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PubMedDate not supplied

The importance of the intrathecal infusion test in the diagnostics of normal pressure hydrocephalus.

OBJECTIVE: The intrathecal infusion test is a reliable method in diagnosing normal pressure hydrocephalus. METHODS: Between May 1982 and January 1997 we investigated 200 patients suspected for a normal pressure hydrocephalus (NPH) by carrying out an intrathecal infusion test in a constant flow technique. The resistance to cerebrospinal fluid outflow (Rout) in the intrathecal infusion test was the main criterion for grouping patients into these with normal pressure hydrocephalus or those with cerebral atrophy. A further differentiation into early stage and late stage was made by measuring the compliance (Cp)--this being the secondary criterion. RESULTS: In 107 patients (54%) the diagnosis of a NPH could be confirmed. Of these, 102 patients (95%) underwent a shunt operation. Graduation of NPH and cerebral atrophy following the results of the infusion test in an early stage and an advanced stage allows the conclusion of prognostic evaluations about the course of disease to be made. Patients with a NPH in an early stage are reporting in the follow up about an improvement of their symptoms after a shunt operation in 65 percent of cases and those with an advanced stage NPH in 50 percent. CONCLUSION: The computer aided infusion test allows a reliable differentiation between patients with NPH and those with cerebral atrophy.

Atrophy↗

PubMed2000

Postural disturbance in patients with normal pressure hydrocephalus.

The postural function in 52 patients with normal pressure hydrocephalus (NPH) and in 19 patients with subcortical arteriosclerotic encephalopathy (SAE) was analysed bedside and in 17 of the NPH, 10 of the SAE and 23 healthy individuals (HI) also examined with a force platform. At the bedside examination, no differences in postural functions between NPH and SAE patients were found. The NPH patients improved more in the postural than in motor functions after shunt surgery. The NPH patients had a larger sway area and a higher backward directed velocity of centre of pressure than HI. The direction of the inclination in the sagittal plane was neutral or forward in the NPH and the SAE patients while it was backward in HI. The postural function was better in positions with open eyes in all 3 groups, but significantly less in the NPH patients, indicating a misinterpretation of afferent visual stimuli in the brainstem postural centre.

Aged↗

PubMed1990

Normal pressure hydrocephalus associated with cauda equina neurinoma.

A 65-year-old woman with normal pressure hydrocephalus experienced improved gait and hydrocephalus following surgical resection of a cauda equina neurinoma. Fibrinogen, detected in the cerebrospinal fluid, may be involved in the pathophysiological process of normal pressure hydrocephalus.

Aged↗

PubMed2004

Cognitive recovery in idiopathic normal pressure hydrocephalus after shunt.

OBJECTIVE: Evaluate long-term changes in cognition after ventriculoperitoneal shunt insertion in patients with idiopathic normal pressure hydrocephalus. BACKGROUND: Although studies have indicated that treatment of normal pressure hydrocephalus with ventriculoperitoneal shunt improves gait, effects of treatment on cognition have been inconsistent. Several studies have reported no significant improvement on neuropsychological tests in patients with idiopathic normal pressure hydrocephalus. Selection of candidates for shunt surgery using a trial of controlled spinal fluid drainage via lumbar catheter may result in more consistent improvement in cognition. DESIGN/METHODS: This was a prospective, longitudinal study of performance on neuropsychological tests before and 6 to 12 months after insertion of a ventriculoperitoneal shunt in 10 patients with idiopathic normal pressure hydrocephalus who showed improvement in at least 1 clinical symptom with temporary lumbar drainage. Nonparametric tests were used to evaluate change. RESULTS: Significant group improvements at follow-up were demonstrated on tests of verbal memory as well as in 1 test of psychomotor speed. Eight of 10 patients showed improvement by more than 1 standard deviation on at least 1 memory test. Six of 10 patients improved significantly on more than 50% of the tests administered. CONCLUSIONS: Patients with idiopathic normal pressure hydrocephalus who show clinical improvement (in any symptom) after lumbar drainage are likely to show significant long-term improvement in memory after ventriculoperitoneal shunt.

Aged↗

PubMed1989

Computed tomography of the brain in the diagnosis of and prognosis in normal pressure hydrocephalus.

Thirty-eight patients with normal pressure hydrocephalus were examined by CT before and after a ventriculo-peritoneal shunt operation. Evans ratio, periventricular hypodensity and width of hemispheric sulci, sylvian fissures, cella media, temporal horns and third and fourth ventricle were examined. Twenty-eight patients improved after the operation while 10 were unchanged (non responders). Those patients who improved had more often enlarged third ventricle, enlarged temporal horns and normal sylvian fissures than those who did not improve. No single CT parameter or combination of CT parameters alone could identify responders and non-responders. The ventriculo-peritoneal shunt operation reduced ventricular size (Evans ratio, cella media width), abolished periventricular hypodensity and reduced width of the temporal horns and third ventricle in both responders and non-responders. Reduction of the width of the third ventricle correlated to clinical improvement.

Aged↗

PubMedDate not supplied

The triad of neurological manifestations in bilateral chronic subdural hematoma and normal pressure hydrocephalus.

A triad of mental changes unsteady gait and urinary incontinence, was seen in normal pressure hydrocephalus and bilateral chronic subdural hematoma. Characteristic mental symptoms in normal pressure hydrocephalus and bilateral chronic subdural hematoma were slowness in mental responses and lack of spontaneity which were thought to be partial akinetic mutism. It is thought that the triad can be developed not only by the periventricular white matter lesion in the cerebrum as proposed in normal pressure hydrocephalus, but also by the infratentorial lesion as speculated from cases with bilateral chronic subdural hematoma.

Adult↗

PubMed2002

Why valve opening pressure plays a relatively minor role in the postural ICP response to ventricular shunts in normal pressure hydrocephalus: modeling and implications.

OBJECTIVES: In normal pressure hydrocephalus, there is no clear evidence that the opening pressure of differential pressure valves influences outcome. In this study, the objective was to determine whether the relationship between valve opening pressure and post-operative postural ICP changes was predictable. METHODS: Eight adult-onset hydrocephalus patients were evaluated using an intraparenchymal ICP microsensor. Postural ICP measurements were obtained before and after placement of a ventricular shunt (VP or VA) with a Codman Hakim programmable valve. RESULTS: Valve opening pressure had a poor correlation with ICP at any head-of-bed elevation across subjects (best r = 0.25). The degree of negative ICP encountered for any given patient did not appear to be determined by the valve pressure, and varied significantly between patients at the same valve pressure. Each individual's ICP correlated well to opening pressure (r > 0.76), but the response is more sigmoidal than linear, and the opening pressure at which ICP changed most was markedly different between patients. CONCLUSIONS: The hydrodynamic pressures generated by shunts with different pressure valves are unpredictable. Our data supports the use of programmable valves in patients with adult onset hydrocephalus and suggests that ICP be measured post-operatively to achieve an optimal clinical outcome.

Cerebrospinal Fluid Shunts↗

PubMedDate not supplied

Psychiatric and behavioural manifestations of normal-pressure hydrocephalus.

Seven patients with psychiatric and behavioural manifestations of normal-pressure hydrocephalus are described. There is little disagreement about the classical triad of symptoms. However, it requires a high index of suspicion when a patient presents with non-specific psychiatric and behavioural symptoms. Clinicians must be alert to the possibility when positive findings point to the diagnosis of normal-pressure hydrocephalus, namely gait disturbance, incontinence, soft neurological signs, history of hypertension and no previous psychiatric history.

Aged↗

PubMed1979

[Normal pressure hydrocephalus (author's transl)].

Report on 21 patients with the syndrome of normal pressure hydrocephalus. All patients were treated by implantation of a shunt-system (ventriculo-atrial shunt). In only 50% of the cases to result was good (complete remission of the clinical signs). The prognosis depends upon the etiology and the duration of the disease. The best results can be expected in cases of normal pressure hydrocephalus following subarachnoid hemorrhage.

Cerebrospinal Fluid Shunts↗

PubMed2001

Normal-pressure hydrocephalus.

This article presents a brief history of normal-pressure hydrocephalus, its clinical presentation, and different theories on its pathophysiology. The different diagnostic tests, differential diagnosis, and its treatment are presented.

Brain↗

PubMed2005

The prognostic value of clinical characteristics and parameters of cerebrospinal fluid hydrodynamics in shunting for idiopathic normal pressure hydrocephalus.

BACKGROUND: It is difficult to predict which patients with symptoms and radiological signs of normal pressure hydrocephalus (NPH) will benefit from a shunting procedure and which patients will not. Risk of this procedure is also higher in patients with NPH than in the overall population of hydrocephalic patients. The aim of this study is to investigate which clinical characteristics, CT parameters and parameters of cerebrospinal fluid dynamics could predict improvement after shunting. METHODS: Eighty-three consecutive patients with symptoms and radiological signs of NPH were included in a prospective study. Parameters of the cerebrospinal fluid dynamics were measured by calculation of computerised data obtained by a constant-flow lumbar infusion test. Sixty-six patients considered candidates for surgery were treated with a medium-pressure Spitz-Holter valve; in seventeen patients a shunting procedure was not considered indicated. Clinical and radiological follow-up was performed for at least one year postoperatively. FINDINGS: The odds ratio, the sensitivity and specificity as well as the positive and negative predictive value of individual and combinations of measured parameters did not show a statistically significant relation to clinical improvement after shunting. CONCLUSIONS: We conclude that neither individual parameters nor combinations of measured parameters show any statistically significant relation to clinical improvement following shunting procedures in patients suspected of NPH. We suggest restricting the term normal pressure hydrocephalus to cases that improve after shunting and using the term normal pressure hydrocephalus syndrome for patients suspected of NPH and for patients not improving after implantation of a proven well-functioning shunt.

Aged↗

PubMed1994

[Pure red cell aplasia with thymoma, myasthenia gravis and normal pressure hydrocephalus].

Cases of pure red cell aplasia with thymoma and myasthenia gravis are rare. We described a patient who had concomitant pure red cell aplasia, thymoma, myasthenia gravis and a normal pressure hydrocephalus. A 63-year-old man with disturbances of gait, left blepharoptosis and anemia was presented to our hospital. Laboratory examination on admission revealed severe anemia. Bone marrow aspirates showed erythroid hypoplasia of marked degree. Chest x-ray and chest CT revealed a tumor to the right of cardiac wall. The tensilon chloride test and antiacetylcholine receptor antibody were positive. A hydrocephalus was demonstrated with brain CT. Cerebrospinal fluid pressure was in the normal range. He was diagnosed as having pure red cell aplasia with thymoma, myasthenia gravis and a normal pressure hydrocephalus. This appears to be a fairly rare case. It seems important to consider that a normal pressure hydrocephalus may have immunological disorders.

Humans↗

PubMed1996

Risks in using siphon-reducing devices in adult patients with normal-pressure hydrocephalus: bench test investigations with Delta valves.

To elucidate the reason for malfunction of Delta valves in patients with normal-pressure hydrocephalus, the authors applied a new concept of the bench test and simulated intracranial pressure (ICP) to measure the resultant flow with a complete shunt system. Subcutaneous pressure on the valve, valve implantation site, and postural hydrostatic differential-pressure changes were simulated in this bench test designed for adult patients with normal-pressure hydrocephalus. Subcutaneous pressure ranged within 6.4 +/- 0.09 cm H2O (mean +/- standard deviation) on the 7th day after the implantation of the valve in rats. A linear correlation between valve closing pressures and the external pressure was observed: gradual increase of the latter resulted in an approximately equal rise in the closing pressure. Closing pressure ranged within the physiological variation of ICP (10 +/- 5 cm H2O) in the supine position. In the erect position it was higher than the physiological variation (+5 to -5 cm H2O) when the valve was placed at the level of the foramen of Monro and lower when placed at the level of the clavicle. This observation indicates that the subcutaneous pressure around the Delta valve significantly affects its closing pressure. An excessive reduction of flow or a functional obstruction occurs when the patient with a Delta valve implanted at the foramen of Monro assumes an erect posture. The authors conclude that Delta valves are not recommended for implantation at the level of the foramen of Monro in patients with normal-pressure hydrocephalus because of the risk of underdrainage. The mastoid process or clavicle may be the alternative levels for its implantation to prevent underdrainage; however, the possibility of shunt malfunction should be kept in mind because subcutaneous pressure is variable among patients and that might affect the performance characteristics of these valves.

Animals↗

PubMed1976

Increased intracranial pressure in so-called 'normal-pressure hydrocephalus'.

Five patients exhibited an apparently communicating hydrocephalus -- type of disorder, with ventricular reflux on the cisternograms, lack of air-encephalographic parasagittal air-filling and clearly enlarged temporal horns. The group seemed heterogeneous, with regard to age distribution; possible etiological factors and duration of the hydrocephalic process. In all 5 patients increased intracranial/intrathecal pressure was observed: in 2 patients, only with intrathecal measurement in the lumbar area, but in the remaining 3 patients with epidural/ventricular fluid pressure monitoring. Continuously increased pressure extending over 1 or more days was observed in these patients. This pressure increase may seem different from the episodic pressure increase previously reported in normal-pressure hydrocephalus. These patients seem to be cases of so-called normal-pressure hydrocephalus according to the commonly accepted criteria. It is therefore suggested that the term normal-pressure hydrocephalus should be abandoned, and replaced by, e.g., low-pressure hydrocephalus, malresorptive or malabsorptive hydrocephalus.

Adult↗

PubMed2004

Management of normal pressure hydrocephalus.

Gait instability, urinary incontinence, and dementia are the signs and symptoms typically found in patients who have normal pressure hydrocephalus. Estimated to cause no more than 5 percent of cases of dementia, normal pressure hydrocephalus often is treatable, and accurate recognition of the clinical triad coupled with radiographic evidence most commonly identifies likely responders. Magnetic resonance imaging or computed tomography typically demonstrates ventricular dilation with preservation of the surrounding brain tissue. The abnormality in normal pressure hydrocephalus occurs secondary to an abnormality in fluid removal, leading to an increase in ventricular size and encroachment of enlarged ventricles on adjacent brain tissue. The pressure exerted on the cerebral parenchyma by immense fluid-filled cavities deforms white matter tracts, instigating gait abnormalities and incomplete control of the bladder, as well as difficulties in processing incoming stimulation and in producing expeditious responses. Signs and symptoms often occur as sequelae to an imbalance between the expected ongoing production of cerebrospinal fluid and continuous efflux. Ventriculoperitoneal shunting is used to relieve excess ventricular fluid not absorbed by normal physiologic channels. Multiple studies have explored various techniques to identify patients with normal pressure hydrocephalus in an effort to predict likely benefit from shunting. However, the effectiveness of cerebrospinal fluid diversion has never been proven in a randomized controlled trial comparing use of a shunt versus no shunt.

Alzheimer Disease↗

PubMed1990

Normal pressure hydrocephalus in a patient with systemic lupus erythematosus.

We describe a patient who had concomitant systemic lupus erythematosus (SLE) and a normal pressure hydrocephalus. She improved only after appropriate therapy for each. Although 6 patients with arthritis and normal pressure hydrocephalus have been described, this is the first report of it occurring in a patient with SLE. It has been emphasized that normal pressure hydrocephalus can easily be overlooked in elderly patients with arthritic conditions. Since neuropsychiatric symptoms are likelier to occur in patients with SLE than in other rheumatologic conditions, the diagnosis of normal pressure hydrocephalus may be delayed or overlooked. Because normal pressure hydrocephalus is a potentially reversible cause of neurologic dysfunction, it should be considered in appropriate populations.

Aged↗

PubMed2003

Lack of relationship between resistance to cerebrospinal fluid outflow and intracranial pressure in normal pressure hydrocephalus.

OBJECTIVE: To explore whether calculation of resistance to cerebrospinal fluid (CSF) outflow (Rout) by the lumbar constant rate infusion test in a reliable way predicts the intracranial pressure (ICP) profile in normal pressure hydrocephalus (NPH). METHODS: A prospective study was undertaken including 16 cases with clinical signs of normal pressure hydrocephalus that were investigated with both continuous ICP monitoring and the lumbar constant rate infusion test. Intracranial pressure monitoring was performed for about 24 h, and supplied with a simultaneous lumbar constant rate infusion test at the end of the monitoring period. The pressure recordings were analysed using the Sensometrics Pressure Analyser. Various characteristics of the pressure curves were compared. RESULTS: The continuous ICP recordings were considered as normal (mean ICP<11.5 mmHg) in all 16 cases. The lumbar infusion test showed an apparently abnormal resistance to CSF outflow (Rout) (> or =12.0 mmHg/ml/min) in 12 of 16 cases. There was no relationship between lumbar Rout and mean ICP during sleep. We could not find any relationship between lumbar Rout and number of nightly ICP elevations of 1525 mmHg lasting 0.5 or 1 min. Neither resistance to CSF outflow (Rout) nor mean ICP during sleep was related to the ventricular size. CONCLUSIONS: The results of this prospective study revealed no significant relationship between resistance to CSF outflow (Rout) and the ICP profile in NPH cases. The results also suggest that caution should be made when predicting the ICP profile on the basis of measuring the lumbar CSF pressure for a few minutes duration.

Adult↗

PubMed2004

[Gravity valves for idiopathic normal pressure hydrocephalus. A Prospective study of 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 a hydrostatic valve (Miethke dual-switch valve) at the Unfallkrankenhaus Berlin. RESULTS: One year after the shunt operation, the clinical picture was very good for 33% of the patients, good for 33%, satisfactory for 17%, and poor for 17%. At 20%, the rate of postoperative complications (catheter dislocations, valve infections, underdrainage and overdrainage) is still relatively high. The opening pressure of the Miethke dual-switch valve did not correlate with the postoperative results of treatment. CONCLUSION: According to our experience, hydrostatic Miethke dual-switch valves 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 of the treatment and the incidence of possible complications. With differentiated diagnosis and therapy, a clinical improvement can be achieved for 83% of such patients.

Adult↗