Ventriculoperitoneal Shunting Versus Endoscopic Third Ventriculostomy for the Surgical Management of Idiopathic Normal Pressure Hydrocephalus: A Retrospective Cohort Analysis

Objective Idiopathic normal pressure hydrocephalus (iNPH) is a chronic condition characterized by ventricular enlargement in the setting of normal opening pressure and presents with gait ataxia, dementia, and urinary incontinence. Surgical treatment options have been shown to be effective for the treatment of iNPH, with the two most common being the placement of a ventriculoperitoneal shunt (VPS) or an endoscopic third ventriculostomy (ETV) procedure. Several studies have compared clinical outcomes across these two modalities but with conflicting results. While some studies report greater symptom resolution and fewer complications with one of the two procedures, others report the opposite. Here, we leveraged a large database to retrospectively compare the clinical outcomes of patients with iNPH who were treated with either VPS or ETV, aiming to provide further insight into this ongoing debate. Methods The electronic health record database, TriNetX, was used to isolate patients aged 50 years or older who were diagnosed with iNPH. Patients were then separated into two cohorts by surgical treatment with either VPS or ETV and propensity score matched based on various demographics and comorbidities, yielding 118 matched patients in each cohort for the final outcome analysis. Outcomes were evaluated within 10 years following surgery and included death, subdural hematoma, seizures, falls, urinary incontinence, emergency department visits, CT of the head, and MRI of the brain. Results Patients in the VPS cohort were significantly more likely to visit the emergency department (p = 0.0333) and receive a CT scan of the head (p = 0.0001), while patients in the ETV cohort were significantly more likely to receive an MRI of the brain (p < 0.0001). There was no significant difference between the two cohorts in the remaining outcomes, including death (p = 0.8510), subdural hematoma (p = 0.8520), seizures (p = 0.9272), falls (p = 0.0829), and urinary incontinence (p = 0.2902). Conclusions Our results showed few differences in outcomes between iNPH patients treated with either VPS or ETV. The differences observed in the use of imaging modalities are not surprising given the nature of each approach, with CT offering efficient visualization of the implanted device in VPS patients and MRI facilitating evaluation of the stoma created during the ETV procedure. Furthermore, the difference in emergency department visits could not be reliably linked to procedural complications as the reason for the visit was unknown. Overall, our findings suggest that outcomes are comparable between these two surgical approaches, though further research is needed to validate this conclusion.