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      Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus

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          Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients.

          The diagnosis and management of idiopathic normal-pressure hydrocephalus (NPH) remains controversial, particularly in selecting patients for shunt insertion. The use of clinical criteria coupled with imaging studies has limited effectiveness in predicting shunt success. The goal of this prospective study was to assess the usefulness of clinical criteria together with brain imaging studies, resistance testing, and external lumbar drainage (ELD) of cerebrospinal fluid (CSF) in determining which patients would most likely benefit from shunt surgery. One hundred fifty-one patients considered at risk for idiopathic NPH were prospectively studied according to a fixed management protocol. The clinical criterion for idiopathic NPH included ventriculomegaly demonstrated on computerized tomography or magnetic resonance imaging studies combined with gait disturbance, incontinence, and dementia. Subsequently, all patients with a clinical diagnosis of idiopathic NPH underwent a lumbar tap for the measurement of CSF resistance. Following this procedure, patients were admitted to the hospital neurosurgical service for a 3-day ELD of CSF. Video assessment of gait and neuropsychological testing was conducted before and after drainage. A shunt procedure was then offered to patients who had experienced clinical improvement from ELD. Shunt outcome was assessed at 1 year postsurgery. Data in this report affirm that gait improvement immediately following ELD is the best prognostic indicator of a positive shunt outcome, with an accuracy of prediction greater than 90%. Furthermore, bolus resistance testing is useful as a prognostic tool, does not require hospitalization, can be performed in an outpatient setting, and has an overall accuracy of 72% in predicting successful ELD outcome. Equally important is the finding that improvement with shunt surgery is independent of age up to the ninth decade of life in patients who improved on ELD.
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            Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging.

            To evaluate magnetic resonance (MR) imaging-based quantitative phase-contrast cerebrospinal fluid (CSF) velocity imaging for prediction of successful shunting in patients with normal-pressure hydrocephalus (NPH). Eighteen patients (mean age, 73 years) with NPH underwent routine MR imaging and CSF velocity MR imaging before ventriculoperitoneal (VP) shunting. The calculated CSF stroke volume and the aqueductal CSF flow void score were compared with the surgical results. All 12 patients with CSF stroke volumes greater than 42 microL responded favorably to CSF shunting. Of the six patients with stroke volumes of 42 microL or less, three improved with shunting while three did not. The relationship between CSF stroke volume greater than 42 microL and favorable response to VP shunting was statistically significant (P < .05). There was no statistically significant relationship between aqueductal CSF flow void score and responsiveness to shunting. CSF velocity MR imaging is useful in the selection of patients with NPH to undergo shunt formation.
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              Alzheimer's disease comorbidity in normal pressure hydrocephalus: prevalence and shunt response.

              The clinical impact of Alzheimer's disease pathology at biopsy was investigated in 56 cognitively impaired patients undergoing shunt surgery for idiopathic normal pressure hydrocephalus (NPH). Cognition was measured by means of the global deterioration scale (GDS), the mini mental status examination (MMSE) and a battery of six psychometric tests. Gait was assessed using objective measurements of velocity and the ambulatory index (AI). The prevalence of cases exhibiting neuritic plaques (positive biopsies) increased in parallel with dementia severity from 18% for patients with GDS 3 to 75% for patients with GDS scores > or =6. Patients with positive biopsies were more cognitively impaired (higher GDS and lower MMSE scores) as well as more gait impaired (higher AI scores and slower velocities) than patients with negative biopsies. After surgery, gait velocity and AI scores improved significantly and to a comparable degree for patients with and without positive biopsies. Similar proportions of positive and negative biopsy patients also had improved gait as assessed by means of subjective video tape comparisons. There were no significant differences between the biopsy groups in the magnitude of postoperative psychometric change or in the proportion of cases exhibiting improved urinary control. Alzheimer's disease pathology is a common source of comorbidity in older patients with idiopathic NPH where it contributes to the clinical impairment associated with this disorder. For patients accurately diagnosed with NPH, concomitant Alzheimer's disease pathology does not strongly influence the clinical response to shunt surgery.
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                Author and article information

                Journal
                Neurologia medico-chirurgica
                Neurol. Med. Chir.(Tokyo)
                Japan Neurosurgical Society
                1349-8029
                0470-8105
                2008
                2008
                : 48
                : Supplement
                : S1-S23
                Article
                10.2176/nmc.48.S1
                18408356
                a816518f-9a21-44c8-b187-444290cd75bb
                © 2008
                History

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