Diagnosis Of Normal Pressure Hydrocephalus Research Articles

Comparative Stereological Analysis of Intracranial Volume fractions among Patients with Brain Atrophy and Normal Pressure Hydrocephalus from a Nigerian Population

Background: Differentiation between symptoms of normal pressure hydrocephalus (NPH) and other neurodegenerative disorders such as Brain Atrophy (BA) are usually confusing. Available diagnostic methods are invasive while the few non-invasive methods did not take care of potential factors known to influence intracranial volumes. We, therefore, aim to determine and compare the intracranial volume fractions among patients with NPH and BA.
 Methods: This was a prospective, cross-sectional age-matched control study among consenting patients that were diagnosed with NPH, BA and healthy control in Aminu Kano Teaching Hospital from March 2018 to November 2020. Each patient was routinely examined with CT-Scan; However, control participants were from other reasons. Participants with a medical history known to influence the intracranial volume were excluded. Volume estimation was based on a stereological Cavalieri method and three volume fractions were determined mathematically for each of the group. Test-point computing was facilitated through a locally developed software (voXas_2018). Ethical approval was sort prior to the study.
 Results: Patients with NPH have higher total CSF: brain ratio, intraventricular volume: brain ratio and extra-ventricular: brain ratio. Similar pattern was exhibited according to age grouping, except in the older age category where BA volume fractions were higher.
 Conclusion: Age, gender and statue are known to influence intracranial volumes. We controlled their potential effects through age-matched control of participants between groups and the use of intracranial volume ratios for objective diagnosis of NPH and BA. However, Tcsf:Br and InV:Br volume fraction ratios were found to be reliable indices for distinguishing patients with NPH and BA.

A Novel deep learning approach for the automated diagnosis of normal pressure hydrocephalus

Normal Pressure Hydrocephalus (NPH), an Atypical Parkinsonian syndrome, is a neurological syndrome that mainly affects elderly people. This syndrome shows the symptoms of Parkinson’s disease (PD), such as walking impairment, dementia, impaired bladder control, and mental impairment. The Magnetic Resonance Imaging (MRI) is the aptest modality for the detection of the abnormal build-up of cerebrospinal fluid in the brain’s cavities or ventricles, which is the major cause of NPH. This work aims to develop an automated biomarker for NPH segmentation and classification (NPH-SC) that efficiently detect hydrocephalus using a deep learning-based approach. Removal of non-cerebral tissues (skull, scalp, and dura) and noise from brain images by skull stripping, unsharp-mask based edge sharpening, segmentation by marker-based watershed algorithm, and labelling are performed to improve the accuracy of the CNN based classification system. The brain ventricles are extracted using the external and internal markers and then fed into the convolutional neural networks (CNN) for classification. This automated NPH-SC model achieved a sensitivity of 96%, a specificity of 100%, and a validation accuracy of 97%. The prediction system, with the help of a CNN classifier, is used for the calculation of test accuracy of the system and obtained promising 98% accuracy.

The Role of Cerebrospinal Fluid Dynamics in Normal Pressure Hydrocephalus Diagnosis and Shunt Prognostication.

Over the years, there have been several reports and trials of the resistance to cerebrospinal fluid (CSF) outflow (Rout) in normal pressure hydrocephalus (NPH). This work aimed to revisit the utility of testing CSF circulation in a large population of patients clinically presenting with NPH. We retrospectively analyzed the data of 369 NPH patients-either shunted or with endoscopic third ventriculostomy (ETV)-in Cambridge between 1992 and 2018. We determined the patients' outcomes (improvement versus no improvement at 6months) by applying a threshold on R out values and compared our results with those of existing literature. We also conducted a correlation analysis between all variables and calculated Chi-Statistics (as a measure of separability between improvement and no improvement outcomes) to determine a subset of variables which achieved the highest accuracy in prediction of outcome. In our dataset, R out of 18mmHg*min/mL achieved the highest Chi-statistics of 9.7 with p-value <0.01 when adjusted for age. In addition to R out, intracranial pressure (ICP) values at the baseline and plateau, CSF production rate and ICP amplitude to slope ratio showed significant Chi-Statistics values (more than 5). Using these variables, an overall accuracy of 0.70±0.09 was achieved for prediction of the shunt outcome. Rout can be used for selecting patients for shunt surgery but not for excluding patients from treatment. Critical, multivariable approaches are required to comprehend CSF dynamics and pressure-volume compensation in NPH. Outcome definition and assessment could also be brought to question.

Clinical tips in diagnosing idiopathic normal pressure hydrocephalus: a new concept beyond the cerebrospinal fluid tap test.

Accurate diagnosis of idiopathic normal pressure hydrocephalus is important to manage patients with idiopathic normal pressure hydrocephalus more appropriately. Based on the clinical features and brain magnetic resonance imaging findings, the idiopathic normal pressure hydrocephalus diagnosis is made up. However, most clinicians do not recommend the shunt operation to their patients with presumed idiopathic normal pressure hydrocephalus unless any patients with idiopathic normal pressure hydrocephalus show a considerable improvement through the cerebrospinal fluid tap test. The cerebrospinal fluid tap test is an invasive method and has some limitations to diagnose idiopathic normal pressure hydrocephalus. Therefore, we suppose that a new diagnostic approach of idiopathic normal pressure hydrocephalus is necessary. Various magnetic resonance imaging findings suggesting idiopathic normal pressure hydrocephalus have been applied to diagnose idiopathic normal pressure hydrocephalus. Besides, advances in neuroimaging techniques, including dopamine transporter imaging, and amyloid imaging may allow clinicians to exclude the potential misdiagnosis including Parkinsonian disorders and Alzheimer's disease in patients with presumed idiopathic normal pressure hydrocephalus. Herein, we suggest a neuroimaging-supportive algorithm for the diagnosis of idiopathic normal pressure hydrocephalus. We suspect that this is the time to change the classical approach of diagnosing idiopathic normal pressure hydrocephalus.

Normal pressure hydrocephalus: Diagnostic delay.

Introduction: Normotensive hydrocephalus is a differential diagnosis in the evaluation of the dementia syndrome. The diagnostic protocols would allow detecting this pathology that has more effective treatment than other dementias.Objective: To describe a population with clinical suspicion of normal pressure hydrocephalus evaluated in a Colombian psychiatric hospital and discuss the possible reasons for its diagnostic and therapeutic delay.Materials and methods: We conducted a retrospective study of medical records to identify patients with suspected normal pressure hydrocephalus during a 5-year period. Results: Thirty-five patients with suspected normal pressure hydrocephalus underwent diagnostic lumbar puncture and five of them were considered candidates for a peritoneal-venous shunt, but none underwent this surgical procedure. After three to six months of the lumbar puncture, the gait pattern improved in 22.8% of the patients, cognition in 22.8%, and sphincter control in 11.4%. Improvement was not sustained in the long term (1 year) in any of them.Conclusion: This study suggests the poor implementation of the protocols for evaluating patients with cognitive deficits and delays in the diagnosis of normal pressure hydrocephalus. A small number of patients were identified as candidates for treatment. Normal pressure hydrocephalus is a potentially reversible clinical entity with the placement of a peritoneal ventricular shunt, but delays in diagnosis and treatment have deleterious consequences for patients and their families.

Dementia with Lewy bodies: A differential diagnosis of normal pressure hydrocephalus

AbstractBackgroundThe diagnosis of idiopathic normal pressure hydrocephalus (NPH) is challenging and remains overestimated because of the absence of specific clinical, imaging or biological features. It relies on association of classical triad of symptoms (gait disturbance, cognition impairment, urinary symptoms) associated to a ventricular enlargement. Several differential diagnoses should be considered with an initial presentation suggestive of NPH, such as dementia with Lewy bodies (DLB), Alzheimer disease (AD) and vascular dementia (VD). The aim of this study was to identify NPH differential diagnosis as well as to highlight clinical and radiological features that could help questioning this diagnosis, before performing invasive procedures.MethodIn this monocentric retrospective study, we included 42 patients fulfilling the criteria of possible NPH on initial presentation. At the end of the follow‐up, we classified the sample into patients with probable NPH (NPH group ; n = 13), differential diagnosis of NPH (NPH‐ group; n = 21) and dual pathology with criteria of probable NPH (NPH+; n = 8), depending on their outcome after cerebrospinal fluid (CSF) drainage. We collected clinical data, including results of cognitive assessment, as well as results of CSF biomarkers, EEG, functional and morphological neuroimaging. Ventricular enlargement profile was analyzed using different visual measures on MRI.ResultThe main differential diagnosis of NPH was DLB (21/21), mixed with vascular dementia in four cases. None of the patient had a CSF profile suggestive of AD. Regarding clinical features, asymmetric parkinsonism, fluctuations, agitation during sleep, visual hallucinations and visuospatial impairment were significantly more frequent in NPH‐ patients, compared to NPH patients (p=0.033). The callosal angle was significantly more acute (&lt;104° ; p &lt;0.01) and fourth ventricular dilatation greater (&gt;17 mm ; p&lt;0.01) in NPH patients than in NPH‐ patients, while there was no significant difference in the dilatation of lateral ventricles and third ventricle.ConclusionDLB appeared as the main differential diagnosis of NPH. Our results indicate that the existence of asymmetric parkinsonism, fluctuations, agitation during sleep, visual hallucinations or visuospatial impairment, as well as the absence of acute callosal angle or fourth ventricular dilatation should lead to consider DLB as a differential diagnosis of NPH.

Normal Pressure Hydrocephalus: A Reversible Late Side-Effect Of Whole Brain Radiation

Describe the value to patients of ventriculoperitoneal (VP) shunting for normal pressure hydrocephalus (NPH) after receipt of whole brain radiation therapy (WBRT) for brain metastases. Patients who underwent WBRT at an NCI Comprehensive Cancer Center were retrospectively cross-matched to a list of patients who were subsequently diagnosed with, and underwent therapeutic VP shunt for NPH between January 1, 2016 and January 31, 2020. All patients were referred by a CNS specialist in radiation oncology to a neurosurgeon for clinical suspicion of NPH including new or progressive symptoms of magnetic gait (G), cognitive changes (C), and/or new onset of urinary incontinence (U). NPH was confirmed via large volume lumbar drain in all patients prior to shunting. Five patients were identified and constitute the subjects of this report. All patients were scored as either having (Y) or not (N) symptoms of G, C and U at diagnosis of NPH, and at post-shunting follow-ups. Time to any symptom failure or last follow-up was calculated. Median time from WBRT to presentation of symptoms suggesting NPH was 40 months (Range, 7-148m). The majority of patients were found to have improvement in all presenting symptoms. Patient 4 did not achieve improvement in cognitive impairment with VP shunt and patient 5 did not experience improvement in gait function after placement of VP shunt. Two patients were found to have durability of symptom improvement at the time of analysis. Three patients experienced relapse of symptoms after VP shunt placement with median time to failure being 2 months (Range, 1-8m). NPH is a potentially reversible side effect of WBRT. VP shunting may achieve complete or partial relief of symptoms in these patients and should be considered by clinicians in the follow-up of long-term survivors with cognitive, gait and urinary changes after WBRT.Abstract 3563; TableResponse to Shunting InterventionPatientWBRT to NPH Dx (Mos)Presenting NPH SxGaitCognitionUrinarySx at relapseTime to sx relapse (Mos)Follow-up without relapse (Mos)163G,C,UYYYNANA11237G,C,UYYYG,C8NA340G,C,UYYYNA447G,CYNNAG1NA5148C,UNANYCNA11NA = not applicable; Dx = Diagnosis Sx = Symptoms; Mos = months Open table in a new tab

149. Increased risk of medical complications in patients with normal pressure hydrocephalus undergoing decompression for cervical myelopathy

BACKGROUND CONTEXT Normal pressure hydrocephalus (NPH) is a rare condition more commonly seen in elderly populations that are prone to degenerative spine pathologies, specifically those that predispose them to cervical myelopathy (CM). While symptomatic presentation can mimic CM, there is limited information about this population in the perioperative setting. Prior studies have demonstrated that patients with NPH have increased complications following orthopedic procedures; however, to date no study has examined the impact of NPH in spine surgery. PURPOSE The aim of this study was to examine if a concomitant diagnosis of NPH increased risk of postoperative complications following elective cervical decompression for CM. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE This study included 5,399 Medicare beneficiaries undergoing elective cervical decompression. OUTCOME MEASURES Initial inpatient length of stay (LOS), 90-day medical complications, 90-day readmissions. METHODS Medicare patients under the age of 85 undergoing elective decompression for CM between the years of 2006-2013 were queried using International Classification of Diseases (ICD) coding. Exclusion criteria included any patients with a prior diagnosis of noncervical myelopathy, spinal infection, spinal trauma, or spinal malignancy 5 years prior to decompression. Patients who met study criteria were then separated into those with preexisting NPH prior to index surgery and those without (controls). NPH patients where then matched in a 1:20 ratio to controls using age, sex, and preexisting comorbidities. All postoperative outcomes of interest between the two populations were evaluated using multivariate logistic regression. Significance was defined as p RESULTS Following application of study criteria and matching, 5,399 patients were identified for the study, of these 266 had a diagnosis of NPH. Within 90 days of index surgery, NPH patients had significantly higher risk of cerebrovascular accident (OR 2.61 [1.19-5.08] p=0.008), pulmonary embolism (OR: 2.73 [1.03-6.03] p=0.024), and urinary tract infection (OR 2.1 [1.44-2.98] p CONCLUSIONS Myelopathic patients with preoperative NPH had an increased risk 90-day medical complications following decompression surgery. Likewise, this population had a protracted initial LOS and higher readmission rates following index surgery. Patients and physicians should be aware of these risks and care should be taken to optimize these patients prior to surgery to mitigate future postoperative complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Evaluation of the evan's and bicaudate index for rural population in central india using computed tomography

Introduction:Evans index (EI) and Bicaudate index (BCI) are practical markers of ventricular volume and are helpful radiological markers in the diagnosis of normal pressure hydrocephalus. Worldwide, variation exists in normative studies for both these indices. Most of the studies conducted for EI and BCI are based on the Western population data. No study has been performed on the rural population of Central India. The purpose of this study is to develop normative data on EI and BCI that can be extrapolated for future reference.Materials and Methods:This was a retrospective study conducted from December 2018 to May 2019 in MGIMS Hospital, Sevagram, Maharashtra, India, which is a rural hospital in Central India. All patients with either a head injury or neurological complaints although with normal computed tomography (CT) brain were included in the study. Patients with diagnosed neurological disorder, clinical features suggesting hydrocephalus, or intracranial pathology on CT brain were excluded from the study. Five hundred and eleven patients were selected for this study, and EI and BCI was calculated for them.Results:The mean value of EI and BCI in our study was 0.2707 and 0.1121, respectively. Both indices showed a statistically significant difference between males and females. The value of both indices increased with age.Conclusion:Although our study is in agreement with the cutoff value of EI to diagnose dilated lateral ventricles as 0.3 for age <70 years, cutoff value of EI for the older population should be reconsidered to 0.34.

Structural volumetry in NPH diagnostics and treatment-future or dead end?

To assess automated volumetric analysis as a potential presurgical diagnostic tool or as a method to potentially shed light on normal pressure hydrocephalus (NPH) pathophysiology. MRI imaging according to our protocol was performed in 29 NPH patients, 45 non-NPH (but suspected) patients and 15 controls. Twenty patients underwent a second MRI 3months after ventriculoperitoneal (VP) shunt surgery. All structures relevant to NPH diagnosis were automatically segmented using commercial software. The results were subsequently tested using ANOVA analysis. Significant differences in the volumes of the corpus callosum, left hippocampus, internal globus pallidus, grey and white matter and ventricular volumes were observed between NPH group and healthy controls. However, the differences between NPH and non-NPH groups were non-significant. Three months after, VP shunt insertion decreased ventricular volume was the only clearly significant result (p value 0.0001). Even though a detailed volumetric study shows several significant differences, volumetric analysis as a standalone method does not provide a simple diagnostic biomarker, nor does it shed a light on an unknown NPH aetiology.

Fall assessment in older adult

Falls are caused by many factors. For an individual, the cause may be a complex interaction between these factors. For this case, fall assessment is mandatory because the patient has hypovitaminosis D, stroke, arthritis, urinary incontinence, cognitive impairment, “dementia,” and osteoporosis. This patient in the past 12 months, he experienced tow falls. The fall assessment was done; it showed gait instability. As the patient complained of back pain, lumbar X-ray was positive for L4 compression fracture; however, his DEXA-scan showed osteoporosis. Osteoporosis magnetic resonance imaging was done to the patient: The result showed normal pressure hydrocephalus and vascular component. lumbar puncture (LP) was done, after the LP, his motor function improved, so the final diagnosis of normal-pressure hydrocephalus was reached. As a clinical guideline, when we face a case of fall, we should perform “a multifactorial falls risk assessment by taking the history, doing the physical examination, some test, and review the medications.”

Computerized predictive model for differential diagnosis of normal pressure hydrocephalus based on complex analysis of MRI image

Background. The main problem is to differentiate idiopathic normal pressure hydrocephalus (iNPH) with other neurodegenerative diseases accompanied by similar clinical presentation. For this purpose, a number of neuroimaging and invasive methods were proposed. The study objective is to assess most reliable magnetic resonance (MR) symptoms of iNPH and to create a prognostic model for differential diagnosis of iNPH by these criteria. Materials and methods. MR-data of 213 iNPH, 144 neurodegenerative (Alzheimer disease, Parkinson disease and early mild cognitive impairment) patients and 79 healthy age-matched controls were retrospectively analyzed. Following criteria were assessed: Evans Index, size of the third ventricle, size of temporal horns, disproportionately enlarged subarachnoid space hydrocephalus, focal convexital sulci enlargement, callosal angle, periventricular hyperintensities, focal subcortical gliosis and perivascular spaces enlargement. One-way ANOVA was used to explore differences between groups. Classification matrix was formed by discriminant analysis. Results. Differential model was established and Excel-tab-calculator was created for complex computed assessment of MR data and differential diagnosis of iNPH patients. Prognostic accuracy of model for iNPH reaches 99.5 %, for degenerative disorders – 89 %, common diagnostic accuracy is 92 %. Conclusion. Advantages of complex approach for assessment of MR-data in iNPH patients were underlined. Prognostic model for prediction of iNPH based on MR criteria was established.

Health Care Expenditures of Medicare Beneficiaries with Normal Pressure Hydrocephalus

Normal pressure hydrocephalus (NPH) is an underdiagnosed and undertreated condition affecting the elderly population and with costs associated with its surgical management reported to be less than those associated with conservative management. To determine if the rate of diagnosis of NPH has improved over the last decade, the rate of treatment has increased, and if surgical treatment costs and socioeconomic factors related to receipt of treatment have changed over time compared with conservative therapy. A retrospective study based on data from a nationally representative random sample of 2,378,637 Medicare beneficiaries (2006-2010) was performed. Shunt surgery, shunt revision, replacement, and removal were analyzed as independent variables. A total of 2321 patients with NPH were included, with 580 (24.99%) receiving a first shunt procedure. The adjusted effect of the procedure is that total 5-year expenditures are $11,676 more per patient (P < 0.001) than expenditures associated with nonsurgical management. Shunt revision ($22,715, P < 0.01) and/or replacement ($46,607, P < 0.001) add significantly to 5-year expenditures. Socioeconomic factors including African American race (P= 0.006); age 75-79 years (P= 0.024), 80-84 years (P<0.001), and ≥85 years (P < 0.001); and Medicaid (P<0.001) have significant negative associations with shunt surgery. There was a 1.66-fold increase in the rate of diagnosis of NPH, from 0.12% in 1999 to 0.2% in 2008. The total costs per surgical patient rose by approximately 145% to 160% comparing 2001 and 2010. This increase was mainly due to hospital (by 167% to 168%) and home health costs (by 118% to 148%). Providing appropriate care across the socioeconomic spectrum warrants further study and requires identifying the factors that limit access to care.

A prospective study on gait dominant normal pressure hydrocephalus.

We characterize idiopathic normal pressure hydrocephalus (NPH) following treatment with lumbar puncture (LP) and shunt placement through clinical evaluation and quantitative ProtoKinetics Zeno walkway assessments. We evaluate the symptomology by determining gait characteristics altered by treatment. Patients at Barrow Neurological Institute (BNI) who underwent a LP, removing 30-32mL cerebrospinal fluid) followed by ventriculoperitoneal shunt placement in February 2015 to February 2017 were analyzed for gait impairments. Inclusion in the study required a diagnosis of NPH, no conflicting comorbidities, and pre-LP, post-LP, and 6-month post-shunt assessments. Analyses of gait and balance data recorded by physical therapists and the ProtoKinetics Zeno Walkway at pre-LP, post-LP, and post-shunt were performed. A total of 28 patients were included and one-way analysis of variance and Tukey-Kramer HSD was performed. Among the 15 clinical assessments, nine were significantly altered. Using the ProtoKinetics Zeno Walkway, 7 out of 10 characteristics recorded were considered significantly different among the three data sets. Furthermore, there were more significant differences between pre-LP assessments and post-shunt assessments in comparison to differences between pre-LP assessments and post-LP assessments. Our results indicate that certain gait characteristics better fit NPH than others. By focusing on the features that are caused by NPH and alleviated by LP and/or shunt placement, a more definitive NPH diagnosis can be attained. Additionally, our findings confirm a cumulative effect of continuous drainage via shunt placement may lead to increased improvement in NPH symptoms over LP results.

Recent Advances in Rational Diagnosis and Treatment of Normal Pressure Hydrocephalus: A Critical Appraisal on Novel Diagnostic, Therapy Monitoring and Treatment Modalities.

Normal pressure hydrocephalus (NPH) is a critical brain disorder in which excess Cerebrospinal Fluid (CSF) is accumulated in the brain's ventricles causing damage or disruption of the brain tissues. Amongst various signs and symptoms, difficulty in walking, slurred speech, impaired decision making and critical thinking, and loss of bladder and bowl control are considered the hallmark features of NPH. The current review was aimed to present a comprehensive overview and critical appraisal of majorly employed neuroimaging techniques for rational diagnosis and effective monitoring of the effectiveness of the employed therapeutic intervention for NPH. Moreover, a critical overview of recent developments and utilization of pharmacological agents for the treatment of hydrocephalus has also been appraised. Considering the complications associated with the shunt-based surgical operations, consistent monitoring of shunting via neuroimaging techniques hold greater clinical significance. Despite having extensive applicability of MRI and CT scan, these conventional neuroimaging techniques are associated with misdiagnosis or several health risks to patients. Recent advances in MRI (i.e., Sagittal-MRI, coronal-MRI, Time-SLIP (time-spatial-labeling-inversion-pulse), PC-MRI and diffusion-tensor-imaging (DTI)) have shown promising applicability in the diagnosis of NPH. Having associated with several adverse effects with surgical interventions, non-invasive approaches (pharmacological agents) have earned greater interest of scientists, medical professional, and healthcare providers. Amongst pharmacological agents, diuretics, isosorbide, osmotic agents, carbonic anhydrase inhibitors, glucocorticoids, NSAIDs, digoxin, and gold-198 have been employed for the management of NPH and prevention of secondary sensory/intellectual complications. Employment of rational diagnostic tool and therapeutic modalities avoids misleading diagnosis and sophisticated management of hydrocephalus by efficient reduction of Cerebrospinal Fluid (CSF) production, reduction of fibrotic and inflammatory cascades secondary to meningitis and hemorrhage, and protection of brain from further deterioration.

A Survey on Normal-Pressure Hydrocephalus in Shanghai Community Health-care Professionals in Yangpu Community Training Program for Rehabilitation Medicine

Objectives: Gait ataxia, incontinence, and cognitive impairment are three typical symptoms of normal pressure hydrocephalus (NPH), however, similarity to other diseases' presentation, the diagnosis of NPH can be frequently missed. NPH-related education program to healthcare professionals appears very well needed and could be a promising way to improve its early diagnosis and treatment, but the actual effect of training programs is unknown. Therefore, we launched the Yangpu Community Training Program and conducted a survey to investigate the knowledge and awareness of NPH among rehabilitation professionals and the effectiveness of our training program. Methods: We conducted a well designed survey among the participants before and after education of NPH and analyzed the responses of returned questionnaires. We compared the percent of respondents who never learned about NPH before and after training, and analyzed potential factors (year of graduation and professions) that might affect NPH education. We also examined the source of the acquired NPH knowledge and the percentage of respondents who demonstrated their increased knowledge of this disease. Results: Eighty-two and eighty-six questionnaires were returned before and after training, respectively. Based on data from the returned questionnaires, more than 80% of participants in the training program are rehabilitation therapists (physical, occupational and speech therapists), 15% are physicians, and 2% are nurses. Before participating in the training program, more than two fifths (41.46%) surveyed healthcare professionals had never learned about NPH, however this number dropped to 4.76% after training, Sixty percent participants indicated that they learned about NPH from the provided training programs. Conclusion: Our results demonstrate that NPH knowledge is lacking among healthcare professionals and that training programs are effective in NPH education. We expect that increased knowledge of this disease would result in improvement on early detection of this condition and appropriate intervention implemented to reduce the patients, family and health care burden in the future.

Role of cine phase-contrast magnetic resonance imaging in the management of normal pressure hydrocephalus

Background and Aim: There are several unanswered queries related to normal pressure hydrocephalus (NPH) regarding the diagnostic criteria and selection of appropriate patients for shunt surgery. This study aimed to evaluate the utility of cine phase-contrast (CPC) magnetic resonance imaging (MRI) in the management of patients with NPH. Patients and Methods: In this prospective study, MRI analysis was done on 1.5 Tesla scanner in 20 patients who presented with clinical features and routine MRI findings which were suggestive of NPH. CPC MRI and clinical assessment were performed before and after a high-volume cerebrospinal fluid (CSF) tap by lumbar puncture. Out of these twenty participants, ten underwent ventriculoperitoneal (VP) shunting. Clinical assessment was also done after VP shunting. CSF flow through the aqueduct was also evaluated in twenty age- and sex-matched controls. Results: There was a statistically significant difference between aqueductal flow void score in cases and controls. However, no significant difference in flow void was seen after the tap or after the shunt. There was also a statistically significant difference between the values of stroke volume (SV) in cases and controls. Very high SVs (>50 μL) correlated with marked clinical improvement after the tap and after the shunt. Mildly elevated SV did not help in making any interpretation regarding the usefulness of shunt. There was also a statistically significant difference between the values of peak velocity (PV) in cases and controls. Patients with PV >10 cm/s and with a fall of ≥2 cm/s after tap significantly correlated with clinical improvement. Conclusions: CPC MRI is a useful adjunctive technique to support the diagnosis of NPH as well as in predicting a favorable response to shunt surgery in these patients.

Development of the Brazilian Portuguese version of the "Grading scale for idiopathic normal pressure hydrocephalus": cross-cultural adaptation, reliability and validity.

The current study translated to Portuguese and validated the normal pressure hydrocephalus (NPH) scale originally developed in English as the Grading Scale for Idiopathic Normal Pressure Hydrocephalus. Following Guillemin's validation protocol, the last version of the Portuguese NPH scale was applied to 121 consecutive patients with a diagnosis of normal pressure hydrocephalus (73 men and 48 women) from the Group of Cerebral Hydrodynamics from July 2010 to March 2012. The mean age was 71.09 years old, ranging from 35 to 92 years. The rate of agreement and reproducibility was high, as confirmed by Cohen's Kappa coefficient, with excellent intraobserver correlation for the NPH scale items individually evaluated: gait (0.80), dementia (0.90) and incontinence (0.87). The Portuguese version of the Grading Scale for Idiopathic Normal Pressure Hydrocephalus was successfully translated and validated for use in Brazilian patients.

“Face of the giant panda” and hydrocephalus

•The face of the giant panda is a MRI sign in Wilson’s disease.•Non-pathological age-related iron accumulations is frequently seen in the red nuclei and the substantia nigra.•Due to a flow void in the aqueduct in NPH patients, the MRI looks very similar to the face of the giant panda. A 67-year-old man presented with a 6-months-history of marked gait disturbance referred to as magnetic gait. There were no other complaints. His medical history was insignificant, and he had no family history of neurological disorders. Routine bloodwork and CSF were unremarkable. The CSF opening pressure was 17 cm H2O. MRI scan of the brain showed a communicating hydrocephalus, but also “the face of the giant panda” (Fig. 1). The most likely diagnosis is:(A)Parkinson’s disease(B)Wilson’s disease(C)Normal pressure hydrocephalus(D)Progressive supranuclear palsy After tapping 30 cc cerebrospinal fluid, the gait disturbance improved remarkably for a short period of time. The diagnosis of normal pressure hydrocephalus (NPH) was made. After placement of a lumbar peritoneal shunt the gait improvement became permanent. The face of the giant panda has generally been described in Wilson’s disease [[1]Gupta A. Chakravarthi S. Goyal M.K. ‘Face of giant panda’: a rare imaging sign in Wilson's disease.QJM. 2014; 107: 579Crossref PubMed Scopus (7) Google Scholar]. However, the clinical presentation of our patient was not suspicious for this disease, and copper and ceruloplasmin values were normal. The face of the giant panda in Wilson’s disease is caused by T2 hyperintensity in the midbrain tegmentum with relative sparing of the red nuclei (eyes), the pars reticulata of the substantia nigra (ears) and the superior colliculus (mouth). In this case the “eyes” and “ears” of the panda are non-pathological age-related iron accumulations in the red nuclei and the pars reticulate of the substantia nigra respectively [[2]Aquino D. Bizzi A. Grisoli M. Garavaglia B. Bruzzone M.G. Nardocci N. et al.Age-related iron deposition in the basal ganglia: quantitative analysis in healthy subjects.Radiology. 2009; 252: 165-172Crossref PubMed Scopus (215) Google Scholar]. The “mouth” of the panda is actually a flow void in the aqueduct caused by higher than normal flow velocity of cerebrospinal fluid. This flow void is frequently present in patients with NPH [[3]Krauss J.K. Regel J.P. Vach W. Jüngling F.D. Droste D.W. Wakhloo A.K. Flow void of cerebrospinal fluid in idiopathic normal pressure hydrocephalus of the elderly: can it predict outcome after shunting?.Neurosurgery. 1997; 40: 67-73PubMed Google Scholar]. The combination of non-pathological age-related iron accumulations and a flow void creates an image almost similar to the face of the giant panda, however in our case it is more a pseudo face of the giant panda, because there is no association with Wilson’s disease. The following are the Supplementary data to this article: Download .xml (.0 MB) Help with xml files Supplementary data 1

Changes of cerebrospinal fluid protein concentrations and gait patterns in geriatric normal pressure hydrocephalus patients after ventriculoperitoneal shunting surgery

Normal pressure hydrocephalus (NPH) was the first type of dementia ever described that can be treated using ventriculoperitoneal shunting surgery. Three typical clinical symptoms of NPH include gait disturbance, progressive cognitive dysfunction, and urinary incontinence. Although there are articles that have discovered several cerebrospinal fluid (CSF) protein biomarkers associated with NPH; however, studies examining individual and total protein concentrations from the ventricular CSF before and after shunting surgery are lacking. This study used proteomics to calculate the CSF individual and total protein concentrations before, and one week, one month and three months after the shunting surgery. Parameters of cadence, step length, walking speed, and percentages of single- and double-limb support in a gait cycle were measured. Protein concentrations associated with anti-oxidation, aging, and in the prevention of neurotoxic agent production increased by at least 2-folds after the surgery, indicating that the brain may become less susceptible to neurodegeneration. These proteins were alpha-1B-glycoprotein, apolipoproteins A-1 & A-IV, prostaglandin-H2 D-isomerase, alpha-1-antitrypsin, and serotransferrin. In gait analysis, lower cadence, decreased double-limb support, longer step length, and increased single-limb support were observed after the surgery, indicating a more stable walking balance. These changes lasted for a period of at least 3 months. As a result, shunting surgery may be recommended for geriatric patients with confirmed diagnosis of normal pressure hydrocephalus.