Probable Normal Pressure Hydrocephalus Research Articles

Comparison of cerebrospinal fluid space between probable normal pressure hydrocephalus and Alzheimer's disease.

Idiopathic normal pressure hydrocephalus (INPH) is a potentially reversible syndrome characterized by complex symptoms, difficulty in diagnosis and a lack of detailed clinical description, and it is difficult to distinguish from Alzheimer's disease (AD). The objective of this study was to design a method for measuring the actual amount of hydrocephalus in patients with INPH and to evaluate INPH. All subjects underwent a 3D T1-weighted MRI. Statistical parametric mapping 12 was used for preprocessing images, statistical analysis, and voxel-based morphometric gray matter (GM) volume, white matter (WM) volume, and cerebrospinal fluid (CSF) volume analysis. The demographic and clinical characteristics of the groups were compared using a t-test for continuous variables and a chi-square test for categorical variables. Pearson's correlation analysis and Bonferroni's statistic-corrected one-way ANOVA were used to determine the relationship among demographic variables. Receiver operating characteristic (ROC) curves were used to assess the accuracy of the callosal angle (CA), WM ratio, and CSF ratio in distinguishing probable INPH from AD. The study included 42 patients with INPH, 32 patients with AD, and 24 healthy control subjects (HCs). There were no differences among the three groups in basic characteristics except for Mini-Mental State Examination (MMSE). There was a correlation between the intracranial CSF ratio and CA. The WM ratio and CSF ratio in patients with INPH and AD were statistically different. Furthermore, the combination of CA, WM ratio, and CSF ratio had a greater differential diagnostic value between INPH and AD patients than CA alone. INPH can be accurately assessed by measuring intracranial CSF ratio, and the addition of WM ratio and CSF ratio significantly improved the differential diagnostic value of probable INPH from AD compared to CA alone.

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 (<104° ; p <0.01) and fourth ventricular dilatation greater (>17 mm ; p<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.

Rupture of a Previously Undiagnosed Anterior Communicating Artery Aneurysm following External Lumbar Drainage in a Patient with Normal Pressure Hydrocephalus: A Case Report

Background and importance: Both asymptomatic unruptured intracranial aneurysms (AUIA) and idiopathic normal pressure hydrocephalus (NPH) have been found in the elderly population to increase in incidence with advancing age. In NPH, external lumbar drainage (ELD) is a gold standard and widely accepted low-risk procedure for supplemental testing of CSF responsiveness and suitability for surgical intervention. Herein, we reported the first case of aneurysmal subarachnoid haemorrhage (SAH) as a cause of neurological decline following ELD for the testing of patients with NPH. Clinical Presentation: A 65-year-old gentleman with probable NPH was admitted for supplemental testing using ELD. He had demonstrated CSF responsiveness as evidenced by improving Tinetti score. Unfortunately, on the third day of post-insertion, his GCS deteriorated from 15 to 3 due to rupture of a previously undiagnosed anterior communicating artery (Acom) aneurysm. He underwent left frontal external ventricular drain in an emergency setting and his GCS improved to E1VtM4. After frank discussion with his family, we proceeded with craniotomy and clipping of the aneurysm. However, his neurological recovery remained poor post-operatively and he had eventually undergone tracheostomy and ventriculo-peritoneal shunt. Conclusion: As SAH is also a known trigger of secondary NPH, there may be a critical role for screening of AUIA prior to ELD for NPH. The characterization of this risk would then allow for a full discussion of surgical or endovascular treatment options for AUIA, as well as the risk-benefit ratio of proceeding with supplemental testing and intervention for NPH.

Myotonic dystrophy type 1 accompanied with normal pressure hydrocephalus: a case report and literature review

BackgroundMyotonic dystrophy type 1 (DM1) is the most common disease that can cause muscle weakness and atrophy among adults. Normal pressure hydrocephalus (NPH) is characterized by the triad of gait disturbance, cognitive impairment and urinary incontinence. The association between DM1 and NPH is extremely rare. We report a Chinese female patient with DM1 in association with NPH.Case presentationThe patient presented with a history of 3-year of walking instability and cognitive impairment. Her brain MRI showed ventriculomegaly with normal cerebrospinal fluid (CSF) pressure and the CSF tap-test was positive, which indicated the diagnosis of probable NPH. DM1 was confirmed by genetic testing.ConclusionsFour patients with DM1-NPH association were found before. The association between NPH and DM1 may not be just a coincidence, NPH may occur in DM1 later in life and it is vital to recognize the association as a shunt surgery may improve patients’ quality of life.

Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients.

A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH. The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded. The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05). The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

Prospective Flutemetamol Positron Emission Tomography and Histopathology in Normal Pressure Hydrocephalus

Backgound/Objective: To determine the level of association between uptake of the amyloid positron emission tomography (PET) imaging agent [¹⁸F]flutemetamol and the level of amyloid-ß measured by immunohistochemical and histochemical staining in a frontal cortical region biopsy site. Methods: Seventeen patients with probable normal pressure hydrocephalus (NPH) underwent prospective [¹⁸F]flutemetamol PET and subsequent frontal cortical brain biopsy during ventriculoperitoneal shunting. Tissue amyloid-ß was evaluated using the monoclonal antibody 4G8, thioflavin S and Bielschowsky silver stain. Results: Four of the 17 patients (23.5%) had amyloid-ß pathology based on the overall pathology read and also showed increased [¹⁸F]flutemetamol uptake. [¹⁸F]Flutemetamol standardized uptake values from the biopsy site were significantly associated with biopsy specimen amyloid-ß levels (Pearson's r = 0.67; p = 0.006). There was also good correlation between the biopsy specimen amyloid-ß level and uptake of [¹⁸F]flutemetamol in the region contralateral to the biopsy site (r = 0.67; p = 0.006), as well as with composite cortical [¹⁸F]flutemetamol uptake (r = 0.65; p = 0.008). The blinded visual read showed a high level of agreement between all readers (κ = 0.88). Two of 3 readers were in full agreement on all images; 1 reader disagreed on 1 of the 17 NPH cases. Blinded visual assessments of PET images by 1 reader were associated with 100% sensitivity to the overall pathology read, and assessments by the 2 others were associated with 75% sensitivity (overall sensitivity by majority read was 75%); specificity of all readers was 100%. Conclusions: [¹⁸F]Flutemetamol detects brain amyloid-ß in vivo and shows promise as a valuable tool to study and possibly facilitate diagnosis of Alzheimer's disease both in patients with suspected NPH and among the wider population.

Institutional Outcomes in Patients Evaluated for Possible Normal Pressure Hydrocephalus: Which Factors Are Predictive of Positive Response to Ventriculoperitoneal Shunt Placement? (P02.245)

Objective: The goal of this study was to examine patient outcomes after their initial evaluation in the Movement Disorders (MD) Clinic at our institution for possible normal pressure hydrocephalus (NPH). We attempted to identify predictive factors that lead to the clinical diagnosis of NPH and ultimately to pursuit of ventriculoperitoneal shunt (VPS) placement, as well as those that lead to positive post-surgical outcomes. Background First, we wanted to review patient outcomes after VPS placement for NPH at our institution. Second, given current limitations in successfully identifying optimal surgical candidates among patients with possible NPH, we wanted to review the clinical and radiological data utilized for decision-making with each patient to see if certain factors were more predictive of positive outcome. Design/Methods: This was a retrospective chart review of patients evaluated in MD Clinic for gait disturbance between January 2007 and October 2010. Outcomes were based on the patients9 postoperative assessments in Neurosurgery and/or MD Clinic and Clinical Global Impression (CGI) scale scores. Results: Fourteen of 25 patients initally evaluated in MD Clinic for gait disturbance and possible NPH ultimately underwent VPS placement, 12 of those at our institution. Of those, 11 had post-operative CGIs between 1 (very much improved) and 3 (minimally improved). Only one patient had no change after surgery. In the patients that underwent high-volume lumbar puncture (LP) as part of evaluation for possible NPH, a higher percent change in gait speed and lower post-LP CGI were associated with surgery, but not necessarily with more positive post-surgical outcome. Conclusions: In general, patients undergoing VPS placement for probable NPH after evaluation in MD Clinic had positive outcomes, with improvement in gait dysfunction. However, measures such as percent change in gait speed after high-volume lumbar puncture, frequently used to predict response to VPS, were not necessarily predictive of the degree of improvement after surgery. Disclosure: Dr. Tate has nothing to disclose. Dr. Siddiqui has nothing to disclose.

Use of the proGAV Shunt Valve in Normal-Pressure Hydrocephalus

Overdrainage is a common complication associated with shunt insertion in normal-pressure hydrocephalus (NPH) patients. Using adjustable valves with antigravity devices has been shown to reduce its incidence. The optimal starting setting of an adjustable shunt valve in NPH is debatable. To audit our single-center practice of setting adjustable valves. We performed a retrospective review of clinical records of all NPH patients treated in our unit between 2006 and 2009 by the insertion of shunts with a proGAV valve, recording demographic and clinical data, shunt complications, and revision rates. Radiological reports of postoperative follow-up computed tomography scans of the brain were reviewed for detected subdural hematomas. A proGAV adjustable valve was inserted in 50 probable NPH patients between July 2006 and November 2009. Mean ± SD age was 76 ± 7 years. Mean follow-up was 15 months. The initial shunt setting was 6 ± 3 cm H2O, and the final setting was 4.9 ± 1.9 cm H2O. Nineteen patients required 24 readjustment procedures (readjustment rate, 38%; readjustment number, 0.48 times per patient). One patient (2%) developed delayed bilateral subdural hematoma after readjustment of his shunt valve setting as an outpatient. Starting with a low opening pressure setting on a proGAV adjustable shunt valve does not increase the chances of overdrainage complications and reduces the need for repeated readjustments.

CSF neurotransmitter metabolites and neuropsychiatric symptomatology in patients with normal pressure hydrocephalus

Patients with normal pressure hydrocephalus (NPH) may exhibit certain neuropsychiatric symptomatology, possibly related to alterations in central neurotransmitter activity. The aim of this study was to relate psychiatric distress, as expressed by the scores in the SCL-90 subscales, to CSF levels of the main metabolites of noradrenaline (MHPG), serotonin (5-HIAA), and dopamine (HVA) in NPH patients. The metabolite levels were estimated in CSF samples taken during the tap test in 19 patients with probable NPH, and compared to 19 sex- and age-matched controls. Cognitive impairment was evaluated by the MMSE. Compared to controls, NPH patients had similar MHPG and 5-HIAA levels, and significantly elevated HVA levels, a notable difference from patients with dementias. There were no significant correlations of metabolite levels to the scores in the nine SCL-90 subscales. MMSE score was not related either to metabolite levels, or to the SCL-90 subscale scores. Patients scored higher than controls in most SCL-90 subscales, more pronounced being the difference in obsessive-compulsive symptomatology. Serotonergic neurotransmitter activity seems not to be altered in NPH patients, and this may explain the reported lack of beneficial effect of serotonergic drugs for obsessive-compulsive symptoms in NPH patients.

INTRA-ABDOMINAL VASCULAR INJURY DURING TROCAR-ASSISTED VENTRICULOPERITONEAL SHUNTING

Laparoscopic trocar injury is a relatively well-described complication of cholecystectomies and gynecological procedures. However, this type of injury has not been reported in association with adult neurological surgery. To increase awareness of this very serious risk, we report a case of intra-abdominal vascular injury during a shunt procedure involved with a common neurosurgical procedure. A 76-year-old man with no previous abdominal surgical history presented with probable normal pressure hydrocephalus. After an appropriate preoperative workup confirming probable normal pressure hydrocephalus, the patient consented to placement of a ventriculoperitoneal shunt with a programmable valve. During placement of the distal catheter using an abdominal trocar, the aorta was punctured inadvertently, necessitating emergency laparotomy for vascular repair. An abdominal trocar should be used with caution in ventriculoperitoneal shunt surgery. Even with meticulous technique, vascular injury can occur with any trocar-based abdominal procedure. The neurosurgeon who uses this technique must be prepared to initiate emergent vascular access and repair, with a vascular surgery team available should such an injury occur. Alternatively, open placement of peritoneal catheters avoids blind peritoneal instrumentation and is an effective method for minimizing potentially catastrophic vascular injuries.

Normal pressure hydrocephalus. Long-term intracranial pressure recording.

Protracted epidural pressure (EDP) measurements were carried out in 3 control patients and 4 patients with normal pressure hydrocephalus (3 definite and 1 probable). Simultaneous intraventricular (VFP) and EDP monitoring was carried out over 24 h in one of the controls, one of the patients with normal pressure hydrocephalus and in the patient with probable normal pressure hydrocephalus. Mean night EDP was higher than day EDP in all except one patient with normal pressure hydrocephalus, in whom the mean night/day ratio was 0.92. The mean night/day ratio for all patients was identical in patients and controls, i.e. 1.06. In this study, there was thus no evidence that normal pressure hydrocephalus patients have higher than normal average intracranial pressure by night. A rather continuous moderate increase in intracranial pressure was found in the one patient with probable normal pressure hydrocephalus. Episodes of increased EDP of more than a few minutes duration were found in both patients and controls, more frequently by night than by day.