Epilepsy, headache, and abdominal pain after shunt surgery for idiopathic normal pressure hydrocephalus: the INPH-CRasH study

J Neurosurg. 2018 Jun;128(6):1674-1683. doi: 10.3171/2017.3.JNS162453. Epub 2017 Sep 8.

Abstract

OBJECTIVE Adverse events related to shunt surgery are common and might have a negative effect on outcome in patients with idiopathic normal pressure hydrocephalus (INPH). The authors' objectives were to establish the frequencies of epilepsy, headache, and abdominal pain and determine their impact on patient quality of life (QOL), in long-term follow-up after shunt surgery for INPH. METHODS One hundred seventy-six shunt-treated patients with INPH (mean age 74 years) and 368 age- and sex-matched controls from the population were included. The mean follow-up time after surgery was 21 months (range 6-45 months). Each participant answered a questionnaire regarding present frequency and severity of headache and abdominal pain. Confirmed diagnoses of epilepsy and all prescriptions for antiepileptic drugs (AEDs) before and after shunt surgery for INPH were gathered from national registries. Equivalent presurgical and postsurgical time periods were constructed for the controls based on the date of surgery (the division date for controls is referred to as virtual surgery). All registry data covered a mean period of 6 years (range 3-8 years) before surgery/virtual surgery and 4 years (range 2-6 years) after surgery/virtual surgery. Provoked epileptic seizures were excluded. Patient QOL was assessed with the EuroQoL 5-dimension 5-level instrument. RESULTS Epilepsy was more common in shunt-treated patients with INPH than in controls (4.5% vs 1.1%, respectively; p = 0.023), as was treatment with AEDs (14.8% vs 7.3%, respectively; p = 0.010). No difference was found between the populations before surgery/virtual surgery (epilepsy, 2.3% [INPH] vs 1.1% [control], p = 0.280; AED treatment, 8.5% [INPH] vs 5.4% [control], p = 0.235). New-onset epilepsy and new AED treatment after surgery/virtual surgery were more common in INPH (epilepsy, 2.3% [INPH] vs 0.0% [control], p = 0.011; AED, 8.5% [INPH] vs 3.3% [control], p = 0.015). At follow-up, more patients with INPH than controls experienced headache several times per month or more often (36.1% vs 11.6%, respectively; p < 0.001). Patients with INPH and unilateral headache had more right-sided headaches than controls (p = 0.038). Postural headache was experienced by 16% (n = 27 of 169) of the patients with INPH. Twenty percent (n = 35) of the patients with INPH had persistent abdominal pain. Headache was not correlated to lower QOL. The study was underpowered to draw conclusions regarding QOL in patients with INPH who had epilepsy and abdominal pain, but the finding of no net difference in mean QOL indicates that no correlation between them existed. CONCLUSIONS Epilepsy, headache, and abdominal pain are common in long-term follow-up in patients after shunt surgery for INPH and are more common among patients with INPH than in the general population. All adverse events, including mild and moderate ones, should be considered during postoperative follow-ups and in the development of new methods for shunt placement.

Keywords: AE = adverse event; AED = antiepileptic drug; CRasH = Comorbidity and Risk Factors Associated With Hydrocephalus; EQ5D5L = EuroQoL 5-dimension 5-level instrument; ICD-10-SE = International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Swedish Edition; INPH = idiopathic normal pressure hydrocephalus; MMSE = Mini-Mental State Examination; QOL = quality of life; SNDR = Swedish National Drug Registry; SNPR = Swedish National Patient Registry; abdominal pain; epilepsy; headache; hydrocephalus; normal pressure; postoperative complications; ventriculoperitoneal shunt.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Abdominal Pain / epidemiology
  • Abdominal Pain / etiology*
  • Aged
  • Aged, 80 and over
  • Anticonvulsants / therapeutic use
  • Case-Control Studies
  • Epilepsy / drug therapy
  • Epilepsy / epidemiology
  • Epilepsy / etiology*
  • Female
  • Follow-Up Studies
  • Headache / epidemiology
  • Headache / etiology*
  • Humans
  • Hydrocephalus, Normal Pressure / surgery*
  • Male
  • Middle Aged
  • Postoperative Complications / epidemiology*
  • Quality of Life
  • Registries
  • Surveys and Questionnaires
  • Ventriculoperitoneal Shunt / adverse effects

Substances

  • Anticonvulsants