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PubMed1976

Neurofibrillary tangles in the dementia of "normal pressure" hydrocephalus.

Routine neuropathological examination could not explain the dramatic improvement exhibited by one patient with "normal pressure" hydrocephalus after shunting. The improved patient contrasted remarkably with the unchanged condition of four others also shunted successfully. The five brains were analysed by quantitative morphometry to determine the degree of neurofibrillary tangle formation in mesial temporal neurons. The density of tangle-bearing nerve cells in the four unimproved cases was markedly greater than in age-matched control brains from nineteen normal subjects, and fell in the same range as that of eight dements with neuropathologically confirmed Alzheimer's disease. The density of the one who recovered was within normal limits. The duration of dementia before shunting, and the total duration of dementia in these five patients rank in the same order as their degree of neurofibrillary formation. Furthermore, a positive linear correlation exists between the Tangle Indices and the total duration of dementia. The data suggest that early diagnosis may improve the chances of reversing the dementia of normal pressure hydrocephalus before histological alterations prove too severe.

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PubMed2006

CSF drainage ameliorates the motor deficit in normal pressure hydrocephalus: evidence from the analysis of grasping movements.

Apart from the classic triad of hypokinetic gait disorder, cognitive dysfunction and urinary incontinence, the clinical spectrum of normal pressure hydrocephalus has been found to affect the upper limbs. It is unclear if the motor deficit of hand and arm movements improves with CSF evacuation. The present study was designed to quantitatively assess the effect of CSF evacuation on the hypokinesia of grasping movements in normal pressure hydrocephalus. Eight subjects with normal pressure hydrocephalus grasped to lift an instrumented object prior to and following evacuation of 40 ml CSF. The build-up of fingertip forces and the kinematics of the lifting movement were slower for patients compared with healthy controls. Patients also generated excessive grasping forces when lifting and holding the object stationary prior to and following CSF evacuation. CSF evacuation significantly improved the gait disorder, the cognitive impairment and the urinary incontinence in normal pressure hydrocephalus. CSF evacuation accelerated the lifting movement and reduced the grip force overshoot. These data suggest that the measurement of grasping forces may provide an additional test to quantify the clinical response to CSF tapping in normal pressure hydrocephalus.

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PubMed2005

Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus.

OBJECTIVE: The response to shunt surgery for idiopathic normal-pressure hydrocephalus (INPH) is variable because INPH is difficult to distinguish from other conditions causing the same symptoms. To date, no clinical picture or diagnostic test can distinguish INPH or predict response to cerebrospinal fluid (CSF) shunt surgery. We reviewed our 10-year experience with INPH to characterize long-term outcome and to identify independent predictors of outcome after shunt surgery. METHODS: Patients were classified as having INPH only if they had: 1) ventriculomegaly, 2) two or more INPH clinical features, 3) no risk factor for secondary normal-pressure hydrocephalus, 4) A- or B-waves on CSF pressure monitoring, and 5) clinical improvement during a 3-day CSF drainage trial via a spinal catheter. Independent predictors of outcome were assessed via a multivariate proportional hazards regression analysis. RESULTS: One hundred thirty-two patients underwent 179 shunt surgeries. Forty-four (33%), 79 (60%), and 99 (75%) patients demonstrated objective improvement 3, 6, and 24 months after shunt surgery, respectively. Gait improved first in 88 (93%) patients. Dementia and urinary incontinence were twofold less likely to improve. Radiological evidence of corpus callosum distension, gait impairment as the primary symptom, and shorter duration of INPH symptoms predicted improvement. Duration of symptoms and gait as the primary symptom were independent predictors by multivariate analysis. CONCLUSION: INPH can be diagnosed accurately with CSF pressure monitoring and CSF drainage via a spinal catheter. CSF shunting is safe and effective for INPH with a long-term shunt response rate of 75%. Independent predictors of improvement are the presence of gait impairment as the dominant symptom and shorter duration of symptoms.

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PubMed2005

Gravity valves for idiopathic normal-pressure hydrocephalus: a prospective study with 60 patients.

OBJECTIVE: Are hydrostatic valves superior to conventional differential pressure shunts in patients with normal-pressure hydrocephalus, with regard to the postoperative results of treatment and possible complications? METHODS: From September 1997 to January 2002, 60 patients with idiopathic normal-pressure hydrocephalus were treated by surgical implantation of hydrostatic valve at the Unfallkrankenhaus Berlin. In a prospective study, the clinical examination and a CT examination were carried out preoperatively, postoperatively and 1 year after the operation. RESULTS: One year after the operation, the clinical picture was very good for 33% of the patients, good for 33% and satisfactory or poor for 17%, each, of the patients. 3 dislocations (5%) of ventricular or abdominal catheters and three valve infections were found as valve-independent. As valve-dependent complications, underdrainage was found in 4 patients (7%) and radiological signs of overdrainage in 2 patients (3%), while 1 patient (1.7%) showed symptomatic over-drainage. CONCLUSION: According to our experience, hydrostatic Dual-switch valves Aesulap are superior to conventional differential pressure shunts without an additional gravity unit especially with regard to the treatment of patients with idiopathic normal-pressure hydrocephalus, concerning both the postoperative results and the incidence of possible complications. A clinical improvement can be achieved for 83% of such patients.

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PubMed1987

Falling spells in normal pressure hydrocephalus: a favourable prognostic sign?

Two patients with idiopathic normal pressure hydrocephalus are described suffering from so called 'falling spells'. Both patients showed marked improvement after ventriculoatrial shunting, and the falling spells ceased. The literature concerning falling spells is reviewed. The possible pathogenesis and the relationship to shunting are discussed.

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PubMed1982

Normal-pressure hydrocephalus: current understanding of diagnostic tests and shunting.

Normal-pressure hydrocephalus is no longer difficult to diagnose or treat-cranial computed tomographic scanning has made the diagnosis of ventricular enlargement straightforward, and shunt placement often helps the patient whose condition can be traced to a specific cause. Predicting accurately whether a patient will benefit from a shunt, however, is still problematic.

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PubMed2004

Increased intracranial volume: a clue to the etiology of idiopathic normal-pressure hydrocephalus?

BACKGROUND AND PURPOSE: The etiology of idiopathic normal-pressure hydrocephalus (NPH) is unknown. The purpose of this study was to examine the hypothesis that NPH begins in infancy as benign external hydrocephalus due to decreased uptake of CSF by the arachnoid villi. Since this occurs before the sutures fuse, a secondary hypothesis is that the intracranial volumes of patients with NPH should be larger than those of healthy individuals. METHODS: Intracranial volumes of 51 patients with clinically suspected NPH were compared with those of age- and sex-matched control subjects. All patients underwent phase-contrast CSF velocity MR imaging. They had aqueductal CSF stroke volumes of at least 60 microL, which was 50% higher than previously published normal values. Intracranial volumes were measured and compared between groups. RESULTS: The average intracranial volume for men with NPH (n = 22) was 1682 mL compared with 1565 for male control subjects (n = 55). The NPH volume averaged 118 mL (7.5%) larger than the control volume (P = .003). The average intracranial volume for women with NPH (n = 29) was 1493 mL compared with 1405 mL for female control subjects (n = 55). The NPH volume was 88 mL (6.3%) larger than the control volume (P = .002). CONCLUSION: Patients with NPH have intracranial volumes significantly larger than normal, suggesting that the initial insult occurs before the sutures fuse at 1 year of age. The patients somehow remain asymptomatic until their later years, when a second insult must occur, leading to symptomatic NPH.

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PubMed1989

Regional cerebral blood flow and oxygen metabolism in normal pressure hydrocephalus after subarachnoid hemorrhage.

To clarify the pathophysiology of normal pressure hydrocephalus (NPH) after subarachnoid hemorrhage, the authors measured cerebral blood flow (CBF), cerebral oxygen metabolic rates (CMRO2), the cerebral oxygen extraction fraction (OEF), and cerebral blood volume (CBV) in eight normal volunteers, six SAH patients with NPH, and seven patients without NPH by 15O-labeled gas and positron emission tomography (PET). In the NPH group, PET revealed a decrease in CBF in the lower regions of the cerebral cortex and a diffuse decrease in CMRO2. The decrease in CBF in the lower frontal, temporal, and occipital cortices was significantly greater in the NPH than in the non-NPH group. Reduction of CMRO2 was also more extensive in the NPH group, and both CBF and CMRO2 were more markedly decreased in the lower frontal region. OEF was increased in all areas in both of the patient groups, but the increase was not significant in most areas. CBF, CMRO2 and OEF did not significantly differ between the non-NPH group and the normal volunteers. There was no significant difference in CBV among the three groups. These results indicate that NPH involves impairment of cerebral oxygen metabolism in the lower regions of the cerebral cortex, particularly in the lower frontal region.

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PubMed1975

Results and complications in 55 shunted patients with normal pressure hydrocephalus.

This retrospective study of 55 shunted patients with "normal pressure" hydrocephalus evaluates the surgical results. Sixty percent of these patients had objective improvement following cerebrospinal fluid diversion but 44% had shunt-related complications of which 9% were fatal. Those patients who received a single theco-peritoneal shunt had a higher improvement rate and a lower incidence of postoperative complications. Successfully treated complications did not preclude postoperative improvement.

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PubMed1979

Nuclear bodies in nerve cells of two patients with normal-pressure hydrocephalus.

Biopsy specimen fragments from two patients with normal-pressure hydrocephalus were studied using ultrastructural methods. Simple nuclear bodies were found in all layers of the cortex and white matter, whereas complex ones were only seen in the fifth and sixth layers and in the underlying white matter. There may be a relationship of these nuclear bodies, either to the neuroglial proliferation observed in both patients or to the existence of a viral infection of the CNS.

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PubMed1989

[Lumboperitoneal shunt and normal pressure hydrocephalus in elderly subjects].

Forty six patients who had normal pressure hydrocephalus (NPH) and who presented 2 or more of the 5 following preoperative signs: dementia with gait disturbances and urinary incontinence, gait disturbance as first sign, known etiology, positive lumbar puncture withdrawal test, presence of periventricular hypodensity on CT and absence of visible cerebral sulci, were treated by lumboperitoneal shunt. Postoperative results were evaluated at 1 month, 6 months and 1 year with 60.6 p. 100 of good results. Complications of LP shunts (26 p. 100) were mild and did not compromise the outcome. We emphasize the necessity of clinical selecting criteria before surgery and the value of LP shunt in the treatment of NPH.

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PubMed2001

Analysis of hearing loss after shunt placement in patients with normal-pressure hydrocephalus.

OBJECT: Following shunt placement for treatment of normal-pressure hydrocephalus (NPH), several patients suffered hearing loss. The authors undertook a study to analyze this outcome. METHODS: Sixteen patients in whom NPH was diagnosed were treated by placement of a ventriculoperitoneal shunt. Their hearing was assessed pre- and postoperatively by using pure tone audiometry. Two thirds of the ears tested showed a postoperative hearing loss of more than 10 dB. Recovery of the hearing loss occurred 6 to 12 weeks after shunt placement in 75% of the ears examined. CONCLUSIONS: Although shunt insertion for treatment of NPH results in a decrease in hearing, most of the loss can be recovered.

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PubMed1997

The predictive value of cerebrospinal fluid tap-test in normal pressure hydrocephalus.

Eighteen patients (mean age of 66.5 years) with normal pressure hydrocephalus (NPH) underwent a ventriculo-peritoneal shunt surgery. Prior to operation a cerebrospinal fluid tap-test (CSF-TT) was performed with measurements of gait pattern and psychometric functions (memory, visuo-motor speed and visuo-constructive skills) before and after the removal of 50 ml CSF by lumbar puncture (LP). Fifteen patients improved and 3 were unchanged after surgery. Short duration of disease, gait disturbance preceding mental deterioration, wide temporal horns and small sulci on CT-scan were associated with good outcome after shunting. There was a good correlation between the results of CSF-TT and shunt surgery (chi 2 = 4.11, phi = 0.48, p < 0.05), with gait test showing highest correlation (r = 0.99, p = 0.01). In conclusion, this version of CSF-TT proved to be an effective test to predict improvement after shunting in patients with NPH.

Adult↗
PubMed1990

Plasticity in the aging brain. Reversibility of anatomic, metabolic, and cognitive deficits in normal-pressure hydrocephalus following shunt surgery.

The course of idiopathic normal-pressure hydrocephalus was studied in a 78-year-old woman with a 4-year history of progressive dementia who underwent neuropsychologic testing, quantitative x-ray computed tomography, magnetic resonance imaging, and positron emission tomography with fludeoxyglucose F 18 to measure rates of regional cerebral glucose utilization. Preshunt cognitive testing demonstrated progressive deterioration during 2 years, and positron emission tomography showed significant reductions in regional cerebral glucose utilization of 34% to 49% as compared with age- and sex-matched control subjects in frontal, temporal, parietal, and whole brain regions. Periodic testing, carried out during a 2-year period after shunt surgery, showed steady improvement in clinical status. Parallel to the clinical changes, there was a significant reversal in neuropsychologic test scores with increased brain volume and increased regional cerebral glucose utilization in several brain regions. These results documented the considerable potential for recovery of compromised brain function in older subjects even after 4 years of progressive brain disease.

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PubMed2004

Impaired wakefulness is associated with reduced anterior cingulate CBF in patients with normal pressure hydrocephalus.

OBJECTIVE: To evaluate if impaired wakefulness (IW) in normal pressure hydrocephalus (NPH) is associated with reduced blood flow in regions associated with the brain arousal system. METHOD: NPH (n = 28) patients were studied before and after surgery. Wakefulness was assessed using a new developed scale. Relative regional cerebral blood flow (rrCBF) was quantified using SPECT and rectangular regions of interest analysis. RESULTS: Sixteen patients presented with IW at baseline and in 14 of these, IW vanished after surgery. Patients presenting with IW had reduced rrCBF in the anterior cingulate cortex compared with those without. After surgery, rrCBF increased significantly in thalamic, frontal and hippocampal grey matter regions. Increased hippocampal rrCBF correlated with increased basal frontal rrCBF (r = 0.64). In patients where IW vanished after surgery, rrCBF increased in the mesencephalon, hippocampus and the frontal association cortex. The postoperative increase in wakefulness correlated with increased rrCBF in frontal (r = 0.74) and parietal (r = 0.65) association cortex areas. CONCLUSION: IW in NPH is associated with reduced rrCBF in the anterior cingulate cortex. Improved wakefulness following surgery corresponds to rrCBF increments in the frontal association cortex. This study provides support for a functional coupling between frontal, hippocampal, thalamic and mesencephalic rrCBF in NPH at large.

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PubMed2006

BDNF serum and CSF concentrations in Alzheimer's disease, normal pressure hydrocephalus and healthy controls.

Alzheimer's disease (AD) and normal pressure hydrocephalus (NPH) are common forms of dementia in the elderly. Recent findings have suggested an involvement of brain-derived neurotrophic factor (BDNF) in the pathogenesis of AD. BDNF is an endogenous protein involved in the maintenance of neuronal function, synaptic plasticity and structural integrity in the adult brain. BDNF serum and cerebrospinal fluid (CSF) concentrations were assessed by a sensitive ELISA in 27 AD patients in comparison to 9 NPH patients and 28 age-matched healthy controls (10 CSF samples). We found a significant decrease of BDNF serum concentration in AD (18.6ng/ml) and NPH patients (18.1ng/ml) as compared to healthy controls (21.3ng/ml; p=0.041/p=0.017). BDNF serum concentrations did not correlate with CSF levels, age or MMSE scores both in AD and NPH patients. In unconcentrated CSF samples, BDNF could be detected in AD patients in 8/27 cases (29.6%; mean of 4.6pg/ml), in NPH patients in 1/9 cases (11.1%; mean of 6.4pg/ml) and in the control subjects in 5/10 cases (50%; mean of 1.6pg/ml) with no significant differences as regards mean concentration and frequency of detectable BDNF in CSF. The decrease of BDNF serum levels in AD and NPH may reflect a lack of trophic support and thus contribute to progressive degeneration in both diseases. In contrast to serum, CSF seems to be no useful source to determine BDNF in AD or NPH because of too low concentrations. Further examinations have to follow to elucidate the potential sources and the meaning of reduced BDNF levels in the blood in AD and NPH.

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PubMed2001

[Postural and locomotor evaluation of normal pressure hydrocephalus: a case report].

Generally, the diagnosis of idiopathic normal pressure hydrocephalus (NPH) is raised in elderly patients with an association of gait disturbances, cognitive impairment, urinary incontinence and widening of the ventricles. Gait disturbances appear as the predominant clinical symptom of NPH, and may precede other symptoms. The main objectives of this study were to determine the effect of ventriculoperitoneal shunt (VPS) on gait and to compare the results obtained in HPN with those obtained in Parkinson's disease (PD). The performance of a patient with NPH on specific postural and locomotion tasks was analyzed during three successive experimental sessions: the first one before VPS, the second one week after VPS and the third three months after VPS. The patient was instructed to walk at his natural speed and also to maintain postural control for one minute. Four gait parameters (mean velocity, stride length, cadency and step width) were calculated for each session to assess the subject's performance. In this NPH patient there was a significant improvement in gait performance before and after VPS. This improvement concerned mean velocity, stride length and step cadency but did not involve the width component which remained unchanged. Before VPS, the NPH patient walked slower and with a shorter stride length than a group of patients with PD. After VPS his performance was better than the PD group except for cadency. Step width remained longer for the HPH patient than in PD patients for all three sessions. From this study, it appears that gait in idiopathic NPH exhibits a specific temporospatial pattern distinct from that in PD or normal age-matched controls. Changes in gait can be evaluated shortly after treatment of NPH. Gait disorders, excepting dynamic balance, may normalize as soon as one week after surgery.

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