What is the recommended treatment for hydrocephalus in the elderly?

Treatment of Hydrocephalus in the Elderly

Ventriculoperitoneal (VP) shunt placement is the first-line treatment for symptomatic hydrocephalus in elderly patients, with endoscopic third ventriculostomy (ETV) being a viable alternative in selected cases, particularly those with primary/idiopathic normal pressure hydrocephalus (NPH) showing aqueductal flow void on MRI. 1, 2, 3

Diagnostic Approach

• Diagnosis should be confirmed with MRI with contrast to evaluate for ventriculomegaly and to rule out other causes of symptoms 2
• Clinical signs of increased intracranial pressure, such as neurological symptoms, are key indicators for surgical intervention 1
• Aqueductal flow void on T2 Sagittal MRI and aqueductal peak velocity greater than 5cm/s on cine MRI are positive predictors for successful ETV outcomes in elderly patients 4

Treatment Options

Ventriculoperitoneal (VP) Shunt

• VP shunt remains the most common treatment for hydrocephalus in elderly patients 3
• Progressive ventricular dilation despite temporizing measures is a clear indication for permanent shunt placement 1
• Clinical signs of increased intracranial pressure are indications for permanent shunt placement 1
• Programmable shunt valves allow for post-operative pressure adjustments, which can temporarily improve symptoms in cases of delayed deterioration 5

Endoscopic Third Ventriculostomy (ETV)

• ETV has emerged as an alternative to VP shunts with lower long-term complication rates 3
• ETV is particularly effective for elderly patients with primary/idiopathic NPH when they show positive aqueduct flow void on MRI 4
• When adjusted for patient age and etiology, ETV has higher early failure rates than shunts but lower failure rates after 3 months 2, 3
• 75% of patients with idiopathic NPH showed favorable outcomes after ETV treatment, compared to poor outcomes in secondary NPH 4

Lumboperitoneal (LP) Shunt

• Recent improvements in LP shunt devices have made this a safer alternative to VP shunts in some cases 6
• Programmable valves in LP shunts can avoid overdrainage complications and reduce revision rates 6

Comparative Outcomes

• Both CSF shunts and ETV demonstrate equivalent overall outcomes in many clinical scenarios 2, 3
• VP shunts have shown higher revision rates (13.5%) compared to newer LP shunt techniques (1.0%) in some studies 6
• Open shunt systems (without valves) have demonstrated lower occlusion rates (7%) compared to conventional valved shunts (39%) in adult hydrocephalus 7
• Continuous flow shunts have shown better long-term performance (14% failure rate) compared to valvular shunts (46% failure rate) 8

Complications and Considerations

• Delayed symptom progression is common after VP shunt placement for NPH, occurring in approximately 49% of initially improved patients at a mean of 28.3 months postoperatively 5
• Increased patient age is associated with higher likelihood of delayed symptom progression after shunt placement 5
• Shunt complications include infection and revision needs, with VP shunts showing higher infection rates (5.7%) compared to newer LP shunt techniques (1.0%) 6
• Overdrainage symptoms developed in 40% of patients treated with valvular shunts in some studies, but were not observed with continuous flow shunts 8

Treatment Algorithm

1. Confirm diagnosis with MRI with contrast 2
2. Evaluate for progressive ventriculomegaly and symptoms 1, 3
3. For patients with primary/idiopathic NPH and suitable anatomy (positive aqueduct flow void), consider ETV first 4
4. For patients with secondary NPH or unsuitable anatomy for ETV, VP shunt is recommended 3, 4
5. Consider programmable valves to allow post-operative pressure adjustments 5
6. Monitor for delayed symptom progression, particularly in older patients 5

Pitfalls and Caveats

• Routine use of serial lumbar punctures is not recommended as a definitive treatment 2
• Patients and families should be counseled about the high likelihood of delayed symptom progression after initially successful shunt placement 5
• Secondary NPH patients have poorer outcomes with ETV and may require VP shunt placement 4
• The size of ventricles is not necessarily a predictor of outcome after treatment 9