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

Restricted access

Object. 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.

Methods. 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.

Conclusions. 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.

Article Information

Contributor Notes

Address reprint requests to: Anthony Marmarou, Ph.D., Department of Neurosurgery, Virginia Commonwealth University Medical Center, 1001 East Broad Street, Suite 235, Richmond, Virginia 23219–0449. email: marmarou@hsc.vcu.edu.
Headings
References
  • 1.

    Benton AL: Revised Visual Retention Test: Clinical and Experimental Applicationsed 4. New York: The Psychological-Corporation1974Benton AL: Revised Visual Retention Test: Clinical and Experimental Applications ed 4. New York: The Psychological-Corporation 1974

    • Search Google Scholar
    • Export Citation
  • 2.

    Benton ALEslinger PJDamasio AR: Normative observations on neuropsychological test performances in old age. J Clin Neuropsychol 3:33421981Benton AL Eslinger PJ Damasio AR: Normative observations on neuropsychological test performances in old age. J Clin Neuropsychol 3:33–42 1981

    • Search Google Scholar
    • Export Citation
  • 3.

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

    • Search Google Scholar
    • Export Citation
  • 4.

    Boon AJTans TJDelwel EJEgeler-Peerdeman SMHanlo PWwurzer HAet al: Dutch normal pressure hydrocephalus study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg 87:6876931997Boon AJ Tans TJ Delwel EJ Egeler-Peerdeman SM Hanlo PW wurzer HA et al: Dutch normal pressure hydrocephalus study: prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg 87:687–693 1997

    • Search Google Scholar
    • Export Citation
  • 5.

    Børgesen SEGjerris FSørensen SC: Intracranial pressure and conductance to outflow of cerebrospinal fluid in normal-pressure hydrocephalus. J Neurosurg 50:4894931979Børgesen SE Gjerris F Sørensen SC: Intracranial pressure and conductance to outflow of cerebrospinal fluid in normal-pressure hydrocephalus. J Neurosurg 50:489–493 1979

    • Search Google Scholar
    • Export Citation
  • 6.

    Borkowski JGBenton ALSpreen O: Word fluency and brain damage. Neuropsychologica 5:1351401967Borkowski JG Benton AL Spreen O: Word fluency and brain damage. Neuropsychologica 5:135–140 1967

    • Search Google Scholar
    • Export Citation
  • 7.

    Czosnyka MGjerris FMaksymowicz Wet al: Computerized lumbar infusion test: multicenter experience in clinical studies in hydrocephalus in Nagai HKamiya KIshii S (eds): Intracranial Pressure IX. Berlin: Springer1994 pp 494495Czosnyka M Gjerris F Maksymowicz W et al: Computerized lumbar infusion test: multicenter experience in clinical studies in hydrocephalus in Nagai H Kamiya K Ishii S (eds): Intracranial Pressure IX. Berlin: Springer 1994 pp 494–495

    • Search Google Scholar
    • Export Citation
  • 8.

    Ekstedt J: CSF hydrodynamic studies in man. 1. Method of constant pressure CSF infusion. J Neurol Neurosurg Psychiatry 40:1051191977Ekstedt J: CSF hydrodynamic studies in man. 1. Method of constant pressure CSF infusion. J Neurol Neurosurg Psychiatry 40:105–119 1977

    • Search Google Scholar
    • Export Citation
  • 9.

    Evans WA: An encephalographic ratio for estimating ventricular enlargement and cerebral atrophy. Arch Neurol Psychiatry 47:9319371942Evans WA: An encephalographic ratio for estimating ventricular enlargement and cerebral atrophy. Arch Neurol Psychiatry 47:931–937 1942

    • Search Google Scholar
    • Export Citation
  • 10.

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

    • Search Google Scholar
    • Export Citation
  • 11.

    Haan JThomeer RTWM: Predictive value of temporary external lumbar drainage in normal pressure hydrocephalus. Neurosurgery 22:3883911988Haan J Thomeer RTWM: Predictive value of temporary external lumbar drainage in normal pressure hydrocephalus. Neurosurgery 22:388–391 1988

    • Search Google Scholar
    • Export Citation
  • 12.

    Hakim SAdams RD: The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 2:3073271965Hakim S Adams RD: The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 2:307–327 1965

    • Search Google Scholar
    • Export Citation
  • 13.

    Hughes CPSiegel BACoxe WSGado MHGrubb RLColeman REet al: Adult idiopathic communicating hydrocephalus with and without shunting. J Neurol Neurosurg Psychiatry 41:9619711978Hughes CP Siegel BA Coxe WS Gado MH Grubb RL Coleman RE et al: Adult idiopathic communicating hydrocephalus with and without shunting. J Neurol Neurosurg Psychiatry 41:961–971 1978

    • Search Google Scholar
    • Export Citation
  • 14.

    Kahlon BSundberg GRehncrona S: Comparison between lumbar infusion and CSF tap test to predict outcome after shunt surgery in suspected normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 73:7217262002Kahlon B Sundberg G Rehncrona S: Comparison between lumbar infusion and CSF tap test to predict outcome after shunt surgery in suspected normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 73:721–726 2002

    • Search Google Scholar
    • Export Citation
  • 15.

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

    • Search Google Scholar
    • Export Citation
  • 16.

    Kosteljanetz MNehen AMKaalund J: Cerebrospinal fluid outflow resistance measurements in the selection of patients for shunt surgery in the normal pressure hydrocephalus syndrome. A controlled trial. Acta Neurochir 104:48531990Kosteljanetz M Nehen AM Kaalund J: Cerebrospinal fluid outflow resistance measurements in the selection of patients for shunt surgery in the normal pressure hydrocephalus syndrome. A controlled trial. Acta Neurochir 104:48–53 1990

    • Search Google Scholar
    • Export Citation
  • 17.

    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

    • Search Google Scholar
    • Export Citation
  • 18.

    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

    • Search Google Scholar
    • Export Citation
  • 19.

    Marmarou AFoda MABandoh KYoshihara MYamamoto TTsusi Oet al: Posttraumatic ventriculomegaly: hydrocephalus or atrophy? A new approach for diagnosis using CSF dynamics. J Neurosurg 85:102610351996Marmarou A Foda MA Bandoh K Yoshihara M Yamamoto T Tsusi O et al: Posttraumatic ventriculomegaly: hydrocephalus or atrophy? A new approach for diagnosis using CSF dynamics. J Neurosurg 85:1026–1035 1996

    • Search Google Scholar
    • Export Citation
  • 20.

    Marmarou AShulman KRosende RM: A nonlinear analysis of the cerebrospinal fluid system and intracranial pressure dynamics. J Neurosurg 48:3323441978Marmarou A Shulman K Rosende RM: A nonlinear analysis of the cerebrospinal fluid system and intracranial pressure dynamics. J Neurosurg 48:332–344 1978

    • Search Google Scholar
    • Export Citation
  • 21.

    Mateer CAMapou RL: Understanding, evaluating and managing attention disorders following traumatic brain injury. J Head Trauma Rehabil 11:1161996Mateer CA Mapou RL: Understanding evaluating and managing attention disorders following traumatic brain injury. J Head Trauma Rehabil 11:1–16 1996

    • Search Google Scholar
    • Export Citation
  • 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

    • Search Google Scholar
    • Export Citation
  • 23.

    Raftopoulos CChaskis CDelecluse FCantraine FBidaut LBrotchi J: Morphological quantitative analysis of intracranial pressure waves in normal pressure hydrocephalus. Neurol Res 14:3893961992Raftopoulos C Chaskis C Delecluse F Cantraine F Bidaut L Brotchi J: Morphological quantitative analysis of intracranial pressure waves in normal pressure hydrocephalus. Neurol Res 14:389–396 1992

    • Search Google Scholar
    • Export Citation
  • 24.

    Schmidt M: Rey Auditory and Verbal Learning Tests. Los Angeles: Western Psychological Services1996Schmidt M: Rey Auditory and Verbal Learning Tests. Los Angeles: Western Psychological Services 1996

    • Search Google Scholar
    • Export Citation
  • 25.

    Spanu GSangiovanni GLocatelli D: Normal-pressure hydrocephalus: twelve years experience. Neurochirurgia 29:15191986Spanu G Sangiovanni G Locatelli D: Normal-pressure hydrocephalus: twelve years experience. Neurochirurgia 29:15–19 1986

    • Search Google Scholar
    • Export Citation
  • 26.

    Spreen OStrauss E: A Compendium of Neuropsychological Tests: Administration Norms and Commentary. New York: Oxford University Press1998Spreen O Strauss E: A Compendium of Neuropsychological Tests: Administration Norms and Commentary. New York: Oxford University Press 1998

    • Search Google Scholar
    • Export Citation
  • 27.

    Stein SCLangfitt TW: Normal-pressure hydrocephalus. Predicting the results of cerebrospinal fluid shunting. J Neurosurg 41: 4634701974Stein SC Langfitt TW: Normal-pressure hydrocephalus. Predicting the results of cerebrospinal fluid shunting. J Neurosurg 41: 463–470 1974

    • Search Google Scholar
    • Export Citation
  • 28.

    Takeuchi TKasahara EIwasaki MMima TMori K: Indications for shunting in patients with idiopathic normal pressure hydrocephalus presenting with dementia and brain atrophy (atypical idiopathic normal pressure hydrocephalus). Neurol Med Chir 40:38472000Takeuchi T Kasahara E Iwasaki M Mima T Mori K: Indications for shunting in patients with idiopathic normal pressure hydrocephalus presenting with dementia and brain atrophy (atypical idiopathic normal pressure hydrocephalus). Neurol Med Chir 40:38–47 2000

    • Search Google Scholar
    • Export Citation
  • 29.

    Vanneste JAugustijn PDavies GADirvan CTan WF: Normal-pressure hydrocephalus: is cisternography still useful in selecting patients for a shunt? Arch Neurol 49: 3663701992Vanneste J Augustijn P Davies GA Dirvan C Tan WF: Normal-pressure hydrocephalus: is cisternography still useful in selecting patients for a shunt? Arch Neurol 49: 366–370 1992

    • Search Google Scholar
    • Export Citation
  • 30.

    Vanneste JAugustijn PDirven 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 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

    • Search Google Scholar
    • Export Citation
  • 31.

    Vanneste JAugustijn PTan WFDirven C: Shunting normal pressure hydrocephalus: the predictive value of combined clinical and CT data. J Neurol Neurosurg Psychiatry 56:2512561993Vanneste J Augustijn P Tan WF Dirven C: Shunting normal pressure hydrocephalus: the predictive value of combined clinical and CT data. J Neurol Neurosurg Psychiatry 56:251–256 1993

    • Search Google Scholar
    • Export Citation
  • 32.

    Walchenbach RGeiger EThomeer RTWMVanneste JAL: The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 72:5035062002Walchenbach R Geiger E Thomeer RTWM Vanneste JAL: The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 72:503–506 2002

    • Search Google Scholar
    • Export Citation
  • 33.

    Wechsler D: Wechsler Memory Scale Revised. San Antonio: The Psychological Corporation1987Wechsler D: Wechsler Memory Scale Revised. San Antonio: The Psychological Corporation 1987

    • Search Google Scholar
    • Export Citation
  • 34.

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

    • Search Google Scholar
    • Export Citation
  • 35.

    Williams AMRazomovsky AYHanley DF: Comparison of Pcsf monitoring and controlled CSF drainage diagnose normal pressure hydrocephalus. Acta Neurochir Suppl 71:3283301998Williams AM Razomovsky AY Hanley DF: Comparison of Pcsf monitoring and controlled CSF drainage diagnose normal pressure hydrocephalus. Acta Neurochir Suppl 71:328–330 1998

    • Search Google Scholar
    • Export Citation
TrendMD
Cited By
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 592 586 68
Full Text Views 378 223 7
PDF Downloads 184 134 6
EPUB Downloads 0 0 0
PubMed
Google Scholar