Personalized Shunt Selection for Idiopathic Intracranial Hypertension: A Systematic Review and Meta-Analysis of Ventriculoperitoneal versus Lumboperitoneal Shunting

Surgical cerebrospinal fluid shunting is frequently required for medically refractory idiopathic intracranial hypertension (IIH); however, the optimal selection between ventriculoperitoneal shunt (VPS) and lumboperitoneal shunt (LPS) remains controversial. We aimed to compare outcomes between these approaches and develop a personalized decision algorithm. We performed a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, analyzing studies comparing VPS and LPS in IIH patients up to April 10, 2025. Key outcomes evaluated were visual improvement, resolution of papilledema, headache relief, shunt failure rates, and complications. Additionally, we conducted subgroup analyses based on patient characteristics and created a prediction model for personalized shunt selection. 12 studies with 5,990 patients indicated that VPS had superior outcomes for visual symptoms (odds ratio [OR]: 4.35) and papilledema resolution (OR: 3.63), whereas LPS delivered faster headache relief (2.2 weeks vs. 6.1 weeks, p < 0.001). Complication risks were also different: VPS had lower blockage (risk ratio [RR]: 0.17) and malposition (RR: 0.17) risks, while LPS had a reduced risk of overdrainage (RR: 0.02). Patient-specific factors significantly influenced outcomes, showing that young patients with severe symptoms had a 97% success rate with VPS compared to 52% with LPS (OR: 29.71), while those with predominant headaches fared better with LPS (73% vs. 64%). Our findings support a personalized approach to shunt selection in IIH. We recommend VPS for patients with severe papilledema and visual symptoms, while LPS appears preferable for those with predominant headache symptoms requiring rapid relief. This tailored approach may optimize outcomes while minimizing complications and revisions in IIH patients.