Neuropsychological assessment of adult patients with shunted hydrocephalus

Global Rostral Midbrain Syndrome (GRMS) and Corpus callosum infarction in the context of shunt overdrainage

We report 3 cases of Global rostral midbrain syndrome (GRMS) and Corpus Callosum (CC) infarction, in the context of hydrocephalus followed by shunt dysfunction and slit ventricles. Prior shunt implantation had been indicated for adult-onset hydrocephalus secondary to aqueductal stenosis of varying causes. All three patients had been stable for months before developing repeated shunt dysfunctions, ultimately progressing to parkinsonism, Parinaud syndrome, akinetic mutism, pyramidal signs, cognitive impairment, CC infarction and slit ventricles, in the context of CSF overdrainage. Parkinsonism-related symptoms responded to dopa in all cases, but Parinaud syndrome and cognitive impairment persisted. Although GRMS has been described in the context of a transtentorial pressure gradient after shunt blockage, in these three cases with similar clinical presentation, reverse transtentorial pressure gradient and slit ventricles due to shunt overdrainage was the likely cause. The authors discuss the role of CC infarction and provide a detailed analysis after gathering previously described data, to unify information under a recognizable clinical entity and better understand the underlying pathophysiology, treatment options and outcome.

Neuropsychological assessments and cognitive profile mostly associated with shunt surgery in idiopathic normal pressure hydrocephalus patients: diagnostic and predictive parameters and practical implications

BACKGROUND

Cognitive decline is a well-documented feature of idiopathic normal pressure hydrocephalus (iNPH) that can be reversible following cerebrospinal fluid tap tests (CSF-TT). The current gold standard for selecting iNPH patients for shunt surgery is measurable improvement in gait tests following CSF-TT. However, the diagnostic significance and predictive role of pre-surgical cognitive evaluations in probable iNPH patients is still controversial.

PURPOSE

To find the neuropsychological (NPSY) tests and cognitive aspects mostly associated with shunt surgery in iNPH.

MATERIAL AND METHODS

A retrospective comparison between probable iNPH patients who, after undergoing CSF-TT with gait and cognitive evaluations, ended up receiving a shunt (group 1) and probable iNPH patients who ended up with no shunt surgery (group 2). Differences in the diagnostic and predictive results of variety of NPSY tests at baseline, pre-CSF-TT, and post-CSF-TT were used for thorough statistical calculations.

RESULTS

A total of 147 patients with probable iNPH were included. Of those, 58 (39.45%, group 1) patients underwent shunt surgery, while 89 (60.55%, group 2) did not. For the vast majority of the cognitive tests used, no statistically significant differences were found between the groups at baseline (pre-CSF-TT). Following CSF-TT, the "naming" component of the Cognistat test was the only single test to show statically significant difference in improvement between the two groups. Combining at least two tests led to increased levels of accuracy and specificity; however, the sensitivity remained < 50. The only two combinations that were associated with sensitivity ≥ 70 were either any improvement in the Cognistat test (p = 0.627) or any improvement in either its naming, memory, or judgment components (p = 0.015).

CONCLUSION

Cognitive tests, even when combined to cover several cognitive aspects, are not sensitive enough to act as an independent reliable diagnostic and predictive tool, especially when relying on their scores as baseline. In order to avoid cumbersome and unnecessary tests to our patients and to reduce the number of patients who are denied proper treatment due to misdiagnosis, we recommend to use NPSY tests that examine the cognitive aspects of naming and memory, in addition to 2-3 tests for executive functions.

More continuous flow, better learning? The effect of aortic valve opening in patients with left ventricular assist device

PURPOSE

The aim of this study was to analyze neurocognitive function in patients who underwent continuous flow left ventricular assist device (LVAD) implantation.

MATERIAL AND METHOD

This cross-sectional study included three groups: LVAD (n = 31), heart failure patients (n = 26), and healthy volunteers (n = 27). The Rey Auditory-Verbal Learning Test (RAVLT), Judgement of Line Orientation Test (JLOT), Trail Making Test (TMT), Stroop Color-Word Interference Test (SCWIT), Verbal Fluency Test (VFT), Symbol-Digit Modality Test (SDMT) were used to assess the neurocognitive functions. Data were analyzed at a median 12 (3-47) months after LVAD implantation. The LVAD patients were also divided by aortic valve opening (AVO) into three subgroups as "closed" (n = 9), "1-6" (n = 8) and "7-10" (n = 14) opening per ten beats and data were re-analyzed accordingly.

RESULTS

There was no significant difference among the groups according to SCWIT, JLOT, SDMT, TMT, and VFT scores. Post-hoc analyzes of RAVLT scores showed significant differences between the LVAD and the other two groups in favor of the LVAD group. Also, the patients with AVO "7-10" the response times were longer and learning scores were found to be lower than those without AVO.

CONCLUSION

With continuous-flow LVAD, neurocognitive functions were not impaired. The learning performance was better in cases where there was no AVO and flow was completely device dependent. We may speculate that neurocognitive functions are not worsening with continuous cerebral blood flow and even it may improve learning performance.

Risk Factors for Mild Cognitive Impairment in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Endovascular Coiling

OBJECTIVE

To assess the potential early risk factors of mild cognitive impairment after aneurysmal subarachnoid hemorrhage.

METHODS

We prospectively enrolled patients with aneurysmal subarachnoid hemorrhage treated with endovascular coiling during a 5-year period. The demographic characteristics and radiologic and laboratory data were collected. Cognitive assessments were carried out using the Montreal Cognitive Assessment at 6 months after ictus. Multivariate logistic regression was used to determine the risk factors associated with the development of mild cognitive impairment.

RESULTS

Of 152 patients, 59 patients (39%) developed cognitive impairment 6 months later. Univariate analysis showed that the patients with anterior communicating artery or anterior cerebral artery aneurysms (P < 0.001) with Glasgow Outcome Scale score of 7 or less at ictus (P = 0.002), Hunt and Hess grade of 3 or higher (P = 0.002), and Fisher grade of 3 or higher (P = 0.032) were more likely to develop mild cognitive impairment. The risk of mild cognitive impairment was increased for patients who had delayed cerebral ischemia (P = 0.040) and hydrocephalus (P = 0.002). In multivariate logistic regression analysis, mild cognitive impairment was independently associated with anterior communicating artery or anterior cerebral aneurysms (odds ratio [OR], 11.046; 95% confidence interval [CI], 3.371-36.198; P < 0.001), delayed cerebral ischemia (OR, 6.153; 95% CI, 1.587-23.855; P = 0.009), and hydrocephalus (OR, 8.768; 95% CI, 2.115-36.345; P = 0.003).

CONCLUSIONS

The location of the aneurysm, delayed cerebral ischemia, and hydrocephalus were independently associated with the occurrence of mild cognitive impairment after aneurysmal subarachnoid hemorrhage and can contribute to improved identification of patients at high risk for mild cognitive impairment.

The effect of nasal polyposis related nasal obstruction on cognitive functions

Chronic rhinosinusitis with nasal polyposis is a chronic inflammatory disease of the respiratory mucosa of the nasal cavity and paranasal sinuses. The aim of this study was investigate the effect of nasal obstruction related to chronic rhinosinusitis with nasal polyposis on cognitive functions. Patients with chronic rhinosinusitis with nasal polyposis causing bilateral total or near total nasal obstruction were enrolled in the study. Symptoms of nasal congestion, loss of smell, postnasal drip, headaches, snoring, concentration difficulties and blunted affect were evaluated by Visual Analog Scale. Brief symptom inventory test, Stroop test, visual aural digit span, serial digit learning test and P300 test were used to evaluate cognitive functions. Three months after treatment, the tests done before surgery were repeated and the results were compared. A total of 30 patients were included in the study. On the Visual Analog Scale, all symptoms showed significant postoperative improvement in all patients (p < 0.001 for all symptoms). Preoperative nasal congestion accompanied with impaired concentration were detected in 27 patients (90%), and these symptoms recovered in all these patients after treatment (p = 0.035) (correlation coefficient 0.4). Only 22 patients completed the neuropsychological tests. The mean preoperative Stroop test (23.16 ± 5.30), visual aural digit span test (24.68 ± 3.52), and serial digit learning test (16.18 ± 5.35) scores were showed significant improvement compared with mean postoperative Stroop test (21.12 ± 5.69), visual aural digit span test (26.45 ± 2.98), and serial digit learning test (19.31 ± 4.47) scores (p = 0.047, p = 0.022, p = 0.005 respectively). The postoperative P300 latency values improved in 19 (63%) patients. The preoperative and postoperative latency values for P300 showed a significant difference (p = 0.029), whereas the preoperative and postoperative amplitude values for P300 did not differ (p = 0.096). In conclusion, the results of this study indicate that chronic rhinosinusitis with nasal polyposis (CRSwNP) has negative effects on cognitive functions, such as the ability to focus and maintain concentration. These cognitive functions improve after the patients undergo endoscopic sinus surgery to treat their CRSwNP.

Short- and long-term neurobehavioral effects of lumbar puncture and shunting in patients with malabsorptive hydrocephalus after subarachnoid haemorrhage: An explorative case study

BACKGROUND

The neuropsychological effects of lumbar puncture and shunting in terms of cognitive functioning and quality of life were analyzed prospectively in four patients with malabsorptive hydrocephalus who became symptomatic in the chronic state after aneurysmal subarachnoid haemorrhage (SAH).

METHODS

A comprehensive battery of neuropsychological tests was applied to four patients before and shortly after lumbar puncture and six months later. In three of them a shunt has been inserted, one patient was treated by repeated lumbar punctures. In addition, the patients completed a quality of life and a depression questionnaire before lumbar puncture and after shunting. The data were analyzed using single-case methodology.

RESULTS

Hydrocephalus was associated with pronounced cognitive deficits in terms of functions of attention, short- and long-term memory, concentration and motor fine-coordination but not with a general mental deterioration. Quality of life and affect were also substantially impaired. Neuropsychological tests of fronto-cortical cognitive capacity, motor fine coordination and reaction time proved to be sensitive for the short-term effects of lumbar puncture. Memory functions and the capacity of divided attention needed more time for regeneration and improved substantially after shunt implantation.

CONCLUSIONS

We found a complex pattern of cognitive improvement after lumbar puncture and shunting. Furthermore, our results also show a typical cluster of cognitive deficits associated with malabsorptive hydrocephalus including motor dysfunction. These preliminary findings should be confirmed in larger patient samples.

Surgical management of arrested hydrocephalus: Case report, literature review, and 18-month follow-up

OBJECTIVE

Arrested hydrocephalus is stable ventriculomegaly without evidence of neurologic deterioration or symptoms. Management of arrested hydrocephalus in asymptomatic adults is controversial, with little clinical data. This case highlights the potential for decompensation in adults with arrested hydrocephalus and reviews the literature regarding pathophysiology and management of this clinical entity.

PATIENTS AND METHODS

A 39 year-old gentleman with arrested hydrocephalus incidentally found during work-up for new-onset seizure and managed conservatively for ten years presented with increasing headache, memory loss, gait instability and urinary and fecal incontinence. Stable massive triventriculomegaly was documented on serial brain imaging, and ophthalmologic exam revealed no papilledema.

RESULTS

The patient underwent endoscopic third ventriculostomy with immediate post-operative improvement of headache, resolution of incontinence, and cessation of seizures. At 15 months after surgery, neuropsychiatric testing demonstrated improvement in visuomotor skills, problem solving, verbal fluency and cognitive flexibility compared to his pre-operative baseline. At 18 months after surgery he remained seizure free with full continence and significant improvement in headaches.

CONCLUSION

Early recognition of arrested hydrocephalus and its potential for decompensation may prompt surgical treatment and prevent neurologic deterioration.

Cognitive impairment in native Chinese with spinocerebellar ataxia type 3

BACKGROUND

Previous studies have shown cognitive impairment in patients with spinocerebellar ataxia type 3 (SCA3). However, there is a lack of data on Chinese patients with SCA3.

METHOD

We investigated 22 native Chinese with SCA3 and 18 controls matched for age, education as well as mental status. Cognitive assessments were carefully carried out to measure verbal fluency, memory, attention, executive function, visuospatial and visuoconstructive functions.

RESULTS

The most common impairments of cognition in native Chinese with SCA3 were disruption of phonemic verbal fluency and frontal executive dysfunction. Deficits in semantic fluency were detected in about 31.8% patients. Impaired visuospatial function and verbal memory were also found in native Chinese with SCA3. The degree of ataxia, CAG repeat length and education were found to correlate with cognitive performance. Multivariate binary logistic regression suggested that an oculomotor disorder and depression are predictors of cognitive impairment.

CONCLUSION

Native Chinese with SCA3 had cognitive impairment of frontal executive function, temporal and parietal functions. An oculomotor disorder might be an index of cognitive dysfunction.

Morphological and behavioral changes in the pathogenesis of a novel mouse model of communicating hydrocephalus

The Ro1 model of hydrocephalus represents an excellent model for studying the pathogenesis of hydrocephalus due to its complete penetrance and inducibility, enabling the investigation of the earliest cellular and histological changes in hydrocephalus prior to overt pathology. Hematoxylin and eosin staining, immunofluorescence and electron microscopy were used to characterize the histopathological events of hydrocephalus in this model. Additionally, a broad battery of behavioral tests was used to investigate behavioral changes in the Ro1 model of hydrocephalus. The earliest histological changes observed in this model were ventriculomegaly and disorganization of the ependymal lining of the aqueduct of Sylvius, which occurred concomitantly. Ventriculomegaly led to thinning of the ependyma, which was associated with periventricular edema and areas of the ventricular wall void of cilia and microvilli. Ependymal denudation was subsequent to severe ventriculomegaly, suggesting that it is an effect, rather than a cause, of hydrocephalus in the Ro1 model. Additionally, there was no closure of the aqueduct of Sylvius or any blockages within the ventricular system, even with severe ventriculomegaly, suggesting that the Ro1 model represents a model of communicating hydrocephalus. Interestingly, even with severe ventriculomegaly, there were no behavioral changes, suggesting that the brain is able to compensate for the structural changes that occur in the pathogenesis of hydrocephalus if the disorder progresses at a sufficiently slow rate.