Clinical Diagnosis and Treatment Management of Normal Pressure Hydrocephalus

Inadequate absorption of cerebrospinal fluid (CSF) at the arachnoid granulation level during circulation results in an increase in CSF in the ventricle and certain neuropsychiatric clinical findings. This syndrome, which often presents with ventricular dilatation, progressive cognitive decline, walking difficulties, and urinary incontinence symptoms in elderly individuals, is called Normal Pressure Hydrocephalus (NPH). It is projected that as people’s quality of life improves and their life expectancy rises, more old people would develop this condition. Although a clear clinical triad has been defined, the identification of patients with NPH and the application of effective treatment modalities still pose a number of challenges for neurosurgeons today. However, despite all these difficulties, if diagnosed and treated early, the unusual appearance of these symptoms affecting elderly individuals can be prevented and significant improvements in quality of life can be achieved.

Tissue damage in herniated brain parenchyma into giant arachnoid granulations: demonstration with high resolution MRI

Background Brain herniation (BH) into arachnoid granulation has been remarkable in recent years. Purpose To evaluate the damage in herniated parenchyma into the giant arachnoid granulation (GAG) and to investigate the clinical–demographic importance of this damage. Material and Methods Patients with BH into GAG were retrospectively included in the study. Each of the patients had at least one high-resolution 3D magnetic resonance imaging (MRI) sequence. The arachnoid granulation dimensions, locations, and origin of herniated parenchyma were evaluated by two experienced radiologists. The demographic and symptomatic features of the patients were recorded from the hospital database. Results A total of 27 patients (21 females, 6 males; age range 6–71 years; mean age 41.3 years) were found to contain BH into GAG. It was most commonly seen in the transverse sinus (67%); the origin was most common in the cerebellar parenchyma (56%). Abnormal signal and morphology were detected in herniated parenchyma in 11 (47%) patients, atrophy in six, and atrophy and gliosis in five. The most common complaints were headache (47%), while other frequent symptoms were vertigo (15%) and blurred vision (11%). There was a statistically significant positive correlation between frequency of damage in herniated brain parenchyma and the maximal size of GAG ( P<0.05). Conclusion In patients with BH into GAG, parenchymal damage may be associated with various symptoms, such as headache and vertigo, although they have not been statistically proven. It is important to carefully evaluate hernia tissue, as the risk of tissue damage may increase in larger GAGs.

Idiopathic Normal Pressure Hydrocephalus: Surgical Outcome of Endoscopic Third Ventriculostomy Comparing VP Shunt

Background: Normal-pressure hydrocephalus (NPH) affects the older people and the presentations are gait disturbance, incontinence and dementia. The reason is still unknown and there is increased CSF volume causing pressure to the periventricular brain causing the symptoms where there is no evidence of absorption failure or obstruction of the CSF pathway. Aims: The main objective of this study is to compare the surgical outcome of endoscopic third ventriculostomy (ETV) and VP shunt (VPS) in NPH. Methodology: A total of 24 patients were included in the study where 12 patients underwent ETV and 12 patients VPS. Patients having a definite cause of hydrocephalus and multiple co-morbid diseases were excluded from the study. Various Scoring systems were studied to see the efficiency of ETV. Results: About 60% of patients were successfully recovered. 40% needed to revision surgery either VP shunt or LP shunt. Some scales showed higher effieciency of ETV. Conclusion: ETV in NPH is a safe and effective procedure. Whether the CSF absorption is hampered at arachnoid granulation is doubtful for failure cases. ETV is a short procedure with a good success rate in selected patients.

A Pacchionian Puzzle

A 73-year-old male with a history of chronic ataxia presented with transient facial droop to the Emergency Department. A CT angiogram and MRI with diffusion weighted imaging (DWI) were negative for stroke. However, incidental note was made of numerous giant arachnoid granulation pits in the posterior fossa predominantly involving the left occipital bone (Figure 1). These arachnoid pits demonstrated multiple foci of herniation of the adjacent cerebellar parenchyma into the pits with gliosis of the herniated parenchyma and focal encephalomalacia of the subjacent cerebellar parenchyma. Review of bone windows on a remote CT brain performed almost 13 years earlier confirmed this to be a longstanding abnormality (Figure 2). The patient’s physical exam was suggestive of cerebellar ataxia with left-sided dysmetria on finger to nose testing and a wide-based unsteady gait.