How to define CSF overdrainage: a systematic literature review

Sarah Hornshoej Pedersen, Tobias Hannibal Prein, Ahmed Ammar, André Grotenhuis, Mark G Hamilton, Torben Skovbo Hansen, Uwe Kehler, Harold Rekate, Ulrich-Wilhelm Thomale & Marianne Juhler

How to define CSF overdrainage – a consensus project

In this systematic literature review, we found a definition of CSF overdrainage (OD) in only 22 of 1309 potentially relevant publications, and only 8 of these were directly aimed at examining OD. The definitions, that included 32 different clinical and radiological characteristics of OD, were ranked by an expert panel according to detail level and level of agreement.

Based on highest ranking, it was suggested to define

  1. OD in children as “a persistent condition with clinical manifestations as postural dependent headache and vomiting, mood change/irritability, sunken fontanelle and decreasing head circumference, and/or radiological signs as slim ventricles/complete ventricular collapse, subdural hygroma/hematoma and overriding or fused cranial sutures”, and
  2. OD in adults as “a persistent condition with clinical manifestations as postural dependent headache, nausea, and vomiting, and/or radiological signs as slim ventricles (with disproportionally wide cortical sulci) and subdural hygroma/hematoma”.

Although arriving at a suggested OD definition in the review, we concluded that the diversity in the described clinical and radiological manifestations is an obstacle for a definition which is clinically useful and robust to identify and treat OD as well as obtain reliable documentation of the incidence, and that there is thus need for an OD consensus generated by people with a great knowledge within the field of hydrocephalus.

Consequently, we gathered a group of people with extended knowledge in both pediatric and adult hydrocephalus and through a Delphi process the clinical and radiological characteristics of OD extracted in the systematic review, are discussed, and ranked. The aim of the project is to reach consensus on a definition of OD in children and in adults.

Purpose

Overdrainage (OD) is one of the most frequent complications related to drainage of the cerebrospinal fluid (CSF). It is mostly associated with valve-bearing shunt systems but should probably be considered as a risk factor in any type of CSF diversion procedure. There is extreme variation in the reported incidence of OD due to the lack of consensus on defining criteria and an unclear perception of the pathophysiology. Hence, OD is probably underreported and underestimated. The objective of this paper was to establish a definition of OD, based on a systematic review of the literature.

Methods

A systematic search was conducted in MEDLNE and EMBASE. Studies providing a definition or a description of diagnostic findings related to OD in ventriculoperitoneal shunt treated hydrocephalus were included. Non-English titles, abstracts and manuscripts were excluded. Extracted descriptions were graded into five groups (class I-V studies) based on how precise the terminology used to describe OD was. Class I studies were included for further analysis and characteristics of OD were extracted. The quality of included descriptions was assessed by a clinical expert panel.

Results

A total of 1309 studies were screened, 190 were graded into groups, and 22, which provided specific definitions or descriptions of OD, were graded as class I studies. We extracted 32 different characteristics consistent with OD (e.g., clinical symptoms, radiological signs, and syndromes).

Conclusion

There was an overall agreement that CSF overdrainage following implantation of a ventriculoperitoneal shunt in a mixed pediatric and adult population is characterized as a persistent condition with clinically manifestations as postural dependent headache, nausea, and vomiting and/or radiological signs of slim ventricles and/or subdural collections.

Read the full paper in Acta Neurochir (click here).

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