VA shunting to ventriculoperitoneal (VP) shunting in cases of normal pressure hydrocephalus (NPH).” 

The authors looked at patients with NPH treated by Dr. McKhann at Columbia University Medical Center/New York Presbyterian Hospital from 2002 and 2011: thirty patients underwent VA shunting and 157 underwent VP shunting.

The authors found no significant differences in complication rates between VA and VP shunting, and they said, “VA shunting was not associated with any cardiopulmonary complications. Thus, in the authors’ experience, VA shunting is at least as safe as VP shunting for treating NPH.”

This is good news, according to Dr. McKhann who says:

“In the past, we reserved VA shunting for adult hydrocephalus patients who had a relative contraindication to VP shunting [That is, they had a medical condition that would make it relatively unsafe]. Now we are reconsidering it as a potential first line option. For example, it is preferable in patients who have had prior abdominal surgery or are overweight. VA shunting is technically simple and safe, and draining spinal fluid into the venous system [via the heart] rather than the abdominal cavity may provide more effective shunt function. Hopefully other large volume centers like ours will contribute their experience to help us determine, as a neurosurgical community if there is a definite advantage to one type of shunting over the other.”

Learn more about this research in the March, 2014 issue of the Journal of neurosurgery or read an abstract of the article online here.

* Co-authors include: McGovern RA, Kelly KM, Chan AK, Morrissey NJ, and  McKhann GM 2nd.

Learn more about Dr. Guy McKhann on his bio page here.

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