Avaliação cognitiva após cirurgia de derivação ventricular em pacientes com hidrocefalia de pressão normal: revisão sistemática com metanálise

Abstract

Introduction and Objectives: Normal pressure hydrocephalus (NPH) is characterized by gait disturbance, urinary incontinence, and cognitive decline, occurring in an incidence of 0.5 to 2.9% in individuals over 65 years old. This condition is considered one of the rare "reversible" causes of dementia. Definitive cerebrospinal fluid shunt surgery is the treatment of choice. However, cognitive improvement does not seem to be consistent across all domains, with evidence of benefit still being controversial. Therefore, our objective was to identify if there is cognitive improvement after definitive cerebrospinal fluid shunt surgery through a systematic review with meta-analysis. Methods: This review was registered on the PROSPERO platform under the number CRD42022271073. We used the DESC and MESH descriptors, and searches were conducted in the Medline, Cochrane, Clinical Trials, Lilac's, and Embase databases. Two independent evaluators performed the search, data extraction, and methodological quality assessment, which was done using the Rayann tool. Meta-analysis was conducted using the random-effects model. Results: A total of 676 studies were found, with 30 studies included for descriptive and quantitative analysis. All studies were observational, and the majority (28/93%) had low methodological quality. Only one study was conducted in a developing country, and the Mini-Mental State Examination (MMSE) was the most prevalent test for assessing cognitive functions (24/80%). In the meta-analysis, there was an improvement in the MMSE (mean difference,-2.34, 95% CI -3.25, -1.44, I2 71.76%). When subcategorized by the methodological quality of the studies, the effect size of the MMSE decreased. All meta-analyses conducted for various cognitive domains showed heterogeneity exceeding 17.89%. Cognitive domains that did not show improvement were visual memory and recent verbal memory. Conclusions: Permanent cerebrospinal fluid shunt surgery appears to have a satisfactory influence on cognition, especially in global cognitive performance, executive function involving vision, reasoning speed, late verbal memory, and semantic fluency. However, most studies have low methodological quality, and the meta-analysis showed high heterogeneity, which raises uncertainty about the absolute assertion that shunting leads to cognitive improvement.