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PubMed1994

Quantitative SPECT cisternography in normal pressure hydrocephalus.

Twenty-one patients with normal pressure hydrocephalus (NPH), 8 patients with various brain diseases with an element of hydrocephalus, and 7 patients with miscellaneous dementia disorders were investigated with quantitative radionuclide cisternography (RC) using single photon emission computerized tomography (SPECT). The total intracranial counts as well as the counts in the lateral and third ventricles were measured. All 15 NPH patients accessible for postoperative examination were improved after shunt surgery. In all groups the ventricular and total intracranial counts level increased during the measurement period but remained constant in distribution in each group. The NPH patients had a higher relative count value in the lateral and third ventricles compared to the patients with miscellaneous dementia disorders. The relative values in the third and lateral ventricles were predictive for the outcome of shunt surgery. Quantitative SPECT RC appears to be a useful diagnostic procedure in NPH investigations.

Adult↗
PubMed2004

Is the placement of shunts in patients with idiopathic normal-pressure hydrocephalus worth the risk? Results of a study based on continuous monitoring of intracranial pressure.

OBJECT: Data from many studies have demonstrated that shunt insertion in patients with idiopathic normal-pressure hydrocephalus (NPH) is associated with high morbidity and a lack of significant improvement; however, the use of strict diagnostic and treatment protocols can improve the results of surgery in these patients. The primary aim in this prospective study was to analyze the results of shunt placement in 43 patients with idiopathic NPH. A secondary aim was to determine the relationship between several clinical and neuroimaging factors, and patient outcome after surgery. METHODS: Thirty men and 13 women with a mean age of 71.1 +/- 6.9 years participated in this study. All patients underwent clinical, neuropsychological, and radiological assessment before and 6 months after surgery. In all patients continuous monitoring of intracranial pressure was performed using a fiberoptic extradural sensor. In 31 patients cerebrospinal fluid dynamics were also determined. Eighty-six percent of patients showed clinical improvement after shunt insertion, 11.6% showed no change, and 2.3% exhibited some worsening. Gait improved in 81.4% of the patients, sphincter control in 69.8%, and cognitive dysfunction in 39.5%. There was no treatment-related death. Early or late postsurgical complications occurred in six patients (14%), although all of these complications were minor or were satisfactorily resolved. The complete clinical triad, cortical sulci size, and periventricular lucencies were related to outcome, whereas patient age, symptom duration, ventricular dilation, and the degree of presurgical dementia were unrelated to outcome. CONCLUSIONS: Given the correct diagnosis, shunt insertion can produce marked improvement in patients with idiopathic NPH syndrome, causing few deaths and few clinically relevant complications.

Aged↗
PubMed1977

Diabetes mellitus in normal pressure hydrocephalus.

Seventeen of 33 patients (51.5%) with normal pressure hydrocephalus were discovered to have diabetes mellitus. This was significantly greater than the 12.1% incidence found in age-matched control subjects. The diabetes was not accounted for either by the patients' ages nor by their physical inactivity due to hospitalisation. Diabetes mellitus concurrent with normal pressure hydrocephalus may result from involvement of hypothalamic and brainstem autonomic structures by the expanding ventricles during the evolution of hydrocephalus.

Age Factors↗
PubMed1989

Does compliance predict ventricular reduction after shunting for normal pressure hydrocephalus.

Ventricular reduction after shunting for normal pressure hydrocephalus (NPH) was classified on the basis of magnitude and rate of reduction in 35 adult patients. Brain compliance and resistance to outflow of cerebrospinal fluid (RCSF) were determined before shunting. Rapid and marked ventricular reduction (n = 11) was associated with a significantly lower compliance than slow and moderate to marked (n = 16) or minimal to mild (n = 8) reduction. Otherwise ventricular size before as well as after shunting did not correlate with compliance or RCSF. It is concluded that both rate and magnitude of ventricular reduction after shunting for NPH vary widely. Reduced compliance seems to be the best predictor of rapid and marked reduction.

Adult↗
PubMedDate not supplied

Normal pressure hydrocephalus in geriatric medicine: a challenge.

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

Aged↗
PubMed1990

Predictive value of quantitative cisternography in normal pressure hydrocephalus.

Twenty-five patients with normal pressure hydrocephalus (NPH) and 16 patients with cerebral atrophy were investigated by quantitative cisternography using anterior images of the head 3, 6 and 24 h after a lumbar injection of 200 MBq 99mTc DTPA (diethylene-triamine-penta-acetic acid). The activity in the lateral ventricles, basal cisterns, hemispheric convexities and total intracranial region was measured. Ratios between these regions/quantities were calculated. Fifteen of the NPH patients improved while 10 were unchanged after ventriculo-peritoneal shunt surgery. The ratio between ventricular and total intracranial activity (V/T) correlated positively with the degree of improvement after shunt surgery. All NPH patients with a V/T ratio higher than 32% improved after the operation but a V/T ratio less than 32% did not exclude the possibility of improvement. With regard to quantitative measurements, the radionuclide cisternography procedure can be reduced to imaging at 24 h.

Aged↗
PubMed2006

Functional and magnetic resonance imaging correlates of corpus callosum in normal pressure hydrocephalus before and after shunting.

BACKGROUND: Normal pressure hydrocephalus (NPH) is associated with corpus callosum abnormalities. OBJECTIVES: To study the clinical and neuropsychological effect of callosal thinning in 18 patients with idiopathic NPH and to investigate the postsurgical callosal changes in 14 patients. METHODS: Global corpus callosum size and seven callosal subdivisions were measured. Neuropsychological assessment included an extensive battery assessing memory, psychomotor speed, visuospatial and frontal lobe functioning. RESULTS: After surgery, patients showed improvements in memory, visuospatial and frontal lobe functions, and psychomotor speed. Two frontal corpus callosum areas, the genu and the rostral body, were the regions most related to the clinical and neuropsychological dysfunction. After surgery, total corpus callosum and four of the seven subdivisions presented a significant increase in size, which was related to poorer neuropsychological and clinical outcome. CONCLUSION: The postsurgical corpus callosum increase might be the result of decompression, re-expansion and increase of interstitial fluid, although it may also be caused by differences in shape due to cerebral reorganisation.

Aged↗
PubMed1990

Hydrocephalic oedema in normal-pressure hydrocephalus.

The hydrocephalic oedema in normal-pressure hydrocephalus (NPH) was evaluated by measurement of the relaxation time of protons of the water molecules of brain tissue. Patients with NPH were divided into two groups: shunt responders and shunt non-responders. In the group of shunt responders both T1 and T2 of periventricular white matter were significantly prolonged compared to those of controls, and shortened after shunting. Both T1 and T2 of white matter were significantly longer than of gray matter, while a reversed relationship was seen in normal controls. However, in the group of shunt non-responders, T1 of white matter was significantly prolonged, while T2 of the same area not. There was no change in either T1 or T2 of this region after shunting. Both T1 and T2 were almost the same in white and gray matter in shunt non-responders. It is suggested that periventricular abnormalities seen in various diseases may be distinguished on the basis of the relaxation behavior of protons of tissue water.

Body Water↗
PubMed2001

Proton chemical shift imaging in normal pressure hydrocephalus.

BACKGROUND AND PURPOSE: Differentiation of normal pressure hydrocephalus (NPH) from other types of dementia and the selection of appropriate candidates for shunt surgery remain a clinical challenge. The aims of this study were to assess the efficacy of cerebral metabolites depicted by proton chemical shift imaging (1H-CSI) in distinguishing NPH from other dementias and to examine the relationship between metabolite changes and the outcome of shunt surgery. METHODS: 1H-CSI measurements were obtained in nine patients with clinical diagnosis of NPH; six patients with other types of dementia, including Alzheimer and Pick disease; and five control subjects. The 1H-CSI sequence consisted of a double spin-echo sequence with imaging parameters of 2000/135/4-2 (TR/TE/acquisitions). Volumes of interest were selected from a section through the lateral ventricles. The peak areas and ratios of N-acetylaspartate, creatine, choline, and lactate were calculated. In two patients, follow-up 1H-CSI and N-isopropyl (123I)-p-iodoamphetamine brain perfusion imaging were available after treatment with continuous spinal drainage. RESULTS: Lactate peaks were observed in the lateral ventricles for all patients with NPH (lactate/creatine, 0.23 +/- 0.14) but not for patients with other types of dementia or control subjects. In all cases, we noted no significant differences in the peak ratios in the voxels located at the white matter near the lateral ventricles. In one patient with NPH, intraventricular lactate disappeared and regional CBF recovered after drainage. CONCLUSION: The intraventricular lactate level may be useful in differentiating NPH from other types of dementia.

Adult↗
PubMed2004

Evaluation of the Miethke dual- switch valve in patients with normal pressure hydrocephalus.

OBJECTIVE: Especially in patients with normal pressure hydrocephalus (NPH), conventional differential-pressure valves are known to create nonphysiological negative intraventricular pressure values (IVP) when the patient moves into the upright position, with the consequence of numerous, sometimes severe, complications. The recently presented gravitational devices promise improvement, primarily in respect to this disadvantage. METHODS: In a prospective multicenter study the new Miethke dual- switch valve (DSV) has been implanted in 128 patients with NPH. The patients have been assessed before operation, at discharge, and re-evaluated 6 to 9 months after surgery. The technical principle of the new device is presented. RESULTS: The clinical follow-up showed excellent results in 63% of the patients, satisfactory results in 16%, and a bad outcome in 21% of the cases. The infection rate was 5%; the rate of mechanical complications including overdrainage and dislocations has been in total 9%, and underdrainage was suspected in 7 cases. The outcome correlated with the preoperative severity of NPH. Despite the clinical outcome, the computed tomography scans showed only minimal or no reduction of the ventricular size in the majority of cases. We found a valve-related rate of overdrainage of 2.5%, which is clearly lower than results of comparable series in the literature. CONCLUSION: The clinical course of patients suffering from NPH is mainly influenced by the stage of the disease, the time of beginning of the therapy, and the gravitational function of the implanted device. Based on our clinical experiences with the Miethke dual-switch valve (MD-SV), we underscore the advantages of this valve for the treatment of hydrocephalus, especially for patients with NPH.

Cerebrospinal Fluid Shunts↗
PubMed1992

["Endogeniform" affective psychoses and normal pressure hydrocephalus].

Four patients with neuroradiological evidence of normal pressure hydrocephalus and psychiatric diagnosis of affective psychoses with major depression--like characteristics are presented. Three patients underwent shunting operations following an observation period of 2 to 6 years. During the post-operative follow-up of 3 to 7 years, resp., no clinical changes were noted. In our opinion, and following critical evaluation of the available literature, major depression--like affective disorders in normal-pressure hydrocephalus are not influenced by shunting operations, unless they occur simultaneously as an additional symptom in an Adams-Hakim syndrome with definite progression.

Affective Disorders, Psychotic↗
PubMed2006

Idiopathic normal pressure hydrocephalus: theoretical concept of a spinal etiology.

Normal pressure hydrocephalus (NPH) is an adult syndrome characterised by a combination of gait disturbance, varying degrees of cognitive decline, urinary incontinence, ventricular enlargement and normal mean intracranial pressure. Since this syndrome was first described, its pathophysiology has been a matter of great debate, although it is now considered that NPH could be divided into two groups: cases with unknown etiology (idiopathic normal pressure hydrocephalus, or INPH) and those which develop from several known causes (such as trauma, meningitis or subarachnoid haemorrhage). The pathophysiology of INPH is still unclear and a matter of debate. In this manuscript, the current pathophysiological conditions of INPH are analysed and the authors put forward the theory that the disease is a dynamic syndrome which occurs in patients who have suffered a significant loss of spinal compliance over time. Consequently, intracranial pressure increases more during systole in INPH patients because it cannot be compensated for by the escape of CSF into the spinal canal as effectively, due to the reduced volume or lack of distension of the spinal canal. This leads to an increase in ventricular size and causes cumulative brain damage over a long period of time and accounts for the slow, progressive nature of NPH. The loss of spinal compliance with age is fundamental to the proposed theory which provides a theoretical justification for studying the spinal canal in INPH and investigating the relationship between the progressive narrowing of the spinal canal and the compensating ability of the craniospinal system.

Cerebrospinal Fluid↗
PubMed1994

Hippocampal atrophy correlates with severe cognitive impairment in elderly patients with suspected normal pressure hydrocephalus.

Measurements of hippocampal formation atrophy using MRI have been useful in distinguishing demented patients with a diagnosis of probable Alzheimer's disease from cognitively normal controls. To determine whether there is a similar relationship between hippocampal size and dementia in elderly patients suspected of normal pressure hydrocephalus (NPH), the authors obtained mini-mental status examination (MMSE) scores and MRI measurements of hippocampal size and CSF volume on 16 elderly patients whose severe ventriculomegaly and unexplained gait impairment made NPH a probable diagnosis. Hippocampal size correlated strongly with MMSE score (r = 0.75, p < 0.001); no significant MMSE correlation was found for ventricular CSF volume or extra-ventricular/ventricular CSF ratio. It was concluded that hippocampal atrophy is associated with severe cognitive dysfunction in many elderly patients with a diagnosis of NPH. As a hypothesis for further investigation, the detection of such atrophy may help identify cases where the presence of a pathology of Alzheimer's disease complicates the diagnosis of NPH.

Aged↗
PubMed2007

Evidence that congenital hydrocephalus is a precursor to idiopathic normal pressure hydrocephalus in only a subset of patients.

OBJECTIVE: To identify the proportion of patients in a large idiopathic normal pressure hydrocephalus (INPH) cohort with large head circumference (HC) who presumably have congenital hydrocephalus that has not become clinically apparent until late in life. METHODS: HC was measured in 158 patients diagnosed with communicating INPH and assigned to HC centile range adjusted for height and sex. The proportion of patients with INPH and HC above the 97th, 90th or 50th centiles was compared with the proportion expected in a normal population. RESULTS: The proportion of patients with HC >90th centile was significantly larger than would be expected in a normal distribution (19.6% vs 10%, p = 0.0001), as was the proportion of patients with HC >97th centile (8.9% vs 3%, p = 0.0001). The relative association between INPH and HC >97th centile was nearly tripled (relative association 2.95; CI 1.36 to 6.41), but the relative association between INPH and HC >50th centile was not significantly higher than predicted (relative association 1.13; CI 0.95 to 1.34). CONCLUSION: A significantly larger proportion of elderly adults with INPH have a HC greater than the 90th or 97th centile than predicted by population norms, supporting the concept that compensated congenital hydrocephalus that does not become symptomatic until late in life is one aetiology of INPH, but is not responsible for all INPH. The mechanism that leads to the development of INPH in most patients remains elusive.

Aged↗
PubMed1998

Correlation between lumbo-ventricular perfusion and MRI-CSF flow studies in idiopathic normal pressure hydrocephalus.

BACKGROUND: After the initial description of normal pressure hydrocephalus (NPH) and its clinical triad, there has been a continuous interest from clinicians and researchers to set different diagnostic criteria that would make the selection of candidates for shunt surgery easier and more precise. METHODS: A preliminary group of 12 patients was given a diagnosis of idiopathic normal pressure hydrocephalus by clinical and radiologic criteria. Each patient underwent two different tests: a magnetic resonance imaging-cerebrospinal fluid (MRI-CSF) flow study and a lumbo-ventricular perfusion test. The purpose was to compare the correlation of the results obtained with these tests and the clinical results obtained after CSF diversion. Eleven patients were given shunts and one was managed with lumbar punctures. RESULTS: One year after treatment, 10 of the 12 patients had improved with good results. The MRI-CSF flow studies were reliable in six patients; there were five false negatives and one false positive. The lumbo-ventricular perfusion test showed reliability in nine patients; there were two false negatives and one false positive. In only three patients were the results of both of these tests in accordance with the outcome. CONCLUSIONS: Even though there are few patients in this study so far, the data suggests that at the present time the most predictive guides for the diagnosis of NPH and its outcome after shunting are the clinical criteria and the radiological findings in computed tomography (CT) and/or MRI rather than lumbo-ventricular perfusion and CSF flow studies.

Adolescent↗
PubMed2002

Measurement of cerebrospinal fluid flow at the cerebral aqueduct by use of phase-contrast magnetic resonance imaging: technique validation and utility in diagnosing idiopathic normal pressure hydrocephalus.

OBJECTIVE: We analyzed the reliability of a protocol for measuring quantitative cerebrospinal fluid (CSF) flow at the cerebral aqueduct and established the range of CSF flows in normal elderly patients, patients with Alzheimer's and other forms of dementia, and patients with idiopathic normal pressure hydrocephalus (NPH). METHODS: A constant flow phantom was used to establish the accuracy of the CSF flow measurement. The clinical variability of the measurement was estimated by calculating the standard deviations and coefficients of variation of intra- and interobserver and intertrial data sets derived from three normal volunteers. A total of 236 patients were studied, including 47 normal elderly patients, 115 patients with cognitive impairment (9 with mild cognitive impairment, 46 with Alzheimer's disease, and 60 with other cognitive impairment), 31 patients in whom NPH was suspected but ultimately excluded, and 43 patients with a final clinical diagnosis of NPH. RESULTS: The intraobserver, interobserver, and intertrial measurement variations of 6.4, 5.4, and 8.8%, respectively, were substantially smaller than the wide variation observed among subjects. There was no statistically significant difference in flow between normal elderly patients and patients with cognitive impairment (P = 0.91). When these populations were pooled, the average flow was 8.47 ml/min (standard deviation, 4.23; range, 0.9-18.5 ml/min). The average flow rate in patients with a final clinical diagnosis of NPH was 27.4 ml/min (standard deviation, 15.3; range, 3.13-62.2 ml/min). This was significantly higher than the flow rate in each of the other three groups (all, P < 0.001). CONCLUSION: CSF flow measurements of less than 18 ml/min with a sinusoidal flow pattern are normal. CSF flow of greater than 18 ml/min suggests idiopathic NPH.

Adult↗
PubMed1990

[Typical CT findings with the intrathecal infusion test in post-traumatic disorders of cerebrospinal fluid dynamics].

Simultaneous computer tomographic and cerebrospinal fluid dynamics examinations in patients with high-pressure hydrocephalus, normal pressure hydrocephalus and cerebral atrophic processes are presented and discussed. Exclusive CT and MR examinations do not allow a differentiation of patients with normal pressure hydrocephalus and patients with cerebral atrophy. In the simultaneous examinations the morphological substrate during the intrathecal infusion test is represented.

Adult↗