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Passos-Neto CEB, Lopes CCB, Teixeira MS, Studart A, Spera RR. Normal pressure hydrocephalus: an update. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:42-52. [PMID: 35976308 PMCID: PMC9491444 DOI: 10.1590/0004-282x-anp-2022-s118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Normal pressure hydrocephalus (NPH) has been a topic of debate since its introduction in publications. More frequent in the elderly population, it is characterized by gait disturbance, urinary urge incontinence and cognitive decline. Therefore, it is a clinical-radiological entity with relatively common findings for the age group, which together may have greater specificity. Therefore, its diagnosis must be careful for an adequate selection of patients for treatment with ventricular shunt, since the symptoms are potentially reversible. The tap test has a high positive predictive value as a predictor of therapeutic response, but a negative test does not exclude the possibility of treatment. Scientific efforts in recent years have been directed towards a better understanding of NPH and this narrative review aims to compile recent data from the literature in a didactic way for clinical practice.
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Affiliation(s)
- Carlos Eduardo Borges Passos-Neto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Neurologia Cognitiva e do Comportamento, São Paulo - SP, Brazil
| | - Cesar Castello Branco Lopes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Neurologia Cognitiva e do Comportamento, São Paulo - SP, Brazil
| | - Mauricio Silva Teixeira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Neurologia Cognitiva e do Comportamento, São Paulo - SP, Brazil
| | - Adalberto Studart
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Neurologia Cognitiva e do Comportamento, São Paulo - SP, Brazil
| | - Raphael Ribeiro Spera
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, Grupo de Neurologia Cognitiva e do Comportamento, São Paulo - SP, Brazil
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Maier IL, Heide M, Hofer S, Dechent P, Fiss I, von der Brelie C, Rohde V, Frahm J, Bähr M, Liman J. High Periventricular T1 Relaxation Times Predict Gait Improvement After Spinal Tap in Patients with Idiopathic Normal Pressure Hydrocephalus. Clin Neuroradiol 2022; 32:1067-1076. [PMID: 35391549 PMCID: PMC9744711 DOI: 10.1007/s00062-022-01155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/02/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE The diagnosis of idiopathic normal pressure hydrocephalus (iNPH) can be challenging. Aim of this study was to use a novel T1 mapping method to enrich the diagnostic work-up of patients with suspected iNPH. METHODS Using 3T magnetic resonance imaging (MRI) we prospectively evaluated rapid high-resolution T1 mapping at 0.5 mm resolution and 4 s acquisition time in 15 patients with suspected iNPH and 8 age-matched, healthy controls. T1 mapping in axial sections of the cerebrum, clinical and neuropsychological testing were performed prior to and after cerebrospinal fluid tap test (CSF-TT). T1 relaxation times were measured in 5 predefined periventricular regions. RESULTS All 15 patients with suspected iNPH showed gait impairment, 13 (86.6%) showed signs of cognitive impairment and 8 (53.3%) patients had urinary incontinence. Gait improvement was noted in 12 patients (80%) after CSF-TT. T1 relaxation times in all periventricular regions were elevated in patients with iNPH compared to controls with the most pronounced differences in the anterior (1006 ± 93 ms vs. 911 ± 77 ms; p = 0.023) and posterior horns (983 ± 103 ms vs. 893 ± 68 ms; p = 0.037) of the lateral ventricles. Montreal cognitive assessment (MoCA) scores at baseline were negatively correlated with T1 relaxation times (r < -0.5, p < 0.02). Higher T1 relaxation times were significantly correlated with an improvement of the 3‑m timed up and go test (r > 0.6 and p < 0.03) after CSF-TT. CONCLUSION In iNPH-patients, periventricular T1 relaxation times are increased compared to age-matched controls and predict gait improvement after CSF-TT. T1 mapping might enrich iNPH work-up and might be useful to indicate permanent shunting.
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Affiliation(s)
- Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Marielle Heide
- Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Sabine Hofer
- Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Peter Dechent
- Institute for Cognitive Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ingo Fiss
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | | | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Frahm
- Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
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Nakajima M, Yamada S, Miyajima M, Ishii K, Kuriyama N, Kazui H, Kanemoto H, Suehiro T, Yoshiyama K, Kameda M, Kajimoto Y, Mase M, Murai H, Kita D, Kimura T, Samejima N, Tokuda T, Kaijima M, Akiba C, Kawamura K, Atsuchi M, Hirata Y, Matsumae M, Sasaki M, Yamashita F, Aoki S, Irie R, Miyake H, Kato T, Mori E, Ishikawa M, Date I, Arai H. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir (Tokyo) 2021; 61:63-97. [PMID: 33455998 PMCID: PMC7905302 DOI: 10.2176/nmc.st.2020-0292] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Among the various disorders that manifest with gait disturbance, cognitive impairment, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. The first edition of these guidelines for management of iNPH was published in 2004, and the second edition in 2012, to provide a series of timely, evidence-based recommendations related to iNPH. Since the last edition, clinical awareness of iNPH has risen dramatically, and clinical and basic research efforts on iNPH have increased significantly. This third edition of the guidelines was made to share these ideas with the international community and to promote international research on iNPH. The revision of the guidelines was undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project. This revision proposes a new classification for NPH. The category of iNPH is clearly distinguished from NPH with congenital/developmental and acquired etiologies. Additionally, the essential role of disproportionately enlarged subarachnoid-space hydrocephalus (DESH) in the imaging diagnosis and decision for further management of iNPH is discussed in this edition. We created an algorithm for diagnosis and decision for shunt management. Diagnosis by biomarkers that distinguish prognosis has been also initiated. Therefore, diagnosis and treatment of iNPH have entered a new phase. We hope that this third edition of the guidelines will help patients, their families, and healthcare professionals involved in treating iNPH.
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Affiliation(s)
- Madoka Nakajima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shigeki Yamada
- Department of Neurosurgery, Shiga University of Medical Science, Ohtsu, Shiga, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kazunari Ishii
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Nagato Kuriyama
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Kyoto, Japan
| | - Hiroaki Kazui
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Hideki Kanemoto
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi Suehiro
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiro Kameda
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoshinaga Kajimoto
- Department of Neurosurgery, Division of Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hisayuki Murai
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Daisuke Kita
- Department of Neurosurgery, Noto General Hospital, Nanao, Ishikawa, Japan
| | - Teruo Kimura
- Department of Neurosurgery, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
| | - Naoyuki Samejima
- Department of Neurosurgery, Tokyo Kyosai Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Takahiko Tokuda
- Department of Functional Brain Imaging Research, National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Chiba, Japan
| | - Mitsunobu Kaijima
- Department of Neurosurgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan
| | - Chihiro Akiba
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kaito Kawamura
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masamichi Atsuchi
- Normal Pressure Hydrocephalus Center, Jifukai Atsuchi Neurosurgical Hospital, Kagoshima, Kagoshima, Japan
| | - Yoshihumi Hirata
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Kumamoto, Japan
| | - Mitsunori Matsumae
- Department of Neurosurgery at Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Makoto Sasaki
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Fumio Yamashita
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryusuke Irie
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroji Miyake
- Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Hyogo, Japan
| | - Takeo Kato
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine, Yamagata, Yamagata, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
| | - Masatsune Ishikawa
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Kyoto, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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Kuchcinski G, Baroncini M, Lopes R, Leclerc X, Hodel J. Letter: Commentary: Idiopathic Normal-Pressure Hydrocephalus: Diagnostic Accuracy of Automated Sulcal Morphometry in Patients With Ventriculomegaly. Neurosurgery 2020; 87:E611-E612. [PMID: 32860054 DOI: 10.1093/neuros/nyaa374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Affiliation(s)
- Grégory Kuchcinski
- UMR_S 1171 'Degenerative and vascular cognitive disorders' Univ Lille, Inserm Lille, France
- Department of Neuroradiology CHU Lille Lille, France
| | | | - Renaud Lopes
- UMR_S 1171 'Degenerative and vascular cognitive disorders' Univ Lille, Inserm Lille, France
| | - Xavier Leclerc
- UMR_S 1171 'Degenerative and vascular cognitive disorders' Univ Lille, Inserm Lille, France
- Department of Neuroradiology CHU Lille Lille, France
| | - Jérôme Hodel
- Department of Neuroradiology Hôpital Henri Mondor Créteil, France
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Alford EN, Rotman LE, Riley KO. In Reply: Commentary: Idiopathic Normal-Pressure Hydrocephalus: Diagnostic Accuracy of Automated Sulcal Morphometry in Patients With Ventriculomegaly. Neurosurgery 2020; 87:E613-E614. [PMID: 32860410 DOI: 10.1093/neuros/nyaa377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
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Manniche C, Simonsen AH, Hasselbalch SG, Andreasson U, Zetterberg H, Blennow K, Høgh P, Juhler M, Hejl AM. Cerebrospinal Fluid Biomarkers to Differentiate Idiopathic Normal Pressure Hydrocephalus from Subcortical Ischemic Vascular Disease. J Alzheimers Dis 2020; 75:937-947. [PMID: 32390628 DOI: 10.3233/jad-200036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) remains a challenge to differentiate from subcortical ischemic vascular disease (SIVD). Despite major research efforts, the cerebrospinal fluid (CSF) biomarker profiles of the two diseases are still not known in detail. OBJECTIVE To determine if novel CSF biomarkers, neurofilament light (NFL) reflecting axonal damage, the synaptic protein neurogranin (NG), and the astroglial marker chitinase-3-like protein 1 (YKL-40), and the core Alzheimer's disease (AD) biomarkers, amyloid-β 42 (Aβ42), total tau (t-tau), phosphorylated tau (p-tau), can differentiate iNPH from SIVD. Patients with AD and healthy controls (HC) were included for comparison purposes. METHODS Patients with iNPH (n = 28), SIVD (n = 30), AD (n = 57), and HC (n = 33) were retrospectively included from the Danish Dementia Biobank. All patients with iNPH had effect of shunt surgery with a follow-up period of 4 to 69 months. CSF biomarkers were measured using immunoassays. RESULTS Lower levels of NFL, NG, Aβ42, and t-tau were found in patients with iNPH versus SIVD, while YKL-40 and p-tau were similar in the two diseases. NFL and Aβ42 were the most reliable biomarkers to differentiate iNPH from SIVD with an area under the curve (AUC) on 0.82 and 0.80, respectively. Combining NFL with Aβ42, t-tau, and p-tau resulted in an AUC of 0.90, which was equivalent to the diagnostic accuracy of all six biomarkers combined. CONCLUSION An addition of NFL to the CSF panel of Aβ42, t-tau, and p-tau may improve the differentiation of iNPH from SIVD.
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Affiliation(s)
- Christina Manniche
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anja Hviid Simonsen
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Steen Gregers Hasselbalch
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,UK Dementia Research Institute at UCL, London, UK.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Peter Høgh
- Department of Neurology, Regional Dementia Research Centre, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne-Mette Hejl
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
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Ghaffari-Rafi A, Gorenflo R, Hu H, Viereck J, Liow K. Role of psychiatric, cardiovascular, socioeconomic, and demographic risk factors on idiopathic normal pressure hydrocephalus: A retrospective case-control study. Clin Neurol Neurosurg 2020; 193:105836. [PMID: 32371292 DOI: 10.1016/j.clineuro.2020.105836] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Currently, predicting and preventing idiopathic normal pressure hydrocephalus (iNPH) remains challenging, especially for patients without a history of cerebrovascular disease. By exploring the role of cardiovascular and psychiatric history, demographics, and socioeconomic status in iNPH, will provide better direction for elucidating the etiology or addressing healthcare inequalities. PATIENTS AND METHODS To investigate iNPH with respect to the selected risk factors, we conducted a retrospective case-control study from a neuroscience institute in Hawaii with a patient pool of 25,843. After excluding patients with a history of cerebrovascular disease, we identified 29 cases which meet the American-European guidelines for iNPH diagnosis. Meanwhile, 116 controls matched to age, sex, and race were also randomly selected. RESULTS Median age at diagnosis was 83 (IQR: 74-88), with cases estimated 22 years older than controls (95 % CI: 14.00-29.00; p = 0.0000001). Patients with iNPH were more likely to be White (OR 4.01, 95 % CI: 1.59-10.11; p = 0.0042) and less likely Native Hawaiian and other Pacific Islander (OR 0.010, 95 % CI: 0.00-0.78; p = 0.014). Median household income was $2874 (95 % CI: 0.000089-6905; p = 0.088) greater amongst iNPH cases. Effect size amongst cardiovascular risk factors was not found statistically significant (i.e., body mass index, hyperlipidemia, type 2 diabetes mellitus, hypertension, coronary artery disease or prior myocardial infarction history, peripheral vascular disease, smoking status, congestive heart failure, atrial fibrillation/flutter, and history of prosthetic valve replacement). However, iNPH patients were more likely to have a history of alcohol use disorder (OR 8.29, 95 % CI: 0.99-453.87; p = 0.050) and history of a psychiatric disorder (OR 2.48; 95 % CI: 1.08-5.68; p = 0.029). Odds ratio for autoimmune disorder, thyroid disorder, glaucoma, and seizures did not reach statistical significance. CONCLUSION Patient race (i.e., White; Native Hawaiian or other Pacific Islander) was found associated with iNPH development. Meanwhile, after excluding those with cerebrovascular disease, cardiovascular risk factors were not found associated with iNPH. Lastly, iNPH cases were more inclined to have a history of alcohol use disorder and prior psychiatric disorder. Overall, this data reveals that a racial disparity exists amongst iNPH, as well as highlights the role of various cardiovascular and psychiatric risk factors, which can potentially provide direction in etiology elucidation.
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Affiliation(s)
- Arash Ghaffari-Rafi
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA; University College London, Queen Square Institute of Neurology, London, England, UK.
| | - Rachel Gorenflo
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA
| | - Huanli Hu
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA
| | - Jason Viereck
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA; Hawaii Pacific Neuroscience, Honolulu, Hawai'i, USA
| | - Kore Liow
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA; Hawaii Pacific Neuroscience, Honolulu, Hawai'i, USA
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Renjen P, Gupta C, Chaudhari D, Mishra A. Diagnosis, pathophysiology, and treatment of normal pressure hydrocephalus: A review of current perspectives. APOLLO MEDICINE 2020. [DOI: 10.4103/am.am_7_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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9
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Akiba C, Gyanwali B, Villaraza S, Nakajima M, Miyajima M, Cheng CY, Wong TY, Venketasubramanian N, Hilal S, Chen C. The prevalence and clinical associations of disproportionately enlarged subarachnoid space hydrocephalus (DESH), an imaging feature of idiopathic normal pressure hydrocephalus in community and memory clinic based Singaporean cohorts. J Neurol Sci 2019; 408:116510. [PMID: 31810041 DOI: 10.1016/j.jns.2019.116510] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/03/2019] [Accepted: 09/27/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Disproportionately Enlarged Subarachnoid space Hydrocephalus (DESH) is considered as an important imaging feature of idiopathic normal pressure hydrocephalus (iNPH). METHOD Subjects aged 60 and over in a memory clinic and a community-based cohort were assessed for the presence of ventriculomegaly, Sylvian dilatation, and high convexity tightness by neuroimaging, and a clinical triad of iNPH symptoms, i.e. cognitive, gait and urinary symptoms. RESULTS In the memory clinic-based study (548 subjects), the prevalence of DESH was 1.1% and increased with age. The clinical triad was significantly more frequent in subjects with DESH (50%) compared to those with normal images (none), Sylvian dilatation (7%), and ventriculomegaly (12%). Gait disturbance was also significantly more frequent in DESH (83%) compared to those with normal images (2%), Sylvian dilatation (14%), and ventriculomegaly (26%). In the community-based cohort (946 subjects), the prevalence of DESH was 1.0% and increased with age. The clinical triad (11%) was significantly more common in subjects with DESH compared to those with normal images (none), Sylvian dilatation (2%), and ventriculomegaly (7%). Gait disturbance was also significantly more common in DESH (33%) compared to those with normal images (1%), Sylvian dilatation (4%), and ventriculomegaly (10%). CONCLUSION The reported prevalence of DESH was approximately 1%, and increased with age. DESH and high convexity tightness were specifically associated with the clinical triad of iNPH. Of the triad, gait disturbance was associated to DESH and high convexity tightness.
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Affiliation(s)
- Chihiro Akiba
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Neurosurgery, Juntendo University, Japan.
| | - Bibek Gyanwali
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Steven Villaraza
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | | | | | - Ching-Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Academic Medicine Research Institute, Duke-NUS Graduate Medical School, Singapore.
| | - Tien Yin Wong
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Academic Medicine Research Institute, Duke-NUS Graduate Medical School, Singapore.
| | - Narayanaswamy Venketasubramanian
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Raffles Neuroscience Centre, Raffles Hospital, Singapore
| | - Saima Hilal
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Christopher Chen
- Memory Ageing and Cognition Centre, National University Health System, Singapore; Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Kuchcinski G, Jacquiez C, Baroncini M, Machuron F, Béhal H, Dumont J, Lopes R, Delmaire C, Lebouvier T, Bottlaender M, Bordet R, Defebvre L, Pruvo JP, Leclerc X, Hodel J. Idiopathic Normal-Pressure Hydrocephalus: Diagnostic Accuracy of Automated Sulcal Morphometry in Patients With Ventriculomegaly. Neurosurgery 2019; 85:E747-E755. [PMID: 31115469 DOI: 10.1093/neuros/nyz121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 03/17/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Idiopathic normal-pressure hydrocephalus (iNPH) is a treatable cause of gait and cognitive impairment. iNPH should be differentiated from ventriculomegaly secondary to brain atrophy to choose the best therapeutic option (ventriculoperitoneal shunt vs medical management). OBJECTIVE To determine the diagnostic accuracy of automated sulcal morphometry to differentiate patients with iNPH from patients with ventriculomegaly of neurodegenerative origin. METHODS Thirty-eight consecutive patients with iNPH (shunt responsive n = 31, nonresponsive n = 7), 35 with vascular cognitive disorder, and 25 age- and sex-matched healthy controls were prospectively included and underwent cognitive evaluation and 3T brain magnetic resonance imaging. Sulcal opening of 10 sulci of interest was retrospectively measured using an automated surface-based approach from the 3-dimensional T1-weighted images. Receiver-operating characteristic curve analyses determined the best parameter to identify iNPH patients. RESULTS The best parameter to discriminate shunt-responsive iNPH from patients with vascular cognitive disorder and healthy controls was the ratio between calcarine sulcus and cingulate sulcus opening with an area under the curve of 0.94 (95% CI: 0.89, 0.99). A cut-off value of 0.95 provided the highest sensitivity (96.8%) and specificity (83.3%). CONCLUSION This preliminary study showed that automated sulcal morphometry may help the neurosurgeon to identify iNPH patients and to exclude other causes of ventriculomegaly.
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Affiliation(s)
- Grégory Kuchcinski
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France.,CHU Lille, Department of Neuroradiology, Lille, France
| | | | | | - François Machuron
- Univ Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Unité de Biostatistiques, Lille, France
| | - Hélène Béhal
- Univ Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Unité de Biostatistiques, Lille, France
| | - Julien Dumont
- CHU Lille, Department of Neuroradiology, Lille, France
| | - Renaud Lopes
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France.,CHU Lille, Department of Neuroradiology, Lille, France
| | - Christine Delmaire
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France.,CHU Lille, Department of Neuroradiology, Lille, France
| | - Thibaud Lebouvier
- CHU Lille, Department of Neurology, Lille, France.,Memory Center, DISTALZ, Lille, France
| | - Michel Bottlaender
- Laboratoire Imagerie Moléculaire In Vivo (IMIV), UMR 1023 Inserm/CEA/Université Paris Sud - ERL 95218 CNRS, CEA/I2BM/Service Hospitalier Frédéric Joliot, Orsay, France.,UNIACT, Neurospin, Direction de la Recherche Médicale, CEA, Gif-sur-Yvette, France
| | - Regis Bordet
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France
| | - Luc Defebvre
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France.,CHU Lille, Department of Neurology, Lille, France
| | - Jean-Pierre Pruvo
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France.,CHU Lille, Department of Neuroradiology, Lille, France
| | - Xavier Leclerc
- Univ Lille, Inserm, UMR_S 1171 'Degenerative and vascular cognitive disorders', Lille, France.,CHU Lille, Department of Neuroradiology, Lille, France
| | - Jérôme Hodel
- Department of Neuroradiology, Hôpital Henri Mondor, Créteil, France
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11
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McGovern RA, Nelp TB, Kelly KM, Chan AK, Mazzoni P, Sheth SA, Honig LS, Teich AF, McKhann GM. Predicting Cognitive Improvement in Normal Pressure Hydrocephalus Patients Using Preoperative Neuropsychological Testing and Cerebrospinal Fluid Biomarkers. Neurosurgery 2019; 85:E662-E669. [DOI: 10.1093/neuros/nyz102] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 03/01/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Though it is well known that normal pressure hydrocephalus (NPH) patients can cognitively improve after ventriculoperitoneal shunting (VPS), one of the major dilemmas in NPH is the ability to prospectively predict which patients will improve.
OBJECTIVE
To prospectively assess preoperative predictors of postshunt cognitive improvement.
METHODS
This was a prospective observational cohort including 52 consecutive patients with approximately 1-yr follow-up. Patients underwent neuropsychological testing at baseline, postlumbar drainage, and postshunt. Cerebrospinal fluid (CSF) biomarkers and cortical biopsies were also collected to examine their relationship with postshunt cognitive improvement.
RESULTS
Rey Auditory Verbal Learning Test-L (RAVLT-L) was the only neuropsychological test to demonstrate statistically significant improvement both postlumbar drain and postshunt. Improvement on the RAVLT-L postlumbar drain predicted improvement on the RAVLT-L postshunt. Patients with biopsies demonstrating Aβ+ Tau+ had lower ventricular CSF Aβ42 and higher lumbar CSF pTau compared to Aβ– Tau– patients. A receiver operating curve analysis using lumbar pTau predicted Aβ+ Tau+ biopsy status but was not related to neuropsychological test outcome.
CONCLUSION
The RAVLT can be a useful preoperative predictor of postoperative cognitive improvement, and thus, we recommend using the RAVLT to evaluate NPH patients. CSF biomarkers could not be related to neuropsychological test outcome. Future research in a larger patient sample will help determine the prospective utility of CSF biomarkers in the evaluation of NPH patients.
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Affiliation(s)
- Robert A McGovern
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Taylor B Nelp
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Kathleen M Kelly
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Pietro Mazzoni
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lawrence S Honig
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Andrew F Teich
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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12
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Oliveira LM, Nitrini R, Román GC. Normal-pressure hydrocephalus: A critical review. Dement Neuropsychol 2019; 13:133-143. [PMID: 31285787 PMCID: PMC6601311 DOI: 10.1590/1980-57642018dn13-020001] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/20/2019] [Indexed: 12/13/2022] Open
Abstract
Normal-pressure hydrocephalus (NPH) is a potentially reversible syndrome characterized by enlarged cerebral ventricles (ventriculomegaly), cognitive impairment, gait apraxia and urinary incontinence. A critical review of the concept, pathophysiology, diagnosis, and treatment of both idiopathic and secondary NPH was conducted. We searched Medline and PubMed databases from January 2012 to December 2018 using the keywords "normal-pressure hydrocephalus" / "idiopathic normal-pressure hydrocephalus" / "secondary normal-pressure hydrocephalus" / "NPH" / "ventriculoperitoneal shunt". The initial search produced 341 hits. After careful selection, a total of 54 articles were chosen and additional relevant studies were included during the process of writing this article. NPH is an important cause of potentially reversible dementia, frequent falls and recurrent urinary infections in the elderly. The clinical and imaging features of NPH may be incomplete or nonspecific, posing a diagnostic challenge for medical doctors and often requiring expert assessment to minimize unsuccessful surgical treatments. Recent advances resulting from the use of non-invasive MRI methods for quantifying cerebral blood flow, in particular arterial spin-labeling (ASL), and the frequent association of NPH and obstructive sleep apnea (OSA), offer new avenues to understand and treat NPH.
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Affiliation(s)
- Louise Makarem Oliveira
- Medical Student, School of Medicine, Federal University of Amazonas
(UFAM), Manaus, AM, Brazil
| | - Ricardo Nitrini
- Professor of Neurology, Department of Neurology, University of São
Paulo Medical School, São Paulo, SP, Brazil
| | - Gustavo C. Román
- The Jack S. Blanton Distinguished Endowed Chair, Neurological
Institute Houston, Methodist Hospital, Professor of Neurology Weill Cornell Medical
College Methodist Neurological Institute, USA
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13
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Igarashi N, Honjo M, Asano S, Takagi K, Aihara M. Optic disc cupping characteristics of normal pressure hydrocephalus patients with normal-tension glaucoma. Sci Rep 2019; 9:3108. [PMID: 30816215 PMCID: PMC6395590 DOI: 10.1038/s41598-019-39526-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/21/2019] [Indexed: 12/21/2022] Open
Abstract
We examined the potential association of idiopathic normal pressure hydrocephalus (iNPH) with the generation of normal-tension glaucoma (NTG), to explore possible relationships between intracranial pressure (ICP) and the presence of glaucoma, and to compare disc morphology of NTG patients with or without iNPH. We investigated 20 iNPH patients, examined the prevalence of glaucoma, and compared the optic discs of NTG patients with iNPH (n = 11) and age-matched NTG patients without iNPH (n = 16). All data were collected prior to the treatment of iNPH, to eliminate the possibility that the treatment may have contributed to the progression of NTG. The diagnoses of NTG were made using visual field data, intraocular pressure measurements, fundoscopy, and optical coherence tomography (OCT). Using OCT, the optic nerve disc depth was also measured. The ICP was higher in the iNPH with NTG compared to iNPH without NTG (p = 0.0425), and the cupping depths of the discs of NTG patients with iNPH were significantly shallower compared with those of NTG patients without iNPH (p = 0.0097). Based on the difference in cupping depth, NTG patients with iNPH may have a different morphology from typical glaucoma patients, which could in turn reflect a different pathogenesis compared to NTG patients without iNPH.
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Affiliation(s)
- Nozomi Igarashi
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Megumi Honjo
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shotaro Asano
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Takagi
- Department of Normal Tension Hydrocephalus, Kashiwa Tanaka Hospital, Chiba, Japan
| | - Makoto Aihara
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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14
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Kawakami K, Yoshino H, Igarashi H, Chiba Y, Yoshino G, Hirose T. A case of idiopathic normal pressure hydrocephalus in an elder diabetic patient. Nihon Ronen Igakkai Zasshi 2017; 54:186-190. [PMID: 28592739 DOI: 10.3143/geriatrics.54.186] [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] [Indexed: 11/11/2022]
Abstract
The clinical entity idiopathic normal pressure hydrocephalus (iNPH) is characterized by dementia, urinary incontinence, gait ataxia. An 80-year old man with a past history of Type 2 diabetes mellitus admitted to our hospital. Combination of twice Aspart and Aspart premixed30/70 insulin were used. Although, he was unable to inject insulin by himself recently. On physical examination, he walked in a mildly wide based manner. According to his family, urinary incontinence was existed. Laboratory data were as follows: Postrandial blood glucose 243 mg/dl and glycated hemoglobin 8.0% (NGSP). Brain magnetic resonance imaging (MRI) scans showed thinning of the corpus callosum with enlargement of the lateral ventricles on a colonal image. Evan's ratio was 0.29. The revised version of Hasegawa's Dementia scale (HDS-R) was 10. The patient showed no evidence a related antecedent event, such as head trauma, intracerebral hemorrhage and meningitis. Thus, he was diagnosed as having possible Idiopathic normal pressure hydrocephalus (iNPH). The following several psychological tests and walking test were applied. Before and after the tap, he was evaluated using the HDS-R, Mini mental state examination (MMSE), Timed Up and Go test (TUG). Insulin was replaced by glargine, and Sitagliptin was added. On the 31 day, the patient underwent Ventriculo-perioneal shunt. Laboratoly data and memory impairment were also improved. 8 month's later, HbA1c was 7.5%. iNPH occurs in the elderly and is characterized by a clinical triad of gait disturbance, urinary incontinence and dementia. In the present case, thinning of the corpus callosum with enlargement of the lateral ventricles was detected by MRI. 49% of iNPH patients had Diabetes mellitus. However, we were unable to detect a relationship iNPH and Diabetes mellitus. Cognitive impairment may interfere with the insulin therapy. In the present case, failure of insulin self-injection was the first clinical sign to appear. We were able to reduce dose of insulin. We conclude that iNPH is a treatable disorder, especially when treatment is started early in the course of the disease.
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Affiliation(s)
- Kyoko Kawakami
- Center for Diabetes Medicine, Shin-suma General Hospital
| | - Hiroshi Yoshino
- Center for Diabetes Medicine, Shin-suma General Hospital.,Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine (Omori), Toho University School of Medicine
| | - Hiroyuki Igarashi
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine (Omori), Toho University School of Medicine
| | | | - Gen Yoshino
- Center for Diabetes Medicine, Shin-suma General Hospital
| | - Takahisa Hirose
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine (Omori), Toho University School of Medicine
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15
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Illán-Gala I, Pérez-Lucas J, Martín-Montes A, Máñez-Miró J, Arpa J, Ruiz-Ares G. Evolución a largo plazo de la hidrocefalia crónica del adulto idiopática tratada con válvula de derivación ventrículo-peritoneal. Neurologia 2017; 32:205-212. [DOI: 10.1016/j.nrl.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 09/20/2015] [Accepted: 10/09/2015] [Indexed: 11/26/2022] Open
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16
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Illán-Gala I, Pérez-Lucas J, Martín-Montes A, Máñez-Miró J, Arpa J, Ruiz-Ares G. Long-term outcomes of adult chronic idiopathic hydrocephalus treated with a ventriculo-peritoneal shunt. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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17
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Garcia-Armengol R, Domenech S, Botella-Campos C, Goncalves FJ, Menéndez B, Teixidor P, Muñoz-Narbona L, Rimbau J. Comparison of elevated intracranial pressure pulse amplitude and disproportionately enlarged subarachnoid space (DESH) for prediction of surgical results in suspected idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2016; 158:2207-2213. [PMID: 27349896 DOI: 10.1007/s00701-016-2858-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/24/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND To compare the prognostic value of pulse amplitude on intracranial pressure (ICP) monitoring and disproportionately enlarged subarachnoid space hydrocephalus (DESH) on magnetic resonance imaging (MRI) for predicting surgical benefit after shunt placement in idiopathic normal pressure hydrocephalus (iNPH). METHOD Patients with suspected iNPH were prospectively recruited from a single centre. All patients received preoperative MRI and ICP monitoring. Patients were classified as shunt responders if they had an improvement of one point or more on the NPH score at 1 year post-surgery. The sensitivity, specificity, Youden index, and positive and negative predictive values of the two diagnostic methods were calculated. RESULTS Sixty-four of 89 patients clinically improved at 1 year post-surgery and were classed as shunt responders. Positive DESH findings had a sensitivity of 79.4 % and specificity of 80.8 % for predicting shunt responders. Fifty-five of 89 patients had positive DESH findings: 50 of these responded to VP shunt, giving a positive and negative predictive value of 90.9 % and 61.8 %, respectively. Fifty-seven of 89 patients had high ICP pulse amplitude. High ICP pulse amplitude had a sensitivity of 84.4 %, specificity of 88 %, positive predictive value of 94.7 % and negative predictive value of 61.8 % for predicting shunt responders. CONCLUSIONS Both positive DESH findings and high ICP pulse amplitude support the diagnosis of iNPH and provide additional diagnostic value for predicting shunt-responsive patients; however, high ICP amplitude was more accurate than positive DESH findings, although it is an invasive test.
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Affiliation(s)
- Roser Garcia-Armengol
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain.
| | - Sira Domenech
- Institut de Diagnòstic per la Imatge (IDI), University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Carlos Botella-Campos
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Francisco Javier Goncalves
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Belén Menéndez
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Pilar Teixidor
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Lucia Muñoz-Narbona
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Jordi Rimbau
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
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18
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Shaw R, Mahant N, Jacobson E, Owler B. A Review of Clinical Outcomes for Gait and Other Variables in the Surgical Treatment of Idiopathic Normal Pressure Hydrocephalus. Mov Disord Clin Pract 2016; 3:331-341. [PMID: 30363503 PMCID: PMC6178707 DOI: 10.1002/mdc3.12335] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 01/07/2016] [Accepted: 01/09/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (INPH) is a treatable cause of gait disturbance, cognitive impairment, and urinary incontinence. This clinical triad of symptoms occurs in association with ventriculomegaly and normal cerebrospinal fluid (CSF) pressure. Although the treatment outcomes after CSF shunting for INPH have improved significantly since its first description in 1965, shortcomings in our understanding still remain. Not all INPH patients exhibit clinical improvement after shunting, and it is challenging to identify patients who are more likely to benefit from shunting. METHODS The Cochrane Library, Medline, Embase, and PubMed databases were searched for English-language publications between 1965 and October 2015. Reference lists of publications were also manually searched for additional publications. RESULTS The findings of this review indicate that, despite efforts to improve patient selection, the degree of clinical improvement after shunting continues to demonstrate significant variability both within and between studies. These discrepancies in treatment outcomes are the result of controversies in 3 distinct but interrelated domains: the underlying pathophysiology of INPH, the diagnosis of INPH, and the identification of likely shunt-responders. CONCLUSIONS This review focuses on these 3 areas and their relation to surgical treatment outcomes. Despite the limitations of published outcome studies and limitations in our understanding of INPH pathophysiology, shunting is a safe and effective means of achieving meaningful clinical improvement in most patients with INPH.
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Affiliation(s)
- Richard Shaw
- Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Neil Mahant
- Department of NeurologyWestmead HospitalSydneyAustralia
- Western Clinical School: Medicine (Westmead)University of SydneySydneyAustralia
| | - Erica Jacobson
- Department of NeurosurgeryPrince of Wales HospitalSydneyAustralia
| | - Brian Owler
- Department of NeurosurgerySydney Adventist HospitalSydneyAustralia
- Department of SurgeryUniversity of SydneySydneyAustralia
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19
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Normal Pressure Hydrocephalus and Parkinsonism: Preliminary Data on Neurosurgical and Neurological Treatment. World Neurosurg 2016; 90:348-356. [DOI: 10.1016/j.wneu.2016.03.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 11/24/2022]
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20
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The Dynamic Gait Index in Evaluating Patients with Normal Pressure Hydrocephalus for Cerebrospinal Fluid Diversion. World Neurosurg 2015; 84:1871-6. [PMID: 26320865 DOI: 10.1016/j.wneu.2015.08.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 08/11/2015] [Accepted: 08/11/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Diagnosing normal pressure hydrocephalus (NPH) remains challenging. Most clinical tests currently used to evaluate suspected NPH patients for shunt surgery are invasive, require inpatient admission, and are not without complications. An objective, noninvasive, and low-cost alternative would be ideal. METHODS A retrospective review was performed of prospectively collected dynamic gait index (DGI) scores, obtained at baseline and on every day of a 3- to 5-day lumbar cerebrospinal fluid (CSF) drainage trial on patients with suspected NPH at our institution. RESULTS Between 2003 and 2014, 170 patients were suspected to have primary NPH (166, 97.6%) or secondary NPH (4, 2.4%). Using responsiveness to lumbar CSF drainage and subsequent shunting as the reference standard, we found that a baseline DGI ≥ 7 was found to have significant ability in selecting patients for permanent CSF diverting shunt surgery: sensitivity of 84.2% (95% confidence interval [95% CI]: 75.6%-90.2%), specificity of 80.6% (95% CI 70.0%-88.0%), and diagnostic odds ratio of 22.1 (95% CI 9.9-49.3). CONCLUSIONS A baseline DGI ≥ 7 appears to provide an objective, low-cost, noninvasive measure to select patients with suspected NPH for a positive response to CSF diversion with high sensitivity, specificity and diagnostic odds ratio.
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22
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KURIYAMA N, YAMADA K, SAKAI K, TOKUDA T, AKAZAWA K, TOMII Y, TAMURA A, KONDO M, WATANABE I, OZAKI E, MATSUI D, NAKAGAWA M, MIZUNO T, WATANABE Y. Ventricular Temperatures in Idiopathic Normal Pressure Hydrocephalus (iNPH) Measured with DWI-based MR Thermometry. Magn Reson Med Sci 2015; 14:305-12. [DOI: 10.2463/mrms.2014-0076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Nagato KURIYAMA
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Kei YAMADA
- Department of Radiology, Kyoto Prefectural University of Medicine
| | - Koji SAKAI
- Graduate School of Medicine, Kyoto University
| | - Takahiko TOKUDA
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Kentaro AKAZAWA
- Department of Radiology, Kyoto Prefectural University of Medicine
| | - Yasuhiro TOMII
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Aiko TAMURA
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Masaki KONDO
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Isao WATANABE
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine
| | - Etsuko OZAKI
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine
| | - Daisuke MATSUI
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine
| | | | - Toshiki MIZUNO
- Department of Neurology, Kyoto Prefectural University of Medicine
| | - Yoshiyuki WATANABE
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine
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23
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Aoki Y, Kazui H, Tanaka T, Ishii R, Wada T, Ikeda S, Hata M, Canuet L, Musha T, Matsuzaki H, Imajo K, Yoshiyama K, Yoshida T, Shimizu Y, Nomura K, Iwase M, Takeda M. EEG and Neuronal Activity Topography analysis can predict effectiveness of shunt operation in idiopathic normal pressure hydrocephalus patients. NEUROIMAGE-CLINICAL 2013; 3:522-30. [PMID: 24273735 PMCID: PMC3830071 DOI: 10.1016/j.nicl.2013.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 09/30/2013] [Accepted: 10/13/2013] [Indexed: 11/19/2022]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a neuropsychiatric syndrome characterized by gait disturbance, cognitive impairment and urinary incontinence that affect elderly individuals. These symptoms can potentially be reversed by cerebrospinal fluid (CSF) drainage or shunt operation. Prior to shunt operation, drainage of a small amount of CSF or "CSF tapping" is usually performed to ascertain the effect of the operation. Unfortunately, conventional neuroimaging methods such as single photon emission computed tomography (SPECT) and functional magnetic resonance imaging (fMRI), as well as electroencephalogram (EEG) power analysis seem to have failed to detect the effect of CSF tapping on brain function. In this work, we propose the use of Neuronal Activity Topography (NAT) analysis, which calculates normalized power variance (NPV) of EEG waves, to detect cortical functional changes induced by CSF tapping in iNPH. Based on clinical improvement by CSF tapping and shunt operation, we classified 24 iNPH patients into responders (N = 11) and nonresponders (N = 13), and performed both EEG power analysis and NAT analysis. We also assessed correlations between changes in NPV and changes in functional scores on gait and cognition scales before and after CSF tapping. NAT analysis showed that after CSF tapping there was a significant decrease in alpha NPV at the medial frontal cortex (FC) (Fz) in responders, while nonresponders exhibited an increase in alpha NPV at the right dorsolateral prefrontal cortex (DLPFC) (F8). Furthermore, we found correlations between cortical functional changes and clinical symptoms. In particular, delta and alpha NPV changes in the left-dorsal FC (F3) correlated with changes in gait status, while alpha and beta NPV changes in the right anterior prefrontal cortex (PFC) (Fp2) and left DLPFC (F7) as well as alpha NPV changes in the medial FC (Fz) correlated with changes in gait velocity. In addition, alpha NPV changes in the right DLPFC (F8) correlated with changes in WMS-R Mental Control scores in iNPH patients. An additional analysis combining the changes in values of alpha NPV over the left-dorsal FC (∆alpha-F3-NPV) and the medial FC (∆alpha-Fz-NPV) induced by CSF tapping (cut-off value of ∆alpha-F3-NPV + ∆alpha-Fz-NPV = 0), could correctly identified "shunt responders" and "shunt nonresponders" with a positive predictive value of 100% (10/10) and a negative predictive value of 66% (2/3). In contrast, EEG power spectral analysis showed no function related changes in cortical activity at the frontal cortex before and after CSF tapping. These results indicate that the clinical changes in gait and response suppression induced by CSF tapping in iNPH patients manifest as NPV changes, particularly in the alpha band, rather than as EEG power changes. Our findings suggest that NAT analysis can detect CSF tapping-induced functional changes in cortical activity, in a way that no other neuroimaging methods have been able to do so far, and can predict clinical response to shunt operation in patients with iNPH.
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Affiliation(s)
- Yasunori Aoki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroaki Kazui
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toshihisa Tanaka
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryouhei Ishii
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Corresponding author at: Department of Psychiatry, Osaka University Graduate School of Medicine, D3 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan. Tel.: + 81-6-6879-3051; fax: + 81-6-6879-3059.
| | - Tamiki Wada
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shunichiro Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiro Hata
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Leonides Canuet
- UCM-UPM Centre for Biomedical Technology, Department of Cognitive and Computational Neuroscience, Complutense University of Madrid, Madrid, Spain
| | | | | | - Kaoru Imajo
- Nihon Kohden Corporation, Shinjuku, Tokyo, Japan
| | - Kenji Yoshiyama
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tetsuhiko Yoshida
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiro Shimizu
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Keiko Nomura
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masao Iwase
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masatoshi Takeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Third Ventriculostomy in Normal Pressure Hydrocephalus. World Neurosurg 2013; 79:S22.e1-7. [DOI: 10.1016/j.wneu.2012.02.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 02/02/2012] [Indexed: 11/20/2022]
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How active are patients with idiopathic normal pressure hydrocephalus and does activity improve after shunt surgery? A controlled actigraphic study. Clin Neurol Neurosurg 2013; 115:192-6. [DOI: 10.1016/j.clineuro.2012.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 05/11/2012] [Accepted: 05/12/2012] [Indexed: 11/21/2022]
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Siraj S. An overview of normal pressure hydrocephalus and its importance: how much do we really know? J Am Med Dir Assoc 2011; 12:19-21. [PMID: 21194654 DOI: 10.1016/j.jamda.2010.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Revised: 05/05/2010] [Accepted: 05/06/2010] [Indexed: 11/28/2022]
Abstract
Normal pressure hydrocephalus (NPH) is a clinical triad of gait disturbance, dementia, and urinary incontinence combined with radiographic findings of ventriculomegaly and laboratory findings of normal cerebrospinal fluid pressures. Although it was first described by Hakim and Adams in 1965, there is no formal definition of NPH, causing discrepancy in its incidence in various studies. This ranges from 2 to 20 per million per year. It is estimated to be the cause of about 5% of cases of dementia and is one of the few reversible causes of dementia. Early diagnosis increases the rate of success to treatment. This makes accurate diagnosis and identification of responders to treatment important. There have been various studies on NPH in the general population, but not much has been said about it in long-term care facilities and the question arises on how many cases are missed. If a screening tool is in place to identify possible cases then further workup could be done to confirm the diagnosis and determine the need for shunting.
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Affiliation(s)
- Seema Siraj
- University of Arkansas for Medical Science, Department of Geriatrics, 4301 W. Markham Street, Little Rock, AR 72205, USA.
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Iseki C, Kawanami T, Nagasawa H, Wada M, Koyama S, Kikuchi K, Arawaka S, Kurita K, Daimon M, Mori E, Kato T. Asymptomatic ventriculomegaly with features of idiopathic normal pressure hydrocephalus on MRI (AVIM) in the elderly: a prospective study in a Japanese population. J Neurol Sci 2008; 277:54-7. [PMID: 18990411 DOI: 10.1016/j.jns.2008.10.004] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 10/06/2008] [Accepted: 10/08/2008] [Indexed: 10/21/2022]
Abstract
We investigated if there are individuals at a preclinical stage of idiopathic normal pressure hydrocephalus (iNPH) in a general population. All the residents (n=1142) aged 61 years (n=306, men/women=156/150) and 70-72 years (n=836, men/women=356/480) in the two communities of Japan were requested to take brain MRI examination. The "iNPH features on MRI" were defined as an Evans index of >0.3 and a narrowing of the subarachnoid space and cortical sulci at the high convexity of the cerebrum. "Possible iNPH" was defined as the presence of one or more symptoms of iNPH, together with such MRI features. 790 (69.2%) of the 1142 residents participated in this study. Among them, 51 individuals (men/women=35/16) (6.46%) had the enlarged ventricles (Evans index of >0.3), 12 (men/women=7/5) (1.52%) of which showed the iNPH features on MRI. Of the 12 individuals, 8 (men/women=4/4) (1.01%) were asymptomatic, while 4 (men/woman=3/1) (0.51%) had gait disturbance and/or dementia (possible iNPH). During a follow-up period of 4-8 years, two of the 8 asymptomatic subjects developed dementia and/or gait disturbance with worsening of ventriculomegaly on brain MRI in one case. The prevalence of possible iNPH was 0.51% (4/790) among Japanese elderly (>61 years of age). Asymptomatic ventriculomegaly with the iNPH features on MRI (AVIM) may represent a preclinical stage of iNPH.
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Affiliation(s)
- Chifumi Iseki
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology (DNHMED), Yamagata University School of Medicine, Yamagata, Japan
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Evaluation of autonomic malfunction in idiopathic normal pressure hydrocephalus. Clin Auton Res 2008; 18:213-20. [DOI: 10.1007/s10286-008-0482-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Accepted: 07/02/2008] [Indexed: 11/25/2022]
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Ishikawa M, Hashimoto M, Kuwana N, Mori E, Miyake H, Wachi A, Takeuchi T, Kazui H, Koyama H. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 2008; 48 Suppl:S1-23. [PMID: 18408356 DOI: 10.2176/nmc.48.s1] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
With the rapid aging of Japanese society, medical care of the elderly has become an important social issue. Among various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, normal pressure hydrocephalus (NPH), especially of idiopathic type (iNPH), is becoming noteworthy. The Guidelines for management of iNPH in Japan are created in compliance with the evidence-based medicine methods and published in 2004. This English version is made to show the diagnosis and treatment of iNPH with reference to the socio-medical background in Japan and to promote the international research on iNPH. They propose three diagnostic levels; possible, probable, and definite. They indicate the diagnostic importance of high convexity tightness and dilated sylvian fissure with mild to moderate ventriculomegaly on coronal magnetic resonance imaging. The cerebrospinal fluid tap test is regarded as an important diagnostic test because of its simplicity to perform and high predictability of the shunt efficacy. The use of programmable valves at shunt surgeries is recommended. Flowcharts for diagnosis, preoperative assessment, and prevention for complications of shunt surgery are made to promote a wide use of them.
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Benejam B, Solana E, Poca M, Junqué C, Sahuquillo J. Alteraciones cognitivas en pacientes con hidrocefalia crónica del adulto (“normotensiva”). Propuesta de un protocolo para su evaluación clínica. Neurocirugia (Astur) 2008. [DOI: 10.1016/s1130-1473(08)70217-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Agren-Wilsson A, Lekman A, Sjöberg W, Rosengren L, Blennow K, Bergenheim AT, Malm J. CSF biomarkers in the evaluation of idiopathic normal pressure hydrocephalus. Acta Neurol Scand 2007; 116:333-9. [PMID: 17922727 DOI: 10.1111/j.1600-0404.2007.00890.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND - To evaluate cerebrospinal fluid (CSF) markers for neuronal degeneration and demyelination in idiopathic normal pressure hydrocephalus (INPH), subcortical arteriosclerotic encephalopathy (SAE), and neurologically healthy subjects. METHODS - Lumbar CSF concentrations of sulfatide, neurofilament protein light (NFL), total-tau (T-tau), hyperphosphorylated tau (P-tau), and beta-amyloid(1-42) (Abeta42) were analyzed in 62 INPH patients, 26 SAE patients, and 23 neurologically healthy controls. In INPH patients, samples before and after shunt surgery were analysed. RESULTS - The CSF concentration of NFL was elevated in INPH and SAE compared with the controls, and levels of T-tau, P-tau, and Abeta42 were lower in INPH compared with SAE and controls. No difference was seen for sulfatide. All markers except Abeta42 were significantly elevated after shunt surgery. CONCLUSIONS - The most striking finding was the power of the combined pattern of NFL, P-tau, and Abeta42 in distinguishing between the clinical diagnoses of INPH, SAE, and neurologically healthy elderly.
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Affiliation(s)
- A Agren-Wilsson
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden.
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Murakami M, Hirata Y, Kuratsu JI. Predictive assessment of shunt effectiveness in patients with idiopathic normal pressure hydrocephalus by determining regional cerebral blood flow on 3D stereotactic surface projections. Acta Neurochir (Wien) 2007; 149:991-7. [PMID: 17680175 DOI: 10.1007/s00701-007-1259-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 07/06/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND The regional cerebral blood flow (rCBF) and cerebral metabolism in patients with idiopathic normal pressure hydrocephalus (iNPH) remain to be studied in detail. PURPOSE Using single-photon emission computed tomography (SPECT), we compared the characteristic rCBF patterns in iNPH patients who did, or did not, respond to shunt operations. MATERIALS AND METHODS We studied 24 consecutive iNPH patients: 14 men and 10 women aged 68 to 88 years (mean 77.5 years). Using the Japanese normal pressure hydrocephalus grading scale, they were divided into responders and non-responders to shunt operations. Follow-up ranged from 10 to 36 months (mean 25 months). We obtained baseline single-photon emission computed tomography (SPECT) data on three-dimensional stereotactic surface projections (3D-SSP) before and after shunt operations, and compared rCBF in responders and non-responders. RESULTS On statistical maps, responders manifested significantly lower rCBF in the basal frontal lobes and cingulate gyrus (anterior-dominant). CONCLUSIONS The preoperative measurement of rCBF by 3D-SSP SPECT may help to identify iNHP patients expected to exhibit a good response to shunt operations.
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MESH Headings
- Aged
- Aged, 80 and over
- Brain/blood supply
- Cerebrospinal Fluid Pressure/physiology
- Dementia/etiology
- Dementia/surgery
- Energy Metabolism/physiology
- Female
- Follow-Up Studies
- Gait Disorders, Neurologic/etiology
- Gait Disorders, Neurologic/surgery
- Humans
- Hydrocephalus, Normal Pressure/diagnostic imaging
- Hydrocephalus, Normal Pressure/physiopathology
- Hydrocephalus, Normal Pressure/surgery
- Image Processing, Computer-Assisted
- Imaging, Three-Dimensional
- Male
- Monitoring, Physiologic
- Neurologic Examination
- Oxygen Consumption/physiology
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/physiopathology
- Prognosis
- Regional Blood Flow/physiology
- Software
- Tomography, Emission-Computed, Single-Photon
- Treatment Outcome
- Urinary Incontinence/etiology
- Urinary Incontinence/surgery
- Ventriculoperitoneal Shunt
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Affiliation(s)
- M Murakami
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Japan.
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Stein SC, Burnett MG, Sonnad SS. Shunts in normal-pressure hydrocephalus: do we place too many or too few? J Neurosurg 2007; 105:815-22. [PMID: 17405250 DOI: 10.3171/jns.2006.105.6.815] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The average 65-year-old patient with moderate dementia can look forward to only 1.4 quality-adjusted life years (QALYs), that is, longevity times quality of life. Some of these patients suffer from normal-pressure hydrocephalus (NPH) and respond dramatically to shunt insertion. Currently, however, NPH cannot be diagnosed with certainty. The authors constructed a Markov decision analysis model to predict the outcome in patients with NPH treated with and without shunts. METHODS Transition probabilities and health utilities were obtained from a review of the literature. A sensitivity analysis and Monte Carlo simulation were applied to test outcomes over a wide range of parameters. Using shunt response and complication rates from the literature, the average patient receiving a shunt would gain an additional 1.7 QALYs as a result of automatic shunt insertion. Even if 50% of patients receiving a shunt have complications, the shunt response rate would need to be less than 5% for empirical shunt insertion to do more harm than good. Authors of most studies have reported far better statistics. CONCLUSIONS In summary, many more patients with suspected NPH should be considered for shunt insertion.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Marmarou A, Young HF, Aygok GA. Estimated incidence of normal-pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities. Neurosurg Focus 2007; 22:E1. [PMID: 17613187 DOI: 10.3171/foc.2007.22.4.2] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The primary objective of this study was to estimate the prevalence of idiopathic normal-pressure hydrocephalus (NPH), both diagnosed and undiagnosed, among residents of assisted-living and extended-care facilities, by using a practical screening tool. A secondary objective was to evaluate prospectively the diagnosis and outcome of surgical treatment in a subset of patients residing in healthcare facilities who were at risk for idiopathic NPH.
Methods
A retrospective chart analysis was performed using the medical records from four nursing homes. The final analysis included 147 patient records. Symptomatology and comorbidity were evaluated, as was the ability to perform activities of daily living. In a subset of 17 patients residing in healthcare facilities, the authors applied a standard idiopathic NPH diagnostic and management protocol and followed up the patients 1 year after treatment.
The estimated incidence of suspected idiopathic NPH among all patients in the retrospective survey ranged from 9 to 14%, depending on the diagnostic criteria used. Among the cohort of 17 patients available for an in-hospital study and 1-year follow up, 11 received shunts and seven of these showed either transient or sustained improvement.
Conclusions
A valid and practical diagnostic method is needed to identify idiopathic NPH accurately before admitting patients to a healthcare facility. Data from a prospective study of 17 patients residing in healthcare facilities indicated that supplementary tests remain predictive of a positive response to shunt insertion but cannot predict whether a favorable outcome will be sustained in a population of patients who have been confined to a wheelchair for a prolonged period of time. This finding supports the notion of a finite window of opportunity for successful treatment of idiopathic NPH and the imperativeness of an early diagnosis.
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Affiliation(s)
- Anthony Marmarou
- Department of Neurosurgery, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0508, USA.
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Bech-Azeddine R, Høgh P, Juhler M, Gjerris F, Waldemar G. Idiopathic normal-pressure hydrocephalus: clinical comorbidity correlated with cerebral biopsy findings and outcome of cerebrospinal fluid shunting. J Neurol Neurosurg Psychiatry 2007; 78:157-61. [PMID: 17012342 PMCID: PMC2077673 DOI: 10.1136/jnnp.2006.095117] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To elucidate the importance of clinically diagnosed cerebral comorbidity in idiopathic normal-pressure hydrocephalus (INPH) and its effect on improvement after shunt surgery as well as concordance with parenchymal pathological changes described in frontal cerebral biopsy specimens. METHODS In 28 consecutive patients diagnosed with INPH and shunted according to clinical, radiological and cerebrospinal fluid dynamic criteria, concomitant disorders were carefully registered, with special emphasis on cerebrovascular disease (CVD) and possible Alzheimer's disease. During shunt surgery, a frontal cerebral biopsy specimen was obtained and subsequently analysed for pathological changes. RESULTS One or several concurrent disorders were present in 89% of the patients, most often CVD (n = 17) and possible Alzheimer's disease (n = 12), of which eight patients presented both, diagnosed according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association. The shunt success rate was 33%. A clear tendency towards increasing prevalence of CVD or Alzheimer's disease was found in the subgroups with no improvement or clinical deterioration compared with the patients improving after shunt surgery. The presence of CVD tended towards an unfavourable shunt outcome. The pathological parenchymal changes reflected the clinical diagnoses of comorbidity, and were described in about half of the biopsy specimens, with Alzheimer's disease (n = 7) and vascular changes (n = 7) being the most common findings. However, no significant correlation was found with the clinical diagnoses of Alzheimer's disease and CVD. The presence of cerebral comorbidity, whether diagnosed clinically or by brain biopsy, did not preclude clinical improvement after shunt operation. CONCLUSIONS A high prevalence of CVD and Alzheimer's disease was found in patients shunted for INPH, which was reflected, although less commonly, by similar neuropathological biopsy findings. No significant correlation was found between the presence of comorbidity and shunt outcome. The findings support the perception of INPH as a multiaetiological clinical entity, possibly overlapping pathophysiologically with CVD and Alzheimer's disease.
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Affiliation(s)
- R Bech-Azeddine
- The University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
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Abstract
Normal pressure hydrocephalus (NPH) is a reversible disorder characterized by gait impairment, subcortical dementia, and urinary urgency and incontinence associated with impaired cerebrospinal fluid circulation and ventriculomegaly. Treatment with shunt surgery is most likely to increase mobility, and may also improve dementia and urinary symptoms. An international, independent study group recently published guidelines for the diagnosis and management of idiopathic NPH. This article helps geriatricians identify patients who might have NPH, and care for these patients after shunt placement.
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Affiliation(s)
- Robin K Wilson
- Department of Neurology, The Johns Hopkins Hospital, Adult Hydrocephalus Program, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Relkin N, Marmarou A, Klinge P, Bergsneider M, Black PM. Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 2006; 57:S4-16; discussion ii-v. [PMID: 16160425 DOI: 10.1227/01.neu.0000168185.29659.c5] [Citation(s) in RCA: 544] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The precise incidence and prevalence of idiopathic normal-pressure hydrocephalus (INPH) is not known, and evidence-based clinical diagnostic criteria have not been developed previously. This report contains evidence-based guidelines for clinical diagnosis of INPH that are intended to facilitate future epidemiological studies of INPH, promote earlier and more accurate diagnosis, and ultimately improve treatment outcome. METHODS The criteria for the diagnosis of INPH are based on evidence from the medical literature, supplemented as necessary by expert opinion. From 1966 to 2003, 653 publications on "normal-pressure hydrocephalus" were cited in MEDLINE, including 29 articles that met the more stringent criteria of including "idiopathic normal-pressure hydrocephalus" in their title. Additional studies were considered that explicitly identified INPH cases and/or specified the criteria for a diagnosis of INPH. Studies were graded according to the class of evidence and results summarized in evidentiary tables. For issues of clinical relevance that lacked substantive evidence from the medical literature, the opinions of consulting experts were considered and contributed to "Options." RESULTS Evidence-based guidelines for the clinical diagnosis of INPH have been developed. A detailed understanding of the range of clinical manifestations of this disorder and adherence to practice guidelines should improve the timely and accurate recognition of this disorder. CONCLUSION It is recommended that INPH be classified into probable, possible, and unlikely categories. We hope that these criteria will be widely applied in clinical practice and will promote greater consistency in patient selection in future clinical investigations involving INPH.
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Affiliation(s)
- Norman Relkin
- Department of Neurology and Neuroscience, The New York Presbyterian-Weill Cornell Medical College, New York, New York, USA
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Poca MA, Mataró M, Matarín M, Arikan F, Junqué C, Sahuquillo J. Good outcome in patients with normal-pressure hydrocephalus and factors indicating poor prognosis. J Neurosurg 2005; 103:455-63. [PMID: 16235677 DOI: 10.3171/jns.2005.103.3.0455] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors set out to describe the outcome in a subgroup of patients with normal-pressure hydrocephalus (NPH) in whom prognostic factors were poor. This subgroup of patients who had received shunts was selected according to strict criteria. METHODS From a cohort of 56 patients with NPH in whom shunts were placed, the authors selected a subgroup with four of the factors traditionally considered to indicate poor prognosis: idiopathic type, cortical atrophy, longstanding symptoms, and presence of dementia in addition to old age. Twelve patients met the inclusion criteria. After receiving shunts, 92% of the patients showed clinical improvement on the NPH scale; gait improved in 100% of patients, sphincter control in 90%, and dementia in 33%. Improvement was significant for gait and sphincter control, general NPH score, and most daily life activity scales. No significant differences regarding clinical, cognitive, or functional changes following surgery were found in comparison with the rest of patients (the good prognosis subgroup). CONCLUSIONS The clinical condition of patients with NPH who present with traditionally accepted markers of poor prognosis can improve after surgery, especially as regards gait and sphincter control. The authors assert that the presence of these markers should not be considered to be an absolute criterion for ruling out shunt surgery in cases of NPH syndrome.
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Affiliation(s)
- Maria A Poca
- Department of Neurosurgery, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Spain.
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Bech-Azeddine R, Gjerris F, Waldemar G, Czosnyka M, Juhler M. Intraventricular or lumbar infusion test in adult communicating hydrocephalus? Practical consequences and clinical outcome of shunt operation. Acta Neurochir (Wien) 2005; 147:1027-35; discussion 1035-6. [PMID: 16044359 DOI: 10.1007/s00701-005-0589-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Accepted: 06/08/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND To investigate the therapeutic consequences of restricting the CSF dynamic evaluation to a lumbar infusion test (LIT), as opposed to our formerly applied intraventricular assessment (VIT), in patients with communicating hydrocephalus (CH). METHOD All patients over 18 years of age referred with clinical and radiological indication of treatment-requiring secondary CH (n = 50) or idiopathic normal-pressure hydrocephalus (INPH, n = 33) were subjected to a LIT. Subsequently, a combination of the results of the LIT (mainly the resistance to CSF outflow) and the clinical presentation determined whether to proceed with (a) VIT before a decision about shunt surgery, (b) shunt surgery or (c) no further diagnostic investigation or surgery. FINDINGS In 88 percent of the patients with secondary CH and 80 percent of the patients with INPH the decision on shunt surgery was made after performing exclusively a LIT. The shunting success rate was 90 percent in patients with secondary CH and 82 percent in patients with INPH, which however in the latter group decreased to 76 percent, when including the patients undergoing an additional VIT. The achieved shunt success rates are equal or better, compared to the results from previous studies using intraventricular assessment. CONCLUSIONS LIT and VIT are equally reliable for selecting shunt responsive patients with CH, using clinical improvement rate as the main criterion for comparison. The practical and economic consequences are substantial: the LIT can be performed in an outpatient setting, whereas VIT necessitates hospitalisation for 1-2 days including occupation of the neurosurgical theatre and postoperative neuro-intensive monitoring.
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Affiliation(s)
- R Bech-Azeddine
- University Clinic of Neurosurgery, The Neuroscience Center, Rigshospitalet, H:S, Copenhagen, Denmark.
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Malm J, Lundkvist B, Eklund A, Koskinen LOD, Kristensen B. CSF outflow resistance as predictor of shunt function. A long-term study. Acta Neurol Scand 2004; 110:154-60. [PMID: 15285771 DOI: 10.1111/j.1600-0404.2004.00302.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Little is known about the long-term impact of a CSF shunt on the human CSF hydrodynamic system. In patients with communicating hydrocephalus, patency of the shunt system is not regularly assessed. In order to reveal postoperative changes in the CSF hydrodynamic system, we prospectively investigated the features of the system in shunted patients with idiopathic adult hydrocephalus syndrome (IAHS) over a 3-year period. MATERIAL AND METHODS Thirty-two patients with IAHS were studied at baseline and at 3, 9, 18 and 36 months postoperatively. All patients were operated on with a Hakim standard valve system and a ventriculo-peritoneal approach. At each visit, the patients were investigated with computed tomography/magnetic resonance imaging, video recording of gait and a lumbar constant pressure infusion method. Six brand-new Hakim valves were investigated in a bench test, and these results were compared with the in vivo results. RESULTS After shunt insertion, the CSF outflow resistance was significantly decreased (13.6 vs 3.8 mmHg/ml/min). The mean outflow resistance of the six in vitro tested valves corresponded to the postoperative values. The variation in resistance in the functioning shunts at different postoperative investigations was negligible. The mean intracranial pressure in the supine position was 13.8 mmHg at the baseline and 14.3, 14.5, 14.8 and 15.7 mmHg at the follow-up visits, respectively. Postoperatively, the CSF pressure after sitting for 10 min (i.e. 'siphoning effect') decreased significantly (mean decrease -5.3, -5.4, -4.7 and -5.3 mmHg at each visit, respectively). Shunt-related complications occurred in seven patients (underdrainage four, overdrainage three). Despite a functioning shunt, eight patients never improved and another nine patients first improved but later deteriorated. CONCLUSIONS The CSF outflow resistance is much decreased postoperatively and does not alter over time in patients with functioning shunts. We consider CSF outflow resistance to be a reliable indicator of shunt function and of fundamental importance to distinguish a dysfunctioning shunt from an aggravation of the primary condition in patients with communicating hydrocephalus. The unaltered intracranial pressure together with the in vitro model results, suggests that the intra-abdominal pressure might be a major determinant of the postoperative intracranial pressure.
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Affiliation(s)
- J Malm
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden.
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Lechowski L, Forette B, Teillet L. Démarche diagnostique devant un syndrome démentiel. Rev Med Interne 2004; 25:363-75. [PMID: 15110954 DOI: 10.1016/j.revmed.2003.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2003] [Accepted: 07/25/2003] [Indexed: 11/27/2022]
Abstract
PURPOSE The high prevalence of dementia, particularly of Alzheimer's disease, the increase of their incidence with age, and the population aging make this group of diseases a major problem for public health. Nevertheless, diagnosis is difficult because it depends on evolution of disturbances that patients often cannot precisely relate, on complex neuropsychological explorations, and on pathological examination difficult to obtain. Today in France, geriatricians are fully implicated in the diagnosis of dementia and all the physicians who give care to elderly, should lead easily a diagnosis of dementia. CURRENT KNOWLEDGE AND KEY POINTS In February 2000 ANAES (French governmental agency for accreditation and evaluation of health system) published recommendations called "practical recommendations for the diagnosis of Alzheimer's disease". These recommendations allow physicians to standardize their practices and consist of a rigorous clinical history and examination, a neuropsychological analysis, standard investigations and application of diagnostic criteria already widely diffused and used. FUTURE PROSPECTS AND PROJECTS Deepening of knowledge, in particular in the domains of neuropsychology and functional cerebral imagery, should allow physicians to diagnose early dementia. These early diagnosis should allow to initiate a multidisciplinary, preventive and effective care for patients. Specific drugs, that will be available, will be intended mostly for patients with early diagnosis, ideally at a pre-dementia state.
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Affiliation(s)
- L Lechowski
- Service de gérontologie II, AP-HP, hôpital Sainte-Périne, 11, rue Chardon-Lagache, 75781 Paris cedex 16, France.
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Poca MA, Mataró M, Del Mar Matarín M, Arikan F, Junqué C, Sahuquillo J. Is the placement of shunts in patients with idiopathic normal pressure hydrocephalus worth the risk? Results of a study based on continuous monitoring of intracranial pressure. J Neurosurg 2004; 100:855-66. [PMID: 15137605 DOI: 10.3171/jns.2004.100.5.0855] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. Data from many studies have demonstrated that shunt insertion in patients with idiopathic normal-pressure hydrocephalus (NPH) is associated with high morbidity and a lack of significant improvement; however, the use of strict diagnostic and treatment protocols can improve the results of surgery in these patients. The primary aim in this prospective study was to analyze the results of shunt placement in 43 patients with idiopathic NPH. A secondary aim was to determine the relationship between several clinical and neuroimaging factors, and patient outcome after surgery.
Methods. Thirty men and 13 women with a mean age of 71.1 ± 6.9 years participated in this study. All patients underwent clinical, neuropsychological, and radiological assessment before and 6 months after surgery. In all patients continuous monitoring of intracranial pressure was performed using a fiberoptic extradural sensor. In 31 patients cerebrospinal fluid dynamics were also determined. Eighty-six percent of patients showed clinical improvement after shunt insertion, 11.6% showed no change, and 2.3% exhibited some worsening. Gait improved in 81.4% of the patients, sphincter control in 69.8%, and cognitive dysfunction in 39.5%. There was no treatment-related death. Early or late postsurgical complications occurred in six patients (14%), although all of these complications were minor or were satisfactorily resolved. The complete clinical triad, cortical sulci size, and periventricular lucencies were related to outcome, whereas patient age, symptom duration, ventricular dilation, and the degree of presurgical dementia were unrelated to outcome.
Conclusions. Given the correct diagnosis, shunt insertion can produce marked improvement in patients with idiopathic NPH syndrome, causing few deaths and few clinically relevant complications.
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Affiliation(s)
- Maria A Poca
- Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain.
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