Treatment Of Normal Pressure Hydrocephalus Research Articles

Evaluation of shunt function in patients who are never better, or better than worse after shunt surgery for NPH.

We investigated the cause of poor outcome in patients with normal pressure hydrocephalus (NPH) who did not respond as expected after shunt surgery. Two methods were used to evaluate shunts: radionuclide shunt patency study, or continuous ICP monitoring. 33/52 shunted patients (64%) from 1989 to 1995 had poor outcome, and 28/52 (54%) were investigated. Of those investigated, 9/28 (32%) were never better, and 19/28 (68%) were initially better then worse. Of 9 patients who were never better, ineffective shunt function was seen in 7; 5 had shunt revision (2 declined), and 1 improved. Of 19 patients who were initially better then worse, 15 had ineffective shunts; 15 underwent shunt revision, and 13 improved. Poor clinical outcome occurred in two-thirds of all patients after shunt surgery for NPH, but a potentially treatable cause (i.e. obstruction of the shunt or a shunt system that was patent but did not adequately correct the CSF circulatory disorder) was found in nearly 80% (22/28) of those investigated. The predominant cause of ineffective shunt function was obstruction of the peritoneal catheter. Clinical recovery occurred in 70% (14/20) of patients who had shunt revision surgery. We conclude that ineffective shunt function is a frequent cause of poor outcome after shunt surgery to treat NPH that should be sought and treated. These results have implications for longitudinal studies of the diagnosis and treatment of NPH. The effect of unrecognized shunt ineffectiveness on prior studies is unknown. Future studies should be designed to confirm that shunts are functioning before the diagnosis of NPH is considered incorrect.

Differing scintigraphic patterns of lumboperitoneal shunt dysfunction in patients with normal pressure hydrocephalus and pseudotumor cerebri.

The scintigraphic patterns of dysfunctioning lumboperitoneal shunts (LPS) may vary with the underlying disease. The authors reviewed 22 LPS studies performed on 15 patients during the past 2 years and correlated the findings with the patency status of the shunt as determined by brain CT/MRI and surgical revision. Most of the patients also had cerebrospinal fluid (CSF) pressure monitoring. Fifteen studies were performed in patients with LPS for the treatment of normal pressure hydrocephalus (NPH) and 7 were performed in patients with LPS for pseudotumor cerebri (PTC). After intrathecal administration of 0.5-1 mCi of In-111 DTPA, sequential 1 minute images of the abdomen were obtained for 20 minutes. Static images of the abdomen were then obtained at 30 minutes and 1, 2, 4, and 24 hours with imaging of the head at 4 and 24 hours. All NPH patients with partial obstruction had tracer activity in the peritoneal cavity with little or no shunt tubing visualization. However, all had marked penetration of the tracer into the lateral ventricles. Pseudotumor cerebri patients with partial obstruction also showed tracer entry into the peritoneal cavity. Shunt tubing and tracer extravasation into the needle tract, at the site of lumbar puncture was seen only in patients of PTC, probably because of high intracranial pressure. Although the tracer flowed quickly into the basal cistern in all patients with PTC, it entered the lateral ventricles. Complete shunt obstruction was characterized by nonvisualization of activity in the peritoneal cavity and flow of the tracer into the basal cistern within 1 hour after injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of Ventricular Shunt Treatment of Normal Pressure Hydrocephalus on Psychological Functions

A prospective trial for diagnosis, treatment and evaluation of normal pressure hydrocephalus (NPH) was carried out in 30 consecutive patients (12 women, 18 men, mean age: 61 years, range 21-80). The clinical diagnosis was based on the presence of one or more of the three clinical elements of NPH: gait disturbance, incontinence and mental deterioration as well as radiological criteria of ventricular enlargement. Preoperatively, physical and radiological investigations and psychological tests were routinely performed. Cognitive functions such as fluency, selective attention and motor speed were re-examined within 24 hours after spinal tap of 40-50 cc. of CSF. Results of shunting were confirmed by CT scans and evaluated by means of psychological tests at least 3 months postoperatively. Psychological tests included IQ tests and tests for memory, selective attention and motor speed. Results indicate that spinal tap had no predictive value for the results after shunting as far as psychological functions are concerned. Shunt treatment showed an effect on cognitive functions of distractibility of attention and motor speed, but not on intelligence of memory. Three patients deteriorated, eleven remained stable and sixteen showed significant improvement on psychological tests, mainly those for attention, motor speed and memory, but rarely did any improvement of intelligence occur.

Normal pressure hydrocephalus in geriatric medicine: a challenge.

Normal pressure hydrocephalus (NPH) in elderly patients is reviewed. Since the clinical signs that characterize NPH--incontinence, difficulty walking, and dementia--occur frequently in the elderly in association with a wide variety of disorders, attention is paid to the differential diagnosis of NPH on the basis of both clinical findings and laboratory tests. Success rates for treatment of NPH using surgical shunting are discussed, as are mortality rates and complication rates for this type of surgery in the elderly. Factors that may be of value in predicting which NPH patients are most likely to benefit from surgical intervention are reviewed, and the need for the development of pharmacological alternatives to surgery for elderly NPH patients is emphasized. As one of the most treatable causes of dementia in the elderly, NPH should be considered in the diagnosis of demented elderly patients with continence and gait disturbances, and it merits further research.

Neuropsychological changes following the neurosurgical treatment of normal pressure hydrocephalus

Extracranial shunting of cerebrospinal fluid is a well-known neurosurgical procedure for the treatment of normal pressure hydrocephalus. Research indicating reasonable success using this technique has been based primarily on subjective and global neurosurgical opinion. Given that the treatment carries morbidity risks, and that decisions to shunt are related to increasing adaptive functioning, attention must be paid to adequate measurement of surgical outcome. As part of a larger study, we report pre and postsurgical neuropsychological, neuroradiological, and clinical data on hydrocephalic patients, as well as presurgical intracranial pressure data. Prior to shunting, increase in ventricular dilatation and cerebral atrophy were associated with decreased cognitive functioning, gait disturbance, and bladder dysfunction. Following shunting, there were significant improvements in neuropsychological functioning in terms of attention, concentration, verbal and nonverbal memory, language and communication skills, and constructional skills, as well as clinical improvement in gait and bladder functioning. Improvement was related to presurgical dilatation of the temporal horns of the lateral ventricles and mental status, particularly memory functions.

A partial recovery following delayed surgical treatment of normal pressure hydrocephalus

A 66-year-old woman with a history of total hysterectomy (1953) and healed myocardial infarction (1978) first complained in 1981 of signs and symptoms suggestive of normal pressure hydrocephalus. The condition was followed up and in 1983 was confirmed by Computer Assisted Tomography (CT). She was treated by ventriculo-peritoneal shunt only in 1986. Rehabilitation was started as early as possible postoperatively. Of the major neurological signs, namely gait abnormality, incontinence and dementia, only gait abnormality showed some improvement although gait-related cerebellar dysfunction remained unchanged. Thus progression of the disease was halted by the surgical procedure and subsequent rehabilitative therapy was partially effective despite the prolonged delay in operative treatment of the disease in this patient.

Treatment of normal pressure hydrocephalus with low versus medium pressure cerebrospinal fluid shunts

Treatment of normal pressure hydrocephalus with low versus medium pressure cerebrospinal fluid shunts

Abdominal Pseudocyst associated with Peritoneal Shunt

Two patients with abdominal pseudocysts as a complication of peritoneal shunt were reported and a review of the literature relating to this complication was presented. Each patient had a ventriculo-peritoneal shunt 3 years previously for normal pressure hydrocephalus. Vomiting and abdominal distention were noted. There was no symptoms or signs of increased intracranial pressure. One patient, Case 1, had a left epidural abscess and one previous shunt revision. The other, Case 2, had no history of prior abdominal surgery or shunt infection and the shunt was converted to a ventriculoarterial diversion. Abdominal pseudocysts are not a common complicaton of peritoneal shunt procedures. In this clinic only 2 (0.9%) of 228 peritoneal shunts, which was performed for the treatment of normal pressure hydrocephalus in the past 5 years, developed this complication. Forty-one cases of abdominal pseudocysts have been reported in the literature. All except one case had abdominal symptoms and/or symptoms of increased intracranial pressure on admission. The clinical signs developed as late as 5 years after catheter insertion, but frequently within 6 months. Associated shunt infection and previous intra-abdominal surgery appeared to be the most constant and related causes in the formation of the pseudocyst. Cerebrospinal fluid shunt into another cavity was considered to be the most reliable treatment of this complication.

PSYCHIATRIC AND BEHAVIORAL MANIFESTATIONS OF NORMAL PRESSURE HYDROCEPHALUS

Normal pressure hydrocephalus (NPH) may suggest its presence by behavioral symptoms. Initally, the symptoms often manifest themselves as depression with marked psychomotor retardation. Older patients without a prior psychiatric history who have soft, nonlocalizing neurological signs and fluctuating cognitive and memory deficits in association with prominent affective and/or psychotic symptomatology of recent onset, such as the case reported here, should raise the clinician's index of suspicion. In such cases, the Halstead-Reitan neuropsychological battery may be helpful in differentiating an underlying dementia from a primary psychological dysfunction. When the presence of a dementing process is suspected, etiological diagnosis should be vigorously pursued with a CAT scan and, as indicated on clinical grounds, confirmatory and further delimiting studies such as pneumoencephalography, ventriculography, RISA scanning, electroencephalography, constant-infusion manometric testing, and/or angiography. Treatment of NPH includes one of several forms of shunting procedures and appropriate neuroleptic therapy for behavioral symptoms. Althoug there is a substantial risk (40 to 50 percent)ioral symptoms. Although there is a substantial risk (40 to 50 per cent) of shunt-related complications, as many as 60 per cent of operated patients will show objective imprvement, making the diagnosis of and referral for appropriate surgical treatment of NPH an important challenge for the psychiatrist.