Normal Pressure Hydrocephalus


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  • Normal Pressure Hydrocephalus

    1. 1. A Sharing Session on Normal Pressure Hydrocephalus (NPH) Suhaila Mohamed Usuludin 17 April 2008
    2. 2. Cerebrospinal Fluid (CSF) <ul><li>A clear, colourless fluid that contains small quantities of glucose and protein </li></ul><ul><li>Fills the ventricles of the brain and the central canal of the spinal cord </li></ul><ul><li>Production by choroid plexus in lateral ventricle at 20ml/hr </li></ul>
    3. 3. Cerebrospinal Fluid (CSF)
    4. 4. Cerebrospinal Fluid (CSF)
    5. 5. <ul><li>Functions </li></ul><ul><ul><li>drainage route for waste products of brain metabolism </li></ul></ul><ul><ul><li>bouyancy </li></ul></ul><ul><ul><li>electrolytes and nutrient exchange </li></ul></ul><ul><li>Pressure decrease from site of production -> site of absorption </li></ul><ul><ul><li>determined by venous pressure </li></ul></ul>Cerebrospinal Fluid (CSF)
    6. 6. <ul><li>Pressure is raised if </li></ul><ul><ul><li>Brain volume increases </li></ul></ul><ul><ul><li>Venous pressure increases </li></ul></ul><ul><ul><li>Outflow obstruction </li></ul></ul><ul><ul><ul><li>At ventricles (non-communicating hydrocephalus) </li></ul></ul></ul><ul><ul><ul><li>At absorptive site (communicating hydrocephalus) </li></ul></ul></ul>Cerebrospinal Fluid (CSF)
    7. 7. NPH <ul><li>Gradual decrease CSF absorption at arachnoid granulations </li></ul><ul><ul><li>back pressure effect </li></ul></ul><ul><ul><li>Increase pressure in ventricles </li></ul></ul><ul><li>Compensatory mechanisms to maintain pressure </li></ul><ul><ul><li>Distension of ventricles </li></ul></ul>
    8. 8. NPH <ul><li>Slowly progressive </li></ul><ul><li>Onset > 40 years </li></ul><ul><li>Most common in elderly </li></ul>
    9. 9. Symptoms of NPH <ul><li>Adams triad </li></ul><ul><ul><li>Impaired gait </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><ul><li>Impaired cognitive function </li></ul></ul>
    10. 10. Impaired gait <ul><li>Usually first and prominent symptom </li></ul><ul><ul><li>reduced step height </li></ul></ul><ul><ul><li>stride length </li></ul></ul><ul><ul><li>velocity </li></ul></ul><ul><ul><li>Shuffling gait </li></ul></ul><ul><ul><li>wide-based </li></ul></ul><ul><ul><li>trunk sway </li></ul></ul><ul><ul><li>‘ magnetic gait’ </li></ul></ul><ul><ul><li>gait apraxia </li></ul></ul>
    11. 11. <ul><li>Timed walking test </li></ul><ul><li>GAITRite gait analysis </li></ul>Assessment: Impaired gait
    12. 12. Urinary Incontinence <ul><li>Usually 2 nd symptom to follow </li></ul><ul><ul><li>Urgency and frequency </li></ul></ul><ul><li>Fecal incontinence </li></ul><ul><ul><li>Rare except in advanced cases </li></ul></ul>
    13. 13. Impaired Cognitive Functions <ul><li>Reversible cause of dementia </li></ul><ul><li>Subcortical dementia </li></ul><ul><ul><li>Inattention </li></ul></ul><ul><ul><li>Delayed recent recall </li></ul></ul><ul><ul><li>Delayed psychomotor functioning </li></ul></ul><ul><ul><li>Behavioural changes </li></ul></ul><ul><ul><li>Emotional instability </li></ul></ul><ul><li>Executive functioning may be affected as disease progresses </li></ul>
    14. 14. <ul><li>MMSE </li></ul><ul><li>AMT </li></ul><ul><li>Neuropsychological tests: </li></ul><ul><ul><li>Trail Making Test </li></ul></ul><ul><ul><li>Digit/Letter Cancellation </li></ul></ul><ul><ul><li>Kendrick Object Learning Test (KOLT): visual memory </li></ul></ul>Assessment of Impaired Cognitive Functions
    15. 15. NOT Expected Symptoms <ul><li>Seizures </li></ul><ul><li>Signs and symptoms of increased ICP </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Altered level of consciousness </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul>
    16. 16. Differential Diagnoses <ul><li>Old age </li></ul><ul><li>Parkinsonism </li></ul><ul><li>Dementia – AD, vascular </li></ul><ul><li>Depression </li></ul><ul><li>Cerebellar/spinal cord involvement </li></ul>
    17. 17. How is it Diagnosed? <ul><li>MRI </li></ul><ul><ul><li>Ventricles (lateral, 3 rd and 4 th ) and Sylvian fissure dilated with normal hippocampus </li></ul></ul>MRI showing ventriculomegaly
    18. 18. <ul><li>CT scan </li></ul><ul><ul><li>Rounding of horns </li></ul></ul><ul><ul><li>Thinning of corpus callosum </li></ul></ul>How is it Diagnosed?
    19. 19. Surgical Management <ul><li>Ventriculoperitoneal Shunt (VP shunt) </li></ul><ul><ul><li>Performed under general anaesthesia </li></ul></ul><ul><ul><li>Catheter placed within a ventricle, and another end at the peritoneal cavity </li></ul></ul>
    20. 20. VP Shunt <ul><li>Valve (fixed or programmable) ensures one-way flow and regulates CSF flow </li></ul><ul><li>Permanent or temporary </li></ul><ul><li>May need replacement or revision if not working properly </li></ul>With five pressure level settings, the programmable, adjustable Strata® valve (top) can be &quot;fine-tuned&quot; by the physician after shunt surgery for NPH. Adjusting the valve and verifying the setting is done quickly in the physician's office using a simple set of magnetic tools (bottom), eliminating the need for additional surgery.
    21. 21. Venticuloatrial Shunt (VA Shunt) <ul><li>CSF is shunted from the cerebral ventricles into the right atrium of the heart. </li></ul><ul><li>2 nd preferred choice if VP shunt is not possible </li></ul><ul><ul><li>Eg. Infection of peritoneal cavity -> affects reabsorption rate of CSF </li></ul></ul>
    22. 22. To Shunt or Not To Shunt? <ul><li>High Volume Lumbar Tap test or External Lumbar Drainage (ELD) </li></ul><ul><ul><li>40-50ml CSF-> beneficial from shunt </li></ul></ul><ul><li>Decrease atrophy/ischemia </li></ul><ul><li>Prominent CSF flow void </li></ul><ul><ul><li>aqueductal stroke volume >42 Ym (Bradley, 1998) </li></ul></ul><ul><li>No known history of intracranial infection </li></ul><ul><li>Pre-morbid functional status </li></ul>
    23. 23. Operation Risks <ul><li>Ileus </li></ul><ul><ul><li>Slow gastric and bowel movement post operation and may feel nausea </li></ul></ul><ul><li>Infection </li></ul><ul><ul><li>Most common organisms are S. epidermidis and S. aureus </li></ul></ul><ul><li>Obstruction </li></ul><ul><ul><li>Most often due to the head tip is obstructed with cells, choroid plexus, or debris. </li></ul></ul>
    24. 24. Operation Risks <ul><li>Misplacement </li></ul><ul><ul><li>Occurs when the ventricular or peritoneal end of the shunt tubing is in a position which does not facilitate free flow of CSF </li></ul></ul><ul><li>Wound breakdown/shunt tube exposure </li></ul><ul><ul><li>Occurs when the wound does not heal well or the overlying skin is thin with minimal subcutaneous tissue layer resulting in wound breakdown. </li></ul></ul>
    25. 25. Prognosis <ul><li>Gait shows highest improvement rates </li></ul><ul><li>Better gait does not correlate to better ADLs functioning </li></ul><ul><li>All components of triad considered to achieve higher ADL scores </li></ul><ul><li>Temporary improvements from 1 to 3 years </li></ul><ul><ul><li>May be substantial for improving QoL </li></ul></ul><ul><li>> 1 year, co-morbidities may affect effects of shunting </li></ul>
    26. 26. Rehabilitation Implications <ul><li>Difficulties in walking </li></ul><ul><ul><li>If given walking aid, may not know how to use it </li></ul></ul><ul><ul><ul><li>Gait apraxia </li></ul></ul></ul><ul><ul><ul><li>Caregiver training on facilitation </li></ul></ul></ul><ul><ul><li>Changing the environment </li></ul></ul><ul><li>Urinary Incontinence </li></ul><ul><ul><li>Time scheduling </li></ul></ul><ul><li>Cognitive Issues </li></ul><ul><ul><li>Caregiver training on psychomotor dysfunctions, behavioural issues etc. </li></ul></ul>
    27. 27. References <ul><li>Presentations from various professionals from the symposium </li></ul><ul><li>Bradley, W.G. (1998). MR Prediction of Shunt Response in NPH: CSF Morphology versus Physiology. American Journal of Neuroradiology , 19 , 1285-1286. </li></ul><ul><li>Department of Neurosurgery (2007). A Patient / Family Informed Consent Guide to Ventricular Peritoneal (VP) Shunt Insertion /Revision . Singapore: National Neuroscience Institute. </li></ul><ul><li>Factora, R. (2006). When do common symptoms indicate normal pressure hydrocephalus?. Cleveland Clinic Journal of Medicine , 73 (5), 447-457. </li></ul><ul><li>Gallia, G.L., Rigamonti, D., & Williams, M.A. (2006). The diagnosis and treatment of idiopathic normal pressure hydrocephalus. Nature Clinical Practice Neurology , 2 (7), 375-381. </li></ul>
    28. 28. Thank You