Cognitive and motor improvement after retesting in normal-pressure hydrocephalus: a real change or merely a learning effect?

Beyond early motor response: Longitudinal cognitive and gait assessments after extended lumbar drainage in normal pressure hydrocephalus

BACKGROUND

Idiopathic normal pressure hydrocephalus (iNPH) is a multifactorial progressive disease affecting cognition, gait, and urinary continence, potentially reversible, or at least improvable, by a prompt surgical intervention. Given its potential surgical improvement, it is crucial to determine who will benefit of a ventriculo-peritoneal shunt. To date, although several procedures are considered useful to diagnose iNPH, there is no agreement concerning the best timing of the clinical assessment or the role played by formal cognitive testing.

METHODS

Thirty participants with suspected iNPH were assessed at baseline, 2, and 15 days after 24-h extended lumbar drainage (ELD). Timed Up and Go test (TUG), Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Frontal Assessment Battery (FAB) were administered in order to quantify motor and cognitive performances. The TUG was used to assess clinical response to ELD.

RESULTS

Our sample showed significant differences between baseline assessment and follow-ups in the majority of tests. Although some enhancements in performances appeared in the first post-ELD assessment, both treatment responders and non-responders showed better performances in the delayed assessment. Post hoc comparison found significant differences in each time point between the two groups.

CONCLUSIONS

These results emphasize the key role of performing multiple assessments post CSF drainage, as response can be more prominent in a delayed rather than an early phase.

Developing multiple shortened forms of virtual reality-based color trails test

The Color Trails Test (CTT) is a pencil-and-paper (P&P) neuropsychological test. The CTT is divided into two parts that assess sustained visual attention (Trails A) and divided attention (Trails B). The CTT can also be performed in a virtual reality setting (VR-CTT) introducing a wider spatial range of targets. In cases of multiple assessments, repeating the same CTT configuration can bias the results due to fatigue and learning effects. The aim of this study is to create five different short versions of the VR-CTT. The different forms were created by rotating or flipping the original targets spatial layout on one of the axes and by ending it at ball #13. Healthy young participants (N = 15) performed the shortened VR-CTT forms (in a counterbalanced order), the P&P CTT and the original VR-CTT. We found no difference between the completion times of the five forms (p > 0.2), and a significant difference between Trails A and B across all forms (p < 0.04). Additionally, there was no evidence of a learning effect between trials (p > 0.4). Moreover, the shortened VR-CTT forms showed correlations with the P&P CTT (p < 0.05) and with the original VR-CTT (p < 0.06). These findings suggest that all five forms have an equal level of difficulty and that the different forms managed to mitigate the learning effects reported for repeated testing of the same spatial layout. This opens the possibility of applying the shortened VR-CTT forms for research settings and sets the basis for developing it into a clinical diagnostics tool.

Alzheimer's Disease CSF Biomarkers as Possible Indicators of Tap-Test Response in Idiopathic Normal Pressure Hydrocephalus

The aim of the present study is the evaluation of established Alzheimer's disease (AD) cerebrospinal fluid (CSF) biomarkers in patients with idiopathic normal-pressure hydrocephalus (iNPH), both individually and as a total profile, and the investigation of their use as potential predictors of Tap-test responsiveness. Fifty-three patients with iNPH participated in the study. Aβ42, Aβ40, total Tau and phospho-Tau proteins were measured in duplicate with double-sandwich ELISA assays. Clinical evaluation involved a 10 m timed walk test before an evacuative lumbar puncture (LP) and every 24 h for three consecutive days afterwards. Neuropsychological assessment involved a mini-mental state examination, frontal assessment battery, 5-word test and CLOX drawing test 1 and 2, which were also performed before and 48 h after LP. Response in the Tap-test was defined as a 20% improvement in gait and/or a 10% improvement in neuropsychological tests. The Aβ42/Aβ40 ratio was found to be significantly higher in Tap-test responders than non-responders. Total Tau and phospho-Tau CSF levels also differed significantly between these two groups, with Tap-test responders presenting with lower levels compared to non-responders. Regarding the AD CSF biomarker profile (decreased amyloid and increased Tau proteins levels), patients with a non-AD profile were more likely to have a positive response in the Tap-test than patients with an AD profile.

Acute disease induced cognitive dysfunction in older patients - an unrecognized syndrome

Background

It is unknown, how many older hospitalized patients experience cognitive changes independently from delirium.

Methods

In this retrospective study, cognitive function was assessed with the Montreal Cognitive Assessment on admission and discharge in 103 acute care geriatric hospital patients.

Results

Mean age was 80.8 ± 7.3 years. The total MoCA score on admission was 17.8 (±4.5) and at discharge 17.7 (±4.4). The mean difference of the total MoCA score was − 0.1 (±3.5). 12 (11.7%) patients suffered from delirium. 46 (44.7%) patients experienced significant changes of cognitive function <− 2 or > 2 MoCA points without delirium. There was no significant association between delirium during hospital stay and the prevalence and magnitude of changes in total MoCA score.

Conclusion

Cognitive changes frequently occur during acute disease of geriatric patients independently from delirium. We propose the term “acute disease induced cognitive dysfunction” (ADICD) for this entity.

Trial registration

German Clinical trial register (DRKS-ID: DRKS00025157 on 28.04.2021).

Update on the Cognitive Presentations of iNPH for Clinicians

This mini-review focuses on cognitive impairment in iNPH. This symptom is one of the characteristic triad of symptoms in a condition long considered to be the only treatable dementia. We present an update on recent developments in clinical, neuropsychological, neuroimaging and biomarker aspects. Significant advances in our understanding have been made, notably regarding biomarkers, but iNPH remains a difficult diagnosis. Stronger evidence for permanent surgical treatment is emerging but selection for treatment remains challenging, particularly with regards to cognitive presentations. Encouragingly, there has been increasing interest in iNPH, but more research is required to better define the underlying pathology and delineate it from overlapping conditions, in order to inform best practise for the clinician managing the cognitively impaired patient. In the meantime, we strongly encourage a multidisciplinary approach and a structured service pathway to maximise patient benefit.

Callosal Angle Sub-Score of the Radscale in Patients with Idiopathic Normal Pressure Hydrocephalus Is Associated with Positive Tap Test Response

The aim of the present study was the implementation of the composite imaging “Radscale” in patients with idiopathic normal pressure hydrocephalus (iNPH) and the evaluation of its score, as well as absolute stroke volume and peak flow velocity of cerebrospinal fluid (CSF) in aqueduct as indicators of a positive response following a tap test. Forty-five patients with iNPH were included. Clinical evaluation involved the 10 m timed walk test before and every 24 h for 3 consecutive days after evacuative lumbar puncture (LP). Neuropsychological evaluation comprised a mini mental state examination (MMSE), frontal assessment battery (FAB), 5-word test (5WT) and CLOX drawing test 1 and 2, which were carried out before and 48 h after LP. The tap test’s response was defined as a ≥20% improvement in gait and/or a ≥10% improvement in neuropsychological tests. All scores of neuropsychological and clinical variables, except for immediate 5WT and CLOX-1, differed significantly before and 48 h after LP. Improvement in time and steps of a 10 m timed walk test differed significantly between female and male patients. Out of 45 total patients, 19 were tap test responders and 26 non-responders. The total score of Radscale and CSF flow parameters did not differ between responders and non-responders. However, “Callosal angle” sub-score differed significantly between these two groups. A greater “callosal angle” sub-score, meaning more acute callosal angle, was associated with a positive tap test response, rendering it a useful measurement in the stratification of iNPH patients that will potentially respond to CSF shunting.

Reactive microglia and mitochondrial unfolded protein response following ventriculomegaly and behavior defects in kaolin-induced hydrocephalus

Ventriculomegaly induced by the abnormal accumulation of cerebrospinal fluid (CSF) leads to hydrocephalus, which is accompanied by neuroinflammation and mitochondrial oxidative stress. The mitochondrial stress activates mitochondrial unfolded protein response (UPRmt), which is essential for mitochondrial protein homeostasis. However, the association of inflammatory response and UPRmt in the pathogenesis of hydrocephalus is still unclear. To assess their relevance in the pathogenesis of hydrocephalus, we established a kaolin-induced hydrocephalus model in 8-week-old male C57BL/6J mice and evaluated it over time. We found that kaolin-injected mice showed prominent ventricular dilation, motor behavior defects at the 3-day, followed by the activation of microglia and UPRmt in the motor cortex at the 5-day. In addition, PARP-1/NF-κB signaling and apoptotic cell death appeared at the 5-day. Taken together, our findings demonstrate that activation of microglia and UPRmt occurs after hydrocephalic ventricular expansion and behavioral abnormal-ities which could be lead to apoptotic neuronal cell death, providing a new perspective on the pathogenic mechanism of hydrocephalus.

Theta-Burst Stimulation Is Able to Impact Cognitive Processing: A P300 and Neuropsychological Test Study

INTRODUCTION

Theta-burst stimulation (TBS) is a safe non-invasive neurostimulation technique used to improve cognitive and neuropsychiatric impairments. Combined outcome evaluation using event-related potentials (ERPs) and neuropsychological tests may allow a more thorough assessment of TBS treatment efficacy; however, some mixed results have been found, and their use remains scarce. Our main objective was to evaluate whether a session of TBS to the left dorsolateral prefrontal cortex (DLPFC) can impact upon the performance of both neuropsychological and neurophysiological tests.

METHODS

This double-blind sham-controlled study involved 28 healthy adults, between 18 and 30 years. Volunteers were randomly allocated to receive excitatory (intermittent [iTBS]), inhibitory (continuous TBS [cTBS]) or sham stimulation on the left DLPFC. Subjects were evaluated using ERPs (auditory oddball paradigm P300) and neuropsychological tests (Trail making test [TMT] and Stroop test of words and colours [STWC]), using a pre-post stimulation protocol.

RESULTS

Inhibitory stimulation led to significantly delayed P300 peak latencies (p < 0.001), with no consistent change in N2P3 amplitudes. cTBS also significantly influenced the expected group performance in Stroop C and Stroop interference (p = 0.025) compared to the iTBS and sham groups. No significant results were found in TMT tests after TBS.

CONCLUSION

Our results suggest that P300 and specific Stroop colour and words test parameters can be similarly influenced by the same TBS protocol. This emphasizes the importance of mixed evaluation using neuropsychological and neurophysiological resources in research associated with the use of transcranial magnetic stimulation and cognition.

A pilot study of multiple time points and multidomain assessment in cerebrospinal fluid tap test for patients with idiopathic normal pressure hydrocephalus

OBJECTIVE

Our study aimed to identify the appropriate evaluation time point and assessment forthe CSF tap test(TT) to predict the shunting responsiveness of patients with idiopathic normal-pressure hydrocephalus (iNPH).

METHODS

Eighty-eight inpatients with clinically possible iNPH who underwent CSF TT at multiple time points (baseline, 8 hours, 24 hours, and 72 hours after CSF TT) at Peking Union Medical College Hospital were recruited. The multidomain assessment included the timed up and go test(TUG), 10-meter walking tests, and a brief executive function battery. Performance in multidomain assessment at the indicated time points were compared. The positive response rate and cumulative positive rate of multidomain assessment at multiple time points were calculated. And their corresponding specificity and sensitivity of predicting shunting response were calculated according to the follow-up results after shunting.

RESULTS

The multidomain assessment performance except TUG at 8 hours were significantly improved at each time point after CSF TT compared with baseline (P<0.01). Reduction more than 10% in the 10-meter walking time and number of steps at 24 hours showed the highest specificity (both 85.7%) and sensitivity (37.5% and 46.7%, respectively) for predicting shunting response. Additionally, an improvement of more than 20% in the composite z score at 72 hours showed 100% specificity and 80% sensitivity for predicting shunting response.

CONCLUSION

Multiple time points and multidomain assessment were helpful to identify more shunting responders. Executive function evaluation might be a candidate tool to increase the effectiveness of CSF TT.

When to Assess: Cognitive Impact of Ventriculoperitoneal Shunt Operation in Elderly Adults with Normal Pressure Hydrocephalus

OBJECTIVE

Normal pressure hydrocephalus (NPH) has clinical manifestations with different cognitive difficulties. Despite the intense interest, the change in cognitive functions after ventriculoperitoneal shunt (VPS) treatment varies widely. The aims of this study were to monitor the effect of NPH on cognition in elderly and the progress of cognitive abilities after VPS surgery.

METHODS

Patients diagnosed with idiopathic NPH (iNPH) who had ventriculomegaly with narrow callosal angle and/or periventricular signal changes not attributable to ischemic changes were included in study. All patients (n = 30) underwent comprehensive neuropsychological assessment and received programmable VPS. After VPS placement, 2 consecutive examinations were performed at approximately 6-month intervals.

RESULTS

At the baseline evaluation, patients with iNPH displayed poorer performance in executive functions (EFs) compared with the matched control group (n = 30). Among those patients, significant improvement was observed in semantic fluency (M = 13.94; standard deviation, 4.95) and clock drawing (M = 3.67; standard deviation, 1.57) at the second follow-up evaluation (P = 0.015 and P = 0.024, respectively). The other prominent finding was in memory process: patients with iNPH showed improvement in delayed recall (P = 0.011), recognition (P = 0.033), and learning scores (P = 0.041) at the second follow-up compared with evaluation before VPS placement.

CONCLUSIONS

iNPH seems to have a detrimental effect predominantly on EFs. As EFs become corrupted, decline occurs in learning and recall processes of memory. VPS provides an improvement of cognitive deterioration; however, efficacy of this treatment on cognitive abilities is shows in a longer period compared with other iNPH symptoms.

Serial Tap Test of patients with idiopathic normal pressure hydrocephalus: impact on cognitive function and its meaning

Background

Idiopathic normal pressure hydrocephalus (INPH) is characterized by gait disturbance, urinary incontinence and cognitive decline. Symptoms are potentially reversible and treatment is based on cerebrospinal fluid shunting. The tap test (TT) is used to identify patients that will benefit from surgery. This procedure consists of the withdrawal of 20 to 50 mL of cerebrospinal fluid (CSF) through a lumbar puncture (LP) after which the symptoms of the triad are tested. Improvement in the quality and speed of gait are already recognized but cognitive improvement depends on several factors such as tests used, the time elapsed after LP for re-testing, and the number of punctures. Serial punctures may trigger similar conditions as external lumbar drainage (ELD) to the organism.

Objective

This study aimed to identify how serial punctures affect cognition to increase the sensitivity of the test and consequently the accuracy of surgical indication.

Methods

Sixty-one patients with INPH underwent baseline memory and executive tests repeatedly following the 2-Step Tap Test protocol (2-STT – two procedures of 30 mL lumbar CSF drainage separated by a 24-h interval). The baseline scores of INPH patients were compared with those of 55 healthy controls, and with intragroup post-puncture scores of the 2-STT.

Results

The group with INPH had lower performance than the control group in all cognitive tests (RAVLT, Stroop, CFT, FAR-COWA, FAB, MMSE, orientation, mental control), except for the forward digit span test (p = 0.707). After conducting LP procedures, the Stroop test (words, colors and errors), RAVLT (stage A1, A6 and B1), and CFT (immediate and delayed R) scores were equal to those of the control group (p > 0.05). The INPH group presented significant improvement after the first puncture in MMSE (p = 0.031) and in the Stroop Test (points) (p < 0.001). After the second puncture, subjects improved in orientation, MMSE, RAVLT (B1), Stroop (points, words, errors) and CFT (IR).

Conclusion

Progressive cognitive improvement occurred over the 2-STT and changes were more significant after the second LP in all cognitive domains except for RAVLT (A7). Encephalic alert system ‘arousal’ seems to participate in early improvements observed during 2-STT. The second LP increased the sensitivity of the drainage test to detect changes in cognitive variables, and consequently improved the quality of the method.

Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus

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.

Neurological and neuropsychological outcome after resection of craniopharyngiomas

OBJECTIVE

Craniopharyngiomas are rare and benign tumors of the sellar and/or parasellar region. Primary treatment involves resection followed by adjuvant radiotherapy. While the grade of resection was frequently analyzed following surgery, the neurological outcome and especially neuropsychological deficits and quality of life have been neglected for many decades. Therefore, the authors retrospectively analyzed their patient series and prospectively assessed neuropsychological outcome and quality of life following resection of craniopharyngiomas in adults.

METHODS

In total, 71 patients (39 men and 32 women) with a mean age of 49 years were enrolled in the retrospective analysis. In addition, 36 of the 71 patients were included in the prospective arm of the study and underwent neurological and neuropsychological testing as well as quality of life (36-Item Short-Form Health Survey; SF-36) assessment. Factors influencing outcome were identified and correlations calculated.

RESULTS

Resection was performed mostly using a pterional (41.6%, 47/113 surgical procedures) or bifrontal translamina terminalis (30.1%, 34/113 surgical procedures) approach. Following surgery, visual acuity was significantly improved (> 0.2 diopters) in 32.4% (23/71) of patients, or remained stable in 45.1% (32/71) of patients. During long-term follow up, 80.3% (57/71) of patients developed pituitary insufficiency, particularly involving the corticotropic and thyrotrophic axes. In total, 75% (27/36) of patients showed neuropsychological deviations in at least 1 test item. In particular, attentiveness, cognitive speed, and short-term memory were affected. Referring to the SF-36 score, quality of life was affected in both the mental and physical score in 19.4% (7/36) and 33.3% (12/36), respectively. The risk factors that were identified were a tumor volume larger than 9 cm3, tumor extension toward/into the third ventricle or the brainstem, and resection using a bifrontal translamina terminalis or left-sided approach.

CONCLUSIONS

This study demonstrated that resection of craniopharyngiomas is frequently associated with postoperative neuropsychological deficits and hence an impaired quality of life. In addition to tumor size and extension toward/into the third ventricle or the brainstem, selection of the surgical approach may play a crucial role in the patient's neuropsychological outcome and quality of life.

The Computerized General Neuropsychological INPH Test revealed improvement in idiopathic normal pressure hydrocephalus after shunt surgery

OBJECTIVE

The Computerized General Neuropsychological INPH Test (CoGNIT) provides the clinician and the researcher with standardized and accessible cognitive assessments in patients with idiopathic normal pressure hydrocephalus (INPH). CoGNIT includes tests of memory, executive functions, attention, manual dexterity, and psychomotor speed. Investigations of the validity and reliability of CoGNIT have been published previously. The aim of this study was to evaluate CoGNIT's sensitivity to cognitive change after shunt surgery in patients with INPH.

METHODS

Forty-one patients with INPH (median Mini-Mental State Examination score 26) were given CoGNIT preoperatively and at a postoperative follow-up 4 months after shunt surgery. Scores were compared to those of 44 healthy elderly control volunteers. CoGNIT was administered by either a nurse or an occupational therapist.

RESULTS

Improvement after shunt surgery was seen in all cognitive domains: memory (10-word list test, p < 0.01); executive functions (Stroop incongruent color and word test, p < 0.01); attention (2-choice reaction test, p < 0.01); psychomotor speed (Stroop congruent color and word test, p < 0.01); and manual dexterity (4-finger tapping, p < 0.01). No improvement was seen in the Mini-Mental State Examination score. Preoperative INPH test scores were significantly impaired compared to healthy control subjects (p < 0.001 for all tests).

CONCLUSIONS

In this study the feasibility for CoGNIT to detect a preoperative impairment and postoperative improvement in INPH was demonstrated. CoGNIT has the potential to become a valuable tool in clinical and research work.Clinical trial registration no.: NCT01618500 (clinicaltrials.gov).

The benefit of delayed reassessment post high-volume CSF removal in the diagnosis of shunt-responsive idiopathic normal-pressure hydrocephalus

The principle aim of the study was to demonstrate the value of performing delayed reassessment in the diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) and selection of suitable candidates for ventriculoperitoneal shunting (VPS). Thirty-one consecutive patients underwent the NPH protocol at the Flinders Medical Centre between March 2017 and November 2018. The protocol involved mobility and cognitive testing with reassessment post high-volume cerebrospinal fluid (CSF) removal at 24 h and 48 h. The Assessment of Quality of Life 6D (AQoL-6D) questionnaire and International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) were completed and repeated again at 6 weeks and 6 months post shunting. Results were analysed to determine the significance of delayed reassessment. Twenty patients (64.5%) underwent insertion of a VPS on the basis of objective improvements and specific criteria. Of these, 6 patients (30%) were shunted based on delayed reassessment at 48 h post CSF removal. Continued improvements were seen for all mobility and cognitive tests from baseline to 48 h post CSF removal. At 6 weeks and 6 months post shunting, there was an overall mean improvement in AQoL-6D and ICIQ-UI SF for the cohort and the improvement was also observed in the subgroup of patients who met shunt criteria at 48 h post CSF removal. In the diagnosis of shunt-responsive idiopathic normal-pressure hydrocephalus, delayed reassessment post CSF removal improves sensitivity and is therefore important.

Changes in Cognitive Function Scores After Cerebrospinal Fluid Tap Testing in Patients with Suspected Idiopathic Normal-Pressure Hydrocephalus

BACKGROUND

In patients suspected of having idiopathic normal-pressure hydrocephalus (iNPH), improvement in impaired cognition is common after a diagnostic cerebrospinal fluid tap test (CSFTT). Measures used to evaluate cognitive function before and after a CSFTT include the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Trail Making Test (TMT). However, the time point at which cognitive function should be reevaluated after a CSFTT remains controversial.

OBJECTIVE

To investigate differences in cognitive function 1 day and 1 week after a CSFTT (versus baseline) in patients with suspected iNPH.

METHODS

This retrospective study, conducted between October 2012 and January 2017, involved 39 patients with suspected iNPH. We analyzed their MMSE, FAB, and TMT scores on tests conducted before and 1 day and 1 week after the CSFTT.

RESULTS

Changes in MMSE scores were negligible 1 day after the CSFTT but began to appear 1 week later. Changes in FAB scores were observed from 1 day to 1 week after the CSFTT. Although no statistically significant differences in TMT scores were observed at either time point, the execution time for the test tended to be shorter on the day after the CSFTT. Changes in cognitive function were not associated with demographic or morphological parameters. More severe impairments at baseline, however, were associated with greater changes in cognitive function.

CONCLUSIONS

Performing several reevaluations using each test may enable more accurate assessment of cognitive function in patients with suspected iNPH. Our results highlight the need for long-term follow-up, regardless of the severity of cognitive impairment.

Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery

BACKGROUND AND PURPOSE

Several studies have evaluated the use of MR imaging markers for the prediction of outcome after shunt surgery in idiopathic normal pressure hydrocephalus with conflicting results. Our aim was to investigate the predictive value of a number of earlier proposed morphologic MR imaging markers in a large group of patients with idiopathic normal pressure hydrocephalus.

MATERIALS AND METHODS

One hundred sixty-eight patients (mean age, 70 ± 9.3 years) with idiopathic normal pressure hydrocephalus, subjected to standardized quantification of clinical symptoms before and after shunt surgery, were included in the study. Outcome was calculated using a composite score. Preoperative T1, FLAIR, and flow-sensitive images were analyzed regarding the presence of 13 different morphologic MR imaging markers.

RESULTS

The median Evans index was 0.41 (interquartile range, 0.37-0.44). All patients had an aqueductal flow void sign present and white matter hyperintensities. The median callosal angle was 68.8° (interquartile range, 57.7°-80.8°). Dilated Sylvian fissures were found in 69%; focally dilated sulci, in 25%; and widening of the interhemispheric fissure, in 55%. Obliteration of the sulci at the convexity was found in 36%, and 36% of patients were characterized as having disproportionately enlarged subarachnoid space hydrocephalus. Sixty-eight percent of patients improved after surgery. None of the investigated MR imaging markers were significant predictors of improvement after shunt surgery.

CONCLUSIONS

Disproportionately enlarged subarachnoid space hydrocephalus, a small callosal angle, and the other MR imaging markers evaluated in this study should not be used to exclude patients from shunt surgery. These markers, though they may be indicative of idiopathic normal pressure hydrocephalus, do not seem to be a part of the mechanisms connected to the reversibility of the syndrome.

Cognitive and upper limb symptom changes from a tap test in Idiopathic Normal Pressure Hydrocephalus

OBJECTIVES

To determine which cognitive and upper limb assessments can identify change in patients undergoing a Cerebrospinal fluid (CSF) tap test (TT) diagnosed with idiopathic Normal Pressure Hydrocephalus (iNPH).

PATIENTS AND METHODS

Prospective observational study of 74 iNPH patients undergoing a CSF TT for consideration of a ventricular peritoneal shunt. Patients who were offered surgical intervention were classified as responders. Patients were assessed with a battery of cognitive and upper limb assessments prior to and following a CSF TT. The Timed up and go cognition (TUG-C), Montreal Cognitive assessment (MoCA) and 9-hole peg test were utilised.

RESULTS

40 patients were classified responders. Significant differences were identified for responders for the MoCA (0.62 points) and TUG-C (-6.02 s). Only the executive function and orientation sub scores of the MoCA showed significant changes for responders. The 9 hole peg test mean change of 4.33 s for responders was not significant. Non-responder change scores for the MoCA (0.22 points), TUG-C (0.3 s) and 9 hole peg test (2.58 s) were not significant.

CONCLUSION

The TUG-C has the potential to identify change in patients resulting from a CSF TT. While statistically significant change was found for the MoCA, a mean change of less than 1 point on this scale is unlikely to be clinically relevant. Similarly, the 9 hole peg test cannot be endorsed as an assessment tool for identifying changed performance in iNPH.

Finger tapping and verbal fluency post-tap test improvement in INPH: its value in differential diagnosis and shunt-treatment outcomes prognosis

BACKGROUND

Idiopathic normal pressure hydrocephalus (INPH) diagnosis is challenging as it can be mimicked by other neurological conditions, such as neurodegenerative dementia and motor syndromes. Additionally, outcomes after lumbar puncture (LP) tap test and shunt treatment may vary due to the lack of a common protocol in INPH assessment. The present study aimed to assess whether a post-LP test amelioration of frontal cognitive dysfunctions, characterizing this syndrome, can differentiate INPH from similar neurological conditions and whether this improvement can predict INPH post-shunt outcomes.

METHOD

Seventy-one consecutive patients referred for INPH suspicion and LP testing, were enrolled. According to the consensus guidelines criteria, 29 patients were diagnosed as INPH and 42 were assigned an alternative diagnosis (INPH-like group) after reviewing clinical, neuropsychological and imaging data, and before LP results. A comprehensive neuropsychological assessment for frontal executive, upper extremity fine motor functions, aphasias, apraxias, agnosias and gait evaluation were administered at baseline. Executive, fine motor functions and gait were re-examined post-LP test in all patients and post-shunt placement in INPH patients.

RESULTS

Of the INPH patients, 86.2% showed cognitive amelioration in the post-LP test; in addition, all but one (97%) presented with neurocognitive and gait improvement post-shunt. Verbal phonological fluency and finger tapping task post-LP improvement predicted positive clinical outcome post-shunt. None of the INPH-like group presented with neurocognitive improvement post-LP.

CONCLUSIONS

Post-LP amelioration of verbal fluency and finger tapping deficits can differentiate INPH from similar disorders and predict positive post-shunt clinical outcome in INPH. This becomes of great importance when gait assessment is difficult to perform in clinical practice.

Prospective analysis of neuropsychological deficits following resection of benign skull base meningiomas

OBJECTIVE Resection of skull base tumors is challenging. The introduction of alternative treatment options, such as radiotherapy, has sparked discussion regarding outcome in terms of quality of life and neuropsychological deficits. So far, however, no prospective data are available on this topic. METHODS A total of 58 patients with skull base meningiomas who underwent surgery for the first time were enrolled in this prospective single-center trial. The average age of the patients was 56.4 ± 12.5 years. Seventy-nine percent of the tumors were located within the anterior skull base. Neurological examinations and neuropsychological testing were performed at 3 time points: 1 day prior to surgery (T1), 3-5 months after surgery (T2), and 9-12 months after surgery (T3). The average follow-up duration was 13.8 months. Neuropsychological assessment consisted of quality of life, depression and anxiety, verbal learning and memory, cognitive speed, attention and concentration, figural memory, and visual-motor speed. RESULTS Following surgery, 23% of patients showed transient neurological deficits and 12% showed permanent new neurological deficits with varying grades of manifestation. Postoperative quality of life, however, remained stable and was slightly improved at follow-up examinations at T3 (60.6 ± 21.5 vs 63.6 ± 24.1 points), and there was no observed effect on anxiety and depression. Long-term verbal memory, working memory, and executive functioning were slightly affected within the first months following surgery and appeared to be the most vulnerable to impairment by the tumor or the resection but were stable or improved in the majority of patients at long-term follow-up examinations after 1 year. CONCLUSIONS This report describes the first prospective study of neuropsychological outcomes following resection of skull base meningiomas and, as such, contributes to a better understanding of postoperative impairment in these patients. Despite deterioration in a minority of patients on subscales of the measures used, the majority demonstrated stable or improved outcome at follow-up assessments.

The effect of shunt surgery on neuropsychological performance in normal pressure hydrocephalus: a systematic review and meta-analysis

We conducted a systematic review of the literature and used meta-analytic techniques to evaluate the impact of shunt surgery on neuropsychological performance in patients with normal pressure hydrocephalus (NPH). Twenty-three studies with 1059 patients were identified for review using PubMed, Web of Science, Google scholar and manual searching. Inclusion criteria were prospective, within-subject investigations of cognitive outcome using neuropsychological assessment before and after shunt surgery in patients with NPH. There were statistically significant effects of shunt surgery on cognition (Mini-Mental State Examination; MMSE), learning and memory (Rey Auditory Verbal Learning Test; RAVLT, total and delayed subtests), executive function (backwards digit span, phonemic verbal fluency, trail making test B) and psychomotor speed (trail making test A) all in the direction of improvement following shunt surgery, but with considerable heterogeneity across all measures. A more detailed examination of the data suggested robust evidence for improved MMSE, RAVLT total, RAVLT delayed, phonemic verbal fluency and trail making test A only. Meta-regressions revealed no statistically significant effect of age, sex or follow-up interval on improvement in the MMSE. Our results suggest that shunt surgery is most sensitive for improving global cognition, learning and memory and psychomotor speed in patients with NPH.

A double-blind randomized trial on the clinical effect of different shunt valve settings in idiopathic normal pressure hydrocephalus

OBJECTIVE

The study aim was to examine the effect of gradually reducing the opening pressure on symptoms and signs in the shunt treatment of idiopathic normal pressure hydrocephalus (iNPH).

METHODS

In this prospective double-blinded, randomized, controlled, double-center study on patients with iNPH, a ventriculoperitoneal shunt with an adjustable Codman Medos Valve was implanted in 68 patients randomized into 2 groups. In 1 group (the 20-4 group) the valve setting was initially set to 20 cm H2O and gradually reduced to 4 cm H2O over the course of the 6-month study period. In the other group (the 12 group), the valve was kept at a medium level of 12 cm H2O during the whole study period. All patients were clinically evaluated using 4 tests preoperatively as well as postoperatively at 1, 2, 3, 4, and 6 months. The test scores between the 2 groups (20-4 and 12) were compared for each clinical evaluation.

RESULTS

Fifty-five patients (81%) were able to complete the study. There were no significant differences between the 2 groups (20-4 and 12) preoperatively or at any time postoperatively. Both groups exhibited significant clinical improvement after shunt insertion at all valve settings compared with the preoperative score, with the greatest improvement observed at the first postoperative evaluation. The clinical improvement was significant within the first 3 months, and thereafter no significant improvement was seen in either group.

CONCLUSIONS

Gradual reduction of the valve setting from 20 to 4 cm H2O did not improve outcome compared with a fixed valve setting of 12 cm H2O. Improvement after shunt surgery in iNPH patients was evident within 3 months, irrespective of valve setting.

Improvement in executive subfunctions following cerebrospinal fluid tap test identifies idiopathic normal pressure hydrocephalus from its mimics

BACKGROUND AND PURPOSE

Patients with idiopathic normal pressure hydrocephalus (iNPH) present cognitive deficits that overlap with other neurological conditions such as Parkinson's disease or vascular dementia, therefore mimicking iNPH. This prospective study aimed to compare cognitive performances between iNPH and iNPH mimics before and after cerebrospinal fluid (CSF) tapping.

METHODS

A total of 57 patients with suspicion of iNPH (75.84 ± 6.42 years; 39% female) were included in this study (37 iNPH and 20 iNPH mimics). Neuropsychological assessments were performed before and 24 h after CSF tapping of 40 ml. Multivariate logistic regressions were used to examine the association between iNPH and cognitive functions, adjusted for age, education, baseline cognitive assessment and disease duration.

RESULTS

Both groups presented the same baseline cognitive performances. After CSF tapping, iNPH patients improved their semantic (P = 0.001) and phonemic verbal fluencies (P = 0.001), whereas iNPH mimics presented similar performances to before CSF tapping. The phonemic verbal fluency (odds ratio 1.43, 95% confidence interval 1.05; 1.96) and the Color Trails Test (odds ratio 0.10, 95% confidence interval 0.01; 0.76) improvements were the two discriminative cognitive tests that identified iNPH from iNPH mimics.

CONCLUSION

Improvement in executive subfunctions after CSF tapping identified iNPH patients from other neurological conditions that mimic iNPH. These findings respond to clinical issues encountered on a daily basis and would improve the diagnostic process of iNPH.

Neuropsychological examination detects post-operative complications in idiopathic normal pressure hydrocephalus (iNPH): report of two cases

Subdural fluid collections (SFC) are characteristic complications of shunting for idiopathic normal pressure hydrocephalus (iNPH). This report presents two shunted iNPH patients with clinically silent postoperative SFC, detected after abnormal neuropsychological findings. These cases highlight the value of neuropsychological assessment in the routine postoperative assessment of iNPH.

A computerized neuropsychological test battery designed for idiopathic normal pressure hydrocephalus

Background

A tool for standardized and repeated neuropsychological assessments in patients with idiopathic normal pressure hydrocephalus (INPH) is needed. The objective of this study was to develop a computerized neuropsychological test battery designed for INPH and to evaluate its reliability, validity and patient’s ability to complete the tests.

Methods

Based on a structured review of the literature on neuropsychological testing in INPH, the eight tests most sensitive to the INPH cognitive profile were implemented in a computerized format. The Geriatric Depression Scale (GDS) was also included. Tests were presented on a touch-screen monitor, with animated instructions and speaker sound. The battery was evaluated with the following cohorts: A. Test-retest reliability, 44 healthy elderly; B. Validity against standard pen and pencil testing, 28 patients with various cognitive impairments; C. Ability to complete test battery, defined as completion of at least seven of the eight tests, 40 investigated for INPH.

Results

A. All except the figure copy test showed good test-retest reliability, r = 0.67-0.90; B. A high correlation was seen between conventional and computerized tests (r = 0.66-0.85) except for delayed recognition and figure copy task; C. Seventy-eight percent completed the computerized battery; Patients diagnosed with INPH (n = 26) performed worse on all tests, including depression score, compared to healthy controls.

Conclusions

A new computerized neuropsychological test battery designed for patients with communicating hydrocephalus and INPH was introduced. Its reliability, validity for general cognitive impairment and completion rate for INPH was promising. After exclusion of the figure copy task, the battery is ready for clinical evaluation and as a next step we suggest validation for INPH and a comparison before and after shunt surgery.

Trial registration

ClinicalTrials.org NCT01265251.

Cognitive functions after spinal tap in patients with normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is characterised by gait disturbance, urinary incontinence and dementia. Even though dementia is a cardinal symptom of NPH, there is few data available concerning cognitive functioning. The aim of this observational case-control study was to evaluate the use of neuropsychological (NPSY) tests prior and after spinal tap test, which might be helpful for diagnosis, treatment and as a prognostic factor for shunt surgery. 15 patients with NPH and 18 controls were examined with eleven different tests covering all neuropsychological domains on two consecutive days. The second examination in NPH patients was 1 day after a spinal tap of 30-50 ml cerebrospinal fluid. A significant difference between NPH and controls in the change between baseline and 1 day after spinal tap was only observed in MMSE. In the domains of visuo-constructive function and attention, controls performed slightly better at day one compared to baseline, which could be interpreted as a learning effect, but after adjusting for multiple testing none of the P values were significant. In contrast to other reports, the MMSE seems to provide a sensitive evaluation of the response to spinal tap in NPH patients and might therefore be included into the routine work up of NPH patients. All other NPSY tests showed less prominent changes within 1 day after spinal tap.

Evaluation of coexistence of Alzheimer's disease in idiopathic normal pressure hydrocephalus using ELISA analyses for CSF biomarkers

BACKGROUND

We investigated levels of the β-amyloid 1-42 (Aβ42), total tau protein (T-tau) and tau phosphorylated at position threonine 181 (P-tau) in cerebrospinal fluid (CSF) of idiopathic normal pressure hydrocephalus (iNPH) patients and tried to find their clinical implications in the evaluation and treatment of iNPH.

METHOD

Twenty-five possible iNPH patients were prospectively enrolled and their CSF was collected to analyze levels of Aβ42, T-tau and P-tau using ELISA method. Gait disturbance, urinary incontinence, and cognitive impairment were semi-quantified and detailed neuropsychological (NP) test was performed.

RESULT

Eight iNPH patients were classified into the lower CSF Aβ42 group and 17 patients were classified into the higher CSF Aβ42 group. There was no difference in the iNPH grading score and its improvement after LP between the two groups. The lower CSF Aβ42 group showed more deficits in attention, visuospatial function and verbal memory in the baseline NP test and less improvement in phonemic categorical naming and frontal inhibitory function after LP.

CONCLUSIONS

Our study suggested that concomitant AD in iNPH patients might contribute to lumbar puncture or shunt unresponsiveness, especially in the field of cognitive dysfunction.

Diagnosis and management of idiopathic normal-pressure hydrocephalus

The diagnosis and management of idiopathic normal-pressure hydrocephalus (iNPH), a disorder of gait impairment, incontinence, and dementia that affects elderly patients, incorporates an organized approach using familiar principles for neurologists. The starting point is a comprehensive history and neurologic examination, review of neuroimaging, and evaluation of the differential diagnosis. Coexisting disorders should be treated before specific iNPH testing is performed. Specific iNPH testing includes assessing patient response to temporary CSF removal and testing CSF hydrodynamics. In properly selected patients, all iNPH symptoms, including dementia, can improve after shunt surgery. The longitudinal care of iNPH patients with shunts includes evaluation of the differential diagnosis of worsening iNPH symptoms and treatment of coexisting disorders. Evaluation of shunt obstruction is often indicated, and if it is found, surgical correction is likely to result in symptomatic improvement.

Counting-backward test for executive function in idiopathic normal pressure hydrocephalus

OBJECTIVES

The aim of this study was to develop and validate a bedside test for executive function in patients with idiopathic normal pressure hydrocephalus (INPH).

MATERIALS AND METHODS

Twenty consecutive patients with INPH and 20 patients with Alzheimer's disease (AD) were enrolled in this study. We developed the counting-backward test for evaluating executive function in patients with INPH. Two indices that are considered to be reflective of the attention deficits and response suppression underlying executive dysfunction in INPH were calculated: the first-error score and the reverse-effect index. Performance on both the counting-backward test and standard neuropsychological tests for executive function was assessed in INPH and AD patients.

RESULTS

The first-error score, reverse-effect index and the scores from the standard neuropsychological tests for executive function were significantly lower for individuals in the INPH group than in the AD group. The two indices for the counting-backward test in the INPH group were strongly correlated with the total scores for Frontal Assessment Battery and Phonemic Verbal Fluency. The first-error score was also significantly correlated with the error rate of the Stroop colour-word test and the score of the go/no-go test. In addition, we found that the first-error score highly distinguished patients with INPH from those with AD using these tests.

CONCLUSION

The counting-backward test is useful for evaluating executive dysfunction in INPH and for differentiating between INPH and AD patients. In particular, the first-error score may reflect deficits in the response suppression related to executive dysfunction in INPH.

Feasibility and reliability of physical fitness tests in older adults with intellectual disability: a pilot study

BACKGROUND

Physical fitness is relevant for wellbeing and health, but knowledge on the feasibility and reliability of instruments to measure physical fitness for older adults with intellectual disability is lacking.

METHODS

Feasibility and test-retest reliability of a physical fitness test battery (Box and Block Test, Response Time Test, walking speed, grip strength, 30-s chair stand, 10-m Incremental Shuttle Walking Test and the Extended Modified Back-Saver Sit-and-Reach Test) were investigated in older adults with ID in a convenience sample of 36 older adults (mean 65.9, range 50-89 years), with differing levels of intellectual disability and mobility.

RESULTS AND CONCLUSION

All tests to measure physical fitness in older adults with ID had moderate to excellent feasibility and had sufficient test-retest reliability (ICCs .63-.96). No statistically significant learning effects were found.

Eine Normierungsstudie eines modifizierten Trail Making Tests im deutschsprachigen Raum

Der Trail Making Test (TMT) ist ein international weit verbreitetes Verfahren, das z. B. zur Untersuchung von Patienten mit erworbenen Hirnschädigungen eingesetzt wird. Die Performanz im TMT wird mit unterschiedlichen neuropsychologischen Domänen, wie z. B. Aufmerksamkeit und Exekutivfunktionen, in Verbindung gebracht. Trotz der häufigen Anwendung im klinischen Alltag liegen bisher keine deutschsprachigen Normen für einen umfassenden Altersrange vor. Die vorliegende Untersuchung hat daher den Einfluss von Alter und Bildung auf die Bearbeitungszeit im TMT bei deutschsprachigen Erwachsenen im Alter zwischen 18 und 85 Jahren erfasst und analysiert. Ausschlusskriterien bildeten neurologische oder psychiatrische Erkrankungen, die Beeinträchtigung des Blickfeldes bzw. der Sehfähigkeit, die motorische Beeinträchtigung der Arme und Hände sowie Drogen- oder Alkoholmissbrauch. Die Stichprobe ist in vier Altersgruppen aufgeteilt: 18 – 34 Jahre (n = 148), 35 – 49 Jahre (n = 111), 50 – 64 Jahre (n = 93) und 65 – 84 Jahre (n = 53). Hinsichtlich der Bildung wurden zwei Gruppen gebildet: niedriges bis mittleres Bildungsniveau ( ≤ 12 Jahre formale Bildung) und höheres Bildungsniveau ( ≥ 12 Jahre formale Bildung). Signifikante Korrelationen zwischen den demografischen Variablen und den Bearbeitungszeiten im TMT-A bzw. TMT-B zeigen, dass sowohl Alter als auch Bildung mit der Leistung im TMT korrelieren (p < .01). Post hoc Analysen machen deutlich, dass sich dabei alle Altersgruppen voneinander unterscheiden. Die Ergebnisse für die Bearbeitungszeit stehen in Einklang mit früheren Normierungsstudien, die ebenfalls Alter und Bildung als die bedeutsamsten Moderatoren für die Leistung im TMT identifiziert hatten.

The neuropsychology of iNPH: findings and evaluation of tests in the European multicentre study

OBJECTIVE

Neuropsychological dysfunction is common in patients with idiopathic normal pressure hydrocephalus (iNPH). Shunt treatment is beneficial, some patients reaching complete or almost complete recovery, while others show only minor improvement. We aimed to assess the efficacy of a small selection of well characterized and sensitive neuropsychological tests in the context of the European multicentre study on iNPH (Eu-INPH).

METHODS

One hundred and forty-two iNPH patients included in Eu-iNPH were tested with the Rey Auditory Verbal Learning Test (RAVLT), the Grooved Pegboard and the Stroop test before and after three and twelve months of treatment with a ventriculoperitoneal shunt. Their performance was compared to that of 108 healthy individuals (HI).

RESULTS

INPH patients performed significantly worse than HI on all of the neuropsychological measures at entry. The discriminative capacities of the eight variables were similar, with areas under the curve (AUC; ROC analysis) ranging between .86 (Delayed Recall) and .95 (Grooved Pegboard). The most usable test was RAVLT (Learning and Delayed Recall), administered to ≥90% of the patients at all occasions. However, the Grooved Pegboard and the Stroop test were more sensitive to treatment effects.

CONCLUSION

The three neuropsychological tests used in the Eu-iNPH are expedient, highly diagnostically discriminative, and well suited to evaluate changes following shunt treatment.

Cognitive profile of idiopathic normal pressure hydrocephalus

Background/Aims

Frontal lobe dysfunction is believed to be a primary cognitive symptom in idiopathic normal pressure hydrocephalus (iNPH); however, the neuropsychology of this disorder remains to be fully investigated. The objective of this study was to delineate a comprehensive profile of cognitive dysfunction in iNPH and evaluate the effects of cerebrospinal fluid (CSF) shunt surgery on cognitive dysfunction.

Methods

A total of 32 iNPH patients underwent neuropsychological testing of memory, attention, language, executive function, and visuoperceptual and visuospatial abilities. Of these 32 patients, 26 were reevaluated approximately 1 year following CSF shunt surgery. The same battery of tests was performed on 32 patients with Alzheimer's disease (AD) and 30 healthy elderly controls.

Results

The iNPH patients displayed baseline deficits in attention, executive function, memory, and visuoperceptual and visuospatial functions. Impairments of attention, executive function, and visuoperceptual and visuospatial abilities in iNPH patients were more severe than in those with AD, whereas the degree of memory impairment was comparable to that in AD patients. A significant improvement in executive function was observed following shunt surgery.

Conclusion

Patients with iNPH are impaired in various aspects of cognition involving both ‘frontal’ executive functions and ‘posterior cortical’ functions. Shunt treatment can ameliorate executive dysfunction.