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Kakinuma K, Morihara K, Shimoda Y, Kawakami N, Kanno S, Otomo M, Tominaga T, Suzuki K. Ventriculoperitoneal Shunt Failure 3-year after Shunt Surgery Caused by Migration of Detached Ventricular Catheter into the Cranium: A Case Study of Idiopathic Normal-pressure Hydrocephalus. NMC Case Rep J 2023; 10:9-14. [PMID: 36873747 PMCID: PMC9981232 DOI: 10.2176/jns-nmc.2022-0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/28/2022] [Indexed: 02/10/2023] Open
Abstract
Idiopathic normal-pressure hydrocephalus (iNPH) is a neurological disorder that typically presents with gait disturbance, cognitive impairment, and urinary incontinence. Although most patients respond to cerebrospinal-fluid shunting, some do not react well because of shunt failure. A 77-year-old female with iNPH underwent ventriculoperitoneal shunt implantation, and her gait impairment, cognitive dysfunction, and urge urinary incontinence improved. However, 3 years after shunting (at the age of 80), her symptoms gradually recurred for 3 months and she did not respond to shunt valve adjustment. Imaging studies revealed that the ventricular catheter detached from the shunt valve and migrated into the cranium. With immediate revision of the ventriculoperitoneal shunt, her gait disturbance, cognitive dysfunction, and urinary incontinence improved. When a patient whose symptoms have been relieved by cerebrospinal-fluid shunting experiences an exacerbation, it is important to suspect shunt failure, even if many years have passed since the surgery. Identifying the position of the catheter is crucial to determine the cause of shunt failure. Prompt shunt surgery for iNPH can be beneficial, even in elderly patients.
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Affiliation(s)
- Kazuo Kakinuma
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Keisuke Morihara
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.,Department of Neurology and Stroke Medicine, Yokohama City University School of Medicine, Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Yoshiteru Shimoda
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Nobuko Kawakami
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Shigenori Kanno
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mayuko Otomo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kyoko Suzuki
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Popal AM, Zhu Z, Guo X, Zheng Z, Cai C, Jiang H, Zhang J, Shao A, Zhu J. Outcomes of Ventriculoperitoneal Shunt in Patients With Idiopathic Normal-Pressure Hydrocephalus 2 Years After Surgery. Front Surg 2021; 8:641561. [PMID: 34869547 PMCID: PMC8634250 DOI: 10.3389/fsurg.2021.641561] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 10/14/2021] [Indexed: 11/29/2022] Open
Abstract
Objective: To evaluate the outcomes and prognostic factors of ventriculoperitoneal shunts (VP-shunts) in patients with idiopathic normal-pressure hydrocephalus (iNPH) at 6 months and 2 years after surgery. Method: We retrospectively analyzed 68 patients admitted to our institute and diagnosed with probable iNPH from January 2017 to March 2021. All patients underwent VP-shunt surgery with a programmable valve, and their outcomes were assessed via the Krauss index and modified Rankin scale (mRS) at 6 months and 2 years post-surgery. Univariate and multivariate regression analysis was performed to identify the prognostic factors. Results: The mean age of the patients was 71.1 ± 8.4 (mean ± standard deviation) years. On the Krauss improvement index, 6-month follow-up results were available for 68 patients. Of these patients, 91.2% experienced attenuation of their preoperative symptoms, with a mean Krauss index of 0.58 ± 0.27, and 48 patients (70.6%) had a Krauss index ≥0.5. Two-year follow-up results were available for 33 patients; 90.9% of them had sustained improvement, with a Krauss index of 0.54 ± 0.31, and 21 patients (66.3%) had a Krauss index ≥0.5. Thirty-three patients (58%) were living independently after 2 years (mRS 0–2). The outcomes were worse for patients with multiple comorbidities. Neither an increased patient age nor a prolonged history of illness was statistically significant prognostic factors for adverse outcomes of VP-shunt surgery. Conclusion: Surgical treatment was well-tolerated by patients with iNPH who received VP-shunts. Most patients experienced attenuation of their preoperative symptoms. Multiple concurrent comorbidities should be considered as adverse prognostic factors before shunt insertion in patients with iNPH.
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Affiliation(s)
- Abdul Malik Popal
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhoule Zhu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xinxia Guo
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chengwei Cai
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hongjie Jiang
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Anwen Shao
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
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de Oliveira MF, Sorte AAB, Emerenciano DL, Rotta JM, Mendes GAS, Pinto FCG. Long term follow-up of shunted idiopathic normal pressure hydrocephalus patients: a single center experience. Acta Neurol Belg 2021; 121:1799-1806. [PMID: 33136273 DOI: 10.1007/s13760-020-01538-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a condition characterized by gait disturbance, dementia and/or urinary incontinence and enlarged ventricular system due to disturbance of cerebrospinal fluid (CSF). This study aims to describe the long-term experience with patients with iNPH submitted to ventriculoperitoneal shunt (VPS) with the programmable valve STRATA® (Medtronic). We prospectively selected a cohort of patients with a diagnosis of iNPH from January 2010 to April 2013 in a Brazilian tertiary hospital. All patients underwent clinical evaluation, which consists of the Mini-Mental State Examination and Time Up and Go tests and the application of Japanese Scale for Idiopathic Normal Pressure Hydrocephalus in three stages: prior to the TT, 3 h after the TT and 72 h after the TT. Fifty patients were submitted to VPS and followed. There were 32 men and 18 women. Mean age was 77.1 with standard deviation of 10.9. Follow-up time ranged from 96 to 120 months, with mean of 106 months. After 1 year of follow-up, 42 (83%) patients presented with clinical improvement, decreasing to 62% of patients at mid-term follow-up and 38% of patients at late follow-up. Complications occurred in 18% of subjects, needing reoperation in 16%. Our results show relevant clinical impact of shunting in iNPH patients, decreasing over time. Complications should not be underestimated, reaching up to 18% and demanding reoperation in 16% of cases. Thus, although much has been improved with current shunt technology, it is still important to consider the drawbacks of treatment.
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Tang YM, Yao Y, Xu S, Li X, Hu F, Wang H, Ding J, Wang X. White Matter Microstructural Damage Associated With Gait Abnormalities in Idiopathic Normal Pressure Hydrocephalus. Front Aging Neurosci 2021; 13:660621. [PMID: 34434100 PMCID: PMC8382089 DOI: 10.3389/fnagi.2021.660621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Idiopathic normal pressure hydrocephalus (iNPH) is a common disease in elderly adults. Patients with iNPH are generally characterized by progressive gait impairment, cognitive deficits, and urinary urgency and/or incontinence. A number of radiographic studies have shown that iNPH patients have enlarged ventricles and altered brain morphology; however, few studies have focused on the relationships between altered brain structure and gait dysfunction due to iNPH. Thus, this study aimed to evaluate the abnormalities of white matter (WM) correlated with gait impairment in iNPH patients and to gain a better understanding of its underlying pathology. Methods: Fifteen iNPH patients (five women, 10 men) were enrolled in this study, and each patient’s demographic and gait indices were collected. First, we performed a correlation analysis between the demographic and gait indices. Then, all gait indices were grouped according to the number of WM hyperintensities (WMH) among each WM tract (JHU WM tractography atlas), to perform comparative analysis. Results: Considering sex and illness duration as covariates, correlation analysis showed a significantly negative correlation between step length (r = −0.80, p = 0.001), pace (r = −0.84, p = 2.96e-4), and age. After removing the effects of age, sex, and illness duration, correlation analysis showed negative correlation between step length (r = −0.73, p = 0.007), pace (r = −0.74, p = 0.005), and clinical-grade score and positive correlation between 3-m round trip time (r = 0.66, p = 0.021), rising time (r = 0.76, p = 0.004), and clinical-grade score. Based on WMH of each white matter tract, gait indices showed significant differences (p < 0.05/48, corrected by Bonferroni) between fewer WMH patients and more WMH in the middle cerebellar peduncle, left medial lemniscus, left posterior limb of the internal capsule (IC), and right posterior limb of the IC. Conclusions: Our results indicated that iNPH patients exhibited gait-related WM abnormalities located in motor and sensory pathways around the ventricle, which is beneficial to understand the underlying pathology of iNPH.
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Affiliation(s)
- Yan-Min Tang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ye Yao
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuai Xu
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Xin Li
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fan Hu
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - He Wang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai, China
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of The State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai, China
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Koo AB, Elsamadicy AA, Lin IH, David WB, Reeves BC, Santarosa C, Cord B, Malhotra A, Kahle KT, Matouk CC. Patient Risk Factors Associated With 30- and 90-Day Readmission After Ventriculoperitoneal Shunt Placement for Idiopathic Normal Pressure Hydrocephalus in Elderly Patients: A Nationwide Readmission Study. World Neurosurg 2021; 152:e23-e31. [PMID: 33862298 DOI: 10.1016/j.wneu.2021.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE For idiopathic normal pressure hydrocephalus (iNPH), risk stratifying patients and identifying those who are likely to fare well after ventriculoperitoneal shunt (VP) surgery may help improve quality of care and reduce unplanned readmissions. The aim of this study was to investigate the drivers of 30- and 90-day readmissions after VP shunt surgery for iNPH in elderly patients. METHODS The Nationwide Readmission Database, years 2013 to 2015, was queried. Elderly patients (≥65 years old) undergoing VP shunt surgery were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and identify 30- and 31- to 90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). RESULTS We identified 7199 elderly patients undergoing VP shunt surgery for iNPH. A total of 1413 (19.6%) patients were readmitted (30-R: n = 812 [11.3%] vs. 90-R: n = 601 [8.3%] vs. Non-R: n = 5786). The most prevalent 30- and 90-day complications seen among the readmitted cohort were mechanical complication of nervous system device implant (30-R: 16.1%, 90-R: 12.4%), extracranial postoperative infection (30-R: 10.4%, 90-R: 7.0%), and subdural hemorrhage (30-R: 6.0%, 90-R: 16.4%). On multivariate regression analysis, age, diabetes, and renal failure were independently associated with 30-day readmission; female sex, and 26th to 50th household income percentile were independently associated with reduced likelihood of 90-day readmission. Having any complication during the index admission independently associated with both 30- and 90-day readmission. CONCLUSIONS In this study, we identify the most common drivers for readmission for elderly patients with iNPH undergoing VP shunt surgery.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - I-Hsin Lin
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Branden Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA.
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Trevisi G, Signorelli F, de Waure C, Stifano V, Sturdà C, Rapisarda A, Pompucci A, Mangiola A, Anile C. Intraventricular infusion test accuracy in predicting short- and long-term outcome of iNPH patients: a 10-year update of a three-decade experience at a single institution. Neurosurg Rev 2021; 44:3323-3334. [PMID: 33590367 DOI: 10.1007/s10143-021-01495-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/19/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In a previous work, we found that an Intracranial Elastance Index (IEI) ≥0.3 at ventricular infusion test had a high accuracy in predicting shunt response at 6 and 12 months in idiopathic normal pressure hydrocephalus (iNPH). The aim of this study was to verify the accuracy of IEI to predict response to shunt at both short- and long-term follow-up. METHODS Retrospective evaluation of 64 patients undergoing ventriculo-peritoneal shunting for iNPH between 2006 and 2015 based on a positive ventricular infusion test (IEI≥0.3). Patients were classified according to Krauss scale and mRS preoperatively, at 1-year and at last follow-up. An improvement of at least one point at Krauss score or at mRS was considered as a good outcome; unchanged or worsened patients were grouped as poor outcome. RESULTS Mean follow-up was 6.6 years. Improvement at Krauss scale was seen in 62.5% and 64.3% of patients at 1-year and last follow-up, respectively. Patients in good functional status (mRS≤2) increased from 25 in the preoperative period to 57% at both 1-year and last follow-up. IEI was significantly associated with Krauss (p=0.041) and mRS (p=0.036) outcome at last follow-up. Patients with worse preoperative Krauss and mRS had higher chance to improve but higher overall scores after treatment. At ROC curves, IEI showed a good long-term prediction of change in mRS from first year to last follow-up. CONCLUSIONS IEI≥0.3 predicts outcomes at both short- and long-term, with more than 50% of patients being able to look after themselves after 6 years from treatment.
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Affiliation(s)
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Chiara de Waure
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Vito Stifano
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Cosimo Sturdà
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alessandro Rapisarda
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Angelo Pompucci
- Neurosurgical Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | - Annunziato Mangiola
- Neurosurgical Unit, Ospedale Spirito Santo, Pescara, Italy.,Department of Neurosciences, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Carmelo Anile
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
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Hamilton M, Isaacs A. Natural History, Treatment Outcomes and Quality of Life in Idiopathic Normal Pressure Hydrocephalus (iNPH). Neurol India 2021; 69:S561-S568. [DOI: 10.4103/0028-3886.332281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kaestner S, Behrends R, Roth C, Graf K, Deinsberger W. Treatment for secondary deterioration in idiopathic normal pressure hydrocephalus in the later course of the disease: a retrospective analysis. Acta Neurochir (Wien) 2020; 162:2431-2439. [PMID: 32623600 DOI: 10.1007/s00701-020-04475-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunting is a highly effective treatment for idiopathic normal pressure hydrocephalus (iNPH). However, secondary deterioration can occur at a later time. Thus, the current study aimed to evaluate the incidence rate and causes of secondary deterioration. METHODS A retrospective analysis was conducted on all patients with iNPH who were treated with implantation of a CSF shunt since 1993. A meticulous shunt workup was recommended to all patients who presented to our department with secondary deterioration during their follow-up visits. Data about the proportion of patients with such deterioration and its causes, subsequent treatment, and clinical outcome were obtained. RESULTS A total of 169 patients were included, and the mean follow-up time was 69.2 months. In total, 119 (70.4%) patients presented with a total of 153 secondary deteriorations. In 9 cases (5.9%), the deterioration was caused by delayed subdural hematoma and in 27 (22.1%) cases, by shunt dysfunction. Invasive shunt testing was commonly required to validate shunt failure. Moreover, 19 of 27 patients experienced a satisfactory improvement after revision surgery. In total, 86 deteriorations were attributed to nonsurgical causes, and the valve pressure was decreased in 79 patients, with only 16.5% presenting with a satisfactory improvement after lowering of valve pressure. CONCLUSIONS Most patients with shunted iNPH presented with deterioration in the later course of the disease. Shunt dysfunction was considered a cause of secondary deterioration. Moreover, shunt revision surgery was a highly effective treatment, and patients with deterioration should undergo screening procedures for shunt dysfunction, including invasive shunt testing.
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Affiliation(s)
- Stefanie Kaestner
- Department of Neurosurgery, Klinikum Kassel, Moencheberg Str. 41-43, 34125, Kassel, Germany.
- Kassel School of Medicine, University of Southampton, 12 University Rd, Southampton, SO17 1BJ, UK.
| | - Rhea Behrends
- Kassel School of Medicine, University of Southampton, 12 University Rd, Southampton, SO17 1BJ, UK
| | - Christian Roth
- Department of Neurology, Red Cross Clinic, Hanstein Str. 29, 34121, Kassel, Germany
| | - Katharina Graf
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstraße 29, 35392, Giessen, Germany
| | - Wolfgang Deinsberger
- Department of Neurosurgery, Klinikum Kassel, Moencheberg Str. 41-43, 34125, Kassel, Germany
- Kassel School of Medicine, University of Southampton, 12 University Rd, Southampton, SO17 1BJ, UK
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Fasano A, Espay AJ, Tang-Wai DF, Wikkelsö C, Krauss JK. Gaps, Controversies, and Proposed Roadmap for Research in Normal Pressure Hydrocephalus. Mov Disord 2020; 35:1945-1954. [PMID: 32959936 DOI: 10.1002/mds.28251] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/09/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus is considered common but remains underinvestigated. There are no uniformly accepted diagnostic criteria and therapeutic guidelines. We summarize the accumulated evidence regarding the definition, pathophysiology, diagnosis, and treatment of idiopathic normal pressure hydrocephalus, highlighting the many gaps and controversies, including diagnostic challenges, the frequent association with neurodegeneration and vascular disease, and the many unknowns regarding patient selection and outcome predictors. A roadmap to fill these gaps and solve the controversies around this condition is also proposed. More evidence is required with respect to diagnostic criteria, the value of ancillary testing, prospective population-based studies and novel trial designs. Furthermore, a need exists to develop new advanced options in shunt technology. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada.,Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,Center for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada.,Howard Cohen Normal Pressure Hydrocephalus Program, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Alberto J Espay
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - David F Tang-Wai
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,Howard Cohen Normal Pressure Hydrocephalus Program, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada.,University Health Network Memory Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Carsten Wikkelsö
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
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Ugga L, Cuocolo R, Cocozza S, Pontillo G, Elefante A, Quarantelli M, Vicidomini C, De Pandis MF, De Michele G, D'Amico A, de Divitiis O, Brunetti A. Magnetic resonance parkinsonism indices and interpeduncular angle in idiopathic normal pressure hydrocephalus and progressive supranuclear palsy. Neuroradiology 2020; 62:1657-1665. [PMID: 32710162 PMCID: PMC7666671 DOI: 10.1007/s00234-020-02500-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022]
Abstract
Purpose The clinical presentation of idiopathic normal pressure hydrocephalus (iNPH) may overlap with progressive supranuclear palsy (PSP). The Magnetic Resonance Parkinsonism Index (MRPI), MRPI 2.0, and the interpeduncular angle (IPA) have been investigated to differentiate PSP from healthy controls (HC) and other parkinsonisms. We aimed to assess equivalences and differences in MRPI, MRPI 2.0, and IPA in iNPH, PSP, and HC groups. Methods We retrospectively recruited 99 subjects (30 iNPH, 32 PSP, 37 HC) from two institutions. MRI exams, acquired on either 1.5 T or 3 T scanners, included 3D T1-weighted images to measure MRPI, MRPI 2.0, and IPA. Inter- and intra-rater reliability was investigated with the intra-class correlation coefficient (ICC), and the two one-sided t tests (TOST) procedure was used to assess these markers in iNPH, PSP, and HC. Results For all the three measures, intra-rater and inter-rater ICC were excellent (range = 0.91–0.93). In the comparison of iNPH and PSP with HC, differences for MRPI and MRPI 2.0 (p < 0.01 in all cases) and no equivalence (p = 1.00 in all cases) were found at TOST. iNPH and PSP MRPI showed no difference (p = 0.06) and no equivalence (p = 0.08). MRPI 2.0 was not equivalent (p = 0.06) and not different (p = 0.09) in the same two populations. PSP and HC IPA proved equivalent (p < 0.01) while iNPH IPA was different (p < 0.01) and not equivalent (p = 0.96 and 0.82) from both PSP and HC. Conclusion MRPI and MRPI 2.0 significantly overlap in iNPH and PSP, with risk of misdiagnosis, and for this reason may not be helpful in the differential diagnosis. Electronic supplementary material The online version of this article (10.1007/s00234-020-02500-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lorenzo Ugga
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Renato Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy.
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Andrea Elefante
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Mario Quarantelli
- Institute of Biostructure and Bioimaging, National Research Council, Naples, Italy
| | - Caterina Vicidomini
- Institute of Biostructure and Bioimaging, National Research Council, Naples, Italy
- San Raffaele Rehabilitation Institute, Cassino, Italy
| | | | - Giovanna De Michele
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Alessandra D'Amico
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Oreste de Divitiis
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
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Andrén K, Wikkelsø C, Sundström N, Israelsson H, Agerskov S, Laurell K, Hellström P, Tullberg M. Survival in treated idiopathic normal pressure hydrocephalus. J Neurol 2019; 267:640-648. [PMID: 31713102 PMCID: PMC7035239 DOI: 10.1007/s00415-019-09598-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/19/2019] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To describe survival and causes of death in 979 treated iNPH patients from the Swedish Hydrocephalus Quality Registry (SHQR), and to examine the influence of comorbidities, symptom severity and postoperative outcome. METHODS All 979 patients operated for iNPH 2004-2011 and registered in the SHQR were included. A matched control group of 4890 persons from the general population was selected by Statistics Sweden. Data from the Swedish Cause of Death Registry was obtained for patients and controls. RESULTS At a median 5.9 (IQR 4.2-8.1) year follow-up, 37% of the iNPH patients and 23% of the controls had died. Mortality was increased in iNPH patients by a hazard ratio of 1.81, 95% CI 1.61-2.04, p < 0.001. More pronounced symptoms in the preoperative ordinal gait scale and the Mini-mental State Examination were the most important independent predictors of mortality along with the prevalence of heart disease. Patients who improved in both the gait scale and in the modified Rankin Scale postoperatively (n = 144) had a similar survival as the general population (p = 0.391). Deaths due to cerebrovascular disease or dementia were more common in iNPH patients, while more controls died because of neoplasms or disorders of the circulatory system. CONCLUSIONS Mortality in operated iNPH patients is 1.8 times increased compared to the general population, a lower figure than previously reported. The survival of iNPH patients who improve in gait and functional independence is similar to that of the general population, indicating that shunt surgery for iNPH, besides improving symptoms and signs, can normalize survival.
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Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden.
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Hanna Israelsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Simon Agerskov
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Katarina Laurell
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
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12
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Skalický P, Mládek A, Vlasák A, De Lacy P, Beneš V, Bradáč O. Normal pressure hydrocephalus—an overview of pathophysiological mechanisms and diagnostic procedures. Neurosurg Rev 2019; 43:1451-1464. [DOI: 10.1007/s10143-019-01201-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/27/2019] [Accepted: 10/25/2019] [Indexed: 01/25/2023]
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13
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Gallagher R, Bateman G, Marquez J, Osmotherly P. Are gait changes linked to CSF flow changes in the sagittal sinus? Neuroradiology 2019; 61:659-666. [DOI: 10.1007/s00234-019-02192-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/21/2019] [Indexed: 11/27/2022]
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14
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Liew BS, Takagi K, Kato Y, Duvuru S, Thanapal S, Mangaleswaran B. Current Updates on Idiopathic Normal Pressure Hydrocephalus. Asian J Neurosurg 2019; 14:648-656. [PMID: 31497081 PMCID: PMC6703007 DOI: 10.4103/ajns.ajns_14_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is one of the neurodegenerative diseases which can be treated surgically with favorable outcome. The gait disturbance, cognitive, and urinary symptoms are known as the clinical triad of iNPH. In this review, we have addressed the comorbidities, differential diagnoses, clinical presentations, and pathology of iNPH. We have also summarized the imaging studies and clinical procedures used for the diagnosis of iNPH. The treatment modality, outcomes, and prognosis were also discussed.
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Affiliation(s)
- Boon Seng Liew
- Department of Neurosurgery, Hospital Sungai Buloh, Selangor, Malaysia
| | - Kiyoshi Takagi
- Normal Pressure Hydrocephalus Center, Tokyo Neurological Center Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Shyam Duvuru
- Department of Neurosurgery, Velammal Hospitals, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Sengottuvel Thanapal
- Department of Neurosurgery, Government Mohan Kumaramangalam Medical College, Salem, Tamil Nadu, India
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15
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Delayed symptom progression after ventriculoperitoneal shunt placement for normal pressure hydrocephalus. J Neurol Sci 2018; 393:105-109. [DOI: 10.1016/j.jns.2018.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/17/2018] [Accepted: 08/02/2018] [Indexed: 11/19/2022]
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16
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Grahnke K, Jusue-Torres I, Szujewski C, Joyce C, Schneck M, Prabhu VC, Anderson DE. The Quest for Predicting Sustained Shunt Response in Normal-Pressure Hydrocephalus: An Analysis of the Callosal Angle's Utility. World Neurosurg 2018; 115:e717-e722. [DOI: 10.1016/j.wneu.2018.04.150] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
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17
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Hong B, Polemikos M, Heissler HE, Hartmann C, Nakamura M, Krauss JK. Challenges in cerebrospinal fluid shunting in patients with glioblastoma. Fluids Barriers CNS 2018; 15:16. [PMID: 29860942 PMCID: PMC5985574 DOI: 10.1186/s12987-018-0101-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/11/2018] [Indexed: 01/17/2023] Open
Abstract
Background Cerebrospinal fluid (CSF) circulation disturbances may occur during the course of disease in patients with glioblastoma. Ventriculoperitoneal shunting has generally been recommended to improve symptoms in glioblastoma patients. Shunt implantation for patients with glioblastoma, however, presents as a complex situation and produces different problems to shunting in other contexts. Information on complications of shunting glioma patients has rarely been the subject of investigation. In this retrospective study, we analysed restropectively the course and outcome of glioblastoma-related CSF circulation disturbances after shunt management in a consecutive series of patients within a period of over a decade. Methods Thirty of 723 patients with histopathologically-confirmed glioblastoma diagnosed from 2002 to 2016 at the Department of Neurosurgery, Hannover Medical School, underwent shunting for CSF circulation disorders. Treatment history of glioblastoma and all procedures associated with shunt implementation were analyzed. Data on follow-up, time to progression and survival rates were obtained by review of hospital charts and supplemented by phone interviews with the patients, their relations or the primary physicians. Results Mean age at the time of diagnosis of glioblastoma was 43 years. Five types of CSF circulation disturbances were identified: obstructive hydrocephalus (n = 9), communicating hydrocephalus (n = 15), external hydrocephalus (n = 3), trapped lateral ventricle (n = 1), and expanding fluid collection in the resection cavity (n = 2). All patients showed clinical deterioration. Procedures for CSF diversion were ventriculoperitoneal shunt (n = 21), subduroperitoneal shunt (n = 3), and cystoperitoneal shunt (n = 2). In patients with lower Karnofsky Performance Score (KPS) (< 60), there was a significant improvement of median KPS after shunt implantation (p = 0.019). Shunt revision was necessary in 9 patients (single revision, n = 6; multiple revisions, n = 3) due to catheter obstruction, catheter dislocation, valve defect, and infection. Twenty-eight patients died due to disease progression during a median follow-up time of 88 months. The median overall survival time after diagnosis of glioblastoma was 10.18 months. Conclusions CSF shunting in glioblastoma patients encounters more challenge and is associated with increased risk of complications, but these can be usually managed by revision surgeries. CSF shunting improves neurological function temporarily, enhances quality of life in most patients although it is not known if survival rate is improved.
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Affiliation(s)
- Bujung Hong
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | - Manolis Polemikos
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Hans E Heissler
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Christian Hartmann
- Institute for Pathology, Department for Neuropathology, Hannover Medical School, Hannover, Germany
| | - Makoto Nakamura
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.,Department of Neurosurgery, Cologne Mehrheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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18
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Pyykkö OT, Nerg O, Niskasaari HM, Niskasaari T, Koivisto AM, Hiltunen M, Pihlajamäki J, Rauramaa T, Kojoukhova M, Alafuzoff I, Soininen H, Jääskeläinen JE, Leinonen V. Incidence, Comorbidities, and Mortality in Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2018; 112:e624-e631. [PMID: 29374607 DOI: 10.1016/j.wneu.2018.01.107] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/14/2018] [Accepted: 01/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECT To investigate the incidence, comorbidities, mortality, and causes of death in idiopathic normal pressure hydrocephalus (iNPH). METHODS A cohort of 536 patients with possible NPH from a defined population with a median follow-up time of 5.1 years, (range 0.04-19.9 years) was included in the study. Patients were evaluated by brain imaging and intraventricular pressure monitoring, with a brain biopsy specimen immunostained against amyloid-β and hyperphosphorylated τ. Hospital records were reviewed for vascular diseases and type 2 diabetes mellitus (T2DM). Death certificates and yearly population of the catchment area were obtained from national registries. RESULTS A total of 283 patients had a clinical diagnosis of iNPH, leading to a median annual incidence of 1.58 iNPH patients per 100,000 inhabitants (range, 0.8-4.5). Alzeimer disease-related brain biopsy findings were less frequent in iNPH patients than in non-iNPH patients (P < 0.05). An overrepresentation of hypertension (52% vs. 33%, P < 0.001) and T2DM (23% vs. 13%, P = 0.002) was noted in iNPH patients. Age (hazard ratio [HR] 1.04/year, 95% confidence interval [CI] 1.03-1.06, P < 0.001) and T2DM (HR 1.63, 95% CI 1.23-2.16, P < 0.001) increased the risk of death in the iNPH patients and in the total population. iNPH was associated with decreased risk of death (HR 0.63, 95% CI 0.50-0.78, P < 0.001). The most frequent causes of death were cardiovascular and cerebrovascular disease. Dementia as a cause of death was more common in non-iNPH patients (27% vs. 10%, P < 0.001). CONCLUSIONS Hypertension and T2DM are common in iNPH and the latter causes excess mortality in the affected patients.
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Affiliation(s)
- Okko T Pyykkö
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
| | - Ossi Nerg
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | | | - Timo Niskasaari
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Anne M Koivisto
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | - Mikko Hiltunen
- Institute of Biomedicine, University of Eastern Finland, Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Jussi Pihlajamäki
- Department of Clinical Nutrition, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, and Clinical Nutrition and Obesity Center, Kuopio University Hospital, Kuopio, Finland
| | - Tuomas Rauramaa
- Department of Pathology, Kuopio University Hospital, and Institute of Clinical Medicine - Pathology, University of Eastern Finland, Kuopio, Finland
| | - Maria Kojoukhova
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Irina Alafuzoff
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Hilkka Soininen
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | | | - Ville Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
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19
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Long-term effects of complications and vascular comorbidity in idiopathic normal pressure hydrocephalus: a quality registry study. J Neurol 2017; 265:178-186. [PMID: 29188384 PMCID: PMC5760598 DOI: 10.1007/s00415-017-8680-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/13/2017] [Indexed: 02/07/2023]
Abstract
Background There is little knowledge about the factors influencing the long-term outcome after surgery for idiopathic normal pressure hydrocephalus (iNPH). Objective To evaluate the effects of reoperation due to complications and of vascular comorbidity (hypertension, diabetes, stroke and heart disease) on the outcome in iNPH patients, 2–6 years after shunt surgery. Methods We included 979 patients from the Swedish Hydrocephalus Quality Registry (SHQR), operated on for iNPH during 2004–2011. The patients were followed yearly by mailed questionnaires, including a self-assessed modified Rankin Scale (smRS) and a subjective comparison between their present and their preoperative health condition. The replies were grouped according to the length of follow-up after surgery. Data on clinical evaluations, vascular comorbidity, and reoperations were extracted from the SHQR. Results On the smRS, 40% (38–41) of the patients were improved 2–6 years after surgery and around 60% reported their general health condition to be better than preoperatively. Reoperation did not influence the outcome after 2–6 years. The presence of vascular comorbidity had no negative impact on the outcome after 2–6 years, assessed as improvement on the smRS or subjective improvement of the health condition, except after 6 years when patients with hypertension and a history of stroke showed a less favorable development on the smRS. Conclusion This registry-based study shows no negative impact of complications and only minor effects of vascular comorbidity on the long-term outcome in iNPH.
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20
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Yang L, Wang X, Li Y, Chen L, Yan Z, She L, Dong J. The Clinical Effect of Postoperative Hyperbaric Oxygen Therapy on Idiopathic Normal Pressure Hydrocephalus: A Retrospective and Comparative Analysis of 61 Patients with Ventriculoperitoneal Shunt. World Neurosurg 2017; 104:376-380. [PMID: 28502690 DOI: 10.1016/j.wneu.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/28/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aim of the study was to examine the clinical effect of postoperative hyperbaric oxygen (HBO) therapy on symptoms and signs in the ventriculoperitoneal (VP) shunt insertion treatment of idiopathic normal pressure hydrocephalus (iNPH). METHODS We conducted a retrospective analysis of 61 patients treated at our institution for iNPH since 2007. Patients were stratified into 2 groups according to undergoing pure VP shunt with gravitational valves (group 1) or combined with postoperative HBO therapy (group 2). Clinical improvements as well as complications were compared between the 2 groups. RESULTS There was no significant difference between the 2 groups regarding age, sexual proportion, body mass index, education years, and the average Normal Pressure Hydrocephalus Scale score before the surgery, as well as the complication rate after the surgery (P > 0.05). On average, the total Normal Pressure Hydrocephalus Scale scores were both increased in the 2 groups at 1, 3, and 6 months after shunting, with no significant differences (P > 0.05). However, group 2 tended to increase more compared with group 1, especially 6 months later after shunting. The increase of cognitive functions was more significant in group 2 (P < 0.05). CONCLUSIONS HBO therapy combined with VP shunt is expected to improve the effect of iNPH treatment, especially for cognitive performance.
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Affiliation(s)
- Lin Yang
- Department of Neurosurgery, Second Affiliated Hospital of Soochow University, Jiangsu Province, China; Department of Neurosurgery, Yizheng People's Hospital, Yizheng, Jiangsu Province, China
| | - Xingdong Wang
- Department of Neurosurgery, Clinical Medical College of Yang Zhou University, Yangzhou, Jiangsu Province, China
| | - Yuping Li
- Department of Neurosurgery, Clinical Medical College of Yang Zhou University, Yangzhou, Jiangsu Province, China
| | - Lang Chen
- Department of Neurosurgery, Clinical Medical College of Yang Zhou University, Yangzhou, Jiangsu Province, China
| | - Zhengcun Yan
- Department of Neurosurgery, Clinical Medical College of Yang Zhou University, Yangzhou, Jiangsu Province, China
| | - Lei She
- Department of Neurosurgery, Clinical Medical College of Yang Zhou University, Yangzhou, Jiangsu Province, China
| | - Jun Dong
- Department of Neurosurgery, Second Affiliated Hospital of Soochow University, Jiangsu Province, China.
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21
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Mortality and risk of dementia in normal-pressure hydrocephalus: A population study. Alzheimers Dement 2017; 13:850-857. [PMID: 28238737 DOI: 10.1016/j.jalz.2017.01.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/28/2016] [Accepted: 01/07/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION We examined mortality, dementia, and progression of hydrocephalic symptoms among untreated individuals with idiopathic normal-pressure hydrocephalus (iNPH) in a population-based sample. METHODS A total of 1235 persons were examined between 1986 and 2012. Shunted individuals were excluded. We examined 53 persons with hydrocephalic ventricular enlargement (probable iNPH: n = 24, asymptomatic or possible iNPH: n = 29). Comparisons were made with individuals without hydrocephalic ventricular enlargement. RESULTS The 5-year mortality was 87.5% among those with probable iNPH. The hazard ratio (HR) for death was 3.8 (95% confidence interval [CI]: 2.5-6.0) for probable iNPH. Those with possible iNPH and asymptomatic hydrocephalic ventricular enlargement had increased risk of developing dementia, HR 2.8 (95% CI: 1.5-5.2). Only two individuals with hydrocephalic ventricular enlargement remained asymptomatic. DISCUSSION In the present sample, persons with clinical and imaging signs of iNPH had excess mortality and an increased risk of dementia. The data also suggest that radiological signs of iNPH might be more important than previously supposed.
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22
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Kaestner S, Poetschke M, Roth C, Deinsberger W. Different origins of hydrocephalus lead to different shunt revision rates. Neurol Neurochir Pol 2017; 51:72-76. [PMID: 28063609 DOI: 10.1016/j.pjnns.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 08/20/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hydrocephalus (HC) occurs due to multiple origins. Time course and dynamic of HC and its therapies differ between underlying pathologies. Different revision rates due to the type of HC are expected. Though hydrocephalus is known to be a life time condition, the lack of shunt malfunction years or decades after initial shunt insertion raises the hope of a superfluous shunt. METHODS We conducted a retrospective survey of our OR-database during a 10 year period. All newly inserted shunt systems and subsequent shunt revisions are recorded according to quantity and time point. All patients were subdivided according their aetiology of HC. RESULTS 260 patients were eligible with a follow-up of 4.5 years. Subgroups were: 90 patients with NPH, 76 patients with posthaemorrhagic and 16 patients had posttraumatic HC. 22 received a shunt as a consequence of a tumour, 41 were children and 15 for other causes. Overall revision rate was 39.5%. During the first 6 months 55.6%, 57.9% and 75% of patients with NPH, posthaemorrhagic and posttraumatic HC had revisions. In contrast only 38.1% of children and 20% of tumour cases required early revision. CONCLUSION Two different patterns of revision are evident: mainly early revisions in morphologically stable diseases such as posthaemorrhagic, posttraumatic and NPH and predominantly late revisions in changing organisms such as children and tumour patients. The conception HC may be transient because of a lack of late revisions cannot be supported by this data.
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Affiliation(s)
| | - Manuela Poetschke
- Applied Statistics, Department 05, University of Kassel, Kassel, Germany
| | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
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23
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Shaw R, Mahant N, Jacobson E, Owler B. A Review of Clinical Outcomes for Gait and Other Variables in the Surgical Treatment of Idiopathic Normal Pressure Hydrocephalus. Mov Disord Clin Pract 2016; 3:331-341. [PMID: 30363503 PMCID: PMC6178707 DOI: 10.1002/mdc3.12335] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 01/07/2016] [Accepted: 01/09/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (INPH) is a treatable cause of gait disturbance, cognitive impairment, and urinary incontinence. This clinical triad of symptoms occurs in association with ventriculomegaly and normal cerebrospinal fluid (CSF) pressure. Although the treatment outcomes after CSF shunting for INPH have improved significantly since its first description in 1965, shortcomings in our understanding still remain. Not all INPH patients exhibit clinical improvement after shunting, and it is challenging to identify patients who are more likely to benefit from shunting. METHODS The Cochrane Library, Medline, Embase, and PubMed databases were searched for English-language publications between 1965 and October 2015. Reference lists of publications were also manually searched for additional publications. RESULTS The findings of this review indicate that, despite efforts to improve patient selection, the degree of clinical improvement after shunting continues to demonstrate significant variability both within and between studies. These discrepancies in treatment outcomes are the result of controversies in 3 distinct but interrelated domains: the underlying pathophysiology of INPH, the diagnosis of INPH, and the identification of likely shunt-responders. CONCLUSIONS This review focuses on these 3 areas and their relation to surgical treatment outcomes. Despite the limitations of published outcome studies and limitations in our understanding of INPH pathophysiology, shunting is a safe and effective means of achieving meaningful clinical improvement in most patients with INPH.
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Affiliation(s)
- Richard Shaw
- Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Neil Mahant
- Department of NeurologyWestmead HospitalSydneyAustralia
- Western Clinical School: Medicine (Westmead)University of SydneySydneyAustralia
| | - Erica Jacobson
- Department of NeurosurgeryPrince of Wales HospitalSydneyAustralia
| | - Brian Owler
- Department of NeurosurgerySydney Adventist HospitalSydneyAustralia
- Department of SurgeryUniversity of SydneySydneyAustralia
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24
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Koivisto AM, Kurki MI, Alafuzoff I, Sutela A, Rummukainen J, Savolainen S, Vanninen R, Jääskeläinen JE, Soininen H, Leinonen V. High Risk of Dementia in Ventricular Enlargement with Normal Pressure Hydrocephalus Related Symptoms1. J Alzheimers Dis 2016; 52:497-507. [DOI: 10.3233/jad-150909] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anne M. Koivisto
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mitja I. Kurki
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Irina Alafuzoff
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University and Department of Pathology and Cytology, Uppsala University Hospital, Uppsala, Sweden
| | - Anna Sutela
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Jaana Rummukainen
- Department of Pathology, Kuopio University Hospital, Kuopio, Finland
| | - Sakari Savolainen
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Ritva Vanninen
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Clinical Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Juha E. Jääskeläinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hilkka Soininen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Ville Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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25
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Qu CY, Xu DF. Comprehensive urodynamics: Being devoted to clinical urologic practice. World J Clin Urol 2014; 3:96-112. [DOI: 10.5410/wjcu.v3.i2.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/12/2014] [Accepted: 06/16/2014] [Indexed: 02/06/2023] Open
Abstract
As a combined electrophysiological system for evaluating the lower urinary tract (LUT), comprehensive urodynamics (UDS) aims at duplicating patient’s micturition process, either normal or abnormal, and further seeking for possible causative origin, either neurogenic or non-neurogenic, in order to guide treatment. Through thorough analysis, some so-called cut-off values, for example, bladder outlet obstruction (BOO) degree or dyssynergic degree between the detrusor and sphincter, could be gained; however, in most cases, their qualitative description, such as stress urinary incontinence, idiopathic detrusor underactivity (DUA), detrusor overactivity (IDO), low compliance, and idiopathic sphincter overactivity (ISO), is more preferable and important. In aged neurologically intact male patients with symptoms of the LUT (LUTS) including benign prostatic hyperplasia, a combined UDS system, which coupled BOO with compliance, was constructed. The patients may be categorized into one of the seven subgroups, including equivocal or mild BOO with sphincter synergia with or without IDO (pattern A), equivocal or mild BOO with ISO (B), classic BOO with sphincter synergia (C) or ISO (D), BOO with only low compliance (E), BOO with both DUA and low compliance (F), and potential BOO with DUA (G). This new system can be used to optimize diagnosis and treatment according to a derived guideline diagram.
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Chotai S, Medel R, Herial NA, Medhkour A. External lumbar drain: A pragmatic test for prediction of shunt outcomes in idiopathic normal pressure hydrocephalus. Surg Neurol Int 2014; 5:12. [PMID: 24678428 PMCID: PMC3942611 DOI: 10.4103/2152-7806.125860] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/18/2013] [Indexed: 01/18/2023] Open
Abstract
Background: The consensus on most reliable supplemental test to predict the shunt responsiveness in patients with idiopathic normal pressure hydrocephalus (iNPH) is lacking. The aim of this study is to discuss the utility of external lumbar drain (ELD) in evaluation of shunt responsiveness for iNPH patients. Methods: A retrospective review of 66 patients with iNPH was conducted. All patients underwent 4-day ELD trial. ELD-positive patients were offered ventriculoperitoneal shunt (VPS) surgery. The primary outcome evaluation parameters were gait and mini mental status examination (MMSE) assessment. The family and patient perception of improvement was accounted for in the outcome evaluation. Results: There were 38 male and 28 female with mean age of 74 years (range 45-88 years). ELD trial was positive in 86% (57/66) of patients. No major complications were encountered with the ELD trial. A total of 60 patients (57 ELD-positive, 3 ELD-negative) underwent VPS insertion. The negative ELD trial (P = 0.006) was associated with poor outcomes following shunt insertion. The positive ELD trial predicted shunt responsiveness in 96% patients (P < 0.0001, OR = 96.2, CI = 11.6-795.3). A receiver operating characteristic (ROC) curve analysis revealed that the ELD trial is reasonably accurate in differentiating shunt responder from non-responder in iNPH patients (area under curve = 0.8 ± 0.14, P = 0.02, CI = 0.52-1.0). The mean follow-up period was 12-months (range 0.3-3 years). The significant overall improvement after VPS was seen in 92% (55/60). The improvement was sustained in 76% of patients at mean 3-year follow-up. The number of comorbid conditions (P = 0.034, OR = 4.15, CI = 1.2-9.04), and a history of cerebrovascular accident (CVA) (P = 0.035, OR = 4.4, CI = 1.9-14.6) were the predictors of poor outcome following shunt surgery. Conclusion: The positive ELD test predicted shunt responsiveness in 96% of patients. With adequate technique, maximal results with minimal complications can be anticipated. The number of comorbidities, history of CVA and negative ELD test were significantly associated with poor shunt outcomes.
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Affiliation(s)
- Silky Chotai
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Ricky Medel
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Nabeel A Herial
- Department of Neurology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Azedine Medhkour
- Division of Neurosurgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
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Koivisto AM, Alafuzoff I, Savolainen S, Sutela A, Rummukainen J, Kurki M, Jääskeläinen JE, Soininen H, Rinne J, Leinonen V. Poor Cognitive Outcome in Shunt-Responsive Idiopathic Normal Pressure Hydrocephalus. Neurosurgery 2013; 72:1-8;discussion 8. [DOI: 10.1227/neu.0b013e31827414b3] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Hermann EJ, Capelle HH, Tschan CA, Krauss JK. Electromagnetic-guided neuronavigation for safe placement of intraventricular catheters in pediatric neurosurgery. J Neurosurg Pediatr 2012; 10:327-33. [PMID: 22880888 DOI: 10.3171/2012.7.peds11369] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ventricular catheter shunt malfunction is the most common reason for shunt revision. Optimal ventricular catheter placement can be exceedingly difficult in patients with small ventricles or abnormal ventricular anatomy. Particularly in children and in premature infants with small head size, satisfactory positioning of the ventricular catheter can be a challenge. Navigation with electromagnetic tracking technology is an attractive and innovative therapeutic option. In this study, the authors demonstrate the advantages of using this technology for shunt placement in children. METHODS Twenty-six children ranging in age from 4 days to 14 years (mean 3.8 years) with hydrocephalus and difficult ventricular anatomy or slit ventricles underwent electromagnetic-guided neuronavigated intraventricular catheter placement in a total of 29 procedures. RESULTS The single-coil technology allows one to use flexible instruments, in this case the ventricular catheter stylet, to be tracked at the tip. Head movement during the operative procedure is possible without loss of navigation precision. The intraoperative catheter placement documented by screenshots correlated exactly with the position on the postoperative CT scan. There was no need for repeated ventricular punctures. There were no operative complications. Postoperatively, all children had accurate shunt placement. The overall shunt failure rate in our group was 15%, including 3 shunt infections (after 1 month, 5 months, and 10 months) requiring operative revision and 1 distal shunt failure. There were no proximal shunt malfunctions during follow-up (mean 23.5 months). CONCLUSIONS The electromagnetic-guided neuronavigation system enables safe and optimal catheter placement, especially in children and premature infants, alleviating the need for repeated cannulation attempts for ventricular puncture. In contrast to stereotactic techniques and conventional neuronavigation, there is no need for sharp head fixation using a Mayfield clamp. This technique may present the possibility of reducing proximal shunt failure rates and costs for hydrocephalus treatment in this age cohort.
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Affiliation(s)
- Elvis J Hermann
- Department of Neurosurgery, Medical School Hannover, Germany.
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Solana E, Sahuquillo J, Junqué C, Quintana M, Poca MA. Cognitive disturbances and neuropsychological changes after surgical treatment in a cohort of 185 patients with idiopathic normal pressure hydrocephalus. Arch Clin Neuropsychol 2012; 27:304-17. [PMID: 22382387 DOI: 10.1093/arclin/acs002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Although idiopathic normal pressure hydrocephalus (iNPH) is considered a treatable dementia, there is still some controversy regarding the cognitive improvement in these patients. The main aims of this study were to analyze baseline cognitive status and to study the neuropsychological changes after surgical treatment in a sample of 185 consecutive iNPH patients. An additional aim was to identify the variables that influenced the cognitive outcome. Specific tests assessing memory, attention, visual scanning, executive functions (EFs), and motor speed were used before and 6 months after shunting. The cognitive domains most affected at baseline were memory, EFs, attention, and psychomotor speed. After shunting, significant differences in the group as a whole were found in all tests except Digits Forward and Trail Making Part B. However, less than 50% of patients showed a significant improvement when analyzed individually. Previous global cognitive status assessed by Mini-Mental State Examination baseline scores was the best predictor for the cognitive outcome.
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Affiliation(s)
- Elisabeth Solana
- Neurosurgery and Neurotraumatology Research Unit, Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Spain
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Mirzayan MJ, Klinge PM, Samii M, Goetz F, Krauss JK. MRI safety of a programmable shunt assistant at 3 and 7 Tesla. Br J Neurosurg 2012; 26:397-400. [DOI: 10.3109/02688697.2011.625060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Leinonen V, Koivisto AM, Alafuzoff I, Pyykkö OT, Rummukainen J, von Und Zu Fraunberg M, Jääskeläinen JE, Soininen H, Rinne J, Savolainen S. Cortical brain biopsy in long-term prognostication of 468 patients with possible normal pressure hydrocephalus. NEURODEGENER DIS 2012; 10:166-9. [PMID: 22343771 DOI: 10.1159/000335155] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 11/16/2011] [Indexed: 11/19/2022] Open
Abstract
Normal pressure hydrocephalus (NPH) can be alleviated by cerebrospinal fluid shunting but the differential diagnosis and patient selection are challenging. Intraventricular intracranial pressure monitoring as part of the diagnostic workup as well as shunting enable to obtain cortical brain biopsies to detect amyloid-β (Aβ) and hyperphosphorylated tau (HPτ), the hallmark lesions of Alzheimer's disease (AD). In possible NPH, Aβ alone indicates an increased risk of AD and when present with HPτ probable AD, but the effect of those brain lesions on survival is not known. The aim of this study was to evaluate the predictive value of brain biopsy for the long-term outcome of possible NPH. Between 1991 and 2006, the Neurosurgery Department of the Kuopio University Hospital evaluated 468 patients for possible NPH by intraventricular intracranial pressure monitoring and frontal cortical brain biopsy immunostained against Aβ and HPτ. All patients were followed up until the end of 2008 (n = 201) or death (n = 267) with a median follow-up of 4.6 years (range 0-17). Logistic regression analysis with Cox models was applied. Out of the 468 cases, Aβ was detected in 197 (42%) cortical biopsies, and together with HPτ in 44 (9%). Aβ alone indicated increased risk of AD and with HPτ probable AD, but it did not affect survival. Vascular aetiology was the most frequent cause of death. Cortical biopsy findings indicate that NPH is at present a heterogeneous syndrome and has notable overlapping with AD. Brain biopsy did not predict survival but may open a novel research window to study the pathobiology of neurodegeneration.
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Affiliation(s)
- Ville Leinonen
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
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Giesemann AM, Capelle HH, Winter R, Krauss JK. Bilateral trochlear nerve palsy subsequent to ventriculoperitoneal shunting of normal pressure hydrocephalus. Br J Neurosurg 2011; 26:110-2. [DOI: 10.3109/02688697.2011.593644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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