Correlation of right frontal hypoperfusion and urinary dysfunction in iNPH: a SPECT study

The grasp reflex in patients with idiopathic normal pressure hydrocephalus

OBJECTIVE

To investigate the prevalence and intensity of grasp reflexes and to examine changes in these reflexes after shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH).

METHODS

We enrolled 147 patients with probable iNPH. A standard procedure was used to determine the presence of grasp reflexes, and the intensity of these reflexes was assessed using a four-category classification. Clinical rating scales and their correlation with grasp reflexes were also evaluated. Grasp reflexes were reassessed in 72 patients 1 year after surgery.

RESULTS

We found that approximately 50.3% of patients with iNPH exhibited a positive grasp reflex. Among these patients, 69% exhibited bilateral positivity, while the remaining patients showed unilateral positivity. Furthermore, the intensity of the grasp reflex was significantly correlated with the severity of gait and with cognitive, urinary, motor, and behavioural symptoms. Surgical interventions led to a reduction (41.7%) or maintenance (30.6%) of the reflex intensity in 72.3% of iNPH patients. The changes in reflex intensity showed significant positive correlations with changes in the number of steps of the Timed Up and Go test and Trail Making Test-A scores but not with changes in total scores on the iNPH Grading Scale.

CONCLUSION

This retrospective study identified grasp reflexes as a highly prevalent phenomenon in patients with iNPH. These reflexes can assist in evaluating the severity of various symptoms, including cognitive, gait, urinary, motor and emotional symptoms.

The impact of neurocognitive and psychiatric disorders on the risk of idiopathic normal pressure hydrocephalus: A bidirectional Mendelian randomization study

BACKGROUND

Neurocognitive and psychiatric disorders have been proved that they can comorbid more often with idiopathic normal pressure hydrocephalus (iNPH) than general population. However, the potential causal association between these disorders and iNPH has not been assessed. Thus, our study aims to investigate the causal relationship between them based on a bidirectional Mendelian randomization (MR) analysis.

METHODS

Random effects of the inverse variance weighted (IVW) method were conducted to obtain the causal association among the neurocognitive disorders, psychiatric disorders, and iNPH. Genome-wide association studies (GWAS) of 12 neurocognitive and psychiatric disorders were downloaded via the OpenGWAS database, GWAS Catalog, and Psychiatric Genomics Consortium, whereas GWAS data of iNPH were obtained from the FinnGen consortium round 9 release, with 767 cases and 375,610 controls of European ancestry. We also conducted the sensitivity analysis in these significant causal inferences using weighted median model, Cochrane's Q test, MR-Egger regression, MR Pleiotropy Residual Sum and Outlier detect and the leave-one-out analysis.

RESULTS

For most of the neurocognitive and psychiatric disorders, no causal association was established between them and iNPH. We have found that iNPH (odds ratio [OR] = 1.030, 95% confidence interval [CI]: 1.011-1.048, p = .001) is associated with increased risk for schizophrenia, which failed in validation of sensitivity analysis. Notably, genetically predicted Parkinson's disease (PD) is associated with increased risk of iNPH (OR = 1.256, 95% CI: 1.045-1.511, p = .015).

CONCLUSION

Our study has revealed the potential causal effect in which PD associated with an increased risk of iNPH. Further study is warranted to investigate the association between PD and iNPH and the potential underlying mechanism.

Noradrenergic Pathways Involved in Micturition in an Animal Model of Hydrocephalus-Implications for Urinary Dysfunction

Hydrocephalus is characterized by enlargement of the cerebral ventricles, accompanied by distortion of the periventricular tissue. Patients with hydrocephalus usually experience urinary impairments. Although the underlying etiology is not fully described, the effects of hydrocephalus in the neuronal network responsible for the control of urination, which involves periventricular areas, including the periaqueductal gray (PAG) and the noradrenergic locus coeruleus (LC). In this study, we aimed to investigate the mechanisms behind urinary dysfunction in rats with kaolin-induced hydrocephalus. For that purpose, we used a validated model of hydrocephalus-the rat injected with kaolin in the cisterna magna-also presents urinary impairments in order to investigate the putative involvement of noradrenergic control from the brain to the spinal cord Onuf's nucleus, a key area in the motor control of micturition. We first evaluated bladder contraction capacity using cystometry. Since our previous characterization of the LC in hydrocephalic animals showed increased levels of noradrenaline, we then evaluated the noradrenergic innervation of the spinal cord's Onuf's nucleus by measuring levels of dopamine β-hydroxylase (DBH). We also evaluated the expression of the c-Fos protooncogene, the most widely used marker of neuronal activation, in the ventrolateral PAG (vlPAG), an area that plays a major role in the control of urination by its indirect control of the LC via pontine micturition center. Hydrocephalic rats showed an increased frequency of bladder contractions and lower minimum pressure. These animals also presented increased DBH levels at the Onuf´s nucleus, along with decreased c-Fos expression in the vlPAG. The present findings suggest that impairments in urinary function during hydrocephalus may be due to alterations in descending noradrenergic modulation. We propose that the effects of hydrocephalus in the decrease of vlPAG neuronal activation lead to a decrease in the control over the LC. The increased availability of noradrenaline production at the LC probably causes an exaggerated micturition reflex due to the increased innervation of the Onuf´s nucleus, accounting for the urinary impairments detected in hydrocephalic animals. The results of the study provide new insights into the neuronal underlying mechanisms of urinary dysfunction in hydrocephalus. Further research is needed to fully evaluate the translational perspectives of the current findings.

Application of LRG mechanism in normal pressure hydrocephalus

Normal pressure hydrocephalus (NPH) is a prevalent type of hydrocephalus, including secondary normal pressure hydrocephalus (SNPH) and idiopathic normal pressure hydrocephalus (INPH). However, its clinical diagnosis and pathological mechanism are still unclear. Leucine-rich α-2 glycoprotein (LRG) is involved in various human diseases, including cancer, diabetes, cardiovascular disease, and nervous system diseases. Now the physiological mechanism of LRG is still being explored. According to the current research results on LRG, we found that the agency of LRG has much to do with the known pathological process of NPH. This review focuses on analyzing the LRG signaling pathways and the pathological mechanism of NPH. According to the collected literature evidence, we speculated that LRG probably be involved in the pathological process of NPH. Finally, based on the mechanism of LRG and NPH, we also summarized the evidence of molecular targeted therapies for future research and clinical application.

Intravesical Electrical Stimulation Improves Abnormal Prefrontal Brain Activity in Patients With Underactive Bladder: A Possible Central Mechanism

PURPOSE

The aim of this study was to explore the mechanisms of central brain action in patients with neurogenic underactive bladder (UAB) treated with intravesical electrical stimulation (IVES).

METHODS

We prospectively recruited patients with neurogenic UAB who chose to receive IVES treatment and healthy subjects (HS). At baseline, the following data were obtained: a 72-hour voiding diary; measurements of postvoid residual urine (PVR), voiding efficiency (VE) and first sensation of bladder filling (FS); American Urological Association Symptom Index Quality of Life (AUA-SI-QOL) scores, and functional near-infrared spectroscopy scans of the prefrontal cortex in the voiding stage. All UAB patients were re-evaluated for these indices after completing 4 weeks of IVES. A >50% improvement in PVR was defined as successful IVES treatment. Prefrontal activity was analyzed using the NIRS_KIT software, corrected with the false discovery rate (P<0.05). Statistical analysis was performed using IBM SPSS Statistics ver. 22.0, and P<0.05 was considered statistically significant.

RESULTS

Eighteen UAB patients and 16 HS were included. IVES treatment was successful in 11 UAB patients and failed in 7. The PVR, VE, 24-hour clean intermittent catheterization, FS volume, and AUA-SI-QOL scores of the UAB group significantly improved after successful IVES treatment. BA9 (right dorsolateral prefrontal cortex [DLPFC]) and BA10 (right frontal pole) were significantly activated after successful IVES, and no significant difference was found between the successful group and HS group after IVES. Before IVES, BA10 (right frontal pole) was significantly deactivated in the failed group compared with the successful group.

CONCLUSION

The possible central mechanism of IVES treatment for neurogenic UAB is that IVES reactivates the right DLPFC and right frontal pole.

Resting-state functional-MRI in iNPH: can default mode and motor networks changes improve patient selection and outcome? Preliminary report

BACKGROUND

Idiopathic normal pressure hydrocephalus (iNPH) is a progressive and partially reversible form of dementia, characterized by impaired interactions between multiple brain regions. Because of the presence of comorbidities and a lack of accurate diagnostic and prognostic biomarkers, only a minority of patients receives disease-specific treatment. Recently, resting-state functional-magnetic resonance imaging (rs-fMRI) has demonstrated functional connectivity alterations in inter-hemispheric, frontal, occipital, default-mode (DMN) and motor network (MN) circuits. Herein, we report our experience in a cohort of iNPH patients that underwent cerebrospinal fluid (CSF) dynamics evaluation and rs-fMRI. The study aimed to identify functional circuits related to iNPH and explore the relationship between DMN and MN recordings and clinical modifications before and after infusion and tap test, trying to understand iNPH pathophysiology and to predict the best responders to ventriculoperitoneal shunt (VPS) implant.

METHODS

We prospectively collected data regarding clinical assessment, neuroradiological findings, lumbar infusion and tap test of thirty-two iNPH patients who underwent VPS implant. Rs-fMRI was performed using MELODIC-ICA both before and after the tap test. Rs-fMRI data of thirty healthy subjects were also recorded.

RESULTS

At the baseline, reduced z-DMN and z-MN scores were recorded in the iNPH cohort compared with controls. Higher z-scores were recorded in more impaired patients. Both z-scores significantly improved after the tap test except in subjects with a low resistance to outflow value and without a significant clinical improvement after the test. A statistically significant difference in mean MN connectivity scores for tap test responders and non-responders was demonstrated both before (p = 0.0236) and after the test (p = 0.00137). A statistically significant main effect of the tap test on DMN connectivity after CSF subtraction was recorded (p = 0.038).

CONCLUSIONS

Our results suggest the presence of a partially reversible plasticity functional mechanism in DMN and MN. Low values compensate for the initial stages of the disease, while higher values of z-DMN were recorded in older patients with a longer duration of symptoms, suggesting an exhausted plasticity compensation. The standardization of this technique could play a role as a non-invasive biomarker in iNPH disease, suggesting the right time for surgery. Trial Registration Prot. IRB 090/2021.

Clinical Features of Idiopathic Normal Pressure Hydrocephalus: Critical Review of Objective Findings

Background

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by the classic clinical triad of gait, cognitive, and urinary dysfunction, albeit incomplete in a relevant proportion of patients. The clinical findings and evolution of these symptoms have been variably defined in the literature.

Objectives

To evaluate how the phenomenology has been defined, assessed, and reported, we performed a critical review of the existing literature discussing the phenomenology of iNPH. The review also identified the instrumental tests most frequently used and the evolution of clinical and radiologic findings.

Methods

The review was divided into 3 sections based on gait, cognitive, and urinary dysfunction. Each section performed a literature search using the terms "idiopathic normal pressure hydrocephalus" (iNPH), with additional search terms used by each section separately. The number of articles screened, duplicates, those meeting the inclusion criteria, and the number of articles excluded were recorded. Findings were subsequently tallied and analyzed.

Results

A total of 1716 articles with the aforementioned search criteria were identified by the 3 groups. A total of 81 full-text articles were reviewed after the elimination of duplicates, articles that did not discuss phenomenological findings or instrumental testing of participants with iNPH prior to surgery, and articles with fewer than 10 participants.

Conclusions

"Wide-based gait" was the most common gait dysfunction identified. Cognitive testing varied significantly across articles, and ultimately a specific cognitive profile was not identified. Urodynamic testing found detrusor overactivity and "overactive bladder" as the most common symptom of urinary dysfunction.

Association of right precuneus compression with apathy in idiopathic normal pressure hydrocephalus: a pilot study

Apathy is frequently observed in idiopathic normal pressure hydrocephalus (iNPH) and worsens cognitive impairment and gait disturbance. In this study, we evaluated the regions associated with apathy in iNPH using statistical imaging analysis on the whole brain, both in terms of cerebral blood flow and gray matter volume. Twenty-seven patients with iNPH were assigned to two groups based on their scores on the neuropsychiatric inventory items related to apathy; 18 patients were assigned to the group with apathy (iNPH + APA) and 9 to the group without apathy (iNPH - APA). The magnetic resonance images and cerebral blood flow single-photon emission computed tomography data of the two groups were compared using statistical parametric mapping 12. The regional gray matter volume of the right precuneus was significantly larger in the iNPH + APA group than in the iNPH - APA group, but the regional cerebral blood flow in any region of the brain was not significantly different between the two groups. These results suggested that the larger gray matter volume, which is thought to reflect gray matter compression, in the precuneus might be involved in apathy in iNPH.

Risk factors for unfavourable outcomes after shunt surgery in patients with idiopathic normal-pressure hydrocephalus

A number of vascular risk factors (VRFs) have been reported to be associated with idiopathic normal-pressure hydrocephalus (iNPH), but it remains unclear whether these VRFs are related to patient outcomes after shunt surgery. Therefore, we investigated the risk factors for unfavourable outcomes after shunt surgery in iNPH patients using two samples from Tohoku University Hospital and from a multicentre prospective trial of lumboperitoneal (LP) shunt surgery for patients with iNPH (SINPHONI-2). We enrolled 158 iNPH patients. We compared the prevalence of VRFs and clinical measures between patients with favourable and unfavourable outcomes and identified predictors of unfavourable outcomes using multivariate logistic regression analyses. The presence of hypertension, longer disease duration, more severe urinary dysfunction, and a lower Evans' index were predictors of unfavourable outcomes after shunt surgery. In addition, hypertension and longer disease duration were also predictors in patients with independent walking, and a lower Evans' index was the only predictor in patients who needed assistance to walk or could not walk. Our findings indicate that hypertension is the only VRF related to unfavourable outcomes after shunt surgery in iNPH patients. Larger-scale studies are needed to elucidate the reason why hypertension can affect the irreversibility of symptoms after shunt placement.

Role of Diffusion Tensor Imaging in Diagnosis and Estimation of Shunt Effect for Hydrocephalus in Stroke Patients: A Narrative Review

Hydrocephalus is a dilatation of the brain ventricular system by the accumulation of cerebrospinal fluid within the ventricle caused by impaired cerebrospinal fluid circulation or clearance. A diagnosis of hydrocephalus at the chronic stage of stroke has been mainly made by clinical features and radiologic findings on brain computed tomography and magnetic resonance imaging. On the other hand, it could not determine the effect of hydrocephalus or shunt effect on the periventricular neural structures. By contrast, these effects on the periventricular neural structures can be estimated using diffusion tensor imaging (DTI). This article reviewed 10 DTI-based studies related to the diagnosis and estimation of the shunt effect for hydrocephalus in stroke patients. These studies suggest that DTI could be a useful diagnostic and estimation tool of the shunt effect for hydrocephalus in stroke patients. In particular, some studies suggested that fractional anisotropy value in the periventricular white matter could be a diagnostic biomarker for hydrocephalus. As a result, the role of DTI in diagnosing and estimating the shunt effect for hydrocephalus in stroke patients appears to be promising. However, the number of studies and patients of all reviewed studies were limited (10 studies including a total of 58 stroke patients with heterogenous brain pathologies).

Pathophysiological Mechanisms Underlying Idiopathic Normal Pressure Hydrocephalus: A Review of Recent Insights

The pathophysiologic mechanisms underpinning idiopathic normal pressure hydrocephalus (iNPH), a clinically diagnosed dementia-causing disorder, continue to be explored. An increasing body of evidence implicates multiple systems in the pathogenesis of this condition, though a unifying causative etiology remains elusive. Increased knowledge of the aberrations involved has shed light on the iNPH phenotype and has helped to guide prognostication for treatment with cerebrospinal fluid diversion. In this review, we highlight the central role of the cerebrovasculature in pathogenesis, from hydrocephalus formation to cerebral blood flow derangements, blood-brain barrier breakdown, and glymphatic pathway dysfunction. We offer potential avenues for increasing our understanding of how this disease occurs.

[A patient with recurrent multiloculated hydrocephalus after Cryptococcal ventriculitis]

We report here a rare case of adult-onset multiloculated hydrocephalus (MLH) after Cryptococcal meningitis. A 63-year-old man had Cryptococcal ventriculitis in 2011, and he recovered with treatment of antimycotic drugs. However, he was admitted again because of disorientation and amnesia, and brain MRI showed dilation of the inferior horn of the left lateral ventricle. He underwent a ventriculoperitoneal shunt (VPS) for noncommunicating hydrocephalus in 2019, and the disorientation and amnesia improved. One year after the VPS, he was admitted because of urinary dysfunction and gait disturbance. Brain MRI showed dilation of the bilateral anterior horns of the lateral ventricles. He underwent an additional VPS into the space in 2020, and urinary dysfunction and gait disturbance improved. This case was supposed that the symptom in agreement with the dilated ventricle by MLH was shown.

Anterior callosal angle correlates with gait impairment and fall risk in iNPH patients

BACKGROUND

In idiopathic normal pressure hydrocephalus (iNPH), gait and balance impairment is the most frequent symptom, and it is often associated with a higher fall risk. In a prior study, the anterior callosal angle (ACA) was validated as a reliable marker to discriminate iNPH from Alzheimer's disease and healthy controls. However, the potential correlation between the ACA with clinical symptoms and functional outcomes has not been assessed. The objective of this study is to determine the utility of the ACA in predicting gait improvement after ventriculoperitoneal (VP) shunting.

METHODS

Patients with probable iNPH who underwent shunt placement at a single institution were prospectively enrolled from May 2015 to May 2019. Patients were assessed preoperatively and at 6 months postoperatively following a standard clinical and MRI protocol. Callosal angle (CA) and ACA were calculated from 3 T MRI preoperatively and at 6 months postoperatively. CA and ACA were tested for correlation with clinical scores.

RESULTS

Forty-seven patients with probable INPH who completed 6-month postoperative follow-up were enrolled in the study. Baseline ACA was significantly correlated with preoperative fall risk, gait, and balance impairment assessed with Tinetti POMA scale. Additionally, baseline ACA differentiated patients who experienced improvement at Tinetti POMA scale after surgery.

CONCLUSIONS

The baseline ACA is a useful neuroradiological marker to differentiate patients by fall risk and has significant correlation with the improvement in gait and balance impairment following surgery. This study demonstrated that the ACA may be a complementary tool to the CA in predicting shunt responsiveness in iNPH.

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.

Pathogenesis and pathophysiology of idiopathic normal pressure hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH), the most common type of adult-onset hydrocephalus, is a potentially reversible neuropsychiatric entity characterized by dilated ventricles, cognitive deficit, gait apraxia, and urinary incontinence. Despite its relatively typical imaging features and clinical symptoms, the pathogenesis and pathophysiology of iNPH remain unclear. In this review, we summarize current pathogenetic conceptions of iNPH and its pathophysiological features that lead to neurological deficits. The common consensus is that ventriculomegaly resulting from cerebrospinal fluid (CSF) dynamics could initiate a vicious cycle of neurological damages in iNPH. Pathophysiological factors including hypoperfusion, glymphatic impairment, disturbance of metabolism, astrogliosis, neuroinflammation, and blood-brain barrier disruption jointly cause white matter and gray matter lesions, and eventually lead to various iNPH symptoms. Also, we review the current treatment options and discuss the prospective treatment strategies for iNPH. CSF diversion with ventriculoperitoneal or lumboperitonealshunts remains as the standard therapy, while its complications prompt attempts to refine shunt insertion and develop new therapeutic procedures. Recent progress on advanced biomaterials and improved understanding of pathogenesis offers new avenues to treat iNPH.

Risk factors, comorbidities, quality of life, and complications after surgery in idiopathic normal pressure hydrocephalus: review of the INPH-CRasH study

OBJECTIVE

Idiopathic normal pressure hydrocephalus (INPH) is a dementia treatable by insertion of a shunt that drains CSF. The cause of the disease is unknown, but a vascular pathway has been suggested. The INPH-CRasH (Comorbidities and Risk Factors Associated with Hydrocephalus) study was a modern epidemiological case-control study designed to prospectively assess parameters regarding comorbidities and vascular risk factors (VRFs) for INPH, quality of life (QOL), and adverse events in patients with shunted INPH. The objective of this review was to summarize the findings of the INPH-CRasH study.

METHODS

VRFs, comorbidities, QOL, and adverse events were analyzed in consecutive patients with INPH who underwent shunt placement between 2008 and 2010 in 5 of 6 neurosurgical centers in Sweden. Patients (n = 176, within the age span of 60–85 years and not having dementia) were compared to population-based age- and gender-matched controls (n = 368, same inclusion criteria as for the patients with INPH). Assessed parameters were as follows: hypertension; diabetes; obesity; hyperlipidemia; psychosocial factors (stress and depression); smoking status; alcohol intake; physical activity; dietary pattern; cerebrovascular, cardiovascular, or peripheral vascular disease; epilepsy; abdominal pain; headache; and clinical parameters before and after surgery. Parameters were assessed through questionnaires, clinical examinations, measurements, ECG studies, and blood samples.

RESULTS

Four VRFs were independently associated with INPH: hyperlipidemia, diabetes, obesity, and psychosocial factors. Physical inactivity and hypertension were also associated with INPH, although not independently from the other risk factors. The population attributable risk percent for a model containing all of the VRFs associated with INPH was 24%. Depression was overrepresented in patients with INPH treated with shunts compared to the controls (46% vs 13%, p < 0.001) and the main predictor for low QOL was a coexisting depression (p < 0.001). Shunting improved QOL on a long-term basis. Epilepsy, headache, and abdominal pain remained common for a mean follow-up time of 21 months in INPH patients who received shunts.

CONCLUSIONS

The results of the INPH-CRasH study are consistent with a vascular pathophysiological component of INPH. In clinical care and research, a complete risk factor analysis as well as screening for depression and a measurement for QOL should probably be included in the workup of patients with INPH. The effect of targeted interventions against modifiable VRFs and antidepressant treatment in INPH patients should be evaluated. Seizures, headache, and abdominal pain should be inquired about at postoperative follow-up examinations.

The Brain and the Bladder: Forebrain Control of Urinary (In)Continence

Neural circuits extending from the cerebral cortex to the bladder maintain urinary continence and allow voiding when it is socially appropriate. Injuries to certain brain regions produce a specific disruption known as urge incontinence. This neurologic symptom is distinguished by bladder spasticity, with sudden urges to void and frequent inability to maintain continence. The precise localization of neural circuit disruptions responsible for urge incontinence remains poorly defined, partly because the brain regions, cell types, and circuit connections that normally maintain continence are unknown. Here, we review what is known about the micturition reflex circuit and about forebrain control of continence from experimental animal studies and human lesion data. Based on this information, we hypothesize that urge incontinence results from damage to a descending pathway that normally maintains urinary continence. This pathway begins with excitatory neurons in the prefrontal cortex and relays subcortically, through inhibitory neurons that may help suppress reflex micturition during sleep and until it is safe and socially appropriate to void. Identifying the specific cell types and circuit connections that constitute the continence-promoting pathway, from the forebrain to the brainstem, will help us better understand why some brain lesions and neurodegenerative diseases disrupt continence. This information is needed to pave the way toward better treatments for neurologic patients suffering from urge incontinence.

Ventriculoperitoneal shunt malfunction due to chronic cholecystitis: A case report

RATIONALE

Ventriculoperitoneal shunt (VPS) is the most common treatment for idiopathic normal pressure hydrocephalus, a subtype of hydrocephalus characterized by gait disturbance, dementia, and urinary incontinence. However, while the malfunction of VPS is reported at a high rate, the involvement of chronic cholecystitis in shunt malfunction is rare.

PATIENT CONCERNS

A 73-year-old woman with idiopathic normal pressure hydrocephalus who received a VPS but subsequently developed chronic cholecystitis. The patient suffered from drowsiness and was unable to walk. Her family found that she presented with poor appetite and was bloated.

DIAGNOSES

Chronic cholecystitis was confirmed through abdominal computed tomography, which showed a swollen, and enlarged gallbladder, and flatulence. A head computed tomography scan indicated hydrocephalus with enlarged ventricular system and paraventricular edema.

INTERVENTIONS

Laparoscopic cholecystectomy was performed successfully, requiring no further shunt manipulation.

OUTCOMES

The patient's memory and cognitive ability were slightly impaired without a positive sign in the abdomen. No catheter or abdominal infection signs were observed during the following 3 months of follow-up.

CONCLUSION

To the best of our knowledge, this report is the first to reveal that shunt malfunction may result from chronic cholecystitis, which induced the presently observed intra-abdominal hypertension.

Anterior Callosal Angle: A New Marker of Idiopathic Normal Pressure Hydrocephalus?

OBJECTIVE

Diagnosing idiopathic normal pressure hydrocephalus (iNPH) still remains a clinical challenge. The callosal angle (CA) is a widely used neuroradiologic marker for iNPH. However, the relationship of the CA to clinical features has not been well investigated. We hypothesize that iNPH symptoms might better correlate with a variant of the CA (anterior callosal angle [ACA]). We aim to establish the validity of the ACA measurement for the diagnosis of iNPH and compare it with current radiologic parameters.

METHODS

The multidisciplinary BOLOGNA PRO-HYDRO Study Group performed a retrospective review of consecutive iNPH patients. Magnetic resonance imaging studies for these patients were collected, as well as magnetic resonance imaging studies from Alzheimer disease and healthy control patients. The CA, ACA, and Evans Index were measured by 2 blinded members of the study team based on magnetic resonance images for each of these populations.

RESULTS

The ACA shows high accuracy, sensitivity, and specificity in distinguishing iNPH patients from healthy control and Alzheimer disease patients. The optimal pathologic diagnostic cut-off value for the ACA is 119 degrees. The diagnostic accuracy of the ACA is not significantly different from the CA.

CONCLUSIONS

The ACA could be a valid radiologic parameter in the diagnostic armamentarium for iNPH.

Management of idiopathic normal pressure hydrocephalus (iNPH) - a retrospective study

Background: Normal pressure hydrocephalus (NPH) is communicating hydrocephalus characterised by normal intraventricular pressures. It presents with the triad of gait impairment, cognitive decline, and urinary incontinence. The term idiopathic normal pressure hydrocephalus (iNPH) is used in cases where the etiology is unknown. The aim of this study was to assess the prevalence and management of iNPH in our institution.Method: This was a retrospective study carried out at a tertiary health care center. Retrospective case series analysis was conducted using the existing electronic medical record data (2009-2017) on patients with hydrocephalus.Results: Forty-two (6.7%) patients with iNPH were identified, mean age 71.5 ± 8.8 years, 21 male (mean age 71.5 ± 9.3 years) and 21 female (mean age 71.5 ± 8.5 years). Ataxia was recorded in 39, symptoms of dementia in 31, and urinary incontinence in 29 patients. Forty patients were treated surgically by placing a ventriculoperitoneal (VP) shunt. One of the two patients treated by endoscopic third ventriculostomy (ETV) was subsequently treated by placing a VP shunt due to clinical deterioration. Significant improvements were noticed in cognitive and urinary symptoms, in the triad symptom sum score on the Japanese NPH scale, as well as in Evans' index and callosal angle (CA) on brain MRI (p < 0.05). Significant positive correlation was found between age and gait disturbance (Spearman's rho = 49.86% p = 0.0017), age and incontinence (Spearman's rho = 35.22%, p = 0.0351), age and triad symptom sum score (Spearman's rho = 44.67%, p = 0.0056), female gender and dementia (Spearman's rho = 34.94%, p = 0.0367), and among all three variables on the Japanese NPH scale (p < 0.0001).Conclusions: Treatment of iNPH with VP shunt showed significant improvement. A properly designed study is required to address the efficacy of ETV in the treatment of iNPH.

Voxel-wise lesion mapping of self-reported urinary incontinence in multiple sclerosis

AIMS

Besides spinal lesions, urinary incontinence may be attributed to particular cerebral lesion sites in multiple sclerosis (MS) patients. We intended to determine the contribution of suprapontine lesions to urinary incontinence in MS using a voxel-wise lesion analysis.

METHODS

In this retrospective study, we sought MS patients with documented urinary incontinence in a local database. We established a control group of MS-patients without documented urinary incontinence matched for gender, age, and disease severity. Patients with urinary incontinence due to local diseases of the urinary tract were excluded. The MS lesions were analyzed on T2-weighted magnetic resonance imaging scans (1.5 or 3T). After manual delineation and transformation into stereotaxic space, we determined the lesion overlap and compared the presence or absence of urinary incontinence voxel-wise between patients with and without lesions in a given voxel performing the Liebermeister test with 4000 permutations.

RESULTS

A total of 56 patients with urinary incontinence and MS fulfilled the criteria and were included. The analysis yielded associations between urinary incontinence and MS in the frontal white matter, temporo-occipital, and parahippocampal regions.

CONCLUSIONS

Our voxel-wise analysis indicated associations between self-reported urinary incontinence and lesions in the left frontal white matter and right parahippocampal region. Thus, our data suggest that dysfunction of supraspinal bladder control due to cerebral lesions may contribute to the pathophysiology of urinary incontinence in MS.

Effect of cerebrospinal fluid shunt surgery on lower urinary tract dysfunction in idiopathic normal pressure hydrocephalus

AIMS

To examine the outcomes of lower urinary tract symptoms (LUTS) and urodynamic test results after cerebrospinal fluid (CSF) shunt surgery in idiopathic normal pressure hydrocephalus (iNPH).

METHODS

Records of 48 patients (33 men; 15 women), who met the definite iNPH criteria and underwent CSF shunt surgery, were retrospectively analyzed. LUTS and their impact on quality of life (QOL) were evaluated using an all-or-none questionnaire targeting four symptoms, the Overactive Bladder Symptoms Score (OABSS), and the QOL index. Urodynamic investigations included filling cystometry and pressure-flow studies performed before and after surgery.

RESULTS

Forty-seven (98%) patients complained of LUTS, 41 (87%) patients of whom experienced LUTS improvement after surgery. The OABSS and QOL index, which before surgery were 6.8 ± 0.7 and 4.1 ± 0.4, respectively, significantly decreased to 4.6 ± 0.6 and 3.2 ± 0.3, respectively, after surgery. The maximum cystometric capacity (174.9 ± 13.3 mL to 222.4 ± 14.7 mL) and bladder compliance (35.8 ± 4.4 ml/cmH₂ O to 52.1 ± 5.4 ml/cmH₂ O) significantly increased after surgery. Detrusor overactivity, which was observed in 37 (77%) patients preoperatively, became undetectable in 7 patients postoperatively. Voiding dysfunction (defined as maximum flow rate <10 mL/s or post-void residual >100 mL) was observed in 29 (60%) patients, 22 (75%) of whom had detrusor underactivity before surgery. None of the voiding urodynamic parameters significantly improved postoperatively.

CONCLUSIONS

iNPH is often associated with LUTS and both storage and voiding dysfunctions. CSF shunt surgery improved LUTS and storage dysfunction, with limited effects on voiding dysfunction.

Interhemispheric Resting-State Functional Connectivity Predicts Severity of Idiopathic Normal Pressure Hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by a clinical triad (gait disturbance, dementia, and urinary incontinence), and by radiological findings of enlarged ventricles reflecting disturbance of central spinal fluid circulation. A diagnosis of iNPH is sometimes challenging, and the pathophysiological mechanisms underlying the clinical symptoms of iNPH remain largely unknown. Here, we used an emerging MRI technique, resting-state functional connectivity MRI (rsfcMRI), to develop a subsidiary diagnostic technique and to explore the underlying pathophysiological mechanisms of iNPH. rsfcMRI data were obtained from 11 patients with iNPH and 11 age-matched healthy volunteers, yielding rsfcMRI-derived functional connectivity (FC) from both groups. A linear support vector machine classifier was trained to distinguish the patterns of FCs of the patients with iNPH from those of the healthy volunteers. After dimensional reduction, the support vector machine successfully classified the two groups with an accuracy of 80%. Moreover, we found that rsfcMRI-derived FC carried information to predict the severity of the triad in iNPH. FCs relevant to the classification of severity were mainly based on interhemispheric connectivity, suggesting that disruption of the corpus callosum fibers due to ventricular enlargement may explain the triad of iNPH. The present results support the usefulness of rsfcMRI as a tool to understand pathophysiology of iNPH, and also to help with its clinical diagnosis.

Nonmotor Symptoms in Vascular and Other Secondary Parkinsonism

Vascular parkinsonism (VP) is a relatively frequent variant of secondary parkinsonism caused by ischemic or hemorrhagic lesions of basal ganglia, midbrain, or their links with frontal cortex. According to different investigations, various forms of cerebrovascular disease cause 1%-15% of parkinsonism cases. Nonmotor symptoms are frequently found in VP and may negatively influence on quality of life. However, nonmotor symptoms such as hallucinations, orthostatic hypotension, REM-sleep behavior disorder, and anosmia are rarely revealed in VP, which may be noted to another diagnosis or mixed pathology. Clinical value of nonmotor symptoms in normal pressure hydrocephalus, toxic, and drug-induced parkinsonism is also discussed.

Improvement in lower urinary tract symptoms across multiple domains following ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus

AIMS

The purpose of this study was to evaluate the change in lower urinary tract symptoms following ventriculoperitoneal shunting in patients with idiopathic normal pressure hydrocephalus (iNPH).

METHODS

Lower urinary tract symptoms in patients with new-onset iNPH were prospectively evaluated using validated questionnaires from the International Consultation on Incontinence to assess overactive bladder (ICIq-OAB), incontinence (ICIq-UI), and quality of life (ICIq-LUTqol), as well as the American Urological Association Symptom Score bother scale, prior to and following ventriculoperitoneal shunting for iNPH. Sub-analysis was performed based on gender, age, and medical comorbidities.

RESULTS

Twenty-three consecutive patients with new-onset iNPH were evaluated prior to, and following, surgical intervention for iNPH via ventriculoperitoneal shunting. Shunting resulted in a significant improvement in urinary urgency, urge incontinence, ability to perform physical activities, and overall quality of life. Women had improvement across more domains than men following shunting, particularly in terms of urinary urgency and overall quality of life. Younger patients experienced significant improvement in scores following shunting as compared to older patients. Patients with two or more medical comorbidities, as well as those with fewer than two comorbidities, reported a significant improvement in overall quality of life.

CONCLUSIONS

Surgical intervention for iNPH results in significant improvement in urinary symptoms, specifically in terms of urinary urgency and urge incontinence as well as overall quality of life, particularly in women and younger patients.

Association between schizophrenia and urinary incontinence: A population-based study

BACKGROUND

Urinary incontinence (UI) is defined as the involuntary loss of urine and can constitute a hygiene or social problem for affected patients. Whether the UI incidence is higher in patients with schizophrenia than in the general population remains undetermined.

METHODS

The patients were selected from the Taiwan National Health Insurance Research Database, using claims data from 2005 to 2011. We compared the risk of UI between schizophrenia and nonschizophrenia groups. Logistic regression models were employed for analyzing the risk of UI after adjustment for sex, age, and comorbidities.

RESULTS

The adjusted odds ratio for UI in the schizophrenia group was 1.78-fold higher than that in the nonschizophrenia group. Furthermore, male patients with schizophrenia were more susceptible to UI than their female counterparts, and a higher risk of UI was observed among younger patients with schizophrenia.

CONCLUSION

Compared with the general population, the risk of UI was higher among the patients with schizophrenia. Early diagnosis and intervention can increase the quality of life among patients with schizophrenia.

[Lower urinary tract dysfunction in normal pressure hydrocephalus: Review of the literature]

INTRODUCTION

Lower urinary tract dysfunction in normal pressure hydrocephalus has received little attention from the scientific community. The aim of this review article was to discuss diagnostic and therapeutic options for these patients.

SOURCES

A literature review of MedLine publications on urinary incontinence in normal pressure hydrocephalus was conducted. The following keywords were used: "hydrocephalus, normal pressure" and "bladder dysfunction" or "urinary incontinence" or "overactive bladder" or "urinary bladder, neurogenic". Prospective and retrospective studies as well as previous reviews were analyzed.

RESULTS

Urinary symptoms in normal pressure hydrocephalus are mainly represented by overactive bladder, which is a significant burden for the concerned patients. Isolated overactive bladder is more frequent (64%) than urinary incontinence (57%). Detrusor overactivity is seen in 95.2% of the cases. Neuro-surgery is efficient on urinary symptoms for 61.5% of the patients. Bladder recovery after surgery relates with increased mid-cingulate perfusion, probably linked with a functional restoration of the mid-cingulate that normally inhibits the micturition reflex. Medical options, added or not to surgery, include anticholinergic drugs unable to pass through the blood-brain barrier, Transcutaneous Electrical Nerve Stimulation and sacral neuromodulation.

CONCLUSION

There is actually an insufficient concern about urinary symptoms in normal pressure hydrocephalus. This article highlights the importance of a harmonization of neuro-urological practices in the pre-therapeutic evaluation of patients suffering from normal pressure hydrocephalus.

Lower urinary tract symptoms in Parkinson's disease: Prevalence, aetiology and management

Lower urinary tract symptoms (LUTS) are common in Parkinson's disease (PD), effecting 27-85% of patients with PD. Irritative symptoms predominate and urodynamic studies confirm high prevalence of detrusor overactivity in PD. LUTS are present early in PD and are more common in PD than in age matched controls. The assessment of LUTS in PD is complicated by coexisting bradykinesia and cognitive impairment. Although LUTS become more troublesome as PD progresses it remains unclear if LUTS severity correlates with motor symptoms and/or duration of PD. The underlying cause of LUTS in PD remains to be fully elucidated. Animal and human studies suggest the net effect of the basal ganglia is to supress micturition. Although LUTS are a common in PD, few studies have examined the assessment and management of LUTS specifically in patients with PD. Pilot studies have suggested that bladder training, antimuscarinic drugs and intravesical botulinum toxin maybe helpful but these trials have been small and frequently lacked a suitable control group making them vulnerable to the placebo effect. Furthermore the adverse effects of antimuscarinic drugs on cognitive and gastrointestinal function may limit the use of these drugs in PD. In this review we summarise the literature describing the prevalence of LUTS in PD, discuss the emerging data delineating the underlying pathophysiology of LUTS and examine interventions helpful in the management of LUTS in people with PD.

White matter hyperintensities and geriatric syndrome: An important role of arterial stiffness

White matter hyperintensities (WMH) are defined as cerebral white matter changes presumed to be of vascular origin, bilateral and mostly symmetrical. They can appear as hyperintense on T2-weighted and fluid-attenuated inversion recovery sequences, and as isointense or hypointense on T1-weighted magnetic resonance imaging of the brain. WMH have been focused on because of their clinical importance as a risk factor for cerebrovascular diseases and cognitive impairment. WMH are associated with geriatric syndrome, which is defined by clinical symptoms characteristic of older adults, including cognitive and functional impairment and falls. Cerebral small vessel diseases, such as WMH, might play an important role as risk factors for cerebrovascular diseases, cognitive impairment and geriatric syndrome through the mechanism of arterial stiffness. However, the vascular, physiological and metabolic roles of arterial stiffness remain unclear. Basically, arterial stiffness indicates microvessel arteriosclerosis presenting with vascular endothelial dysfunction. These changes might arise from hemodynamic stress as a result of a "tsunami effect" on cerebral parenchyma. In the present article, we review the clinical characteristics of WMH, focusing particularly on two associations: (i) those between cerebral small vessel diseases including WMH and arterial stiffness; and (ii) those between WMH and geriatric syndrome.

Bladder recovery relates with increased mid-cingulate perfusion after shunt surgery in idiopathic normal-pressure hydrocephalus: a single-photon emission tomography study

AIMS OF STUDY

It is reported that severe bladder disorder in idiopathic normal-pressure hydrocephalus (iNPH) is predicted by right frontal hypoperfusion. However, it is not known whether bladder recovery is predicted by brain perfusion change after shunt surgery. To address this issue, we compared bladder and brain function before and after shunt surgery in iNPH.

METHODS

We enrolled 75 patients in the study. Before and 12 months after shunt surgery, we analyzed brain perfusion by SPECT and bladder disorder by a specialized grading scale. The scale consisted of grade 0, none; grade 1, urinary urgency and frequency; grade 2, urinary incontinence 1-3 times a week; grade 3, urinary incontinence >daily; and grade 4, loss of bladder control. More than one grade improvement is defined as improvement, and more than one grade decrement as worsening; otherwise no changes.

RESULTS

Comparing before and after surgery, in the bladder-no-change group (32 cases) there was an increase in blood flow which is regarded as reversal of enlargement in the Sylvian fissure and lateral ventricles (served as control). In contrast, in the bladder-improved group (32 cases) there was an increase in bilateral mid-cingulate, parietal, and left frontal blood flow (p < 0.05). In the bladder-worsened group (11 cases) no significant blood flow change was observed.

CONCLUSION

The present study showed that after shunt surgery, bladder recovery is related with mid-cingulate perfusion increase in patients with iNPH. The underlying mechanism might be functional restoration of the mid-cingulate that normally inhibits the micturition reflex.

Functional imaging of structures involved in neural control of the lower urinary tract

Recent functional brain imaging studies, building on earlier observations, suggest a working model of brain control of the lower urinary tract. It comprises a few cerebral neural circuits that, during the storage phase, act on the midbrain periaqueductal gray to inhibit the long-loop, spinobulbospinal voiding reflex, thus promoting continence. Circuit 1, centered on the medial prefrontal cortex, appears to be concerned with conscious control of both continence and voiding. Circuit 2, centered on the dorsal anterior cingulate (midcingulate) and supplementary motor area, is concerned with emotional aspects of bladder control: desire to void or urgency with concomitant urethral sphincter activation to delay leakage. A subcortical circuit 3 has been less well studied. Circuit 1 is bilateral with a right-sided preference. Scattered studies of the connectivity of the control network suggest that white-matter damage may contribute to urinary incontinence. A few studies confirm that isolated cerebral lesions, if in the medial prefrontal cortex or its connecting pathways, may lead to incontinence. Lower urinary tract dysfunction in other neurologic diseases (normal-pressure hydrocephalus, Parkinson's disease, and multiple systems atrophy) appears consistent with the working model, and even spinal or peripheral lesions have central effects. However, this model omits the contributions of brain regions already observed in some imaging studies and therefore is certainly oversimplified.

Lower urinary tract dysfunction in patients with brain lesions

Stroke and brain tumor are well-known brain diseases. The incidence of lower urinary tract dysfunction (LUTD) in these patients ranges from 14% to 53%, mostly overactive bladder (OAB), and is higher when the frontal cortex is involved. This presumably reflects damage at the prefrontal cortex, cingulate cortex, and other areas that regulate (mainly inhibit) the micturition reflex. White-matter disease (WMD) is a chronic, bilateral form of cerebrovascular disease, leading to a high prevalence of OAB (up to 90%). Since WMD is particularly common in the elderly, WMD may be one of the anatomic substrates for elderly OAB. Traumatic brain injury and normal-pressure hydrocephalus are rather diffuse brain diseases, which cause OAB with a prevalence rate of 60-95%. Recent neuroimaging studies have shown a relationship between LUTD and the frontal cortex in these diseases. Data on other brain diseases, particularly affecting deep brain structures, are limited. Small infarctions, tumors, or inflammatory diseases affecting the basal ganglia, hypothalamus, and cerebellum lead to mainly OAB. In contrast, similar diseases affecting the brainstem lead to either OAB or urinary retention. The latter reflects damage at the periaqueductal gray and the pontine micturition center that directly relay and modulate the micturition reflex. Urinary incontinence (UI) in brain disease can be divided into two types: neurogenic UI (due to OAB) and functional UI (immobility and loss of initiative/cognition). These two types of UI may occur together, but management differs significantly. Management of neurogenic UI includes anticholinergic drugs that do not penetrate the blood-brain barrier easily. Management of functional UI includes behavioral therapy (timed/prompted voiding with physical assistance and bladder/pelvic floor training) and drugs to treat gait as well as cognition that facilitate continence. These treatments will maximize the quality of life in patients with brain diseases.

Assessment of the urodynamic diagnosis in patients with urinary incontinence associated with normal pressure hydrocephalus

AIMS

To assess the urodynamic patterns present in patients with adult normal pressure hydrocephalus (NPH) in our institution.

METHODS

Retrospectively conducted study on patients diagnosed with NPH by the Neurosurgery Department of our institution, without etiological treatment or urogynecological disorders, who underwent an urodynamic study (UDS) performed according to methods proposed by the International Society of Continence (ICS). Clinical information, complementary tests and UDS were collected, and descriptive analysis was performed, with special focus in urodynamic final diagnosis.

RESULTS

Eighty-one UDS performed between 2003 and 2013. Fifty-one Males (63%). Mean age: 74.89 ± 8.58 years old (range 52-88 years). Classical triad of symptoms: gait disturbance, dementia, and urinary incontinence (UI) presented in 48.1%. Urinary urgency in 80.9% and UI in 70%. In two cases (2.5%) UDS was not valuable. Urodynamic features of the 79 remaining studies revealed overactive detrusor (OD) in 56 patients (70.9%), being associated with Stress UI (SUI) in one case and with bladder outlet obstruction (BOO) in 19. SUI in six patients (7.6%) and BOO in five (6.3%). Detrusor underactivity in four cases (5%) and normal study in eight (10.1%). About 47.1% of males presented BOO. Cerebrospinal fluid shunt surgery was performed on 32 patients during follow-up, with subsequent clinical improvement in 90.6% of them.

CONCLUSIONS

OD was the most frequent diagnosis within UDS conducted on adult NPH patients in our institution, with BOO in an elevated percentage of them. Etiological treatment led to symptomatic improvement in most of patients.

Association between milder brain deformation before a shunt operation and improvement in cognition and gait in idiopathic normal pressure hydrocephalus

We investigated the association between the degree of deformation of the brain before shunt operation and improvement of gait and cognitive impairment after shunt operation in 16 patients with idiopathic normal pressure hydrocephalus (iNPH). We evaluated gait and cognitive impairment and measured the cerebrospinal fluid volume in the ventricles/sylvian fissure (vVS) and the subarachnoid space at high convexity/midline areas (vHCM) using MR images with voxel-based morphometry before and 3 months after shunt operation. We used the ratio of vVS to vHCM (vVS/vHCM) as an index of the severity of brain deformation. After shunt operation, improvements were observed in gait, as shown by the Timed Up and Go (TUG) test and 10-meter reciprocating walking test (WT), and in cognitive function, as shown by the Mini-Mental State Examination, Alzheimer Disease Assessment Scale, Frontal Assessment battery (FAB), and Trail Making test A (TMT-A). The vVS/vHCM ratio was negatively correlated with improvement of the FAB, TMT-A and TUG. Preoperative vVS/vHCM was not significantly correlated with preoperative clinical assessments. The rate of change of vVS/vHCM was positively correlated with improvement in the WT. The improvements of gait and cognitive function were larger in iNPH patients with milder deformation of the brain before shunt operation.

Indications for valve-pressure adjustments of gravitational assisted valves in patients with idiopathic normal pressure hydrocephalus

Background:

Modern ventriculoperitoneal shunts (VPS) are programmable, which enables clinicians to adjust valve-pressure according to their patients’ individual needs. The aim of this retrospective analysis is to evaluate indications for valve-pressure adjustments in idiopathic normal pressure hydrocephalus (iNPH).

Methods:

Patients operated between 2004 and 2011 diagnosed with iNPH were included. Kiefer-Scale was used to classify each patient. Follow-up exams were conducted 3, 6, and 12 months after shunt implantation and yearly thereafter. Initial valve-pressure was 100 or 70 mmH₂O. Planned reductions of the valve-pressure to 70 and 50 mmH₂O, respectively, were carried out and reactive adjustment of the valve-pressure to avoid over- and under-drainage were indicated.

Results:

A total of 52 patients were provided with a Medos-Hakim valve^Codman® with a Miethke shunt-assistant^Aesculap® and 111 patients with a Miethke-proGAV^Aesculap®. 180 reductions of the valve-pressure took place (65% reactive, 35% planned). Most patients (89%) needed one or two adjustments of their valve-pressures for optimal results. In 41%, an improvement of the symptoms was observed. Gait disorder was improved most often after valve-pressure adjustments (32%). 18 times an elevation of valve-pressure was necessary because of headaches, vertigo, or the development of subdural hygroma. Optimal valve-pressure for most patients was around 50 mmH₂O (36%).

Conclusion:

The goal of shunt therapy in iNPH should usually be valve-pressure settings between 30 and 70 mmH₂O. Reactive adjustments of the valve-pressure are useful for therapy of over- and underdrainage symptoms. Planned reductions of the valve opening pressure are effective even if postoperative results are already satisfactory.

Influence of comorbidities in idiopathic normal pressure hydrocephalus - research and clinical care. A report of the ISHCSF task force on comorbidities in INPH

Idiopathic normal pressure hydrocephalus (INPH) is a syndrome of ventriculomegaly, gait impairment, cognitive decline and incontinence that occurs in an elderly population prone to many types of comorbidities. Identification of the comorbidities is thus an important part of the clinical management of INPH patients. In 2011, a task force was appointed by the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders (ISHCSF) with the objective to compile an evidence-based expert analysis of what we know and what we need to know regarding comorbidities in INPH. This article is the final report of the task force. The expert panel conducted a comprehensive review of the literature. After weighing the evidence, the various proposals were discussed and the final document was approved by all the task force members and represents a consensus of expert opinions. Recommendations regarding the following topics are given: I. Musculoskeletal conditions; II. Urinary problems; III. Vascular disease including risk factors, Binswanger disease, and white matter hyperintensities; IV. Mild cognitive impairment and Alzheimer disease including biopsies; V. Other dementias (frontotemporal dementia, Lewy body, Parkinson); VI. Psychiatric and behavioral disorders; VII. Brain imaging; VIII. How to investigate and quantify. The task force concluded that comorbidity can be an important predictor of prognosis and post-operative outcome in INPH. Reported differences in outcomes among various INPH cohorts may be partly explained by variation in the rate and types of comorbidities at different hydrocephalus centers. Identification of comorbidities should thus be a central part of the clinical management of INPH where a detailed history, physical examination, and targeted investigations are the basis for diagnosis and grading. Future INPH research should focus on the contribution of comorbidity to overall morbidity, mortality and long-term outcomes.