Neurological symptoms and signs in adult aqueductal stenosis

Chronic Subdural Hematoma after Endoscopic Third Ventriculostomy for Chronic Obstructive Hydrocephalus: A Case Report

Endoscopic third ventriculostomy (ETV) is a safe treatment option for chronic obstructive hydrocephalus. However, we encountered a case of chronic subdural hematoma (CSDH) with bilateral large hematoma volumes after ETV for chronic obstructive hydrocephalus. We herein report a rare complication of ETV. The patient was a 53-year-old woman who had been diagnosed with asymptomatic ventricular enlargement with aqueductal stenosis 5 years previously. However, over the course of 5 years, her gait and cognitive function gradually declined. ETV was administered to relieve symptoms. Head Magnetic resonance imaging performed 1 week after ETV indicated bilateral subdural hygroma. Three weeks after ETV, she presented with headache and left incomplete paralysis, and head Computed tomography (CT) demonstrated bilateral CSDH with a large volume hematoma. Burr-hole evacuation and drainage of the bilateral CSDH were performed, after which the symptoms resolved. However, 7 weeks after ETV, she again presented with headache and incomplete right paralysis, and CT revealed bilateral CSDH re-enlargement. After the second burr-hole evacuation and drainage of bilateral CSDH, her symptoms resolved. The bilateral CSDH continued to shrink following the second hematoma evacuation surgery and completely disappeared on CT scan performed 3 months after ETV. Ventricular enlargement due to chronic obstructive hydrocephalus stretches the brain mantle for several years. This long-term stretching may have diminished the brain compliance and led to the development, growth, and recurrence of CSDH. In ETV for chronic obstructive hydrocephalus, surgeons should consider the risk of postoperative CSDH with a high hematoma volume and tendency to recur.

Freezing of gait in idiopathic normal pressure hydrocephalus

BACKGROUND

Reports of freezing of gait (FoG) in idiopathic normal pressure hydrocephalus (iNPH) are few and results are variable. This study's objective was to evaluate the frequency of FoG in a large cohort of iNPH patients, identify FoG-associated factors, and assess FoG's responsiveness to shunt surgery.

METHODS

Videotaped standardized gait protocols with iNPH patients pre- and post-shunt surgery (n = 139; median age 75 (71-79) years; 48 women) were evaluated for FoG episodes by two observers (Cohens kappa = 0.9, p < 0.001). FoG episodes were categorized. Mini-mental state examination (MMSE) and MRI white matter hyperintensities (WMH) assessment using the Fazekas scale were performed. CSF was analyzed for Beta-amyloid, Tau, and Phospho-tau. Patients with and without FoG were compared.

RESULTS

Twenty-two patients (16%) displayed FoG at baseline, decreasing to seven (8%) after CSF shunt surgery (p = 0.039). The symptom was most frequently exhibited during turning (n = 16, 73%). Patients displaying FoG were older (77.5 vs. 74.6 years; p = 0.029), had a slower walking speed (0.59 vs. 0.89 m/s; p < 0.001), a lower Tinetti POMA score (6.8 vs. 10.8; p < 0.001), lower MMSE score (21.3 vs. 24.0; p = 0.031), and longer disease duration (4.2 vs. 2.3 years; p < 0.001) compared to patients not displaying FoG. WMH or CSF biomarkers did not differ between the groups.

CONCLUSIONS

FoG is occurring frequently in iNPH patients and may be considered a typical feature of iNPH. FoG in iNPH was associated with higher age, longer disease duration, worse cognitive function, and a more unstable gait. Shunt surgery seems to improve the symptom.

Idiopathic Aqueductal Stenosis: Late Neurocognitive Outcome in ETV Operated Adult Patients

Objective

The aim of the present study is to evaluate a neurocognitive outcome in patients affected by late-onset idiopathic aqueductal stenosis (LIAS) who underwent endoscopic third ventriculostomy (ETV).

Materials and Methods

A prospective study was conducted between January 2015 and December 2017 in a series of 10 consecutive adult patients referred to the Neurosurgery Department of IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy. All the adult patients admitted with absence of CSF flow through the aqueduct in phase-contrast (PC)—MRI sequences or a turbulence void signal in T2—weighted images in midsagittal thin-slice MR sequences underwent a specific neuroradiological, neurological, and neurocognitive assessment pre- and postoperatively.

Results

All patients affected by gait and sphincter disturbances improved after ETV. Attentive and executive functions as well as visuo-spatial memory and verbal executive functions improved in several patients. Similarly, the affective and behavioral scales improved in almost 50% of the patients. No major complications have been recorded, and no patients required a second surgery for shunt placement.

Conclusion

Endoscopic third ventriculostomy represents a safe and effective surgical procedure for the treatment of LIAS. In addition to neurological improvement, we demonstrated also postoperative neurocognitive improvement mainly in attentive and executive functions, visuo-spatial memory, verbal executive functions, and behavioral and affective domains.

Assessment of neurological symptoms in adult hydrocephalus occlusus. A pilot study

BACKGROUND

Comprehensively describe and compare (pre⁄postoperatively) the clinical symptomatology in adult non-communicated hydrocephalus. Associated hydrocephalus signs were analyzed with the idiopathic Normal Pressure Hydrocephalus Scale (iNPH Scale). A standardized clinical scale for non-communicated hydrocephalus is currently not in use.

METHODS

Ten patients with hydrocephalus occlusus (HO) were analyzed. Hydrocephalus signs were examined with the iNPH Scale in gait, neuropsychology, continence, and balance before and three months after treatment with shunt operation or third endoscopic ventriculostomy.

RESULTS

Patients significantly improved in iNPH total score (25.8%) and gait score (35.4%) three months after neurosurgical intervention. Domain scores in neuropsychology, continence, and balance reached statistical trends (p ≤ 0.066). Most clinical symptoms and signs at baseline improved after surgery (dizziness, lapse of concentration, gait instability, and headache).

CONCLUSION

Patients with non-communicated HO also showed classical hydrocephalus symptoms as communicated in iNPH patients. The iNPH Scale allows a structured neurological assessment over the disease's progress and surgical intervention. Further studies with a larger patient samples are necessary to support our results.

Does Phase-Contrast Imaging through the Cerebral Aqueduct Predict the Outcome of Lumbar CSF Drainage or Shunt Surgery in Patients with Suspected Adult Hydrocephalus?

BACKGROUND AND PURPOSE

Radiologic imaging plays a key role in diagnosing chronic adult hydrocephalus, but its role in predicting prognosis is still controversial. We sought to evaluate the effectiveness of cardiac-gated phase-contrast MR imaging through the cerebral aqueduct in predicting the clinical response to diagnostic lumbar puncture/lumbar drainage and shunt surgery in suspected adult hydrocephalus.

MATERIALS AND METHODS

In this retrospective study, the phase-contrast MR imaging of 185 patients with suspected chronic adult hydrocephalus was evaluated using the CSF Flow software package. Decision-making for shunt placement was performed in this cohort on the basis of clinical assessment alone without the availability of quantitative phase-contrast MR imaging results. We recorded the response to lumbar puncture or lumbar drainage and shunt surgery using quantitative tests such as the Tinetti Test, the Timed Up and Go, and the Mini-Mental State Examination and qualitative measures of gait, urinary, and cognitive symptom improvement before and after lumbar puncture/lumbar drainage and shunt surgery. Quantitative analysis of phase-contrast MR imaging was compared with clinical outcome measures.

RESULTS

Both CSF stroke volume and flow rate overlapped between lumbar puncture/lumbar drainage responders and nonresponders. There was also a significant overlap between shunt responders and nonresponders. Aqueductal stroke volume or flow rate alone was a poor predictor of lumbar puncture/lumbar drainage and shunt surgery response. Quantitative clinical measures after lumbar puncture/lumbar drainage were better predictors of shunt response.

CONCLUSIONS

This study suggests that the results of phase-contrast MR imaging through the cerebral aqueduct alone should not be used to select patients for diagnostic or therapeutic CSF diversion.

A Curious Distal Tibiofibular Neuropathic Fracture: A Case Report

Hindfoot and distal leg neuropathic fracture collapse secondary to normal pressure hydrocephalus is a very rare clinical pathology. The authors present a case of a 69-year-old woman who sustained a distal tibiofibular fracture that resulted in a recurvatum deformity with idiopathic neuropathy and gait instability on initial presentation. A subtalar and ankle joint arthrodesis was performed achieving rectus alignment of the lower extremity with no postoperative complications. Her neuropathic etiology was negative for common causative factors, including diabetes, infection, nutritional deficiencies, congenital neuropathy, and trauma. Approximately 6 months postoperatively, the patient had persistent bilateral lower extremity weakness with the sensation of her "feet sticking to the floor" on ambulation. A referral to neurology revealed a normal pressure hydrocephalus as a possible etiology for her gait abnormalities and neuropathy. She required a ventriculoperitoneal shunt, with resolved gait disturbance and associated weakness approximately 1.5 years postoperatively.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case report.

Does aqueductal stenosis influence the lumbar infusion test in normal-pressure hydrocephalus?

BACKGROUND

Late-onset idiopathic aqueductal stenosis may present with clinical features indistinct from idiopathic normal-pressure hydrocephalus (NPH). Moreover, aqueductal stenosis (AS) is not always detected by conventional magnetic resonance imaging (MRI). The aim of this study was to compare the hydrodynamic pattern among NPH patients according to the patency of the aqueduct.

METHODS

Fifty-six consecutive lumbar infusion tests were performed in patients with NPH syndrome. Precipitating causes of hydrocephalus were excluded, and aqueductal patency was examined through high-resolution, T2-weighted 3D MRI. Patients were classified into two groups: non-patent aqueduct and patent aqueduct. Mean values of pressure and pulse amplitude were obtained from basal and plateau stages of infusion studies.

RESULTS

Twelve of 56 patients with NPH-like symptoms presented with morphological AS (21.4 %). Patent aqueduct and non-patent aqueduct groups had similar values of mean opening lumbar pressure (8.2 vs. 8.1 mmHg), and mean opening pulse amplitude (3.1 vs. 2.9 mmHg). Mean pressure in the plateau stage (28.6 vs. 23.2 mmHg), and mean pulse amplitude in the plateau stage (12.5 vs. 10.6 mmHg) were higher in the patent aqueduct group. These differences were not statistically significant. Only Rout was significantly higher in the patent aqueduct group (13.6 vs. 10.1 mmHg/ml/min). One-third of NPH patients with AS presented Rout >12 mmHg/ml/min.

CONCLUSIONS

No differences in mean pressure or pulse amplitude during basal and plateau epochs of the lumbar infusion test in NPH patients were detected, regardless of aqueductal patency. However, Rout was significantly higher in patients with patent aqueduct.

The role of the neurologist in the longitudinal management of normal pressure hydrocephalus

BACKGROUND

Since normal pressure hydrocephalus (NPH) was first described in 1965, neurologists have been involved in the initial diagnostic evaluation for it but have rarely followed patients specifically to monitor response to therapy after shunt surgery.

REVIEW SUMMARY

The potential role for the neurologist in the longitudinal management of NPH has broadened, partly because of improvement in the tools used to diagnose and treat NPH and partly because of progress in understanding how NPH mimics and interacts with other common disorders of the elderly. The interplay of Alzheimer dementia, vascular dementia, Parkinson disease, and spinal stenosis with NPH presents the clinician with a patient profile that may be challenging to assess. Neurologists also face a broad differential spectrum of less common neurologic diseases that may present with similar signs (including ventriculomegaly) and symptoms; these diseases include frontotemporal dementia, progressive supranuclear palsy, Lewy body disease, corticobasal degeneration, Huntington disease, spongiform encephalopathy, and multiple-system atrophy.

CONCLUSIONS

The neurologist is in a unique position to differentiate NPH from alternative diagnoses, to suggest management strategies for patients with concomitant NPH and another neurologic disorder, and to participate in longitudinal management of NPH.

Chronic cough as the presenting symptom of hydrocephalus

Chronic cough is defined as a daily cough lasting for more than eight weeks. We report an unusual case of chronic cough as the primary manifestation of obstructive hydrocephalus. Chronic cough in our case was determined to be of neurogenic origin only after exhaustive investigations failed to reveal a systemic cause, and, in particular, after a positive response to treatment of the hydrocephalus was observed. To the best of our knowledge, this is the first report of hydrocephalus presenting as chronic cough. We believe this case will remind physicians of the importance of considering neurological disease as a cause of chronic cough after common causes are excluded.

Cerebral haemodynamics in patients with glutaryl-coenzyme A dehydrogenase deficiency

In glutaric aciduria type 1, glutaryl-coenzyme A and its derivatives are produced from intracerebral lysine and entrapped at high concentrations within the brain, where they interfere with energy metabolism. Biochemical toxicity is thought to trigger stroke-like striatal degeneration in susceptible children under 2 years of age. Here, we explore vascular derangements that might also contribute to brain damage. We studied injured and non-injured Amish glutaric aciduria type 1 patients using magnetic resonance imaging (n = 26), transcranial Doppler ultrasound (n = 35) and perfusion computed tomography (n = 6). All glutaric aciduria type 1 patients had wide middle cerebral, internal carotid and basilar arteries. In non-injured patients, middle cerebral artery velocities were 18-26% below control values throughout late infancy and early childhood, whereas brain-injured children had an early velocity peak (18 months) and low values thereafter. Perfusion scans from six patients showed that tissue blood flow did not undergo a normal developmental surge. We observed four different perfusion patterns. (i) Three children (two non-injured) had low cerebral blood flow, prolonged mean transit time, elevated cerebral blood volume and high mean transit time/cerebral blood flow and cerebral blood volume/cerebral blood flow ratios. This pattern optimizes substrate extraction at any given flow rate but indicates low perfusion pressure and limited autoregulatory reserve. (ii) Ten hours after the onset of striatal necrosis in an 8-month-old infant, mean transit time and cerebral blood volume were low relative to cerebral blood flow, which varied markedly from region to region. This pattern indicates disturbed autoregulation, regional perfusion pressure gradients, or redistribution of flow from functional capillaries to non-exchanging vessels. (iii) In an infant with atrophic putaminal lesions, striatal flow was normal but mean transit time and cerebral blood volume were low, consistent with perfusion in excess of metabolic demand. (iv) Finally, a brain-injured adult with glutaric aciduria type 1 had regional perfusion values within the normal range, but the putamina, which normally have the highest regional perfusion, had cerebral blood flow values 24% below cortical grey matter. Although metabolic toxicity appears central to the pathophysiology of striatal necrosis, cerebrovascular changes probably also contribute to the process. These changes may be the primary cause of expanded cerebrospinal fluid volume in newborns, intracranial and retinal haemorrhages in infants and interstitial white matter oedema in children and adults. This pilot study suggests important new areas for clinical investigation.

Idiopathic normal pressure hydrocephalus: increased supplementary motor activity accounts for improvement after CSF drainage

In patients with idiopathic normal pressure hydrocephalus (INPH), the changes in brain function that take place in conjunction with improved behavioural performance after CSF drainage is still unknown. In this study, we use functional MRI (fMRI) to investigate the changes in cortical activity that accompany improved motor and cognitive performance after long-term external lumbar drainage (ELD) of CSF in patients with INPH. Eighteen INPH patients were initially included together with age- and sex-matched controls. Data from 11 INPH patients were analysed both before and after ELD. The average drain volume for these 11 patients was 400 ml/3 days. Brain activation was investigated by fMRI before and after the procedure on a 1.5T Philips scanner using protocols taxing motor performance (finger tapping and reaction time) and cognitive functioning (memory and attention). Behavioural data were compared using non-parametric tests at a significance level of 0.05, whereas fMRI data were analysed by statistical parametric mapping including conjunction analysis of areas with enhanced activity after drainage in patients and areas activated in controls (P < 0.005, uncorrected). Improved regions were defined as areas in the INPH brain that increased in activity after ELD with the requirement that the same areas were activated in control subjects. Following ELD, right-hand finger tapping improved from 104 +/- 38 to 117 +/- 25 (mean +/- SD) (P = 0.02). Left-hand finger tapping showed a tendency to improve, the number of keystrokes increasing from 91 +/- 40 to 105 +/- 20 (P = 0.12). Right-hand reaction time improved from 1630 +/- 566 ms to 1409 +/- 442 ms, whereas left-hand reaction time improved from 1760 +/- 600 ms to 1467 +/- 420 ms (both P-values = 0.01). Significant improvements in motor performance were accompanied by bilateral increased activation in the supplementary motor area. No improvement was found in cognitive functioning. The results suggest that motor function recovery in INPH patients after CSF removal is related to enhanced activity in medial parts of frontal motor areas considered crucial for motor planning; a finding consistent with INPH being a syndrome related to a reversible suppression of frontal periventricular cortico-basal ganglia-thalamo-cortical pathways.

Surgical management of adult hydrocephalus

The management of adult hydrocephalus spans a broad range of disorders and ages. Modern management strategies include endoscopic and adjustable cerebrospinal fluid shunt diversionary techniques. The assessment and management of the following clinical conditions are discussed: 1) the adult patient with congenital or childhood-onset hydrocephalus, 2) adult slit ventricle syndrome, 3) multicompartmental hydrocephalus, 4) noncommunicating hydrocephalus, 5) communicating hydrocephalus, 6) normal pressure hydrocephalus, and 7) the shunted patient with headaches. The hydrodynamics of cerebrospinal fluid shunt diversion are discussed in relation to mechanisms of under- and overdrainage conditions. A rationale for the routine implementation of adjustable valves for adult patients with hydrocephalus is provided based on objective clinical and experimental data. For the condition of normal pressure hydrocephalus, recommendations are offered regarding the evaluation, surgical treatment, and postoperative management of this disorder.

Adult aqueductal stenosis presenting as a thunderclap headache: a case report

Thunderclap headache is well known to be a presenting feature of a variety of causal events. Indeed, a primary form is considered in the International Classification of Headache Disorders-II, but such diagnosis must be made only after exclusion of a possible secondary cause. We report a case of late-onset idiopathic aqueductal stenosis presenting with thunderclap headache, in the absence of abnormal neurological findings or indirect signs of raised intracranial pressure. The patient recovered completely after endoscopic third ventriculostomy. This case indicates primary aqueduct stenosis as a possible, never previously reported, cause of thunderclap headache.

Polyneuropathy complicating the diagnosis of normal pressure hydrocephalus: case report and review of literature

Polyneuropathy is a rare association of normal pressure hydrocephalus (NPH) and may complicate the diagnosis of both diseases. We describe a patient with NPH who presented with acute polyneuropathy. The patient was initially thought to have Guillain-Barré disease (GBS). Early consideration of NPH in patients presenting with acute polyneuropathy could result in prompt diagnosis and treatment of NPH.

Intracranial Pressure during Wakefulness and Sleep in 55 Adult Patients with Chronic Hydrocephalus

OBJECTIVE:

To record the levels of intracranial pressure (ICP) during wakefulness and sleep in hydrocephalic adults and to correlate the ICP levels with symptoms and degree of improvement after surgical treatment.

METHODS:

ICP and patient behavior were registered overnight (17–26 h) in 29 patients with noncommunicating and 26 with communicating hydrocephalus. Mean ICP was calculated during wakefulness (sitting or lying supine) and during sleep. Clinical symptoms and changes after surgery were scored on a continuous scale.

RESULTS:

Mean ICP during sleep was 13.4 mmHg (11.1–15.7 mmHg) in noncommunicating hydrocephalus versus 10.1 mmHg (8.8–11.4 mmHg) in communicating hydrocephalus (P &lt; 0.001). Patients with idiopathic communicating hydrocephalus had higher ICP, 11.4 mmHg (9.9–12.9 mmHg), than patients with secondary communicating hydrocephalus, 8.6 mmHg (6.5–10.6 mmHg). ICP was higher during sleep than when the patients were awake lying supine, 10.9 mmHg (8.7–13.1 mmHg) in noncommunicating versus 6.8 mmHg (5.3–8.3 mmHg) in communicating hydrocephalus (P &lt; 0.0001). The mean ICP in the sitting position was 2.4 mmHg (0.5–4.3 mmHg) in noncommunicating versus 0.5 mmHg (-0.7–1.8 mmHg) in communicating hydrocephalus. All but one patient with communicating hydrocephalus had a normal ICP (≤ 15 mmHg) versus 20 of the 29 patients with noncommunicating hydrocephalus. ICP levels showed no correlation with either symptoms or improvement after surgery.

CONCLUSION:

ICP is higher during sleep than during periods of awake lying supine (P &lt; 0.001) and is not correlated with either symptoms or the rate of improvement after surgery. ICP is normal in most adults with hydrocephalus.

How should primary aqueductal stenosis in adults be treated? A review

In 10% of adult patients with hydrocephalus, the cause is because of aqueductal stenosis (AS), causing enlargement of the lateral and third ventricles. There are currently two alternate forms of surgical treatment for AS; shunt surgery and ventriculostomy. Shunt surgery is associated with high complication rates and many patients need revisions, but the effectiveness is high. Endoscopic third ventriculostomy (ETV), re-establishing a physiological route of CSF dynamics, has become the treatment of choice for AS in most neurosurgical centers. ETV has fewer complications and revisions are rare, but some patients need shunt surgery to improve despite a patent ventriculostomy. There are today no common criteria for patient selection to either ETV or ventriculo-peritoneal shunt surgery.