Good outcome in patients with normal-pressure hydrocephalus and factors indicating poor prognosis

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Object

The authors set out to describe the outcome in a subgroup of patients with normal-pressure hydrocephalus (NPH) in whom prognostic factors were poor. This subgroup of patients who had received shunts was selected according to strict criteria.

Methods

From a cohort of 56 patients with NPH in whom shunts were placed, the authors selected a subgroup with four of the factors traditionally considered to indicate poor prognosis: idiopathic type, cortical atrophy, longstanding symptoms, and presence of dementia in addition to old age. Twelve patients met the inclusion criteria.

After receiving shunts, 92% of the patients showed clinical improvement on the NPH scale; gait improved in 100% of patients, sphincter control in 90%, and dementia in 33%. Improvement was significant for gait and sphincter control, general NPH score, and most daily life activity scales. No significant differences regarding clinical, cognitive, or functional changes following surgery were found in comparison with the rest of patients (the good prognosis subgroup).

Conclusions

The clinical condition of patients with NPH who present with traditionally accepted markers of poor prognosis can improve after surgery, especially as regards gait and sphincter control. The authors assert that the presence of these markers should not be considered to be an absolute criterion for ruling out shunt surgery in cases of NPH syndrome.

Article Information

Address reprint requests to: Maria A. Poca, M.D., Ph.D., Neurosurgery Department, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119–129, 08035 Barcelona, Spain. email: 26382app@comb.es.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Algorithm demonstrating patient selection in this study. 1) Active hydrocephalus: mean ICP greater than 12 mm Hg with the presence of A and/or B waves. 2) Compensated hydrocephalus: mean ICP less than or equal to 12 mm Hg with the presence of A and/or B waves. 3) Ex-vacuo hydrocephalus: mean ICP less than or equal to 12 mm Hg, with no pathological wave and an Rout less than 10 mm Hg/ml/min.

  • View in gallery

    Computerized tomography scans (upper) and ICP reading (lower) from a patient with NPH. Despite enlarged sylvian fissures and cortical sulci, the patient demonstrated intracranial hypertension on the ICP tracing, with 51% of high-amplitude B waves. Clinically, the patient showed a predominance of gait alterations and urinary incontinence, with subtle recent memory deficit and no other symptomatology.

  • View in gallery

    Computerized tomography scans (left) and ICP readings (right) from a patient with NPH before (upper) and after (lower) a shunt procedure. Before shunt implantation, the patient was unable to ambulate, suffered continuous urinary and fecal incontinence, and had severe memory problems with behavior disturbances. Note that the presurgical scan revealed only moderate ventricular enlargement (Evans Index = 0.33) with dilated cortical sulci, whereas the ICP tracing revealed between 5 and 10% of low-amplitude B waves (< 10 mm Hg). After shunt placement, this patient experienced marked improvement (abnormal but independent and stable gait, normal sphincter control, and fewer self-reported memory problems—all of which persist to date, 8 years after the shunt was inserted).

  • View in gallery

    Bar graphs demonstrating baseline conditions and clinical conditions after surgery according to the NPH scale. Light gray bars, before surgery; dark gray bars, 6 months after surgery.

References

  • 1.

    Bech-Azeddine RWaldemar GKnudsen GMHogh PBruhn PWildschiodtz Get al: Idiopathic normal-pressure hydrocephalus: evaluation and findings in a multidisciplinary memory clinic. Eur J Neurol 8:6016112001Bech-Azeddine R Waldemar G Knudsen GM Hogh P Bruhn P Wildschiodtz G et al: Idiopathic normal-pressure hydrocephalus: evaluation and findings in a multidisciplinary memory clinic. Eur J Neurol 8:601–611 2001

  • 2.

    Black PM: Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg 52:3713771980Black PM: Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg 52:371–377 1980

  • 3.

    Borgesen SE: Conductance to outflow of CSF in normal pressure hydrocephalus. Acta Neurochir 71:1451984Borgesen SE: Conductance to outflow of CSF in normal pressure hydrocephalus. Acta Neurochir 71:1–45 1984

  • 4.

    Borgesen SEGjerris F: The predictive value of conductance to outflow of CSF in normal pressure hydrocephalus. Brain 105:65861982Borgesen SE Gjerris F: The predictive value of conductance to outflow of CSF in normal pressure hydrocephalus. Brain 105:65–86 1982

  • 5.

    Caruso RCervoni LVitale AMSalvati M: Idiopathic normalpressure hydrocephalus in adults: result of shunting correlated with clinical findings in 18 patients and review of the literature. Neurosurg Rev 20:1041071997Caruso R Cervoni L Vitale AM Salvati M: Idiopathic normalpressure hydrocephalus in adults: result of shunting correlated with clinical findings in 18 patients and review of the literature. Neurosurg Rev 20:104–107 1997

  • 6.

    Cohen AR: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:118411852001Cohen AR: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:1184–1185 2001

  • 7.

    Fillenbaum GG: Screening the elderly. A brief instrumental activities of daily living measure. J Am Geriatr Soc 33:6987061985Fillenbaum GG: Screening the elderly. A brief instrumental activities of daily living measure. J Am Geriatr Soc 33:698–706 1985

  • 8.

    Folstein MFFolstein SEMcHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:1891981975Folstein MF Folstein SE McHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198 1975

  • 9.

    Graff-Radford NRGodersky JC: Normal-pressure hydrocephalus. Onset of gait abnormality before dementia predicts good surgical outcome. Arch Neurol 43:9409421986Graff-Radford NR Godersky JC: Normal-pressure hydrocephalus. Onset of gait abnormality before dementia predicts good surgical outcome. Arch Neurol 43:940–942 1986

  • 10.

    Hebb AOCusimano MD: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:116611862001Hebb AO Cusimano MD: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:1166–1186 2001

  • 11.

    Hughes CPBerg LDanziger WLCoben LAMartin RL: A new clinical scale for the staging of dementia. Br J Psychiatry 140:5665721982Hughes CP Berg L Danziger WL Coben LA Martin RL: A new clinical scale for the staging of dementia. Br J Psychiatry 140:566–572 1982

  • 12.

    Jacobs LConti DKinkel WRManning EJ: “Normal-pressure” hydrocephalus. Relationship of clinical and radiographic findings to improvement following shunt surgery. JAMA 235:5105121976Jacobs L Conti D Kinkel WR Manning EJ: “Normal-pressure” hydrocephalus. Relationship of clinical and radiographic findings to improvement following shunt surgery. JAMA 235:510–512 1976

  • 13.

    Jorm AFJacomb PA: The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol Med 19:101510221989Jorm AF Jacomb PA: The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates reliability validity and some norms. Psychol Med 19:1015–1022 1989

  • 14.

    Katzman RHussey F: A simple constant-infusion manometric test for measurement of CSF absortion. I. Rationale and method. Neurology 20:5345441970Katzman R Hussey F: A simple constant-infusion manometric test for measurement of CSF absortion. I. Rationale and method. Neurology 20:534–544 1970

  • 15.

    Krauss JKRegel JP: The predictive value of ventricular CSF removal in normal pressure hydrocephalus. Neurol Res 19:3573601997Krauss JK Regel JP: The predictive value of ventricular CSF removal in normal pressure hydrocephalus. Neurol Res 19:357–360 1997

  • 16.

    Lamas EEsparza JDiez Lobato R: Intracranial pressure in adult non-tumoral hydrocephalus. J Neurosurg Sci 19:2262331975Lamas E Esparza J Diez Lobato R: Intracranial pressure in adult non-tumoral hydrocephalus. J Neurosurg Sci 19:226–233 1975

  • 17.

    Lamas ELobato RD: Intraventricular pressure and CSF dynamics in chronic adult hydrocephalus. Surg Neurol 12:2872951979Lamas E Lobato RD: Intraventricular pressure and CSF dynamics in chronic adult hydrocephalus. Surg Neurol 12:287–295 1979

  • 18.

    Larsson AWikkelso CBilting MStephensen H: Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta Neurol Scand 84:4754821991Larsson A Wikkelso C Bilting M Stephensen H: Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta Neurol Scand 84:475–482 1991

  • 19.

    Linn MWLinn BS: The rapid disability rating scale-2. J Am Geriatr Soc 30:3783821982Linn MW Linn BS: The rapid disability rating scale-2. J Am Geriatr Soc 30:378–382 1982

  • 20.

    Malm JKristensen BKarlsson TFagerlund MElfverson JEkstedt J: The predictive value of cerebrospinal fluid dynamic tests in patients with the idiopathic adult hydrocephalus syndrome. Arch Neurol 52:7837891995Malm J Kristensen B Karlsson T Fagerlund M Elfverson J Ekstedt J: The predictive value of cerebrospinal fluid dynamic tests in patients with the idiopathic adult hydrocephalus syndrome. Arch Neurol 52:783–789 1995

  • 21.

    Meier UMiethke C: Predictors of outcome in patients with normal-pressure hydrocephalus. J Clin Neurosci 10:4534592003Meier U Miethke C: Predictors of outcome in patients with normal-pressure hydrocephalus. J Clin Neurosci 10:453–459 2003

  • 22.

    Petersen RCMokri BLaws ER Jr: Surgical treatment of idiopathic hydrocephalus in elderly patients. Neurology 35:3073111985Petersen RC Mokri B Laws ER Jr: Surgical treatment of idiopathic hydrocephalus in elderly patients. Neurology 35:307–311 1985

  • 23.

    Pickard JDTeasdale GMatheson MLindsay KGalbraith SWyper Det al: Intraventricular pressure waves. The best predictive test for shunting in normal pressure hydrocephalus in Shulman KMarmarou AMiller JDet al (eds): Intracranial Pressure IV. Berlin: Springer-Verlag1980 pp 498500Pickard JD Teasdale G Matheson M Lindsay K Galbraith S Wyper D et al: Intraventricular pressure waves. The best predictive test for shunting in normal pressure hydrocephalus in Shulman K Marmarou A Miller JD et al (eds): Intracranial Pressure IV. Berlin: Springer-Verlag 1980 pp 498–500

  • 24.

    Poca MAMataro MDel Mar Matarín MArikan FJunque CSahuquillo J: 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. J Neurosurg 100:8558662004Poca MA Mataro M Del Mar Matarín M Arikan F Junque C Sahuquillo J: 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. J Neurosurg 100:855–866 2004

  • 25.

    Poca MASahuquillo JBarba MAAnez JDArikan F: Prospective study of methodological issues in intracranial pressure monitoring in patients with hydrocephalus. J Neurosurg 100:2602652004Poca MA Sahuquillo J Barba MA Anez JD Arikan F: Prospective study of methodological issues in intracranial pressure monitoring in patients with hydrocephalus. J Neurosurg 100:260–265 2004

  • 26.

    Poca MASahuquillo JMataro M: Actualizaciones en el diagnóstico y tratamiento de la hidrocefalia “normotensiva” (hidrocefalia crónica del adulto). Neurología 16:3533692001Poca MA Sahuquillo J Mataro M: Actualizaciones en el diagnóstico y tratamiento de la hidrocefalia “normotensiva” (hidrocefalia crónica del adulto). Neurología 16:353–369 2001

  • 27.

    Reilly P: In normal pressure hydrocephalus, intracranial pressure monitoring is the only useful test. J Clin Neurosci 8:66672001Reilly P: In normal pressure hydrocephalus intracranial pressure monitoring is the only useful test. J Clin Neurosci 8:66–67 2001

  • 28.

    Reitan RM: Validity of the trail making test as an indicator of organic brain damage. Percept Mot Skills 8:2712761958Reitan RM: Validity of the trail making test as an indicator of organic brain damage. Percept Mot Skills 8:271–276 1958

  • 29.

    Rosenfeld JVSiraruj S: In normal pressure hydrocephalus, intracranial pressure monitoring is the only useful test. J Clin Neurosci 8:68692001Rosenfeld JV Siraruj S: In normal pressure hydrocephalus intracranial pressure monitoring is the only useful test. J Clin Neurosci 8:68–69 2001

  • 30.

    Sahuquillo JRubio ECodina AMolins AGuitart JMPoca MAet al: Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “normal pressure hydrocephalus” syndrome. Acta Neurochir 112:50611991Sahuquillo J Rubio E Codina A Molins A Guitart JM Poca MA et al: Reappraisal of the intracranial pressure and cerebrospinal fluid dynamics in patients with the so-called “normal pressure hydrocephalus” syndrome. Acta Neurochir 112:50–61 1991

  • 31.

    Sand TBovim GGrimse RMyhr GHelde GCappelen J: Idiopathic normal pressure hydrocephalus: the CSF tap-test may predict the clinical response to shunting. Acta Neurol Scand 89:3113161994Sand T Bovim G Grimse R Myhr G Helde G Cappelen J: Idiopathic normal pressure hydrocephalus: the CSF tap-test may predict the clinical response to shunting. Acta Neurol Scand 89:311–316 1994

  • 32.

    Tans JT: Differentiation of normal pressure hydrocephalus and cerebral atrophy by computed tomography and spinal infusion test. J Neurol 222:1091181979Tans JT: Differentiation of normal pressure hydrocephalus and cerebral atrophy by computed tomography and spinal infusion test. J Neurol 222:109–118 1979

  • 33.

    Thomsen AMBorgesen SEBruhn PGjerris F: Prognosis of dementia in normal-pressure hydrocephalus after a shunt operation. Ann Neurol 20:3043101986Thomsen AM Borgesen SE Bruhn P Gjerris F: Prognosis of dementia in normal-pressure hydrocephalus after a shunt operation. Ann Neurol 20:304–310 1986

  • 34.

    Vanneste JAugustijn PDirven CDirven CTan WFGoedhart ZD: Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology 42:54591992Vanneste J Augustijn P Dirven C Dirven C Tan WF Goedhart ZD: Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review. Neurology 42:54–59 1992

  • 35.

    Wechsler D: A standardized memory scale for clinical use. J Psychol 19:87951945Wechsler D: A standardized memory scale for clinical use. J Psychol 19:87–95 1945

  • 36.

    Wikkelso CAndersson HBlomstrand CLindqvist GSvendsen P: Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-test. Acta Neurol Scand 73:5665731986Wikkelso C Andersson H Blomstrand C Lindqvist G Svendsen P: Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-test. Acta Neurol Scand 73:566–573 1986

  • 37.

    Wood JHBartlet DJames Ae JrUdvarhelyi GB: Normal-pressure hydrocephalus: diagnosis and patient selection for shunt surgery. Neurology 24:5175261974Wood JH Bartlet D James AE Jr Udvarhelyi GB: Normal-pressure hydrocephalus: diagnosis and patient selection for shunt surgery. Neurology 24:517–526 1974

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