Impact of duration of symptoms on CSF dynamics in idiopathic normal pressure hydrocephalus

Czosnyka Z, Owler B, Keong N, Santarius T, Baledent O, Pickard JD, Czosnyka M. Impact of duration of symptoms on CSF dynamics in idiopathic normal pressure hydrocephalus.
Acta Neurol Scand: 2011: 123: 414–418.
© 2010 John Wiley & Sons A/S. Objective – Cerebrospinal fluid (CSF) pressure–volume compensation may change over time as part of normal ageing, where the resistance to CSF outflow increases and the formation of CSF decreases with age. Is CSF compensation dependent on duration of symptoms in idiopathic normal pressure hydrocephalus (iNPH)? Methods – We investigated 92 patients presenting with iNPH. Mean age was 73 (range 47–86). There were 60 men and 32 women. They all presented with gait disturbance and ventricular dilatation. Memory deficit occurred in 72% and urinary incontinence in 52% of patients. All patients underwent computerized CSF infusion tests. Sixty‐four shunted patients were available for follow‐up, and their improvement was expressed using the NPH score. Results – Mean intracranial pressure (ICP) was 10.1 ± 5.1 mmHg, and mean resistance to CSF outflow was 17.3 ± 5.2 mmHg/(ml/min). Mean duration of symptoms was 24 ± 19 months (range from 2 weeks to 86 months). Baseline ICP, magnitude of ICP pulse waveform, brain compliance and improvement after shunting (72% of patients improved) did not exhibit any dependency on the duration of symptoms. The resistance to CSF outflow showed a strong tendency to decrease in time with the duration of symptoms beyond 2 years (R = −0.702; P < 0.005). Conclusion – This is a preliminary observation, and it suggests that for patients with duration of symptoms longer than 2–3 years, the threshold for normal resistance to CSF outflow should be duration‐adjusted.     

兔实验性脑积水模型的建立

目的 建立兔实验性脏积水模型。方法取成年家兔28只，随机抽取分为实验组18只，对照Ⅰ组6只，对照Ⅱ组4只。全麻后，三组均测ICP。实验组取实验动物自体颈部肌肉5g加生理盐水2mL研浆，注入枕大池；对照组Ⅰ注入等量生理盐水，对照Ⅱ组仅行枕大池穿刺。19d后全麻，测ICP后断头处死，取全脑固定，切片，测量脑室大小。结果 实验组18只均出现枕大池及第4脑室流出道粘连、梗阻，形成梗阻性脑积水；手术前三组动物之间mICP差异无显著性（P〉0.05）；手术后实验组mICP明显高于对照Ⅰ组和对照Ⅱ组（P〈0．05），而对照Ⅰ组和对照Ⅱ组之间差异无显著性（P〉0.05）；实验组侧脑室、第4脑室明显大于对照Ⅰ、Ⅱ两组（P〈0.01），而对照Ⅰ、Ⅱ组之间差异无显著性（P〉0.05）。结论 用此方法建立的脑积水动物模型简便易行，重复性和稳定性好。采用自体肌浆作阻塞、粘连材祷术后反应轻，其病理过程更接近临床，适用于脑积水的实验研究。     

Post-haemorrhagic hydrocephalus in the preterm infant

Abstract This prospective study documents the incidence, clinical features and risk factors for post-haemorrhagic hydrocephalus (PHH) as well as the short-term outcome after serial CSF taps. Serial real-time ultrasound scans were performed on 220 infants: on all admissions ≤1250 g and on an additional 130 infants with birthweights >1250 g with risk factors for intraventricular haemorrhage (IVH). Based on percentile charts of postnatal increase in ventricular size and head circumference growth rate, PHH was defined as ventricular dilatation >95th centile associated with either a head circumference growth >95th centile or with clinical features of raised intracranial pressure (ICP). Forty-eight (22%) infants were found to have IVH of whom 14 had intracerebral extension of IVH. Sixteen (40%) of 40 infants who survived the acute episode of IVH developed PHH. PHH occurred more commonly in those who survived severe birth asphyxia and/or intracerebral extension of IVH. Fifteen infants who developed clinical features of raised ICP were treated with serial CSF taps. This procedure was effective in a staged treatment for PHH in relieving clinical symptoms and deferring ventriculo-peritoneal (VP) shunting. Morbidity associated with serial CSF taps and VP shunting is minimal. A high red cell count and protein concentration in the CSF at diagnosis of PHH identified all five infants who subsequently required VP shunting.     

Tumors and approaches to the lateral ventricles

Summary There are a variety of tumors that arise within the lateral ventricles and they present a unique surgical challenge. These lesions commonly are benign and because they frequently are slowly expanding and cause nonspecific symptoms they can grow to a large size before they reach medical attention. This report presents an introduction to and an overview of the problems caused by lateral ventricular tumors and summarizes the author's experience in the evaluation and management of these lesions. The most consistent neurological problems associated with lateral ventricular tumors are cognitive impairments commonly associated with hydrocephalus. Consequently, effective management not only requires successful surgical therapy, but also returning the patient to normal neurological and cognitive function. Recognition of these problems and minimizing further injury are the best methods of providing for an optimal outcome. Address for offprints: J.M. Piepmeier, Yale University School of Medicine, Section of Neurosurgery, PO. Box 208039, New Haven, CT 06520-8039, USA     

Cerebral hemodynamics before and after shunting in normal pressure hydrocephalus

OBJECTIVE: To study the relationship between cerebral hemodynamics and clinical performance in normal pressure hydrocephalus (NPH), before and after surgery. MATERIAL AND METHODS: Ten patients were studied prospectively before and 3 months after shunt surgery by means of transcranial Doppler (TCD). Clinical performance was scored by means of an NPH scale and the modified Rankin scale. RESULTS: Peak systolic and mean cerebral blood flow velocity (MCV) were lower and cerebrovascular CO2 reactivity was higher after shunt surgery. The three patients with clinical improvement had higher preoperative end diastolic cerebral blood flow velocity and MCV. All postoperative cerebral blood flow velocities were higher in patients with clinical improvement. CONCLUSION: Our data suggest that higher cerebral blood flow velocity before surgery in patients with NPH is related to clinical improvement after shunt surgery. Cerebral hemodynamic parameters may develop into predictors of successful shunt surgery in patients with normal pressure hydrocephalus.     

Five-year outcome of normal pressure hydrocephalus with or without a shunt: predictive value of the clinical signs,neuropsychological evaluation and infusion test

Summary. Summary.   Background: Between 1993–1995, 51 patients under 75 years of age with clinical symptoms and CT-based diagnosis of normal pressure hydrocephalus were investigated prospectively in order to clarify the value of neuropsychological tests, clinical symptoms and signs and infusion test in the differential diagnosis and prediction of outcome in normal pressure hydrocephalus.   Methods: Patients had a thorough neurological examination, and neuropsychological evaluation. A 24-hour intraventricular ICP-measurement, infusion test, neurophysiological investigations and MRI study were performed, and a cortical biopsy was obtained. The ICP measurement defined the need for a shunt. All 51 patients were re-examined three and twelve months later. The final follow-up was accomplished five years postoperatively.   Findings: 25 of the patients needed a shunt operation. One year after a shunt placement 72% of these patients had a good recovery concerning activities of daily living, 58% benefited in their urinary incontinence and 57% walked better. During the 5 years of follow-up 8 patients with shunt and 9 without shunt had died. Positive effect of shunting remained. Only one neuropsychological test, recognition of words test, distinguishes the patients with the need for a shunt. Simple mini mental examination test was not different in those who improved. In the postoperative follow-up patients with shunt showed no change in neuropsychological tests even if they were subjectively better. The infusion test was of no value in diagnosing NPH. The 16 patients with Alzheimer's disease did worse after one year than those without pathological changes, but the mortality was not increased.   Interpretation: Specific neuropsychological tests are of little value in diagnosing NPH. Mini-Mental status examination was neither of value in diagnosing NPH nor in prediction of the outcome. In this study the infusion test did not improve diagnostic accuracy of NPH, but shunt placement relieves urinary incontinence and walking disability in patients with increased ICP. The patients with positive Alzheimer diagnosis on biopsy did not improve. Published online June 20, 2002     

Management of childhood diseases during the Byzantine period: V − Hydrocephalus

Hydrocephalus was a recognizable medical problem during the Byzantine period. In the medical texts of the time it was attributed to the pressure that was applied on the newborn's head during labour. The suggested treatments focused on the relief of the symptoms only and surgical methods were believed to be helpful in very rare cases.     

Management of overdrainage in cerebrospinal fluid shunting

Objective : To reveal the effectiveness and safety of adding a single slit valve serially to the ventriculoperitoneal shunt system in order to reverse overdrainage. Materials and Methods : The study is a retrospective review of clinical experience in a regional hospital (Tuen Mun Hospital, Hong Kong). A series of 10 cases are reported. All cases showed evidence of cerebrospinal fluid overdrainage after a ventriculoperitoneal shunt procedure. The advantages and disadvantages of other treatment options are also reviewed. Results : The symptoms of all six patients who presented symptomatically subsided or improved after the procedure. Nine of the 10 patients had radiological improvement in their postoperative computed tomography scan. No procedure‐related complication occurred. Conclusion : The early results of such a treatment option appeared safe and rewarding. However, longer term follow up and more experience is needed before the treatment’s efficacy can be proved definitely.      

Tuberculous meningitis in children

Between May 1988 and November 1992 the data from 52 patients with tuberculous meningitis (TBM) were noted down for their symptoms and signs, BCG vaccines, PPD tests; clinical, laboratory, radiologic and microbiologic findings. These data were discussed by means of literature knowledge. Cranial computed tomography (CT) demonstrated hydrocephalus (HC) in 98% of the patients. There was a statistically significant difference among the clinical stages on admission in respect to prognosis (P < 0.05). In addition, there was also a significant relationship between prognosis and HC (P < 0.05). However, we did not find any significant relationship between parenchymal involvement, basilar meningitis and prognosis (P > 0.05).