Clinical outcomes of normal pressure hydrocephalus in 116 patients: objective versus subjective assessment

2020 ◽  
Vol 132 (6) ◽  
pp. 1757-1763 ◽  
Author(s):  
Eva M. Wu ◽  
Tarek Y. El Ahmadieh ◽  
Benjamin Kafka ◽  
James P. Caruso ◽  
Om J. Neeley ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Clinical Characteristics ◽  
Objective Assessment ◽  
Normal Pressure ◽  
Subjective Assessment ◽  
Complication Rates ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Significant Difference ◽  
Shunt Response

OBJECTIVEObjective assessment tests are commonly used to predict the response to ventriculoperitoneal (VP) shunting in patients with normal pressure hydrocephalus (NPH). Whether subjective reports of improvement after a lumbar drain (LD) trial can predict response to VP shunting remains controversial. The goal in this study was to compare clinical characteristics, complication rates, and shunt outcomes of objective and subjective LD responders who underwent VP shunt placement.METHODSThis was a retrospective review of patients with NPH who underwent VP shunt placement after clinical improvement with the LD trial. Patients who responded after the LD trial were subclassified into objective LD responders and subjective LD responders. Clinical characteristics, complication rates, and shunt outcomes between the 2 groups were compared with chi-square test of independence and t-test.RESULTSA total of 116 patients received a VP shunt; 75 were objective LD responders and 41 were subjective LD responders. There was no statistically significant difference in patient characteristics between the 2 groups, except for a shorter length of stay after LD trial seen with subjective responders. The complication rates after LD trial and VP shunting were not significantly different between the 2 groups. Similarly, there was no significant difference in shunt response between objective and subjective LD responders. The mean duration of follow-up was 1.73 years.CONCLUSIONSReports of subjective improvement after LD trial in patients with NPH can be a reliable predictor of shunt response. The currently used objective assessment scales may not be sensitive enough to detect subtle changes in symptomatology after LD trial.

A prospective study of cerebral blood flow and cerebrovascular reactivity to acetazolamide in 162 patients with idiopathic normal-pressure hydrocephalus

2009 ◽  
Vol 111 (3) ◽  
pp. 610-617 ◽  
Author(s):  
Chia-Cheng Chang ◽  
Hiroyuki Asada ◽  
Toshiro Mimura ◽  
Shinichi Suzuki
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Cerebrovascular Reactivity ◽  
Healthy Controls ◽  
Shunt Placement ◽  
Significant Difference ◽  
A Prospective Study

Object Cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to acetazolamide were investigated prospectively in 162 patients with a proposed diagnosis of idiopathic normal-pressure hydrocephalus (NPH). The aim of this study was to assess the usefulness of the measurement of CBF and CVR in determining which patients would be likely to benefit from shunt placement. Methods The mean CBF of the whole brain was measured according to the Patlak plot method by using technetium-99m hexamethylpropyleneamine oxime. The CVR value was obtained from the response to administration of 500 mg acetazolamide and calculated as the percentage change from the baseline mean CBF value. Results One hundred forty-six patients (90.1%) responded to shunt placement (“responders”), but 16 patients (9.9%) did not (“nonresponders”). No significant difference in preoperative CBF was observed between responders and nonresponders. Preoperative CVR was significantly impaired (p < 0.0025) in responders compared with healthy controls, but not in nonresponders. Responders with the incomplete triad had a significant reduction (p < 0.001) in preoperative CVR, but not in preoperative CBF, compared with healthy controls. Responders with the complete triad had significantly lower preoperative CBF and CVR than those with the incomplete triad (p < 0.01 and p < 0.05, respectively). Postoperative CBF and CVR increased significantly (p < 0.025 and p < 0.001, respectively) in responders. Conclusions Both CBF and CVR decrease with the development of NPH, suggesting that hemodynamic ischemia may be responsible for manifestation of the symptoms. Impaired CVR and reduced CBF with the development of symptoms can be proposed as diagnostic criteria for idiopathic NPH.

A randomized controlled dual-center trial on shunt complications in idiopathic normal-pressure hydrocephalus treated with gradually reduced or “fixed” pressure valve settings

2014 ◽  
Vol 121 (5) ◽  
pp. 1257-1263 ◽  
Author(s):  
Terje Sæhle ◽  
Dan Farahmand ◽  
Per Kristian Eide ◽  
Magnus Tisell ◽  
Carsten Wikkelsö
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Improvement Rate ◽  
Vp Shunt ◽  
Shunt Complications ◽  
Pressure Setting ◽  
Randomized Controlled ◽  
Adjustable Valve ◽  
Significant Difference

Object This study was undertaken to investigate whether a gradual reduction of the valve setting (opening pressure) decreases the complication rate in patients with idiopathic normal-pressure hydrocephalus (iNPH) treated with a ventriculoperitoneal (VP) shunt. Methods In this prospective double-blinded, randomized, controlled, dual-center study, a VP shunt with an adjustable valve was implanted in 68 patients with iNPH, randomized into two groups. In one group (the 20–4 group) the valve setting was initially set to 20 cm H2O and gradually reduced to 4 cm H2O over the course of the 6-month study period. In the other group (the 12 group), the valve was kept at a medium pressure setting of 12 cm H2O during the whole study period. The time to and type of complications (hematoma, infection, and mechanical problems) as well as overdrainage symptoms were recorded. Symptoms, signs, and outcome were assessed by means of the iNPH scale and the NPH grading scale. Results Six patients in the 20–4 group (22%) and 7 patients in the 12 group (23%) experienced a shunt complication; 9 had subdural hematomas, 3 mechanical obstructions, and 1 infection (no significant difference between groups). The frequency of overdrainage symptoms was significantly higher for a valve setting ≤ 12 cm H2O compared with a setting > 12 cm H2O. The 20–4 group had a higher improvement rate (88%) than the 12 group (62%) (p = 0.032). There was no significant relationship between complications and body mass index, the use of an antisiphon device, or the use of anticoagulants. Conclusions Gradual lowering of the valve setting to a mean of 7 cm H2O led to the same rate of shunt complications and overdrainage symptoms as a fixed valve setting at a mean of 13 cm H2O but was associated with a significantly better outcome.

Shunts in normal-pressure hydrocephalus: do we place too many or too few?

2006 ◽  
Vol 105 (6) ◽  
pp. 815-822 ◽  
Author(s):  
Sherman C. Stein ◽  
Mark G. Burnett ◽  
Seema S. Sonnad
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Transition Probabilities ◽  
Normal Pressure ◽  
Decision Analysis Model ◽  
Complication Rates ◽  
Analysis Model ◽  
Shunt Insertion ◽  
Life Years ◽  
Wide Range ◽  
Shunt Response

Object The average 65-year-old patient with moderate dementia can look forward to only 1.4 quality-adjusted life years (QALYs), that is, longevity times quality of life. Some of these patients suffer from normal-pressure hydrocephalus (NPH) and respond dramatically to shunt insertion. Currently, however, NPH cannot be diagnosed with certainty. The authors constructed a Markov decision analysis model to predict the outcome in patients with NPH treated with and without shunts. Methods Transition probabilities and health utilities were obtained from a review of the literature. A sensitivity analysis and Monte Carlo simulation were applied to test outcomes over a wide range of parameters. Using shunt response and complication rates from the literature, the average patient receiving a shunt would gain an additional 1.7 QALYs as a result of automatic shunt insertion. Even if 50% of patients receiving a shunt have complications, the shunt response rate would need to be less than 5% for empirical shunt insertion to do more harm than good. Authors of most studies have reported far better statistics. Conclusions In summary, many more patients with suspected NPH should be considered for shunt insertion.

Motor cortex disinhibition in normal-pressure hydrocephalus

2012 ◽  
Vol 116 (2) ◽  
pp. 453-459 ◽  
Author(s):  
Andrei V. Chistyakov ◽  
Hava Hafner ◽  
Alon Sinai ◽  
Boris Kaplan ◽  
Menashe Zaaroor
Keyword(s):  
Motor Cortex ◽  
Healthy Volunteers ◽  
Normal Pressure Hydrocephalus ◽  
Close Association ◽  
Motor Evoked Potential ◽  
Normal Pressure ◽  
Corticospinal Excitability ◽  
Conduction Time ◽  
Shunt Placement ◽  
Resting Motor Threshold

Object Previous studies have shown a close association between frontal lobe dysfunction and gait disturbance in idiopathic normal-pressure hydrocephalus (iNPH). A possible mechanism linking these impairments could be a modulation of corticospinal excitability. The aim of this study was 2-fold: 1) to determine whether iNPH affects corticospinal excitability; and 2) to evaluate changes in corticospinal excitability following ventricular shunt placement in relation to clinical outcome. Methods Twenty-three patients with iNPH were examined using single- and paired-pulse transcranial magnetic stimulation of the leg motor area before and 1 month after ventricular shunt surgery. The parameters of corticospinal excitability assessed were the resting motor threshold (rMT), motor evoked potential/M-wave area ratio, central motor conduction time, intracortical facilitation, and short intracortical inhibition (SICI). The results were compared with those obtained in 8 age-matched, healthy volunteers, 19 younger healthy volunteers, and 9 age-matched patients with peripheral neuropathy. Results Significant reduction of the SICI associated with a decrease of the rMT was observed in patients with iNPH at baseline evaluation. Ventricular shunt placement resulted in significant enhancement of the SICI and increase of the rMT in patients who markedly improved, but not in those who failed to improve. Conclusions This study demonstrates that iNPH affects corticospinal excitability, causing disinhibition of the motor cortex. Recovery of corticospinal excitability following ventricular shunt placement is correlated with clinical improvement. These findings support the view that reduced control of motor output, rather than impairment of central motor conduction, is responsible for gait disturbances in patients with iNPH.

Abstract 224: No Difference in Complications or Mortality by Implanted Cardioverter Defibrillator Type in Veterans Enrolled in The Outcomes Among Veterans with Implantable Devices (OVID) Registry

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Preston M Schneider ◽  
Cara N Pellegrini ◽  
Paul Heidenreich ◽  
Edmund Keung ◽  
Barry M Massie ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Cardiac Resynchronization ◽  
Complication Rates ◽  
Composite Outcome ◽  
Dual Chamber ◽  
Icd Implantation ◽  
Single Chamber ◽  
Clinical Covariates ◽  
Social Security Death Index ◽  
Significant Difference

Introduction: Dual chamber ICD implantation has been associated with higher complication rates than single chamber ICD implantation without associated decrease in morbidity or mortality in prior reports. If this association is present using validated long term outcomes or whether the same is true for cardiac resynchronization therapy defibrillator (CRT-D) devices is not well described. Methods: The OVID registry enrolled 3,918 veterans between 2003 and 2009. Retrospective chart abstraction from enrollment to implant date captured pre- and peri-procedural data. Patients were then followed prospectively until death or study conclusion. Abstraction was done by trained abstractors. Clinical outcomes and mortality were abstracted and validated. Mortality was cross referenced with the social security death index. Association of ICD type (single chamber, dual chamber, CRT-D) with mortality, non-fatal major events (major adverse cardiac events, TIA, stroke, cardiogenic syncope, cardiac hospitalization, device complication or infection, procedural complications), and the composite of mortality and non-fatal events was examined using Cox proportional hazards regression, adjusting for baseline clinical characteristics and comorbidities. Results: There were 786 deaths and 1143 non-fatal major events over 11,290 person years of follow up. In unadjusted analyses, CRT-D was associated with non-fatal major events (HR 1.26, 95% CI 1.09-1.45; p<0.05) and the composite outcome (HR 1.12, 95% CI 1.06-1.35; p<0.05) as was Dual chamber ICD (non-fatal major-HR 1.19, 95% CI 1.03-1.37; p<0.05, composite-HR 1.17, 95% CI 1.04-1.31; p<0.05). No significant difference existed in risk between ICD types in the unadjusted analysis of mortality or for any outcome when adjusted for clinical covariates. Conclusions: Unadjusted analyses showed an association between dual chamber ICD and CRT-D devices and risk of non-fatal major events and the composite outcome versus single chamber ICD implantation. This did not persist when adjusted for clinical characteristics and comorbidities, though we are underpowered for small differences. Further study is needed as prior reports may not have adjusted adequately for clinical covariates and lacked validated outcomes.

scholarly journals Prevalence of Cervical Stenosis and Myelopathy in Patients With Idiopathic Normal Pressure Hydrocephalus

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Ryan M Naylor ◽  
Karina Lenartowicz ◽  
Jonathan Graff-Radford ◽  
Jeremy Cutsforth-Gregory ◽  
Benjamin D Elder
Keyword(s):  
Cervical Spine ◽  
Normal Pressure Hydrocephalus ◽  
Cervical Myelopathy ◽  
Clinical Manifestations ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Decompression Surgery ◽  
Consecutive Series ◽  
Cervical Stenosis ◽  
Shunt Placement

Abstract INTRODUCTION Both idiopathic normal pressure hydrocephalus (iNPH) and cervical myelopathy may result in progressive gait impairment. It is possible that some of the patients who do not respond to shunting despite a positive tap test may have gait dysfunction from cervical myelopathy. The objective of this study was to determine the prevalence of cervical stenosis with or without myelopathy in patients with iNPH. METHODS We screened a consecutive series of patients who underwent shunt placement for iNPH for comorbid cervical stenosis. Clinical manifestations of iNPH and cervical myelopathy, grade of cervical stenosis based on previously published criteria, cervical spine surgical intervention, timing of intervention, and outcomes were recorded. RESULTS A total of 42 patients with iNPH were included for analysis. Slightly more patients were male (65%), with a mean age of 75 yr (SD 7 yr) for the entire cohort. All patients presented with gait disturbances and underwent cervical spine MRI. 30/42 (71%) had at least cervical stenosis, while 7/42 (17%) had significant (grade 2-3) cervical stenosis with myelopathy requiring surgical decompression. All patients with grade 2-3 cervical stenosis and symptoms of cervical myelopathy in addition to iNPH underwent cervical decompression surgery. CONCLUSION Clinically significant cervical stenosis is highly prevalent in patients with iNPH, though this finding requires validation in a larger population. Based on these results, cervical imaging should be considered preoperatively or in patients whose gait does not improve after shunt placement.

scholarly journals Normalized power variance of eLORETA at high-convexity area predicts shunt response in idiopathic normal pressure hydrocephalus

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Yasunori Aoki ◽  
Hiroaki Kazui ◽  
Ricardo Bruña ◽  
Roberto D. Pascual-Marqui ◽  
Kenji Yoshiyama ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Power Variance ◽  
Shunt Response

scholarly journals Phase-contrast magnetic resonance imaging reveals net retrograde aqueductal flow in idiopathic normal pressure hydrocephalus

2016 ◽  
Vol 124 (6) ◽  
pp. 1850-1857 ◽  
Author(s):  
Geir Ringstad ◽  
Kyrre Eeg Emblem ◽  
Per Kristian Eide
Keyword(s):  
Flow Rate ◽  
Normal Pressure Hydrocephalus ◽  
Phase Contrast ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Conservative Group ◽  
Shunt Placement ◽  
Before And After ◽  
Shunt Group ◽  
Antegrade Flow

OBJECT The objective of this study was to assess the net aqueductal stroke volume (ASV) and CSF aqueductal flow rate derived from phase-contrast MRI (PC-MRI) in patients with probable idiopathic normal pressure hydrocephalus (iNPH) before and after ventriculoperitoneal shunt surgery, and to compare observations with intracranial pressure (ICP) scores. METHODS PC-MRI at the level of the sylvian aqueduct was undertaken in patients undergoing assessment for probable iNPH. Aqueductal flow in the craniocaudal direction was defined as positive, or antegrade flow, and net ASV was calculated by subtracting retrograde from antegrade aqueductal flow. Aqueductal flow rate per minute was calculated by multiplying net ASV by heart rate. During the same hospital admission, clinical examination was performed using NPH score and overnight continuous ICP monitoring. Twelve patients were followed prospectively 12 months after shunt placement with clinical assessment and a second PC-MRI. The study also included 2 healthy controls. RESULTS Among 21 patients examined for iNPH, 17 (81%) received a shunt (shunt group), and 4 were treated conservatively (conservative group). Among the patients with shunts, a clinical improvement was observed in 16 (94%) of the 17. Net ASV was negative in 16 (76%) of 21 patients before shunt placement and in 5 (42%) of 12 patients after shunt placement, and increased from a median of −5 μl (range −175 to 27 μl) to a median of 1 μl (range −61 to 30 μl; p = 0.04). Among the 12 patients with PC-MRI after shunt placement, 11 were shunt responders, and in 9 of these 11 either a reduced magnitude of retrograde aqueductal flow, or a complete reversal from retrograde to antegrade flow, occurred. Net ASV was significantly lower in the shunt group than in the conservative group (p = 0.01). The aqueductal flow rate increased from −0.56 ml/min (range −12.78 to 0.58 ml/min) to 0.06 ml/min (range −4.51 to 1.93 ml/min; p = 0.04) after shunt placement. CONCLUSIONS In this cohort of patients with iNPH, retrograde net aqueductal flow was observed in 16 (76%) of 21 patients. It was reversed toward the antegrade direction after shunt placement either by magnitude or completely in 9 (75%) of 12 patients examined using PC-MRI both before and after shunt placement (p = 0.04); 11 of the 12 were shunt responders. The study results question previously established concepts with respect to both CSF circulation pathways and CSF formation rate.

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