Normal Pressure Hydrocephalus

[Not"Nursey", RN]

I work as the RN Coordinator for a team of hospital based Neurosurgeons. Recently, we've implemented performing a trial of slow, system CSF removal via Lumbar Drain to assess for gait/mentation improvement BEFORE inserting a final Ventriuloperitoneal shunt. I would be curious to hear from any of you and your experiences on how it is determined a patient qualifies for a (VP) Shunt?

Thank you in advance!

[LovingLife123]

Why are you using a lumbar drain to determine a VP shunt and not an EVD?

[Not"Nursey", RN]

We use the lumbar drain during an inpatient trial to systematically withdraw 3cc of CSF every 2 hrs. If gait or mentation improve, we have conclusive proof inserting a permanent VP shunt will be beneficial to the patients.

[Here.I.Stand, BSN, RN]

I think what LovingLife123 was getting at is, hydrocephalus is the accumulation of CSF in the *ventricles* — not from the spinal canal. The treatment is a VENTRICULAR peritoneal shunt — not a SPINAL peritoneal shunt.

If you’re studying the efficacy of a treatment, shouldn’t you be treating the actual problem, and therefore withdraw the CSF from a ventricle?

[Not"Nursey", RN]

I do understand what you both are saying and yes, ultimately, we would place a VP shunt if patient exhibited s/s of improvement. However, CSF is an intricate & connected fluid system thus, we can temporarily illicit VP shunt results from reducing overall CSF via systematically tapping the lumbar area.

[LovingLife123]

But would you have not had an EVD initially? And maybe I’m not fully understanding your patient population and the determination for a lumbar drain. My patients are acute Neuro patients. We have many that end up needing VP shunts, but it’s because they don’t tolerate the raising or clamping of the EVD. We assess mentation and use CT scans to determine.

We’ve never used a lumbar drain. Not have I ever intermittently drained 3mL every 2 hours. If I’m intermittently draining it’s usually 5mL an hour.

Any lumbar drain I have had is used for the build up of CSF in the spinal cord after a large spinal fusion surgery is which I usually drain 10mL an hour.

I work with a top neurosurgery practice in the nation and I have yet to see this.

[Not"Nursey", RN]

None of the patients we chose to trial are acute. This would, of course, not be appropriate treatment for that patient population.

[CCU BSN RN]

Sounds like you're doing research. Seems legit to me, but I've had 2 or 3 lumbar drains in as many years, and my background is definitely not neuro.

It seems like you're trying to figure out how many people are walking around with normal pressure hydrocephalus that's essentially misdiagnosed by inserting a drain that is temporary and would have lower risk than other drainage options.

Unfortunately it sounds like early-stage clinical research that isn't a standard of care, and you're catching flack instead of getting answers.

Also, in one of your responses, you used the word 'illicit' when you were looking for the word 'elicit' which is an easy error but big difference in actual meaning.

[Not"Nursey", RN]

True, grammatically incorrect - have the flu and hopped up on NyQuil. Lol Nothing “illicit” in our research. Thanks!

[Mindful, RN]

I have been Critical Care RN for 20 yrs. My husband has been diagnosed with Normal Pressure Hydocephalous (NPH), he is being treated in a large research, teaching University Hospital. He has had Neropsych 4 hr observations, a 4 hr neurologist assessment & objective testing of an MRI which showed very enlarged ventricles with increased CSF. They use the LP by removing large-volume, 50- 100 cc of CSF from the "Subarachnoid Space" in the spinal canal & then assess his gait mainly in addition to cognition over 4 hrs to see if removing the fluid tempoarily shows improvement. If so, then they will place a VP Shunt. The Mayo Clinic, John Hopkins & my highly-recognized hospital has performed numerous LPs to diagnose NPH VP Stunts using 2 different types of valves with a high success rate for many yrs. I feel you may benefit by researching other well-known, reputable hospitals & their LP procedures leading to the diagnosis of NPH.

[Not"Nursey", RN]

Thank you! This is precisely why I wanted to reach out to my fellow nurses and see if anyone else out there is doing the less invasive lumbar drain 1st before actually inserted a final VP shunt. Good luck to you and your husband!