# Comparative efficacy and safety of surgical interventions for communicating hydrocephalus: a systematic review and network meta-analysis of randomized controlled trials

## TL;DR

This study compares different surgeries for treating fluid buildup in the brain, finding that lumbar procedures are more effective and safer than others.

## Contribution

The study provides a network meta-analysis comparing multiple surgical interventions for communicating hydrocephalus, identifying the most effective and safest options.

## Key findings

- Lumboperitoneal shunt (LPS) and LPS with laparoscope (LPS+LS) showed higher efficacy than ventriculoperitoneal shunt (VPS).
- LPS and LPS+LS had fewer complications compared to VPS and ETV+CPC.
- Lumbar surgeries improved outcomes and reduced complications compared to cranial approaches.

## Abstract

Surgical intervention is the standard treatment for communicating hydrocephalus (CH), a condition involving cerebrospinal fluid (CSF) accumulation in the ventricles without a blockage. The optimal surgical approach for CH remains uncertain, with clinical decisions varying by patient characteristics and institutional practices. This study aims to compare the efficacy and safety of surgical interventions for CH.

In this systematic review and network meta-analysis (NMA), we searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, China National Knowledge Infrastructure (CNKI), Wanfang, Vip, China Biomedical Literature, and the Chinese Clinical Trial Registry (ChiCTR) from inception to September 24, 2024, for randomized controlled trials (RCTs). Primary outcomes were efficacy (favorable outcome) and safety (complications). Secondary outcomes included revision, infection, seizures, operation time (minutes), and duration of hospitalization (days). Bayesian NMAs synthesized the data, and the certainty of evidence was assessed using the confidence in NMA (CINeMA) framework. Surface under the Cumulative Ranking Curve (SUCRA) values were generated to rank the treatments. This study is registered with PROSPERO (CRD42024585931).

Of 4,159 citations identified by our search, 34 trials (2,528 participants) met the inclusion criteria. For efficacy, lumboperitoneal shunt (LPS) [risk ratio (RR) 1.18, 95% credible interval (CrI) 1.13–1.23; high certainty] and LPS with laparoscope (LPS + LS) (RR 1.27, 95% CrI 1.18–1.39; high certainty) were more effective than ventriculoperitoneal shunt (VPS). Both LPS and LPS + LS outperformed endoscopic third ventriculostomy (ETV) and ETV with choroid plexus cauterization (ETV + CPC) (RR range 1.16–1.48; high to moderate certainty). For safety, LPS, LPS + LS, and ETV had fewer complications than VPS (RR range 0.20–0.40; high certainty). LPS + LS had fewer complications than LPS (RR 0.49, 95% CrI 0.29–0.79; moderate certainty). Compared with cranial approaches, lumbar surgeries improved favorable outcomes [RR 1.23, 95% confidence interval (CI) 1.19–1.28; moderate certainty], and reduced complications (RR 0.33, 95% CI 0.26–0.43; moderate certainty).

LPS and LPS + LS appeared to be the most efficacious surgical interventions for treating CH, with fewer complications than VPS and ETV + CPC, indicating the potential advantages of lumbar approaches.

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024585931, CRD42024585931.

Infographic summarizing a network meta-analysis of 34 randomized clinical trials with 2,528 patients comparing five surgical interventions for communicating hydrocephalus. The left side shows anatomical illustrations for each procedure: ETV with or without CPC, VAS, LPS, VPIS, and VPSS. The top right features a table comparing efficacy and safety risk ratios for each intervention; notable values include high efficacy for ETV and LPS+LS. A bar graph below displays SUCRA scores, where LPS+LS ranks highest in both efficacy and safety.