Dutch Normal-Pressure Hydrocephalus Study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid

1997 ◽  
Vol 87 (5) ◽  
pp. 687-693 ◽  
Author(s):  
Agnita J. W. Boon ◽  
Joseph T. J. Tans ◽  
Ernst J. Delwel ◽  
Saskia M. Egeler-Peerdeman ◽  
Patrick W. Hanlo ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Scale Score ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Predictive Values ◽  
Content Type ◽  
Efficacy Analysis ◽  
Intention To Treat ◽  
Scale Scores ◽  
Fine Print

✓ The authors examined whether measurement of resistance to outflow of cerebrospinal fluid (Rcsf) predicts outcome after shunting for patients with normal-pressure hydrocephalus (NPH). In four centers 101 patients (most of whom had idiopathic NPH) who fulfilled strict entry criteria underwent shunt placement irrespective of their level of Rcsf obtained by lumbar constant flow infusion. Gait disturbance and dementia were quantified by using an NPH scale and the patient's level of disability was assessed by using the modified Rankin scale (mRS). In addition the Modified Mini-Mental State Examination was performed. Patients were assessed prior to and 1, 3, 6, 9, and 12 months after surgery. Primary outcome measures were based on differences between the preoperative and last NPH scale scores and mRS grades. Improvement was defined as a change measuring at least 15% in the NPH scale score and at least one mRS grade. Intention-to-treat analysis of all patients at 1 year yielded improvement for 57% in NPH scale score and 59% in mRS grade. Efficacy analysis, excluding serious events and deaths that were unrelated to NPH, was performed for 95 patients. Improvement rose to 76% in NPH scale score and 69% in mRS grade. Six cut-off levels of Rcsf were related to improvement in NPH scale score using two-by-two tables. Positive predictive values were approximately 80% for an Rcsf of 10, 12, or 15 mm Hg/ml/minute, 92% for an Rcsf of 18 mm Hg/ml/minute, and 100% for an Rcsf of 24 mm Hg/ml/minute. Negative predictive values were low. More important was the highest likelihood ratio of 3.5 for an Rcsf of 18 mm Hg/ml/minute. Extensive comorbidity was a major prognostic factor. Measurement of Rcsf reliably predicts outcome if the limit for shunting is raised to 18 mm Hg/ml/minute. At lower Rcsf values the decision depends mainly on the extent to which clinical and computerized tomography findings are typical of NPH.

Dutch Normal-Pressure Hydrocephalus Study: randomized comparison of low- and medium-pressure shunts

1998 ◽  
Vol 88 (3) ◽  
pp. 490-495 ◽  
Author(s):  
Agnita J. W. Boon ◽  
Joseph T. J. Tans ◽  
Ernst J. Delwel ◽  
Saskia M. Egeler-Peerdeman ◽  
Patrick W. Hanlo ◽  
...  
Keyword(s):  
Outcome Measures ◽  
Normal Pressure Hydrocephalus ◽  
Ventriculoperitoneal Shunt ◽  
Normal Pressure ◽  
Content Type ◽  
Efficacy Analysis ◽  
Intention To Treat ◽  
Medium Pressure ◽  
Shunt Group ◽  
Fine Print

Object. The goal of this prospective study was to compare outcome after placement of a low- or medium-pressure shunt in patients with normal-pressure hydrocephalus (NPH). Methods. Ninety-six patients with NPH were randomized to receive a low-pressure ventriculoperitoneal shunt (LPV; 40 ± 10 mm H2O) or medium high—pressure ventriculoperitoneal shunt (MPV; 100 ± 10 mm H2O). The patients' gait disturbance and dementia were quantified by applying an NPH scale, and their level of disability was evaluated by using the modified Rankin scale (mRS). Patients were examined prior to and 1, 3, 6, 9, and 12 months after surgery. Primary outcome measures were determined by differences between preoperative and last NPH scale scores and mRS grades. The LPV and MPV shunt groups were compared by calculating both the differences between mean improvements and the proportions of patients showing improvement. Intention-to-treat analysis of mRS grades yielded a mean improvement of 1.27 ± 1.41 for patients with LPV shunts and 0.68 ± 1.58 for patients with MPV shunts (p = 0.06). Improvement was found in 74% of patients with LPV shunts and in 53% of patients with MPV shunts (p = 0.06) and a marked-to-excellent improvement in 45% of patients with LPV shunts and 28% of patients with MPV shunts (p = 0.12). All outcome measures indicated trends in favor of the LPV shunt group, with only the dementia scale reaching significance. After exclusion of serious events and deaths unrelated to NPH, efficacy analysis showed the advantage of LPV shunts to be diminished. Reduction in ventricular size was also significantly greater for patients in the LPV shunt group (p = 0.009). Subdural effusions occurred in 71% of patients with an LPV shunt and in 34% with an MPV shunt; however, their influence on patient outcome was limited. Conclusions. Outcome was better for patients who had an LPV shunt than for those with an MPV shunt, although most differences were not statistically significant. The authors advise that patients with NPH be treated with an LPV shunt.

scholarly journals Evaluating the cerebrospinal fluid tap test with the Hellström iNPH scale for patients with idiopathic normal pressure hydrocephalus

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Johanna Rydja ◽  
Andreas Eleftheriou ◽  
Fredrik Lundin
Keyword(s):  
Cerebrospinal Fluid ◽  
Scale Score ◽  
Normal Pressure Hydrocephalus ◽  
Postoperative Outcome ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Urinary Continence ◽  
Predictive Values ◽  
Tap Test ◽  
Total Scale Score

Abstract Background The cerebrospinal fluid tap test (CSF TT) is used for selecting shunt surgery candidates among patients with idiopathic normal pressure hydrocephalus (iNPH). We aimed to evaluate the predictive value of the CSF TT, by using the Hellström iNPH scale for shunted iNPH patients with a standardized method. Methods One hundred and sixteen shunt-operated iNPH patients were retrospectively included in this study. The gait and balance domains in the iNPH scale were used as outcome measures for the CSF TT and the total iNPH scale score as the postoperative outcome. A positive response to CSF TT was defined as a change of ≥ 5 points in the gait domain and ≥ 16 points in the balance domain. Differences between CSF TT responders and non-responders, sensitivity, specificity, positive and negative predictive values, accuracy, and correlations between changes from baseline to post CSF TT and from baseline to the postoperative follow-up, were calculated. Results In the CSF TT there were 63.8% responders in the gait domain and correspondingly 44.3% in the balance domain. CSF TT responders had a significantly better postoperative outcome in the total scale score (gait P ≤ 0.001, balance P ≤ 0.012) and gait CSF TT responders improved more in gait (P ≤ 0.001) and balance CSF TT responders in balance (P ≤ 0.001). No differences between CSF TT gait or balance responders could be found in neuropsychological or urinary continence assessments postoperatively. The sensitivity and specificity of the CSF TT and the outcome of the total iNPH scale score postoperatively were 68.1% and 52.0% for gait and 47.8% and 68.0% for balance, respectively. Conclusions The CSF TT, with the Hellström iNPH scale as the outcome measure, has clear limitations in predicting postoperative results. The gait domain may be used to predict outcomes for gait, but the balance domain is too insensitive.

scholarly journals Evaluating the Cerebrospinal Fluid Tap Test With the Hellström iNPH Scale for Patients With Idiopathic Normal Pressure Hydrocephalus – a Retrospective Cohort Study of 132 Patients

2020 ◽  
Author(s):  
Johanna Rydja ◽  
Andreas Eleftheriou ◽  
Fredrik Lundin
Keyword(s):  
Cerebrospinal Fluid ◽  
Scale Score ◽  
Outcome Measures ◽  
Sensitivity And Specificity ◽  
Normal Pressure Hydrocephalus ◽  
Outcome Measure ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Predictive Values ◽  
Tap Test

Abstract Background The cerebrospinal fluid tap test (CSF TT) is used for selecting shunt surgery candidates in idiopathic normal pressure hydrocephalus (iNPH). Variations in performance, and different outcome measures and cut-off levels in previous research on the CSF TT make comparison of accuracy difficult between studies. We aimed to evaluate the CSF TT, by using the Hellström iNPH scale for shunted iNPH patients with a standardized method. Methods One hundred thirty-two shunt operated iNPH patients were retrospectively included in this study. The gait and balance domains in the iNPH scale were used as outcome measures for the CSF TT and the total iNPH scale score as postoperatively outcome. To identify responders a cut-off level ≥ 5 points was used. Differences between responders and non-responders to the CSF TT, as well as the sensitivity, specificity, positive and negative predictive values, accuracy and correlations between outcomes of the CSF TT and postoperatively were calculated. Results In the gait domain, there were 62.9% responders and correspondingly 42.7 % in the balance domain of the CSF TT. CSF TT responders had significantly better outcomes in both the gait and balance domains but not in the neuropsychology or continence domains postoperatively. The sensitivity and specificity of the CSF TT and the outcome of the total iNPH scale score postoperatively were 67.6% and 53.3% for gait and 47.5% and 73.3% for balance. For age ≥ 80 years, the sensitivity and specificity for gait were 52.2% and 60.0%, and for age ≤ 80 years 72.2% and 50.0%. Gait as an outcome measure for both the CSF TT and postoperatively had the highest sensitivity, (73.2%) and specificity (65.7%) for all ages. Conclusions The CSF TT, with Hellström´s iNPH scale as the outcome measure, has clear limitations in predicting postoperative results. The gait domain may be used to detect changes of outcomes in gait, but the balance domain is too insensitive to use as an assessment for the CSF TT. The value of the CFS TT for patients over 80 years of age appears to be even lower. Differential diagnostic considerations together with radiological assessments remain cornerstones in selecting eligible shunt responders.

Variations of intraventricular pressure during pneumoencephalography

1974 ◽  
Vol 40 (1) ◽  
pp. 101-106 ◽  
Author(s):  
Jacques Philippon ◽  
Bernard George ◽  
Jean Metzger
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypertension ◽  
Normal Pressure Hydrocephalus ◽  
Initial Pressure ◽  
Normal Pressure ◽  
Intraventricular Pressure ◽  
Csf Dynamics ◽  
Content Type ◽  
Fine Print

✓ Intraventricular pressure was studied in eight patients during and after diagnostic pneumoencephalography. In cases with normal initial pressure and normal cerebrospinal fluid (CSF) dynamics, variations in pressure were moderate, immediate, and disappeared at the end of the examination. In cases of normal-pressure hydrocephalus, there was a slow but relatively important elevation that continued for at least 24 hours. In cases with intracranial hypertension, there was a rapid significant increase; return to normal depended principally upon the flow from a large CSF compartment.

Focal dilation and paradoxical collapse of cortical fissures and sulci in patients with normal-pressure hydrocephalus

1998 ◽  
Vol 89 (5) ◽  
pp. 742-747 ◽  
Author(s):  
Andrei I. Holodny ◽  
Ajax E. George ◽  
Mony J. de Leon ◽  
James Golomb ◽  
Andrew J. Kalnin ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Ventricular System ◽  
Cortical Atrophy ◽  
Imaging Studies ◽  
Content Type ◽  
Radiological Features ◽  
Shunting Procedure ◽  
Fine Print

Object. The authors describe a subgroup of patients with shunt-proven normal-pressure hydrocephalus (NPH) who presented with focal fissural and sulcal dilation on imaging studies. The specific radiological features and methods of differentiating this condition from cortical atrophy are delineated. Methods. Normal-pressure hydrocephalus has been described as dilation of the ventricles that is out of proportion to the sulci. Sulcal dilation has been taken as evidence of cortical atrophy and has even been used as a criterion to exclude patients from undergoing a shunting procedure. The authors describe five cases of patients with shunt-proven NPH who presented with focal dilation of cortical fissures and sulci. In three of the cases, there was a paradoxical decrease in the size of the dilated fissures and sulci that paralleled the decrease in the size of the lateral ventricles following successful shunting. Conclusions. This study demonstrates that focal fissural and sulcal dilation may represent reservoirs of cerebrospinal fluid analogous to the ventricular system. Patients should not be denied a shunting procedure solely on the basis of focally dilated fissures of sulci.

Intracranial pressure and conductance to outflow of cerebrospinal fluid in normal-pressure hydrocephalus

1979 ◽  
Vol 50 (4) ◽  
pp. 489-493 ◽  
Author(s):  
Svend Erik Børgesen ◽  
Flemming Gjerris ◽  
Søren Claus Sørensen
Keyword(s):  
Cerebrospinal Fluid ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Intraventricular Pressure ◽  
Content Type ◽  
Normal Limits ◽  
Selection Of Patients ◽  
Selection Of ◽  
Fine Print ◽  
High Conductance

✓ Forty patients with clinical evidence of normal-pressure hydrocephalus were studied by monitoring intraventricular pressure during a 24-hour period, and by a lumboventricular perfusion test for measurement of the conductance to outflow of cerebrospinal fluid (CSF). The purpose of the study was to investigate whether there is a relationship between intraventricular pressure and conductance to outflow of CSF, and whether it is possible to use the results from pressure monitoring in the selection of patients who may be expected to benefit from shunting therapy. The conductance to outflow was used as an evaluation factor in the selection of patients to be treated by a shunt. The conductance to CSF outflow differed by twelvefold between the lowest and highest values. The level of resting intraventricular pressure was within normal limits in all patients. Accordingly, there was no evidence of a relationship between conductance to outflow and intraventricular pressure. So-called B-waves were seen more frequently in patients with decreased conductance to outflow, but were also present in patients with high conductance to outflow. Therefore, the presence of B-waves does not imply a low conductance to outflow of CSF.

Normal-pressure hydrocephalus

1974 ◽  
Vol 41 (4) ◽  
pp. 463-470 ◽  
Author(s):  
Sherman C. Stein ◽  
Thomas W. Langfitt
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Saline Infusion ◽  
Clinical Factors ◽  
Predictive Values ◽  
Content Type ◽  
Clinical Evaluations ◽  
Isotope Cisternography ◽  
Shunt Response ◽  
Fine Print

✓ After shunting, 43 patients with normal-pressure hydrocephalus were followed for 6 to 30 months. All patients had complete preoperative clinical evaluations, pneumoencephalograms, and isotope cisternography; in addition, 21 had saline infusion studies, and 15 had biopsies. Of the 10 patients in whom the etiology of the hydrocephalus was known eight (80%) were significantly improved. Of the other 33 patients, 21 (64%) showed some improvement; this was substantial and sustained in only eight (24%). The whole series of patients with idiopathic normal pressure hydrocephalus was divided into two groups on the basis of shunt response and the relative predictive values of preoperative tests. No significant association was found between the results of shunting and preoperative clinical factors, pneumoencephalography, isotope cisternography, saline infusion tests, or various combinations of clinical and laboratory abnormalities. The significance of these findings is discussed.

Cerebral hemodynamics in normal-pressure hydrocephalus

1984 ◽  
Vol 61 (3) ◽  
pp. 510-514 ◽  
Author(s):  
Norihiko Tamaki ◽  
Tadaki Kusunoki ◽  
Toshimitsu Wakabayashi ◽  
Satoshi Matsumoto
Keyword(s):  
Computerized Tomography ◽  
Transit Time ◽  
Normal Pressure Hydrocephalus ◽  
Mean Transit Time ◽  
Contrast Material ◽  
Normal Pressure ◽  
Cerebral Hemodynamics ◽  
Content Type ◽  
Poor Outcome ◽  
Fine Print

✓ Cerebral hemodynamics in 31 patients with suspected normal-pressure hydrocephalus were studied by means of the xenon-133 (133Xe) inhalation method and on dynamic computerized tomography (CT) scanning. Cerebral blood flow (CBF) is reduced in all patients with dementia. Hypoperfusion was noted in a frontal distribution in these patients compared with normal individuals. There was no difference in CBF patterns between patients with good and those with poor outcome. The CBF was increased following cerebrospinal fluid (CSF) shunting in patients who responded to that procedure: increase in flow correlated with clinical improvement, frontal and temporal lobe CBF was most markedly increased, and the CBF pattern became normal. In contrast, CBF was decreased after shunt placement in patients who were considered to have suffered from degenerative dementia, as evidenced by non-response to shunting. Dynamic computerized tomography studies demonstrated that patients with a good outcome showed a postoperative reduction in mean transit time of contrast material, most prominent in the frontal and temporal gray matter, and slight in the deep frontal structures, but not in the major cerebral vessels. Patients with poor outcome after shunting, however, had an increase in transit time in all regions. This corresponded well with the results as determined by the 133Xe inhalation method.

Cerebral cysticercosis with aqueductal obstruction

1980 ◽  
Vol 53 (2) ◽  
pp. 252-255 ◽  
Author(s):  
Tung Pui Poon ◽  
Edward J. Arida ◽  
Wolodymyr P. Tyschenko
Keyword(s):  
Intracranial Hypertension ◽  
Brain Stem ◽  
Normal Pressure Hydrocephalus ◽  
Signs And Symptoms ◽  
Normal Pressure ◽  
Content Type ◽  
Neurological Signs ◽  
Cerebral Cysticercosis ◽  
The Brain ◽  
Fine Print

✓ The authors report a case of cerebral cysticercosis which presented with generalized nonspecific neurological signs and symptoms attributed to acute aqueductal obstruction, with concomitant intracranial hypertension. These were characteristic intracranial calcifications along with angiographically demonstrated signs of hydrocephalus. Contrast encephalography clearly demonstrated aqueductal obstruction. Pathologically, the aqueductal obstruction was shown to be due to parasitic invasion of the brain stem with compression of the aqueduct. The presence of typical intracranial calcification in conjunction with either obstructive or normal-pressure hydrocephalus should alert the observer to the possibility of cerebral cysticercosis.

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

2004 ◽  
Vol 100 (5) ◽  
pp. 855-866 ◽  
Author(s):  
Maria A. Poca ◽  
Maria Mataró ◽  
Maria Del Mar Matarín ◽  
Fuat Arikan ◽  
Carmen Junqué ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Normal Pressure Hydrocephalus ◽  
Continuous Monitoring ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Symptom Duration ◽  
High Morbidity ◽  
Shunt Insertion ◽  
Content Type ◽  
Fine Print

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.

Sign in / Sign up

Export Citation Format

Share Document