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Chen J, Xian J, Wang F, Zuo C, We L, Chen Z, Hu R, Feng H. Long-term outcomes of ventriculoperitoneal shunt therapy in idiopathic normal pressure hydrocephalus. BMC Surg 2025; 25:157. [PMID: 40221677 PMCID: PMC11992790 DOI: 10.1186/s12893-025-02895-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2024] [Accepted: 04/01/2025] [Indexed: 04/14/2025] Open
Abstract
BACKGROUND Limited data are available regarding the long-term functional outcomes and associated factors in patients with idiopathic normal pressure hydrocephalus (iNPH) undergoing ventriculoperitoneal shunt (VPS) placement. This study aimed to retrospectively evaluate the long-term outcomes of iNPH patients treated with VPS. METHODS Functional outcomes were assessed preoperatively and at 1-year, 2-year, and 3-year intervals postoperatively using the modified Rankin Scale (mRS), the iNPH grading scale (iNPHGS), and the Mini-Mental State Examination (MMSE). RESULTS Significant improvements were observed in mRS and iNPHGS scores at 1, 2, and 3 years post-surgery compared to the baseline level. MMSE scores showed significant improvement at 1-year and 3-year follow-ups. Multivariate regression analysis identified key factors influencing changes in mRS scores: postoperative complications and education level at 1 year, postoperative complications at 2 years, and sex, education level, postoperative complications, and smoking at 3 years. For iNPHGS scores, significant factors included sex, age at surgery, and smoking at 1 and 2 years. Changes in MMSE scores were associated with sex and the duration of preoperative symptoms at 1 year, and postoperative complications, education level, and smoking at 3 years. CONCLUSION This study affirmed the efficacy and safety of VPS in managing iNPH. Factors influencing postoperative outcomes predominantly included education level, smoking, duration of preoperative symptoms, and postoperative complications. However, further research is required to validate these findings.
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Affiliation(s)
- Jingyu Chen
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China.
| | - Jishu Xian
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
| | - Feilong Wang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
| | - Chenghai Zuo
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
| | - Li We
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
| | - Rong Hu
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, 400038, P. R. China
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Asahara Y, Suda M, Omoto S, Kobayashi K, Atsuchi M, Nagashima H, Suzuki M. Predictive Ability of Frontal Assessment Battery for Cognitive Improvement After Shunt Surgery in Individuals With Idiopathic Normal Pressure Hydrocephalus. Cogn Behav Neurol 2023; 36:228-236. [PMID: 37530564 DOI: 10.1097/wnn.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 03/12/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The predictive ability of the Frontal Assessment Battery (FAB) for postoperative cognitive improvement in idiopathic normal pressure hydrocephalus (iNPH) is unstudied. OBJECTIVE To compare the predictive ability of the FAB and the Mini-Mental State Examination (MMSE) for postoperative cognitive improvement in individuals with iNPH after shunt surgery. METHOD We retrospectively reviewed the medical records of individuals with iNPH who had shunt surgery between January 2016 and October 2018. Individuals had completed the tap test and clinical evaluations (FAB, MMSE, Timed Up and Go [TUG]) both before and 24-48 hours after CSF tapping and after surgery. We excluded individuals without complete clinical evaluations and those with shunt surgery performed >6 months after CSF tapping. Factors associated with postoperative FAB and MMSE improvement as per the 2011 iNPH guidelines were extracted using univariate and multivariate logistic regression analyses. Independent variables were baseline FAB and MMSE scores, FAB and MMSE score changes and TUG amelioration rate after CSF tapping, Evans index, age, and days from CSF tapping to surgery and from surgery to postoperative assessment. RESULTS The mean number of days from CSF tapping to surgery and from surgery to postoperative assessment were 77.5 (SD = 36.0) and 42.0 (SD = 14.5), respectively. Logistic regression analyses showed significant associations in the univariate analyses of postoperative FAB improvement with baseline FAB scores ( P = 0.043) and with FAB score changes after CSF tapping ( P = 0.047). CONCLUSION The FAB may help predict postoperative cognitive improvement after shunt surgery better than the MMSE.
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Affiliation(s)
| | | | | | | | - Masamichi Atsuchi
- Neurosurgery, The Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Hiroyasu Nagashima
- Neurosurgery, The Jikei University Katsushika Medical Center, Tokyo, Japan
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Rostgaard N, Olsen MH, Lolansen SD, Nørager NH, Plomgaard P, MacAulay N, Juhler M. Ventricular CSF proteomic profiles and predictors of surgical treatment outcome in chronic hydrocephalus. Acta Neurochir (Wien) 2023; 165:4059-4070. [PMID: 37857909 PMCID: PMC10739511 DOI: 10.1007/s00701-023-05832-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND By applying an unbiased proteomic approach, we aimed to search for cerebrospinal fluid (CSF) protein biomarkers distinguishing between obstructive and communicating hydrocephalus in order to improve appropriate surgical selection for endoscopic third ventriculostomy vs. shunt implants. Our second study purpose was to look for potential CSF biomarkers distinguishing between patients with adult chronic hydrocephalus benefitting from surgery (responders) vs. those who did not (non-responders). METHODS Ventricular CSF samples were collected from 62 patients with communicating hydrocephalus and 28 patients with obstructive hydrocephalus. CSF was collected in relation to the patients' surgical treatment. As a control group, CSF was collected from ten patients with unruptured aneurysm undergoing preventive surgery (vascular clipping). RESULTS Mass spectrometry-based proteomic analysis of the samples identified 1251 unique proteins. No proteins differed significantly between the communicating hydrocephalus group and the obstructive hydrocephalus group. Four proteins were found to be significantly less abundant in CSF from communicating hydrocephalus patients compared to control subjects. A PCA plot revealed similar proteomic CSF profiles of obstructive and communicating hydrocephalus and control samples. For obstructive hydrocephalus, ten proteins were found to predict responders from non-responders. CONCLUSION Here, we show that the proteomic profile of ventricular CSF from patients with hydrocephalus differs slightly from control subjects. Furthermore, we find ten predictors of response to surgical outcome (endoscopic third ventriculostomy or ventriculo-peritoneal shunt) in patients with obstructive hydrocephalus.
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Affiliation(s)
- Nina Rostgaard
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sara Diana Lolansen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas Hernandez Nørager
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Plomgaard
- Department of Clinical Biochemistry, Centre of Diagnostic Investigations, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nanna MacAulay
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Hasselbalch SG, Carlsen JF, Alaouie MM, Munch TN, Holst AV, Taudorf S, Rørvig-Løppentien C, Juhler M, Waldemar G. Prediction of shunt response in idiopathic normal pressure hydrocephalus by combined lumbar infusion test and preoperative imaging scoring. Eur J Neurol 2023; 30:3047-3055. [PMID: 37433569 DOI: 10.1111/ene.15981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND AND PURPOSE Idiopathic normal pressure hydrocephalus (iNPH) is a potentially treatable disorder, but prognostic tests or biomarkers are lacking. The aim was to study the predictive power of clinical, neuroimaging and lumbar infusion test parameters (resistance to outflow Rout , cardiac-related pulse amplitude PA and the PA to intracranial pressure ICP ratio). METHODS In all, 127 patients diagnosed with iNPH who had a lumbar infusion test, a subsequent ventriculo-peritoneal shunt operation and at least 2 months of postoperative follow-up were retrospectively included. Preoperative magnetic resonance images were visually scored for NPH features using the iNPH Radscale. Preoperative and postoperative assessment was performed using cognitive testing, as well as gait and incontinence scales. RESULTS At follow-up (7.4 months, range 2-20 months), an overall positive response was seen in 82% of the patients. Gait was more severely impaired at baseline in responders compared to non-responders. The iNPH Radscale score was borderline significantly higher in responders compared with non-responders, whereas no significant differences in infusion test parameters were seen between responders and non-responders. Infusion test parameters performed modestly with high positive (75%-92%) but low negative (17%-23%) predictive values. Although not significant, PA and PA/ICP seemed to perform better than Rout , and the odds ratio for shunt response seemed to increase in patients with higher PA/ICP, especially in patients with lower iNPH Radscale scores. CONCLUSION Although only indicative, lumbar infusion test results increased the likelihood of a positive shunt outcome. Pulse amplitude measures showed promising results that should be further explored in prospective studies.
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Affiliation(s)
- Steen Gregers Hasselbalch
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonathan Frederik Carlsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Radiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mohamed Moussa Alaouie
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Tina Nørgaard Munch
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Anders Vedel Holst
- Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Sarah Taudorf
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Christina Rørvig-Løppentien
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Gunhild Waldemar
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Kanemoto H, Mori E, Tanaka T, Suehiro T, Yoshiyama K, Suzuki Y, Kakeda K, Wada T, Hosomi K, Kishima H, Kazui H, Hashimoto M, Ikeda M. Cerebrospinal fluid amyloid beta and response of cognition to a tap test in idiopathic normal pressure hydrocephalus: a case-control study. Int Psychogeriatr 2023; 35:509-517. [PMID: 34399871 DOI: 10.1017/s1041610221000661] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To examine the relationship between cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD) and tap test response to elucidate the effects of comorbidity of AD in idiopathic normal-pressure hydrocephalus (iNPH). DESIGN Case-control study. SETTING Osaka University Hospital. PARTICIPANTS Patients with possible iNPH underwent a CSF tap test. MEASUREMENTS Concentrations of amyloid beta (Aβ) 1-40, 1-42, and total tau in CSF were measured. The response of tap test was judged using Timed Up and Go test (TUG), 10-m reciprocation walking test (10MWT), Mini-Mental State Examination (MMSE), and iNPH grading scale. The ratio of Aβ1-42 to Aβ1-40 (Aβ42/40 ratio) and total tau concentration was compared between tap test-negative (iNPH-nTT) and -positive (iNPH-pTT) patients. RESULTS We identified 27 patients as iNPH-nTT and 81 as iNPH-pTT. Aβ42/40 ratio was significantly lower (mean [SD] = 0.063 [0.026] vs. 0.083 [0.036], p = 0.008), and total tau in CSF was significantly higher (mean [SD] = 385.6 [237.2] vs. 293.6 [165.0], p = 0.028) in iNPH-nTT than in iNPH-pTT. Stepwise logistic regression analysis revealed that low Aβ42/40 ratio was significantly associated with the negativity of the tap test. The response of cognition was significantly related to Aβ42/40 ratio. The association between Aβ42/40 ratio and tap test response, especially in cognition, remained after adjusting for disease duration and severity at baseline. CONCLUSIONS A low CSF Aβ42/40 ratio is associated with a poorer cognitive response, but not gait and urinary response, to a tap test in iNPH. Even if CSF biomarkers suggest AD comorbidity, treatment with iNPH may be effective for gait and urinary dysfunction.
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Affiliation(s)
- Hideki Kanemoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
| | - Toshihisa Tanaka
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Suehiro
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yukiko Suzuki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kyosuke Kakeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tamiki Wada
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Hosomi
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Kazui
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Mamoru Hashimoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
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Nienhaus S, Stummer W, Khaleghi Ghadiri M. Normal Pressure Hydrocephalus and Comorbidities: A Quality Study of the University Hospital Münster. World Neurosurg 2023; 177:e126-e134. [PMID: 37295465 DOI: 10.1016/j.wneu.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Idiopathic normal pressure hydrocephalus (NPH) is commonly accompanied by diverse comorbidities that impact the postoperative course and result in a distinction between shunt responders and shunt non-responders. This study aimed to enhance diagnostics by identifying prognostic differences between NPH patients, individuals with comorbidities, and those with other complications. METHODS The data of 119 patients with NPH coding at the University Clinic Münster from January 2009 to June 2017 were examined. The study primarily concentrated on examining symptoms, comorbidities, and radiological measurements, including callosal angle (CA) and Evans index (EI). To evaluate the progression of symptoms, a novel scoring system was developed to quantitatively assess the course at specific time points: 5-7 weeks, 1-1.5 years, and 2.5 years after the operation. This scoring system aimed to provide a standardized approach for measuring and tracking the development of symptoms over time. Logistic regression analyses were employed to identify predictor associated with 3 key outcomes: shunt implantation, surgical success, and the development of complications. RESULTS Among the comorbidities observed, hypertension was the most prevalent. Gait disturbance, in the absence of polyneuropathy, was identified as a predictor of a favorable surgical outcome. Hygroma development was associated with a combination of vascular factors and cognitive disorders. The presence of spinal/skeletal changes, diabetes, and vascular constellations were found to increase the likelihood of developing complications. CONCLUSIONS The evaluation of comorbidities accompanied by NPH holds significant importance and necessitates meticulous observation, expertise, and multidisciplinary care.
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Affiliation(s)
- Susanne Nienhaus
- Department of Pediatric, Christliches Kinderhospital Osnabrück, Osnabrück, Germany
| | - Walter Stummer
- Department of Neurosurgery, University of Münster, Münster, Germany
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Thavarajasingam SG, El-Khatib M, Vemulapalli K, Iradukunda HAS, K. SV, Borchert R, Russo S, Eide PK. Radiological predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:369-419. [PMID: 36435931 PMCID: PMC9922237 DOI: 10.1007/s00701-022-05402-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery, though the predictors of shunt response remain debated. Currently, radiological features play an important role in the diagnosis of iNPH, but it is not well established which radiological markers most precisely predict shunt responsive iNPH. OBJECTIVE To conduct a systematic review and meta-analysis to identify radiological predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most predictive radiological features. METHODS Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating radiological predictors of shunt response in iNPH patients. Included studies were assessed using the ROBINS-1 tool, and eligible studies were evaluated using a univariate meta-analysis. RESULTS Overall, 301 full-text papers were screened, of which 28 studies were included, and 26 different radiological features were identified, 5 of these met the inclusion criteria for the meta-analysis: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The meta-analysis showed that only callosal angle and periventricular white matter changes significantly differentiated iNPH shunt responders from non-responders, though both markers had a low diagnostic odds ratio (DOR) of 1.88 and 1.01 respectively. None of the other radiological markers differentiated shunt responsive from shunt non-responsive iNPH. CONCLUSION Callosal angle and periventricular changes are the only diagnostically effective radiological predictors of shunt responsive iNPH patients. However, due to the DORs approximating 1, they are insufficient as sole predictors and are advised to be used only in combination with other diagnostic tests of shunt response. Future research must evaluate the combined use of multiple radiological predictors, as it may yield beneficial additive effects that may allow for more robust radiological shunt response prediction.
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Affiliation(s)
| | | | | | | | | | - Robin Borchert
- Department of Clinical Neurosciences, Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Salvatore Russo
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Per K. Eide
- Department of Neurosurgery, Oslo University Hospital – Rikshospitalet, Oslo, Norway ,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Kazui H, Hashimoto M, Takeda S, Chiba Y, Goto T, Fuchino K. Evaluation of Patients With Cognitive Impairment Due to Suspected Idiopathic Normal-Pressure Hydrocephalus at Medical Centers for Dementia: A Nationwide Hospital-Based Survey in Japan. Front Neurol 2022; 13:810116. [PMID: 35693019 PMCID: PMC9184737 DOI: 10.3389/fneur.2022.810116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 04/11/2022] [Indexed: 11/27/2022] Open
Abstract
Objective Treatment of idiopathic normal-pressure hydrocephalus (iNPH) requires collaboration between dementia specialists and neurosurgeons. The role of dementia specialists is to differentiate patients with iNPH from patients with other dementia diseases and to determine if other dementia diseases are comorbid with iNPH. We conducted a nationwide hospital-based questionnaire survey on iNPH in medical centers for dementia (MCDs). Methods We developed a questionnaire to assess how physicians in MCDs evaluate and treat patients with cognitive impairment due to suspected iNPH and the difficulties these physicians experience in the evaluation and treatment of patients. The questionnaire was sent to all 456 MCDs in Japan. Results Questionnaires from 279 MCDs were returned to us (response rate: 61.2%). Patients underwent cognitive tests, evaluation of the triad symptoms of iNPH, and morphological neuroimaging examinations in 96.8, 77.8, and 98.2% of the MCDs, respectively. Patients with suspected iNPH were referred to other hospitals (e.g., hospitals with neurosurgery departments) from 78.9% of MCDs, and cerebrospinal fluid (CSF) tap test was performed in 44 MCDs (15.8%). iNPH guidelines (iNPHGLs) and disproportionately enlarged subarachnoid space hydrocephalus (DESH), a specific morphological finding, were used and known in 39.4% and 38% of MCDs, respectively. Logistic regression analysis with “Refer the patient to other hospitals (e.g., hospitals with neurosurgery departments) when iNPH is suspected.” as the response variable and (a) using the iNPHGLs, (b) knowledge of DESH, (c) confidence regarding DESH, (d) difficulty with performing brain magnetic resonance imaging, (e) knowledge of the methods of CSF tap test, (f) absence of physician who can perform lumbar puncture, and (g) experience of being told by neurosurgeons that referred patients are not indicated for shunt surgery as explanatory variables revealed that the last two factors were significant predictors of patient referral from MCDs to other hospitals. Conclusion Sufficient differential or comorbid diagnosis using CSF tap test was performed in a few MCDs. Medical care for patients with iNPH in MCDs may be improved by having dementia specialists perform CSF tap tests and share the eligibility criteria for shunt surgery with neurosurgeons.
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Affiliation(s)
- Hiroaki Kazui
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Mamoru Hashimoto
- Department of Neuropsychiatry, Faculty of Medicine, Kindai University, Osakasayama, Japan
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Popal AM, Zhu Z, Guo X, Zheng Z, Cai C, Jiang H, Zhang J, Shao A, Zhu J. Outcomes of Ventriculoperitoneal Shunt in Patients With Idiopathic Normal-Pressure Hydrocephalus 2 Years After Surgery. Front Surg 2021; 8:641561. [PMID: 34869547 PMCID: PMC8634250 DOI: 10.3389/fsurg.2021.641561] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 10/14/2021] [Indexed: 11/29/2022] Open
Abstract
Objective: To evaluate the outcomes and prognostic factors of ventriculoperitoneal shunts (VP-shunts) in patients with idiopathic normal-pressure hydrocephalus (iNPH) at 6 months and 2 years after surgery. Method: We retrospectively analyzed 68 patients admitted to our institute and diagnosed with probable iNPH from January 2017 to March 2021. All patients underwent VP-shunt surgery with a programmable valve, and their outcomes were assessed via the Krauss index and modified Rankin scale (mRS) at 6 months and 2 years post-surgery. Univariate and multivariate regression analysis was performed to identify the prognostic factors. Results: The mean age of the patients was 71.1 ± 8.4 (mean ± standard deviation) years. On the Krauss improvement index, 6-month follow-up results were available for 68 patients. Of these patients, 91.2% experienced attenuation of their preoperative symptoms, with a mean Krauss index of 0.58 ± 0.27, and 48 patients (70.6%) had a Krauss index ≥0.5. Two-year follow-up results were available for 33 patients; 90.9% of them had sustained improvement, with a Krauss index of 0.54 ± 0.31, and 21 patients (66.3%) had a Krauss index ≥0.5. Thirty-three patients (58%) were living independently after 2 years (mRS 0–2). The outcomes were worse for patients with multiple comorbidities. Neither an increased patient age nor a prolonged history of illness was statistically significant prognostic factors for adverse outcomes of VP-shunt surgery. Conclusion: Surgical treatment was well-tolerated by patients with iNPH who received VP-shunts. Most patients experienced attenuation of their preoperative symptoms. Multiple concurrent comorbidities should be considered as adverse prognostic factors before shunt insertion in patients with iNPH.
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Affiliation(s)
- Abdul Malik Popal
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhoule Zhu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xinxia Guo
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chengwei Cai
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hongjie Jiang
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Anwen Shao
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
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10
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Sergej R, Leonie G, Holger A, Pawel G, Ullrich M, Johannes L. The role of shuntography in diagnosis of mechanic complications after implantation of ventriculoperitoneal shunts in patients with idiopathic normal pressure hydrocephalus: a retrospective clinical evaluation. Neuroradiology 2021; 64:745-752. [PMID: 34825966 PMCID: PMC8907103 DOI: 10.1007/s00234-021-02834-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/11/2021] [Indexed: 11/26/2022]
Abstract
Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.
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Affiliation(s)
- Rot Sergej
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Goelz Leonie
- Institute of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Arndt Holger
- Institute of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Gutowski Pawel
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Department of Neurosurgery, Brodno Masovian Hospital, Warsaw Postgraduate Medical Centre, Warsaw, Poland
| | - Meier Ullrich
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Lemcke Johannes
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
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11
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Thavarajasingam SG, El-Khatib M, Rea M, Russo S, Lemcke J, Al-Nusair L, Vajkoczy P. Clinical predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Acta Neurochir (Wien) 2021; 163:2641-2672. [PMID: 34235589 PMCID: PMC8437907 DOI: 10.1007/s00701-021-04922-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/13/2021] [Indexed: 11/29/2022]
Abstract
Background Positive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). However, multiple pathologies mimic iNPH symptoms, making it difficult to select patients who will respond to shunt surgery. Although presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose. Objective To conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests. Methods Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating clinical predictors of SR in iNPH patients. Included studies were assessed using the QUADAS-2 tool, and eligible studies were evaluated using univariate and bivariate meta-analyses. Results Thirty-five studies were included. Nine studies discussed the diagnostic use of presenting clinical features, 8 studies ELD, 8 studies IT, 11 studies ICPM, and 6 studies TT. A meta-analysis of 21 eligible studies was conducted for TT, ELD, IT, and ICPM. ICPM yielded the highest diagnostic effectiveness, with diagnostic odds ratio (DOR) = 50.9 and area under curve (AUC) = 0.836. ELD yielded DOR = 27.70 and AUC = 0.753, IT had DOR = 5.70 and AUC = 0.729, and TT scored DOR = 3.86 and AUC = 0.711. Conclusion Intraparenchymal ICPM is statistically the most effective diagnostic test, followed by ELD, IT, and lastly TT. Due to the higher accessibility of TT and IT, they are recommended to be used first line, using a timed-up-and-go improvement ≥ 5.6 s or a Rout cut-off range between 13 and 16 mmHg, respectively. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison.
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Affiliation(s)
| | - Mahmoud El-Khatib
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Mark Rea
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Salvatore Russo
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Lana Al-Nusair
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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12
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Zwimpfer TJ, Salterio N, Williams MA, Holubkov R, Katzen H, Luciano MG, Moghekar A, Nagel SJ, Wisoff JH, Golomb J, McKhann GM, Edwards RJ, Hamilton MG. Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus. J Neurosurg 2021; 136:887-894. [PMID: 34534954 DOI: 10.3171/2021.3.jns203424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus. METHODS Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included. RESULTS A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19-79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7-1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1-1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0-0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6-1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1-1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2-0.6 m/sec, p < 0.001). The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23-27) that improved to 26/30 (IQR 24-28) post-ETV. The median within-patient change was +1 point (IQR 0-2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22-27), which improved to 26/30 (IQR 25-28) post-ETV. The median within-patient change was +2 points (IQR 1-3 points, p = 0.007), which is both statistically and clinically significant. CONCLUSIONS Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.
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Affiliation(s)
- Thomas J Zwimpfer
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas Salterio
- 1Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael A Williams
- 2Departments of Neurology and Neurological Surgery, University of Washington, Seattle, Washington
| | - Richard Holubkov
- 3Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Heather Katzen
- 4Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Abhay Moghekar
- 6Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Sean J Nagel
- 7Department of Neurosurgery, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio
| | | | - James Golomb
- 9Neurology, New York University School of Medicine, New York, New York
| | - Guy M McKhann
- 10Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Richard J Edwards
- 11Department of Neurosurgery, Southmead Hospital, Bristol, United Kingdom; and
| | - Mark G Hamilton
- 12Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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13
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da Rocha SFB, Kowacs PA, de Souza RKM, Pedro MKF, Ramina R, Teive HAG. Serial Tap Test of patients with idiopathic normal pressure hydrocephalus: impact on cognitive function and its meaning. Fluids Barriers CNS 2021; 18:22. [PMID: 33957939 PMCID: PMC8101193 DOI: 10.1186/s12987-021-00254-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022] Open
Abstract
Background Idiopathic normal pressure hydrocephalus (INPH) is characterized by gait disturbance, urinary incontinence and cognitive decline. Symptoms are potentially reversible and treatment is based on cerebrospinal fluid shunting. The tap test (TT) is used to identify patients that will benefit from surgery. This procedure consists of the withdrawal of 20 to 50 mL of cerebrospinal fluid (CSF) through a lumbar puncture (LP) after which the symptoms of the triad are tested. Improvement in the quality and speed of gait are already recognized but cognitive improvement depends on several factors such as tests used, the time elapsed after LP for re-testing, and the number of punctures. Serial punctures may trigger similar conditions as external lumbar drainage (ELD) to the organism. Objective This study aimed to identify how serial punctures affect cognition to increase the sensitivity of the test and consequently the accuracy of surgical indication. Methods Sixty-one patients with INPH underwent baseline memory and executive tests repeatedly following the 2-Step Tap Test protocol (2-STT – two procedures of 30 mL lumbar CSF drainage separated by a 24-h interval). The baseline scores of INPH patients were compared with those of 55 healthy controls, and with intragroup post-puncture scores of the 2-STT. Results The group with INPH had lower performance than the control group in all cognitive tests (RAVLT, Stroop, CFT, FAR-COWA, FAB, MMSE, orientation, mental control), except for the forward digit span test (p = 0.707). After conducting LP procedures, the Stroop test (words, colors and errors), RAVLT (stage A1, A6 and B1), and CFT (immediate and delayed R) scores were equal to those of the control group (p > 0.05). The INPH group presented significant improvement after the first puncture in MMSE (p = 0.031) and in the Stroop Test (points) (p < 0.001). After the second puncture, subjects improved in orientation, MMSE, RAVLT (B1), Stroop (points, words, errors) and CFT (IR). Conclusion Progressive cognitive improvement occurred over the 2-STT and changes were more significant after the second LP in all cognitive domains except for RAVLT (A7). Encephalic alert system ‘arousal’ seems to participate in early improvements observed during 2-STT. The second LP increased the sensitivity of the drainage test to detect changes in cognitive variables, and consequently improved the quality of the method.
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Affiliation(s)
| | - Pedro André Kowacs
- Neurological Institute of Curitiba (INC), Curitiba, Street Jeremias Maciel Perretto, 300, Curitiba, Paraná, 81210-310, Brazil.,Headache Division and Pain Residence, Neurology Division, Hospital Clinics, Federal University of Paraná, Curitiba, Brazil
| | | | - Matheus Kahakura Franco Pedro
- Neurological Institute of Curitiba (INC), Curitiba, Street Jeremias Maciel Perretto, 300, Curitiba, Paraná, 81210-310, Brazil
| | - Ricardo Ramina
- Neurological Institute of Curitiba (INC), Curitiba, Street Jeremias Maciel Perretto, 300, Curitiba, Paraná, 81210-310, Brazil
| | - Hélio A Ghizoni Teive
- Neurology Service, Internal Medicine Department, Hospital Clinics, Federal University of Paraná, Curitiba, Paraná, Brazil
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14
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Suehiro T, Kazui H, Kanemoto H, Yoshiyama K, Sato S, Suzuki Y, Azuma S, Matsumoto T, Kishima H, Ishii K, Ikeda M. Changes in brain morphology in patients in the preclinical stage of idiopathic normal pressure hydrocephalus. Psychogeriatrics 2019; 19:557-565. [PMID: 30950145 DOI: 10.1111/psyg.12445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Specific ventriculomegaly features, including tight high-convexity and medial subarachnoid spaces, are found on magnetic resonance images in patients with idiopathic normal pressure hydrocephalus (iNPH). However, some healthy elderly individuals with no typical triad symptoms of iNPH also exhibit specific magnetic resonance image features of iNPH. Therefore, this study quantitatively clarified the brain morphology of suspected iNPH patients with no objective triad symptoms (iNPH-NOS). METHODS We recruited patients with suspected iNPH and divided them into two groups based on their iNPH grading scale scores: the iNPH-NOS group and the iNPH with apparent objective triad symptoms (iNPH-AOS) group. Data for normal controls (NC) were taken from the database used in our previous study. We compared the relative volumes of ventricle systems (VS), Sylvian fissures (SF), and sulci at high convexity and the midline (SHM), adjusted by the intracranial volume, of the iNPH-NOS, iNPH-AOS, and NC groups. Additionally, we compared the relative volumes of VS, SF, and SHM in iNPH-NOS patients between their first visit and follow-up 1 year later. RESULTS Fifteen iNPH-NOS patients and 45 iNPH-AOS patients were recruited, and 24 NCs were found in the database. The relative volumes of VS and SF were significantly smaller than in NCs than in the iNPH-NOS and iNPH-AOS groups, and the relative volume of SHM was significantly larger in NCs. The relative volume of SHM was significantly larger in the iNPH-NOS group than in the iNPH-AOS group, but there were no significant differences in the relative volumes of VS and SF between these groups. In the iNPH-NOS group, the relative volumes of VS and SF were significantly smaller at the first visit than 1 year later, whereas the relative volume of SHM was significantly larger. In 6 of 15 iNPH-NOS patients, objective symptoms appeared during the observation period. CONCLUSIONS Our results indicate that iNPH-NOS patients were in the transitional stage between normal and iNPH-AOS, both morphologically and clinically.
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Affiliation(s)
- Takashi Suehiro
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroaki Kazui
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Neuropsychiatry, Kochi Medical School, Kochi University, Kochi, Japan
| | - Hideki Kanemoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Psychiatry, Mizuma Hospital, Kaizuka, Japan.,Cognitive Reserve Research Center, Osaka Kawasaki Rehabilitation University, Kaizuka, Japan
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shunsuke Sato
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yukiko Suzuki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Japan
| | - Shingo Azuma
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuya Matsumoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazunari Ishii
- Faculty of Medicine, Department of Radiology, Kindai University, Osakasyama, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
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15
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Azuma S, Kazui H, Kanemoto H, Suzuki Y, Sato S, Suehiro T, Matsumoto T, Yoshiyama K, Kishima H, Shimosegawa E, Tanaka T, Ikeda M. Cerebral blood flow and Alzheimer's disease-related biomarkers in cerebrospinal fluid in idiopathic normal pressure hydrocephalus. Psychogeriatrics 2019; 19:527-538. [PMID: 30916850 DOI: 10.1111/psyg.12435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/26/2018] [Accepted: 01/13/2019] [Indexed: 11/26/2022]
Abstract
AIM Alzheimer's disease (AD) pathology is highly prevalent in patients with idiopathic normal pressure hydrocephalus (iNPH), and the presence of AD pathology may involve regional cerebral blood flow (rCBF). In this study, we examined the relationship between rCBF and AD-related biomarkers in the cerebrospinal fluid of iNPH patients. METHODS Patients with iNPH (n = 39) were classified into groups with (iNPH/AD+) (n=15) and without (iNPH/AD-) (n=24) high biomarker probability of AD (i.e. combined low amyloid β 42 and high total tau in the cerebrospinal fluid). rCBF was quantified in 17 regions of interest by N-isopropyl-p-[123 I]iodoamphetamine single-photon emission computed tomography with the autoradiography method. We compared rCBF between the iNPH/AD- and iNPH/AD+ groups at baseline using a t-test and then compared changes in rCBF after shunt surgery between the groups using a paired t-test and two-way repeated measures ANOVA. RESULTS At baseline, there were no significant differences in rCBF between the groups in most regions apart from the putamen. After shunt surgery, a significant increase in rCBF in the putamen, amygdala, hippocampus, and parahippocampal gyrus was observed in iNPH/AD- patients. In iNPH/AD+ patients, no significant improvement in rCBF was observed in any region. In repeated measures analysis of variance, a significant group × shunt interaction was observed in the parietal lobe, frontal lobe, posterior cingulate cortex, precuneus, lateral temporal lobe, amygdala, hippocampus, parahippocampal gyrus, and putamen. CONCLUSIONS Improvement in rCBF after shunt surgery in iNPH/AD+ patients may be poorer than that in iNPH AD- patients.
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Affiliation(s)
- Shingo Azuma
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroaki Kazui
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Hideki Kanemoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Psychiatry, Mizuma Hospital, Kaizuka, Japan.,Cognitive Reserve Research Center, Osaka Kawasaki Rehabilitation University, Kaizuka, Japan
| | - Yukiko Suzuki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Japan
| | - Shunsuke Sato
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takashi Suehiro
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuya Matsumoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Eku Shimosegawa
- Department of Molecular Imaging in Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toshihisa Tanaka
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan
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16
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Agerskov S, Wallin M, Hellström P, Ziegelitz D, Wikkelsö C, Tullberg M. Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery. AJNR Am J Neuroradiol 2018; 40:74-79. [PMID: 30523139 DOI: 10.3174/ajnr.a5910] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/24/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have evaluated the use of MR imaging markers for the prediction of outcome after shunt surgery in idiopathic normal pressure hydrocephalus with conflicting results. Our aim was to investigate the predictive value of a number of earlier proposed morphologic MR imaging markers in a large group of patients with idiopathic normal pressure hydrocephalus. MATERIALS AND METHODS One hundred sixty-eight patients (mean age, 70 ± 9.3 years) with idiopathic normal pressure hydrocephalus, subjected to standardized quantification of clinical symptoms before and after shunt surgery, were included in the study. Outcome was calculated using a composite score. Preoperative T1, FLAIR, and flow-sensitive images were analyzed regarding the presence of 13 different morphologic MR imaging markers. RESULTS The median Evans index was 0.41 (interquartile range, 0.37-0.44). All patients had an aqueductal flow void sign present and white matter hyperintensities. The median callosal angle was 68.8° (interquartile range, 57.7°-80.8°). Dilated Sylvian fissures were found in 69%; focally dilated sulci, in 25%; and widening of the interhemispheric fissure, in 55%. Obliteration of the sulci at the convexity was found in 36%, and 36% of patients were characterized as having disproportionately enlarged subarachnoid space hydrocephalus. Sixty-eight percent of patients improved after surgery. None of the investigated MR imaging markers were significant predictors of improvement after shunt surgery. CONCLUSIONS Disproportionately enlarged subarachnoid space hydrocephalus, a small callosal angle, and the other MR imaging markers evaluated in this study should not be used to exclude patients from shunt surgery. These markers, though they may be indicative of idiopathic normal pressure hydrocephalus, do not seem to be a part of the mechanisms connected to the reversibility of the syndrome.
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Affiliation(s)
- S Agerskov
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - M Wallin
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - P Hellström
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - D Ziegelitz
- Department of Neuroradiology (D.Z.), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - C Wikkelsö
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - M Tullberg
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
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17
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Vivas-Buitrago T, Pinilla-Monsalve G, Jusué-Torres I, Oishi K, Robison J, Crawford JA, Pletnikov M, Xu J, Baledént O, Lokossou A, Hung AL, Blitz AM, Lu J, Herzka DA, Guerrero-Cazares H, Oishi K, Mori S, Quiñones-Hinojosa A, Rigamonti D. Ventricular Volume Dynamics During the Development of Adult Chronic Communicating Hydrocephalus in a Rodent Model. World Neurosurg 2018; 120:e1120-e1127. [PMID: 30217783 DOI: 10.1016/j.wneu.2018.08.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The pathophysiology of normal-pressure hydrocephalus and the correlation with its symptomatology is not well understood. OBJECTIVE To monitor and evaluate the enlargement patterns of the ventricular system for each ventricle and its correlation with the presenting symptoms. METHODS Bilateral kaolin injection into the subarachnoid space overlying the cranial convexities was done in 18 adult rats. Magnetic resonance imaging was performed on an 11.7-T scanner 15, 60, 90, and 120 days after injection. Volumes of the ventricular system were measured for each ventricle and correlated with biweekly behavioral findings. RESULTS There was a progressive increase in the ventricular volume for the lateral ventricles since day 15 in the kaolin-injected animals. There was a nonsignificant trend in volume growth for the third ventricle, but its enlargement was synchronous with the lateral ventricles. No significant change for the fourth ventricle. No symptoms were detected in the first 60 days. Association was found between the ventricular volume and locomotor changes. In addition, the odds of locomotor symptoms increased by 3% for every additional cubic millimeter of volume in the left (P < 0.001) and right (P = 0.023) ventricles, and for the total magnetic resonance imaging volume by 1% (P = 0.013). CONCLUSIONS Expansion of the lateral ventricles maintained similar proportions over time, accompanied by a synchronous third ventricular expansion with less proportion and a nonsignificant fourth enlargement. Lateral ventricles enlarged most in those animals that were to develop late locomotor deterioration. Further research using this animal model combined with different radiologic imaging techniques, such as diffusion tensor imaging and perfusion studies, is recommended.
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Affiliation(s)
- Tito Vivas-Buitrago
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA; Faculty of Health Sciences, School of Medicine, Universidad de Santander UDES, Bucaramanga, Colombia
| | | | - Ignacio Jusué-Torres
- Department of Neurosurgery, Loyola University School of Medicine, Maywood, Illinois, USA
| | - Kumiko Oishi
- Johns Hopkins University, Center for Imaging Science, Whiting School of Engineering, Baltimore, Maryland, USA
| | - Jamie Robison
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Joshua A Crawford
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mikhail Pletnikov
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jiadi Xu
- Kennedy Krieger Institute, Kirby Research Center for Functional Brain Imaging, Baltimore, Maryland, USA
| | - Olivier Baledént
- Amiens University Hospital, Image Processing Unit, Amiens, France
| | - Armelle Lokossou
- Amiens University Hospital, Image Processing Unit, Amiens, France
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ari M Blitz
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Lu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel A Herzka
- Johns Hopkins University, Center for Imaging Science, Whiting School of Engineering, Baltimore, Maryland, USA
| | | | - Kenichi Oishi
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Susumu Mori
- Kennedy Krieger Institute, Kirby Research Center for Functional Brain Imaging, Baltimore, Maryland, USA; Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia.
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18
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Agerskov S, Hellström P, Andrén K, Kollén L, Wikkelsö C, Tullberg M. The phenotype of idiopathic normal pressure hydrocephalus-a single center study of 429 patients. J Neurol Sci 2018; 391:54-60. [PMID: 30103972 DOI: 10.1016/j.jns.2018.05.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/06/2018] [Accepted: 05/28/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Idiopathic Normal Pressure Hydrocephlaus (iNPH) is, despite a vastly improved knowledge of the disorder since its first description still underdiagnosed and undertreated. Because of this, there is a need for further large studies describing the typical symptomatology and reversibility of symptoms in iNPH, which was the aim of this study. METHODS In all, 429 patients (mean age 71 years) were included. Detailed pre- and postoperative examinations of symptoms and signs were analyzed. A composite outcome measure was constructed. RESULTS Sixty-eight % improved after surgery. Preoperatively, 72% exhibited symptoms from three or four of the assessed domains (gait, balance, neuropsychology and continence) while 41% had symptoms from all four domains. Ninety % had gait disturbances, of which 75% had broad-based gait, 65% shuffling gait and 30% freezing of gait. These disturbances coexisted in most patients preoperatively, but were more likely to appear as isolated findings after surgery. Impaired balance was seen in 53% and retropulsion in 46%. MMSE <25 was seen in 53% and impaired continence in 86%. Improvements were seen in all symptom domains postoperatively. CONCLUSIONS The iNPH phenotype is characterized by a disturbance in at least 3/4 symptom domains in most patients, with improvements in all domains after shunt surgery. Most patients present with a broad-based and shuffling gait as well as paratonia. Present symptoms in all domains and a shuffling gait at the time of diagnosis seem to predict a favorable postoperative outcome, whereas symptom severity does not.
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Affiliation(s)
- Simon Agerskov
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Per Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Kerstin Andrén
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Lena Kollén
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carsten Wikkelsö
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
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Pyykkö OT, Nerg O, Niskasaari HM, Niskasaari T, Koivisto AM, Hiltunen M, Pihlajamäki J, Rauramaa T, Kojoukhova M, Alafuzoff I, Soininen H, Jääskeläinen JE, Leinonen V. Incidence, Comorbidities, and Mortality in Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2018; 112:e624-e631. [PMID: 29374607 DOI: 10.1016/j.wneu.2018.01.107] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/14/2018] [Accepted: 01/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECT To investigate the incidence, comorbidities, mortality, and causes of death in idiopathic normal pressure hydrocephalus (iNPH). METHODS A cohort of 536 patients with possible NPH from a defined population with a median follow-up time of 5.1 years, (range 0.04-19.9 years) was included in the study. Patients were evaluated by brain imaging and intraventricular pressure monitoring, with a brain biopsy specimen immunostained against amyloid-β and hyperphosphorylated τ. Hospital records were reviewed for vascular diseases and type 2 diabetes mellitus (T2DM). Death certificates and yearly population of the catchment area were obtained from national registries. RESULTS A total of 283 patients had a clinical diagnosis of iNPH, leading to a median annual incidence of 1.58 iNPH patients per 100,000 inhabitants (range, 0.8-4.5). Alzeimer disease-related brain biopsy findings were less frequent in iNPH patients than in non-iNPH patients (P < 0.05). An overrepresentation of hypertension (52% vs. 33%, P < 0.001) and T2DM (23% vs. 13%, P = 0.002) was noted in iNPH patients. Age (hazard ratio [HR] 1.04/year, 95% confidence interval [CI] 1.03-1.06, P < 0.001) and T2DM (HR 1.63, 95% CI 1.23-2.16, P < 0.001) increased the risk of death in the iNPH patients and in the total population. iNPH was associated with decreased risk of death (HR 0.63, 95% CI 0.50-0.78, P < 0.001). The most frequent causes of death were cardiovascular and cerebrovascular disease. Dementia as a cause of death was more common in non-iNPH patients (27% vs. 10%, P < 0.001). CONCLUSIONS Hypertension and T2DM are common in iNPH and the latter causes excess mortality in the affected patients.
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Affiliation(s)
- Okko T Pyykkö
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
| | - Ossi Nerg
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | | | - Timo Niskasaari
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Anne M Koivisto
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | - Mikko Hiltunen
- Institute of Biomedicine, University of Eastern Finland, Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Jussi Pihlajamäki
- Department of Clinical Nutrition, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, and Clinical Nutrition and Obesity Center, Kuopio University Hospital, Kuopio, Finland
| | - Tuomas Rauramaa
- Department of Pathology, Kuopio University Hospital, and Institute of Clinical Medicine - Pathology, University of Eastern Finland, Kuopio, Finland
| | - Maria Kojoukhova
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Irina Alafuzoff
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Hilkka Soininen
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | | | - Ville Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
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20
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Hong YJ, Kim MJ, Jeong E, Kim JE, Hwang J, Lee JI, Lee JH, Na DL. Preoperative biomarkers in patients with idiopathic normal pressure hydrocephalus showing a favorable shunt surgery outcome. J Neurol Sci 2018; 387:21-26. [PMID: 29571865 DOI: 10.1016/j.jns.2018.01.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/20/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Idiopathic normal pressure hydrocephalus (INPH) is known to be a potentially treatable neurologic condition. The neurocognitive outcomes after surgery, however, have been variable. It is important to define preoperative characteristics of patients that predicts the shunting outcome. We aimed to compare baseline differences between shunt-responsive and unresponsive patients after 1year from surgery in order to identify preoperative predictors showing favorable clinical outcomes. METHODS Among 69 candidates, 31 patients with probable INPH completed the study. Patients were divided into two groups, responsive group (n=17) and unresponsive group (n=14), according to the clinical outcomes on INPH grading scale and modified Rankin score (MRS). Preoperative cerebrospinal (CSF) Aß, tau levels, MRI findings, and clinical characteristics were compared between the groups. Correlations between shunt responsiveness and preoperative characteristics were also assessed. RESULTS After 1year from shunt, gait problem was the most likely to improve. Shunt-responsive group showed lower CSF p-tau/Aß, fewer lacunes, and higher incidence of disproportionately enlarged subarachnoid space (DESH) signs on MRIs compared to those in unresponsive group. Favorable outcome was related with positive DESH sign and fewer lacunes. CONCLUSIONS Our results suggest that biomarkers representing non-INPH related pathology including Alzheimer's disease and small vessel disease might show less favorable clinical outcomes after 1year from surgery.
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Affiliation(s)
- Yun Jeong Hong
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea; Biomedical Research Institute, Pusan National University Hospital, Pusan, South Korea
| | - Min-Jeong Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Eunhye Jeong
- Department of Neurology, Bundang Jesaeng Hospital, Seongnam, South Korea
| | - Ji-Eun Kim
- Department of Neurology, University of Ulsan College of Medicine, Gangneung Asan Medical Center, Gangneung, South Korea
| | - Jihye Hwang
- Department of Neurology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, South Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae-Hong Lee
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
| | - Duk L Na
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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21
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Espay AJ, Da Prat GA, Dwivedi AK, Rodriguez-Porcel F, Vaughan JE, Rosso M, Devoto JL, Duker AP, Masellis M, Smith CD, Mandybur GT, Merola A, Lang AE. Deconstructing normal pressure hydrocephalus: Ventriculomegaly as early sign of neurodegeneration. Ann Neurol 2017; 82:503-513. [PMID: 28892572 DOI: 10.1002/ana.25046] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/21/2017] [Accepted: 09/01/2017] [Indexed: 12/27/2022]
Abstract
Idiopathic normal pressure hydrocephalus (NPH) remains both oversuspected on clinical grounds and underconfirmed when based on immediate and sustained response to cerebrospinal fluid diversion. Poor long-term postshunt benefits and findings of neurodegenerative pathology in most patients with adequate follow-up suggest that hydrocephalic disorders appearing in late adulthood may often result from initially unapparent parenchymal abnormalities. We critically review the NPH literature, highlighting the near universal lack of blinding and controls, absence of specific clinical, imaging, or pathological features, and ongoing dependence for diagnostic confirmation on variable cutoffs of gait response to bedside fluid-drainage testing. We also summarize our long-term institutional experience, in which postshunt benefits in patients with initial diagnosis of idiopathic NPH persist in only 32% of patients at 36 months, with known revised diagnosis in over 25% (Alzheimer's disease, dementia with Lewy bodies, and progressive supranuclear palsy). We postulate that previously reported NPH cases with "dual" pathology (ie, developing a "second" disorder) more likely represent ventriculomegalic presentations of selected neurodegenerative disorders in which benefits from shunting may be short-lived, with a consequently unfavorable risk-benefit ratio. Ann Neurol 2017;82:503-513.
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Affiliation(s)
- Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Gustavo A Da Prat
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH.,Sanatorio de la Trinidad Mitre, Departamento de Neurologia, Ciudad de Buenos Aires, Argentina
| | - Alok K Dwivedi
- Department of Biomedical Sciences, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center (TTUHSC), El Paso, TX
| | - Federico Rodriguez-Porcel
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Jennifer E Vaughan
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Michela Rosso
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Johnna L Devoto
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Andrew P Duker
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Mario Masellis
- Cognitive & Movement Disorders Clinic, Sunnybrook Health Sciences Centre, University of Toronto, and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Charles D Smith
- Departments of Neurology and Radiology, Magnetic Resonance Imaging & Spectroscopy Center, University of Kentucky, Lexington, KY
| | - George T Mandybur
- Mayfield Clinic, Department of Neurosurgery, University of Cincinnati, Cincinnati, OH
| | - Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Anthony E Lang
- Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, University of Toronto, Toronto, ON, Canada
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22
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[Idiopathic normal pressure hydrocephalus: High incidence in people over 80 years of age]. Rev Esp Geriatr Gerontol 2017; 53:85-88. [PMID: 28734501 DOI: 10.1016/j.regg.2017.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/12/2017] [Accepted: 06/17/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Idiopathic normal pressure hydrocephalus is usually observed in adults over 60 years of age. The highest incidence of cases is between 70 and 80 years-old, and it could be under-diagnosed in over 80 year-olds. OBJECTIVE A description is presented on the overall incidence and age group incidence, the delay in the diagnosis, and main outcomes. PATIENTS AND METHODS A descriptive study was performed on patients with idiopathic normal pressure hydrocephalus, in the population of Osona County during the years 2010-2015. RESULTS The annual incidence rate was 4.43 per 100,000 inhabitants. The incidence increased with age; from 8.09 per 100,000 in the 60 to 69 years age group, to 23.61 per 100,000 in the 70-79 years age group of, and to 37.02 per 100,000 in the 80-89 years age. The delay in the diagnosis was 15.01 ± 10.35 months. All the patients improved after surgery, but only 73.3% of the patients maintained the improvement after one year. CONCLUSIONS Idiopathic normal pressure hydrocephalus is an age related disease and probably underdiagnosed in the elderly. An early diagnosis and a clinical suspicion are essential in patients over 80 years old.
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23
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Levin OS, Chimagomedova AS, Skripkina NA, Lyashenko EA, Babkina OV. Nonmotor Symptoms in Vascular and Other Secondary Parkinsonism. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:1303-1334. [PMID: 28805574 DOI: 10.1016/bs.irn.2017.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Vascular parkinsonism (VP) is a relatively frequent variant of secondary parkinsonism caused by ischemic or hemorrhagic lesions of basal ganglia, midbrain, or their links with frontal cortex. According to different investigations, various forms of cerebrovascular disease cause 1%-15% of parkinsonism cases. Nonmotor symptoms are frequently found in VP and may negatively influence on quality of life. However, nonmotor symptoms such as hallucinations, orthostatic hypotension, REM-sleep behavior disorder, and anosmia are rarely revealed in VP, which may be noted to another diagnosis or mixed pathology. Clinical value of nonmotor symptoms in normal pressure hydrocephalus, toxic, and drug-induced parkinsonism is also discussed.
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Affiliation(s)
- Oleg S Levin
- Russian Medical Academy of Professional Continuous Education, Centre of Extrapyramidal Disorders, Moscow, Russia.
| | - Achcha Sh Chimagomedova
- Russian Medical Academy of Professional Continuous Education, Centre of Extrapyramidal Disorders, Moscow, Russia
| | - Natalia A Skripkina
- Russian Medical Academy of Professional Continuous Education, Centre of Extrapyramidal Disorders, Moscow, Russia
| | - Elena A Lyashenko
- Russian Medical Academy of Professional Continuous Education, Centre of Extrapyramidal Disorders, Moscow, Russia
| | - Olga V Babkina
- Russian Medical Academy of Professional Continuous Education, Centre of Extrapyramidal Disorders, Moscow, Russia
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24
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Feinkohl I, Winterer G, Pischon T. Hypertension and Risk of Post-Operative Cognitive Dysfunction (POCD): A Systematic Review and Meta-Analysis. Clin Pract Epidemiol Ment Health 2017; 13:27-42. [PMID: 28603544 PMCID: PMC5447947 DOI: 10.2174/1745017901713010027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 01/16/2023]
Abstract
Background: Post-operative cognitive dysfunction (POCD) occurs frequently after major surgery. Hypertension is well-established as a risk factor for age-related cognitive impairment, but it is unclear whether or not it also increases the risk of POCD. Objective: To evaluate the role of hypertension in POCD risk in a systematic review and meta-analysis. Method: PubMed, Ovid SP and the Cochrane Database of Systematic Reviews were searched for longitudinal studies of adults undergoing surgery with reporting of hypertension, blood pressure and/or anti-hypertensive treatment associations with POCD as relative risks or odds ratios. Fixed-effects meta-analyses were performed using Review Manager (version 5.3). Results: Twenty-four studies on 4317 patients (mean age 63 years) were included. None of the studies had set out to assess hypertension as a risk factor for POCD. Hypertension was used as a categorical predictor throughout and only 2 studies adjusted for potential confounders. Across all 24 studies, hypertension was not significantly associated with POCD risk (RR 1.01; 95% CI 0.93, 1.09; p=0.82), though among 8 studies with >75% males, we found hypertension associations with a 27% increased risk of POCD (RR 1.27, 95% CI 1.07, 1.49; p=0.005). Conclusion: Our findings do not support the hypothesis that hypertension is a risk factor for POCD. However, since none of the studies included in our analysis were hypothesis-driven and most did not adjust for potential confounders, further systematic investigations are needed to evaluate the role of hypertension in the epidemiology of POCD.
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Affiliation(s)
- I Feinkohl
- Molecular Epidemiology Research Group, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - G Winterer
- Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - T Pischon
- Molecular Epidemiology Research Group, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Charité - Universitaetsmedizin Berlin, Berlin, Germany.,MDC/BIH Biobank, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), and Berlin Institute of Health (BIH), Berlin, Germany
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25
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Krzastek SC, Robinson SP, Young HF, Klausner AP. Improvement in lower urinary tract symptoms across multiple domains following ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus. Neurourol Urodyn 2017; 36:2056-2063. [PMID: 28185313 DOI: 10.1002/nau.23235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 01/02/2017] [Accepted: 01/09/2017] [Indexed: 01/31/2023]
Abstract
AIMS The purpose of this study was to evaluate the change in lower urinary tract symptoms following ventriculoperitoneal shunting in patients with idiopathic normal pressure hydrocephalus (iNPH). METHODS Lower urinary tract symptoms in patients with new-onset iNPH were prospectively evaluated using validated questionnaires from the International Consultation on Incontinence to assess overactive bladder (ICIq-OAB), incontinence (ICIq-UI), and quality of life (ICIq-LUTqol), as well as the American Urological Association Symptom Score bother scale, prior to and following ventriculoperitoneal shunting for iNPH. Sub-analysis was performed based on gender, age, and medical comorbidities. RESULTS Twenty-three consecutive patients with new-onset iNPH were evaluated prior to, and following, surgical intervention for iNPH via ventriculoperitoneal shunting. Shunting resulted in a significant improvement in urinary urgency, urge incontinence, ability to perform physical activities, and overall quality of life. Women had improvement across more domains than men following shunting, particularly in terms of urinary urgency and overall quality of life. Younger patients experienced significant improvement in scores following shunting as compared to older patients. Patients with two or more medical comorbidities, as well as those with fewer than two comorbidities, reported a significant improvement in overall quality of life. CONCLUSIONS Surgical intervention for iNPH results in significant improvement in urinary symptoms, specifically in terms of urinary urgency and urge incontinence as well as overall quality of life, particularly in women and younger patients.
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Affiliation(s)
- Sarah C Krzastek
- Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Samuel P Robinson
- Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Harold F Young
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Adam P Klausner
- Division of Urology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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26
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Multimodal analysis to predict shunt surgery outcome of 284 patients with suspected idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2016; 158:2311-2319. [PMID: 27743250 DOI: 10.1007/s00701-016-2980-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Optimal selection of idiopathic normal pressure hydrocephalus (iNPH) patients for shunt surgery is challenging. Disease State Index (DSI) is a statistical method that merges multimodal data to assist clinical decision-making. It has previously been shown to be useful in predicting progression in mild cognitive impairment and differentiating Alzheimer's disease (AD) and frontotemporal dementia. In this study, we use the DSI method to predict shunt surgery response for patients with iNPH. METHODS In this retrospective cohort study, a total of 284 patients (230 shunt responders and 54 non-responders) from the Kuopio NPH registry were analyzed with the DSI. Analysis included data from patients' memory disorder assessments, age, clinical symptoms, comorbidities, medications, frontal cortical biopsy, CT/MRI imaging (visual scoring of disproportion between Sylvian and suprasylvian subarachnoid spaces, atrophy of medial temporal lobe, superior medial subarachnoid spaces), APOE genotyping, CSF AD biomarkers, and intracranial pressure. RESULTS Our analysis showed that shunt responders cannot be differentiated from non-responders reliably even with the large dataset available (AUC = 0.58). CONCLUSIONS Prediction of the treatment response in iNPH is challenging even with our extensive dataset and refined analysis. Further research of biomarkers and indicators predicting shunt responsiveness is still needed.
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Bey E, Nicot B, Casez O, Le Normand L. [Lower urinary tract dysfunction in normal pressure hydrocephalus: Review of the literature]. Prog Urol 2016; 26:1191-1199. [PMID: 27816462 DOI: 10.1016/j.purol.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Lower urinary tract dysfunction in normal pressure hydrocephalus has received little attention from the scientific community. The aim of this review article was to discuss diagnostic and therapeutic options for these patients. SOURCES A literature review of MedLine publications on urinary incontinence in normal pressure hydrocephalus was conducted. The following keywords were used: "hydrocephalus, normal pressure" and "bladder dysfunction" or "urinary incontinence" or "overactive bladder" or "urinary bladder, neurogenic". Prospective and retrospective studies as well as previous reviews were analyzed. RESULTS Urinary symptoms in normal pressure hydrocephalus are mainly represented by overactive bladder, which is a significant burden for the concerned patients. Isolated overactive bladder is more frequent (64%) than urinary incontinence (57%). Detrusor overactivity is seen in 95.2% of the cases. Neuro-surgery is efficient on urinary symptoms for 61.5% of the patients. Bladder recovery after surgery relates with increased mid-cingulate perfusion, probably linked with a functional restoration of the mid-cingulate that normally inhibits the micturition reflex. Medical options, added or not to surgery, include anticholinergic drugs unable to pass through the blood-brain barrier, Transcutaneous Electrical Nerve Stimulation and sacral neuromodulation. CONCLUSION There is actually an insufficient concern about urinary symptoms in normal pressure hydrocephalus. This article highlights the importance of a harmonization of neuro-urological practices in the pre-therapeutic evaluation of patients suffering from normal pressure hydrocephalus.
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Affiliation(s)
- E Bey
- Département de chirurgie urologique, CHU de Grenoble, avenue Maquis-du-Grésivaudan, 38700 La Tronche, France.
| | - B Nicot
- Département de neuro-chirurgie, CHU de Grenoble, avenue Maquis-du-Grésivaudan, 38700 La Tronche, France
| | - O Casez
- Département de neurologie, CHU de Grenoble, avenue Maquis-du-Grésivaudan, 38700 La Tronche, France
| | - L Le Normand
- Département de chirurgie urologique, CHU de Nantes, 85, rue Saint-Jacques, Nantes, France
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Jusué-Torres I, Jeon LH, Sankey EW, Lu J, Vivas-Buitrago T, Crawford JA, Pletnikov MV, Xu J, Blitz A, Herzka DA, Crain B, Hulbert A, Guerrero-Cazares H, Gonzalez-Perez O, McAllister JP, Quiñones-Hinojosa A, Rigamonti D. A Novel Experimental Animal Model of Adult Chronic Hydrocephalus. Neurosurgery 2016; 79:746-756. [DOI: 10.1227/neu.0000000000001405] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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29
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Sosvorova L, Mohapl M, Vcelak J, Hill M, Vitku J, Hampl R. The impact of selected cytokines in the follow-up of normal pressure hydrocephalus. Physiol Res 2016; 64:S283-90. [PMID: 26680491 DOI: 10.33549/physiolres.933069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Cytokines are widely known mediators of inflammation accompanying many neurodegenerative disorders including normal pressure hydrocephalus (NPH). NPH is caused by impaired cerebrospinal fluid (CSF) reabsorption and treated by surgical shunt insertion. The diagnostics is still complicated and the shunt effect is not durable; after several years, dementia may develop. In the clinical practice, biomarkers support the diagnostics as well as the further time course of many neurodegenerative diseases. Until recently, no reliable biomarker for NPH was evaluated. The attempt of this review was to make a survey concerning cytokines as possible NPH markers. Among all reviewed cytokines, the most promising are CSF IL-10 and IL-33, enabling to follow-up the disease progression and monitoring the effectiveness of the shunt insertion.
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Affiliation(s)
- L Sosvorova
- Department of Steroids and Proteofactors, Institute of Endocrinology, Prague, Czech Republic.
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30
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Arosio B, Casati M, Gussago C, Ferri E, Abbate C, Scortichini V, Colombo E, Rossi PD, Mari D. Adenosine Type A2A Receptor in Peripheral Cell from Patients with Alzheimer’s Disease, Vascular Dementia, and Idiopathic Normal Pressure Hydrocephalus: A New/Old Potential Target. J Alzheimers Dis 2016; 54:417-25. [DOI: 10.3233/jad-160324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Beatrice Arosio
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Fondazione Ca’ Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Casati
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Nutritional Sciences, University of Milan, Milan, Italy
| | - Cristina Gussago
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - Evelyn Ferri
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Nutritional Sciences, University of Milan, Milan, Italy
| | - Carlo Abbate
- Fondazione Ca’ Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Elena Colombo
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Daniela Mari
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Fondazione Ca’ Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
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Krzastek SC, Bruch WM, Robinson SP, Young HF, Klausner AP. Characterization of lower urinary tract symptoms in patients with idiopathic normal pressure hydrocephalus. Neurourol Urodyn 2016; 36:1167-1173. [PMID: 27490149 DOI: 10.1002/nau.23084] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/06/2016] [Indexed: 01/28/2023]
Abstract
AIMS The purpose of this study was to evaluate lower urinary tract symptoms (LUTS) in idiopathic normal pressure hydrocephalus (iNPH). METHODS Patients with new-onset iNPH were prospectively evaluated for LUTS via detailed history and physical, and administration of questionnaires from the International Consultation on Incontinence to assess incontinence (ICIq-UI), overactive bladder (ICIq-OAB), and quality of life (ICIq-LUTqol), as well as the American Urological Association Symptom Score bother scale. All patients with moderate-to-severe LUTS were offered urodynamic testing. Sub-analysis was performed based on gender, medical comorbidities, and age. RESULTS Fifty-five consecutive patients with iNPH completed the initial evaluation and surveys. Total urinary incontinence score was mild to moderate (8.71 ± 0.64: 0-21 scale) with 90.9% experiencing leakage and 74.5% reporting urge incontinence. The most common OAB symptom was nocturia (2.2 ± 0.14: 0-4 scale) with urge incontinence the most bothersome (3.71 ± 0.44: 0-10 scale). Quality-of-life impact was moderate (4.47 ± 0.4: 0-10 scale) and American Urological Association Symptom Score bother scale was 2.89 ± 0.22 (0-6 scale). Urodynamics testing revealed 100% detrusor overactivity and mean bladder capacity of 200 mL. Several differences were identified based on gender, medical comorbidities, and age. CONCLUSIONS Patients with iNPH present with mild-moderate incontinence of which nocturia is the most common symptom, urge incontinence the most bothersome, with 100% of patients having detrusor overactivity. Younger patients experienced greater bother related to LUTS. To our knowledge, this is the only prospective evaluation of urinary symptoms in patients with new-onset iNPH.
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Affiliation(s)
- Sarah C Krzastek
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - William M Bruch
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Samuel P Robinson
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Harold F Young
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Adam P Klausner
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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SOSVOROVA L, MOHAPL M, HILL M, STARKA L, BICIKOVA M, VITKU J, KANCEVA R, BESTAK J, HAMPL R. Steroid Hormones and Homocysteine in the Outcome of Patients With Normal Pressure Hydrocephalus. Physiol Res 2015; 64:S227-36. [DOI: 10.33549/physiolres.933072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Normal pressure hydrocephalus (NPH) is one of a few treatable conditions of cognitive decline affecting predominately elderly people. Treatment, commonly based on the ventriculoperitoneal shunt insertion, leads to a partial or complete correction of patient's state, although its effect does not unfortunately always last. The aim of our study was to observe the changes of homocysteine and selected steroids and neurosteroids and follow-up the patients with respect to the duration of the NPH-related dementia improvement. The cerebrospinal fluid and plasma levels of cortisol, cortisone, dehydroepiandrosterone (DHEA), 7α-hydroxy-DHEA, 7β-hydroxy-DHEA, 7-oxo-DHEA, 16α-hydroxy-DHEA (all LC-MS/MS), DHEA-sulphate (DHEAS) (radioimmunoassay) and homocysteine (gas chromatography) were determined in NPH-diagnosed subjects before, during and 6, 12 and 24 months after shunt insertion. The cognitive functions ameliorated after shunt insertion and remain improved within 2 years. Changes in cerebrospinal fluid DHEAS, DHEA and its ratio, cortisone/cortisol and 16α-hydroxy-DHEA and plasma DHEAS, 7β-hydroxy-DHEA, cortisone/cortisol and homocysteine were found. Mentioned changes may contribute to the clarification of NPH pathogenesis. Altered neurosteroids levels are possible indicators to be utilized in the follow-up of NPH subjects. Moreover, plasma homocysteine may serve as an early indicator of NPH-related dementia.
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Affiliation(s)
- L. SOSVOROVA
- Department of Steroids and Proteofactors, Institute of Endocrinology, Prague, Czech Republic
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Sosvorova L, Hill M, Mohapl M, Vitku J, Hampl R. Steroid hormones in prediction of normal pressure hydrocephalus. J Steroid Biochem Mol Biol 2015; 152:124-32. [PMID: 25976421 DOI: 10.1016/j.jsbmb.2015.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/13/2015] [Accepted: 05/07/2015] [Indexed: 12/20/2022]
Abstract
Normal pressure hydrocephalus (NPH) is a treatable neurological disorder affecting elderly people with the prevalence increasing with age. NPH is caused by abnormal cerebrospinal fluid (CSF) reabsorption and manifested as a balance impairment, urinary incontinence and dementia development. These symptoms are potentially reversible if recognized early. Diagnosis of NPH is difficult and can be easily mistaken for other neurodegenerative disorders, which makes NPH one of the major misdiagnosed diseases worldwide. The aim of the study was to find out the appropriate combination of indicators, based on CSF steroids, which would contribute to a clearer NPH diagnosis. The levels of CSF cortisol, cortisone, dehydroepiandrosterone (DHEA), 7α-OH-DHEA, 7β-OH-DHEA, 7-oxo-DHEA, 16α-OH-DHEA and aldosterone (all LC-MS/MS) were determined in our patients (n=30; NPH, 65-80 years) and controls (n=10; 65-80 years). The model of orthogonal projections to latent structures (OPLS) was constructed to predict NPH. Cortisone, 7α-OH-DHEA, 7β-OH-DHEA, 7-oxo-DHEA, aldosterone, 7α-OH-DHEA /DHEA, 7-oxo-DHEA/7α-OH-DHEA, 7β-OH-DHEA/7-oxo-DHEA and 16α-OH-DHEA/DHEA in the CSF were identified as the key predictors and the model discriminated patients from controls with 100% sensitivity and 100% specificity. The suggested model would contribute to early and accurate NPH diagnosis, enabling promptly treatment of the disease.
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Affiliation(s)
- Lucie Sosvorova
- Institute of Endocrinology, Department of Steroids and Proteofactors, Narodni 8, 116 94 Prague, Czech Republic.
| | - Martin Hill
- Institute of Endocrinology, Department of Steroids and Proteofactors, Narodni 8, 116 94 Prague, Czech Republic
| | - Milan Mohapl
- University Military Hospital Prague, Department of Neurosurgery, U Vojenske nemocnice 1200, 169 02 Prague, Czech Republic
| | - Jana Vitku
- Institute of Endocrinology, Department of Steroids and Proteofactors, Narodni 8, 116 94 Prague, Czech Republic
| | - Richard Hampl
- Institute of Endocrinology, Department of Steroids and Proteofactors, Narodni 8, 116 94 Prague, Czech Republic
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Kazui H, Kanemoto H, Suzuki Y, Sato S, Suehiro T, Azuma S, Yoshiyama K, Tanaka T. Association between high biomarker probability of Alzheimer's disease and improvement of cognition and gait after shunt surgery in patients with idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2015. [PMCID: PMC4582274 DOI: 10.1186/2045-8118-12-s1-o48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Campos-Juanatey F, Gutiérrez-Baños JL, Portillo-Martín JA, Zubillaga-Guerrero S. Assessment of the urodynamic diagnosis in patients with urinary incontinence associated with normal pressure hydrocephalus. Neurourol Urodyn 2014; 34:465-8. [PMID: 24729303 DOI: 10.1002/nau.22600] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 03/03/2014] [Indexed: 11/06/2022]
Abstract
AIMS To assess the urodynamic patterns present in patients with adult normal pressure hydrocephalus (NPH) in our institution. METHODS Retrospectively conducted study on patients diagnosed with NPH by the Neurosurgery Department of our institution, without etiological treatment or urogynecological disorders, who underwent an urodynamic study (UDS) performed according to methods proposed by the International Society of Continence (ICS). Clinical information, complementary tests and UDS were collected, and descriptive analysis was performed, with special focus in urodynamic final diagnosis. RESULTS Eighty-one UDS performed between 2003 and 2013. Fifty-one Males (63%). Mean age: 74.89 ± 8.58 years old (range 52-88 years). Classical triad of symptoms: gait disturbance, dementia, and urinary incontinence (UI) presented in 48.1%. Urinary urgency in 80.9% and UI in 70%. In two cases (2.5%) UDS was not valuable. Urodynamic features of the 79 remaining studies revealed overactive detrusor (OD) in 56 patients (70.9%), being associated with Stress UI (SUI) in one case and with bladder outlet obstruction (BOO) in 19. SUI in six patients (7.6%) and BOO in five (6.3%). Detrusor underactivity in four cases (5%) and normal study in eight (10.1%). About 47.1% of males presented BOO. Cerebrospinal fluid shunt surgery was performed on 32 patients during follow-up, with subsequent clinical improvement in 90.6% of them. CONCLUSIONS OD was the most frequent diagnosis within UDS conducted on adult NPH patients in our institution, with BOO in an elevated percentage of them. Etiological treatment led to symptomatic improvement in most of patients.
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Affiliation(s)
- Félix Campos-Juanatey
- Urology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - José Luis Gutiérrez-Baños
- Urology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain.,School of Medicine, University of Cantabria, Santander, Spain
| | - José Antonio Portillo-Martín
- Urology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain.,School of Medicine, University of Cantabria, Santander, Spain
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