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Normal Pressure Hydrocephalus

Normal Pressure Hydrocephalus






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Normal Pressure Hydrocephalus Normal Pressure Hydrocephalus Presentation Transcript

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