Survival and Quality of Life Following CSF Diversion in Adult Patients with Leptomeningeal Metastases-Associated Hydrocephalus - a Systematic Review & Meta-Analysis

Abstract Aim Leptomeningeal Metastases (LM) is associated with altered CSF flow dynamics (50-70%), and 1-5% of patients will develop communicating hydrocephalus, adversely impacting quality of life (QoL), functional status, and overall survival (OS). There is equipoise for CSF diversion in LM-associated hydrocephalus (LM-H). This systematic review and meta-analysis aims to assess the effect of CSF diversion on OS and QoL in this context. Method This systematic review was conducted in accordance with PRISMA guidelines. Pubmed/MEDLINE, EMBASE, Web of Science, and Scopus were searched for articles evaluating the role of CSF diversion in adult patients with systemic cancer LM-H. A meta-analysis was conducted using random effects models, mean differences, and 95% confidence intervals (CI). Bias was assessed using the ROBINS-I tool. Results Ten eligible studies with a total of 494 patients were included. Two studies reported multivariate hazard ratios for median OS, suggesting no significant effect of shunting on OS (pooled HR = 0.42; p = 0.27; 95% CI 0.09-1.94). A pre-operative and post-operative Karnofsky Performance Status (KPS) mean difference of 17.6 points (CI 10.44-24.68; p<0.0001) was calculated from 4 studies. Across all studies, a symptomatic improvement rate of 67-100% was observed, with high rates of improvement of headaches and nausea and lower rates for cranial nerve palsies. Complication rates across nine studies ranged from 0-21.1%. Conclusions The present findings prompt the generation of a standardised decision-making tool, a critical analysis of individual patient risk-benefit ratios, and systematic measurements for QoL for these patients. Implementation of these will facilitate and optimise surgical management for LM-H patients.