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Commentary: Postural Headache Associated with Ventriculo-Peritoneal Shunt Overdrainage: What are Our Options?

Copyright C © 2017 by the Congress of Neurological Surgeons I n 1956, ventricular shunts dramatically changed the outcome and quality of life of hydrocephalic patients.1 Currently, the ventriculo-peritoneal (VP) shunt serves as a mainstay of neurosurgical intervention for cerebrospinal fluid (CSF) diversion and treatment of hydrocephalus. Despite the continued development of various valve types, ventricular shunting of CSF continues to be associated with numerous complications. Freimann et al2 reported the incidence of shuntrelated complications ranging from 3% to 17%, depending on the target population, and approximately 10% of patients with long-term shunts will experience symptoms of overdrainage.3-5 Distal catheter drainage sites, commonly the peritoneum and right atrium, retain cavity pressures differing from ventricular pressure, thus establishing a dynamic pressure gradient that influences shunt flow.1,5,6 Consequently, subdural hematomas, craniosynostosis, slit ventricle syndrome, and postural headaches can be precipitated as a result of overdrainage. VP shunts have greater tendency for overdrainage due to tubing length and the influence of gravity induced hydrostatic suction. Prior studies conclude that modern shunt systems are unable to maintain steady state CSF diversion without encountering numerous influential factors and recommend insertion of a gravitational assistive valve or prophylactic implantation of a suction-inhibiting antisiphon device (ASD).1,2,4 A retrospective investigation was performed to identify patients at our institution who underwent VP shunt system insertion for hydrocephalus, and then underwent an additional procedure with inline gravitational add-on valve, between 2006 and 2013. We selected patients showing symptoms suggestive of postural headaches secondary to CSF overdrainage. Surgery was offered to patients that failed medical treatment, which typically consisted of at least 3 months of prophylactic medications such as cyproheptadine or topiramate. Elevated intracranial pressure (ICP) was ruled out based on clinical exam data, and papilledema was not detected on ocular fundi examination. In uncertain cases, an ICP monitor can be considered. We measured the status of postural headache following surgical intervention based on our hypothesis that a shunt assistive device in children and adults would relieve postural headaches associated with overdrainage. This is a retrospective review and has been approved by the Institutional Review Board (IRB) as exempt.