The sustained improvement after lumbar puncture in an idiopathic normal pressure hydrocephalus subject with synucleinopathy

Object Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable–shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP). Methods The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory. Results Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs 27.0, respectively; p = 0.005). Conclusions Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.

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EP 51. Determination of gait improvement after lumbar puncture in idiopathic normal pressure hydrocephalus

Clinical Neurophysiology ◽

10.1016/j.clinph.2016.05.105 ◽

2016 ◽

Vol 127 (9) ◽

pp. e260

Author(s):

K. Möhwald ◽

M. Wuehr ◽

C. Pradhan ◽

M. Dieterich ◽

T. Brandt ◽

...

Keyword(s):

Lumbar Puncture ◽

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus

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Management of idiopathic normal-pressure hydrocephalus: a multi-institutional study conducted in Japan

Journal of Neurosurgery ◽

10.3171/jns.2001.95.6.0970 ◽

2001 ◽

Vol 95 (6) ◽

pp. 970-973 ◽

Cited By ~ 96

Author(s):

Koreaki Mori

Keyword(s):

Lumbar Puncture ◽

Normal Pressure Hydrocephalus ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Gait Disturbance ◽

Early Assessment ◽

Content Type ◽

Programmable Valve ◽

Csf Diversion ◽

Fine Print

Object. A cooperative study was undertaken to identify factors that could be used to predict a favorable outcome after extracranial cerebrospinal fluid (CSF) diversion (shunting) in patients with suspected idiopathic normal-pressure hydrocephalus (NPH). Methods. Questionnaires concerning patients with suspected idiopathic NPH were sent to 14 members of the Committee for Scientific Research on Intractable Hydrocephalus, sponsored by the Ministry of Health and Welfare of Japan. After the questionnaires were returned, a retrospective analysis of the responses was undertaken. To be included in the study, patients had to be 65 years of age or older and had to have undergone surgery between October 1995 and October 1998. Clinical measures included degrees of gait disturbance, dementia, and urinary incontinence as evaluated before, 3 months after, and 3 years after shunt placement. Diagnostic tests in various combinations included lumbar puncture in which CSF was withdrawn; intracranial pressure monitoring; measurements of CSF outflow resistance, level of serum α-1-antichymotrypsin, cerebral arteriovenous differences of oxygen content, and cerebral blood flow; and computerized tomography cisternography. In this study, 120 patients were identified as having idiopathic NPH and these patients underwent placement of shunts. A ventriculoperitoneal shunt with a programmable valve was used in two thirds of the patients. At the end of 3 months (early assessment), there was an 80% overall rate of clinical improvement, which dropped to 73.3% of the 105 patients who could be evaluated at the end of the 3-year study. Of the three variables, gait disturbance was most improved, both at early and late testing periods. Shunt complications occurred in 22 (18.3%) of the patients. Conclusions. Patients suspected of having idiopathic NPH did not form a homogeneous group, making it difficult to select those who would most likely respond to CSF diversion. Of the diagnostic studies, the most reliable result was improvement in clinical symptoms following a lumbar puncture in which CSF was withdrawn. The use of a programmable valve is recommended because it offers advantages in preventing problems of over- and underdrainage.

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P.122 The prediction of outcome after shunting for idiopathic normal pressure hydrocephalus

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.214 ◽

2019 ◽

Vol 46 (s1) ◽

pp. S45

Author(s):

B Daud Shah ◽

A Persad ◽

K Meguro

Keyword(s):

Lumbar Puncture ◽

Normal Pressure Hydrocephalus ◽

Charlson Comorbidity Index ◽

Laparoscopic Approach ◽

Retrospective Chart Review ◽

Normal Pressure ◽

Idiopathic Normal Pressure Hydrocephalus ◽

Distal Catheter ◽

Age At Surgery ◽

Comorbidity Index

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a triad of impaired gait, cognition and urinary control in the setting of normal pressure ventriculomegaly. Various options for shunt implantation exist, but there is limited ability to predict outcome. Methods: This study is a retrospective chart review of 82 shunted patients for iNPH between 2007 and 2018. Factors examined included age, sex, lumbar puncture results, use of laparoscopic approach, type of shunt used, Charlson Comorbidity Index and imaging (callosal angle and DESH). Patient outcome was assessed via modified Rankin Scale (mRS). Results: 52 patients were male and 30 were female. Average age at surgery was 71.4 years. 58/62 (94%) improved following lumbar puncture. 41% of patients had VP shunt, and 59% of patients had LP shunt. 30/79 (38%) had laparoscopic placement of the distal catheter. 23/75 (31%) and 30/81 (36%) had a complication and required reoperation, respectively. Callosal angle showed statistically significant increase post-shunting (76 to 94 degrees, p<0.005). Presence of DESH did not change post-shunting. Average Charlson Comorbidity Index was 4.4. The mRS decreased from 3.84 to 2.66 post-operatively (p<0.005). Conclusions: In our centre, iNPH patients had clinicoradiologic improvement following shunting. We will perform regressional statistics to elucidate the factors influencing outcomes.

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