Normotensive hydrocephalus
Normotensive hydrocephalus (lat. hydrocephalus normotensivus, English NPH - normal pressure hydrocephalus) is communicating hydrocephalus with normal intracranial pressure. During a lumbar puncture lying down, we measure the pressure up to 18 cm H2O.
NPH is still underdiagnosed (10%) due to considerable competition from other neurodegenerative comorbidities. NPH is referred to as one of the few treatable dementia, as there is a possibility of improvement of clinical symptoms (up to 75% of patients) with timely and adequate treatment. Treatment primarily consists in the implantation of a shunt - most often it is a ventriculoperitoneal shunt (VP shunt), which drains CSF from the lateral ventricles into the peritoneal space.
Prevalence and classification[edit | edit source]
Currently, there are approximately 50 million people in the world suffering from a cognitive deficit, and it is likely to expect an increase in this number in the perspective of the next years. The number of people with dementia is expected to triple by 2050 due to the overall aging of the population [1]. With regard to NPH, the exact prevalence is unclear, estimated at 1.3% of people over 65 years of age [2].
We distinguish NPH into two basic groups:
- idiopathic NPH' (iNPH), i.e. NPH without an obvious cause, which mainly affects people over 65 [3];
- secondary NPH' (sNPH), which occurs as a result of subarachnoid hemorrhage, craniocerebral trauma, meningitis, brain surgery, etc., while it can occur at any age.
Symptomatology[edit | edit source]
Clinically, the so-called Adams-Hakim triad appears at a typical age of over 60:
- gait disorder - usually the first symptom, walking with a wide base, short steps, magnetic phenomenon when starting to walk (difficult initiation, slowing down at the beginning of the movement "as if the patient's legs were stuck to country");
- dementia - short-term memory disorders, bradypsychism;
- urinary incontinence [4],
while up to half of patients with NPH do not show all three mentioned symptoms. In addition to the mentioned trias, patients with NPH may experience secondary symptoms, most often psychological alterations (depression, personality changes, anxiety, etc.) [5][6].
The symptomatology is determined by intermittent rises [[Intintracranial hypertension] (so-called B waves) – cause changes in the periventricular white matter.
Diagnostics[edit | edit source]
Non-invasive tests[edit | edit source]
The primary diagnosis is CT of the brain, it will show cerebrospinal fluid expansion. However, due to the epidemiology of the disease prevailing in the older part of the population, it is impossible to determine a clear diagnosis of NPH with this imaging method alone. Typically, neurodegenerative comorbidities are also present (Alzheimer's disease, vascular dementia, Parkinson's disease etc.), therefore identifying and differentiating NPH from these pathologies is significantly complicated [7][8]. MRI is typically performed on the basis of an already performed CT to rule out potential obstruction or a more detailed view of CSF flow. MR spectroscopy is often used. [9]
Invasive tests[edit | edit source]
Several lycodynamic tests are performed, the most common being the following.
- Lumbar infusion test (LIT) - intracranial pressure is measured continuously during the infusion of a CSF substitute (most often Ringer's solution) into the lumbar subarachnoid space at a rate of 1.5 ml/min, while the patient must be supine on the side so that the measured pressure values are not erroneous.
- Tap test - this is an important examination for the correct identification of surgical candidates, the principle of which is to drain approx. 30-50 ml of cerebrospinal fluid and then evaluate improvement/deterioration, or no change in the patient's symptoms.
- Continuous measurement of intracranial pressure - not commonly done, but it is possible to encounter this procedure. The principle is 12-48-hour monitoring of intracranial pressure, which is measured either lumbar, parenchymal [10], intraventricularly or epidurally [11].
In addition, recent research examines the relevance of biomarkers from CSF analyzes in terms of distinguishing NPH from neurodegenerative comorbidities. In clinical practice, this diagnostic method is not yet used due to the lack of specific markers that would be able to distinguish individual abnormalities and thus facilitate the differential diagnosis of NPH.
Therapy[edit | edit source]
When indicating a shunt, we consider:
- duration of clinical problems,
- correlation of clinical symptoms, comorbidities, CT/MRI findings and the result of the lycodynamic test.
It is usually performed VP (ventriculoperitoneal) shunt (or other shunts in case of VP shunt failure) with a programmable valve, while we set the valve to a value of 8 –11 cm H2O (can be adjusted later when monitoring the patient) Cite error: Closing </ref>
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tag[12]. MRI is typically performed on the basis of an already performed CT to rule out potential obstruction or a more detailed view of CSF flow. MR spectroscopy is often used. [13]
Invasive tests[edit | edit source]
Several lycodynamic tests are performed, the most common being the following.
- Lumbar infusion test (LIT) - intracranial pressure is measured continuously during the infusion of a CSF substitute (most often Ringer's solution) into the lumbar subarachnoid space at a rate of 1.5 ml/min, while the patient must be supine on the side so that the measured pressure values are not erroneous.
- Tap test - this is an important examination for the correct identification of surgical candidates, the principle of which is to drain approx. 30-50 ml of cerebrospinal fluid and then evaluate improvement/deterioration, or no change in the patient's symptoms.
- Continuous measurement of intracranial pressure - not commonly done, but it is possible to encounter this procedure. The principle is 12-48-hour monitoring of intracranial pressure, which is measured either lumbar, parenchymal [14], intraventricularly or epidurally [15].
In addition, recent research examines the relevance of biomarkers from CSF analyzes in terms of distinguishing NPH from neurodegenerative comorbidities. In clinical practice, this diagnostic method is not yet used due to the lack of specific markers that would be able to distinguish individual abnormalities and thus facilitate the differential diagnosis of NPH.
Therapy[edit | edit source]
When indicating a shunt, we consider:
- duration of clinical problems,
- correlation of clinical symptoms, comorbidities, CT/MRI findings and the result of the lycodynamic test.
It is usually performed VP (ventriculoperitoneal) shunt (or other shunts in case of VP shunt failure) with a programmable valve, while we set the valve to a value of 8 –11 cm H2O (can be adjusted later when monitoring the patient) [16]. The primary requirement is that it is one-way, so that there is no reverse flow of cerebrospinal fluid into the lateral chamber.
Links[edit | edit source]
Related Articles[edit | edit source]
- Hydrocephalus
- Surgical treatment of hydrocephalus
- Dementia
- Alzheimer's disease
- Vascular dementia
- Parkinson's disease
References[edit | edit source]
- {{#switch: article
|book =
Incomplete publication citation. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al2020. pp. 1451-1464.
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Incomplete citation of contribution in proceedings. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. 2020. pp. 1451-1464. {{ #if: |978-80-7262-438-6} } |article = SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. Normal pressure hydrocephalus — an overview of pathophysiological mechanisms and diagnostic procedures. 2020, year 2020, pp. 1451-1464, ISSN 0344-5607. DOI: 10.1007/s10143-019-01201-5.
|web =
Incomplete site citation. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. ©2020.
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|corporate_literature =
Incomplete citation of company literature. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. 2020. legislative_document = Incomplete citation of legislative document. 2020. s. 1451-1464. ISSN 0344-5607.
- {{#switch: article
|book =
Incomplete publication citation. SKALICKY, Peter, Ales VLASÁK and Arnošt MLADEK, et al2021. pp. 99-107.
|collection =
Incomplete citation of contribution in proceedings. SKALICKY, Peter, Ales VLASÁK and Arnošt MLADEK, et al. 2021. pp. 99-107. {{ #if: |978-80-7262-438-6} } |article = SKALICKY, Peter, Ales VLASÁK and Arnošt MLADEK, et al. Role of DESH, callosal angle and cingulate sulcus sign in prediction of gait responsiveness after shunting in iNPH patients. 2021, year 2021, pp. 99-107, ISSN 0967-5868. DOI: 10.1016/j.jocn.2020.11.020.
|web =
Incomplete site citation. SKALICKY, Peter, Ales VLASÁK and Arnošt MLADEK, et al. ©2021.
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Incomplete citation of company literature. SKALICKY, Peter, Ales VLASÁK and Arnošt MLADEK, et al. 2021. legislative_document = Incomplete citation of legislative document. 2021. s. 99-107. ISSN 0967-5868.
- {{#switch: article
|book =
Incomplete publication citation. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al2022. pp. 127-132.
|collection =
Incomplete citation of contribution in proceedings. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. 2022. pp. 127-132. {{ #if: |978-80-7262-438-6} } |article = SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. First experiences with Miethke M.blue® valve in iNPH patients. 2022, year 2022, pp. 127-132, ISSN 0967-5868. DOI: 10.1016/j.jocn.2022.02.004.
|web =
Incomplete site citation. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. ©2022.
|cd =
Incomplete carrier citation. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. ©2022.
|db =
Incomplete database citation. ©2022.
|corporate_literature =
Incomplete citation of company literature. SKALICKY, Peter, Arnošt MLADEK and Ales VLASÁK, et al. 2022. legislative_document = Incomplete citation of legislative document. 2022. s. 127-132. ISSN 0967-5868.
References[edit | edit source]
- ↑ {{#switch: article |book = Incomplete publication citation. and Kaoru SHINKAWA?. |collection = Incomplete citation of contribution in proceedings. and Kaoru SHINKAWA. ?. {{ #if: |978-80-7262-438-6} } |article = Incomplete article citation. and Kaoru SHINKAWA. Tablet-Based Automatic Assessment for Early Detection of Alzheimer's Disease Using Speech Responses to Daily Life Questions. ?, year ?, ISSN 2673-253X. DOI: 10.3389/fdgth.2021.653904. |web = Incomplete site citation. and Kaoru SHINKAWA. ©?. |cd = Incomplete carrier citation. and Kaoru SHINKAWA. ©?. |db = Incomplete database citation. ©?. |corporate_literature = Incomplete citation of company literature. and Kaoru SHINKAWA. ?. legislative_document = Incomplete citation of legislative document. ?. ISSN 2673-253X.
- ↑ {{#switch: article |book = Incomplete publication citation. MARTÍN-LÁEZ, Ruben, Hugo CABALLERO-ARZAPALO and Luis Ángel LÓPEZ-MENÉNDEZ2015. |collection = Incomplete citation of contribution in proceedings. MARTÍN-LÁEZ, Ruben, Hugo CABALLERO-ARZAPALO and Luis Ángel LÓPEZ-MENÉNDEZ. 2015. {{ #if: |978-80-7262-438-6} } |article = Incomplete article citation. MARTÍN-LÁEZ, Ruben, Hugo CABALLERO-ARZAPALO and Luis Ángel LÓPEZ-MENÉNDEZ. Epidemiology of Idiopathic Normal Pressure Hydrocephalus: A Systematic Review of the Literature. 2015, year 2015, ISSN 1878-8750. DOI: 10.1016/j.wneu.2015.07.005. |web = Incomplete site citation. MARTÍN-LÁEZ, Ruben, Hugo CABALLERO-ARZAPALO and Luis Ángel LÓPEZ-MENÉNDEZ. ©2015. |cd = Incomplete carrier citation. MARTÍN-LÁEZ, Ruben, Hugo CABALLERO-ARZAPALO and Luis Ángel LÓPEZ-MENÉNDEZ. ©2015. |db = Incomplete database citation. ©2015. |corporate_literature = Incomplete citation of company literature. MARTÍN-LÁEZ, Ruben, Hugo CABALLERO-ARZAPALO and Luis Ángel LÓPEZ-MENÉNDEZ. 2015. legislative_document = Incomplete citation of legislative document. 2015. ISSN 1878-8750.
- ↑ {{#switch: article |book = Incomplete publication citation. MARMAROU, Anthonysuppl_3. |collection = Incomplete citation of contribution in proceedings. MARMAROU, Anthony. suppl_3. {{ #if: |978-80-7262-438-6} } |article = Incomplete article citation. MARMAROU, Anthony. Development of Guidelines for Idiopathic Normal-pressure Hydrocephalus: Introduction. suppl_3, year suppl_3, ISSN 0148-396X. DOI: 10.1227/01.neu.0000168188.25559.0e. |web = Incomplete site citation. MARMAROU, Anthony. ©suppl_3. |cd = Incomplete carrier citation. MARMAROU, Anthony. ©suppl_3. |db = Incomplete database citation. ©suppl_3. |corporate_literature = Incomplete citation of company literature. MARMAROU, Anthony. suppl_3. legislative_document = Incomplete citation of legislative document. suppl_3. ISSN 0148-396X.
- ↑
„ {{{1}}} “ - ↑ {{#switch: article |book = Incomplete publication citation. and José M. ROTTA2014. pp. 435-438. |collection = Incomplete citation of contribution in proceedings. and José M. ROTTA. 2014. pp. 435-438. {{ #if: |978-80-7262-438-6} } |article = and José M. ROTTA. Psychiatric symptoms are present in most of the patients with idiopathic normal pressure hydrocephalus. 2014, year 2014, pp. 435-438, ISSN 0004-282X. DOI: 10.1590/0004-282x20140047. |web = Incomplete site citation. and José M. ROTTA. ©2014. |cd = Incomplete carrier citation. and José M. ROTTA. ©2014. |db = Incomplete database citation. ©2014. |corporate_literature = Incomplete citation of company literature. and José M. ROTTA. 2014. legislative_document = Incomplete citation of legislative document. 2014. s. 435-438. ISSN 0004-282X.
- ↑ {{#switch: article |book = Incomplete publication citation. and Anders EKLUND2. pp. 161-168. |collection = Incomplete citation of contribution in proceedings. and Anders EKLUND. 2. pp. 161-168. {{ #if: |978-80-7262-438-6} } |article = and Anders EKLUND. Symptoms of Depression are Common in Patients With Idiopathic Normal Pressure Hydrocephalus. 2, year 2, pp. 161-168, ISSN 0148-396X. DOI: 10.1227/neu.0000000000001093. |web = Incomplete site citation. and Anders EKLUND. ©2. |cd = Incomplete carrier citation. and Anders EKLUND. ©2. |db = Incomplete database citation. ©2. |corporate_literature = Incomplete citation of company literature. and Anders EKLUND. 2. legislative_document = Incomplete citation of legislative document. 2. s. 161-168. ISSN 0148-396X.
- ↑ {{#switch: article |book = Incomplete publication citation. ISEKI, Chifumi and Hikaru NAGASAWA2009. pp. 54-57. |collection = Incomplete citation of contribution in proceedings. ISEKI, Chifumi and Hikaru NAGASAWA. 2009. pp. 54-57. {{ #if: |978-80-7262-438-6} } |article = ISEKI, Chifumi and Hikaru NAGASAWA. Asymptomatic ventriculomegaly with features of idiopathic normal pressure hydrocephalus on MRI (AVIM) in the elderly: A prospective study in a Japanese population. 2009, year 2009, pp. 54-57, ISSN 0022-510X. DOI: 10.1016/j.jns.2008.10.004. |web = Incomplete site citation. ISEKI, Chifumi and Hikaru NAGASAWA. ©2009. |cd = Incomplete carrier citation. ISEKI, Chifumi and Hikaru NAGASAWA. ©2009. |db = Incomplete database citation. ©2009. |corporate_literature = Incomplete citation of company literature. ISEKI, Chifumi and Hikaru NAGASAWA. 2009. legislative_document = Incomplete citation of legislative document. 2009. s. 54-57. ISSN 0022-510X.
- ↑ {{#switch: article |book = Incomplete publication citation. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI2020. pp. 703-711. |collection = Incomplete citation of contribution in proceedings. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. 2020. pp. 703-711. {{ #if: |978-80-7262-438-6} } |article = MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. Normal Pressure Hydrocephalus Associated with Alzheimer's Disease. 2020, year 2020, pp. 703-711, ISSN 0364-5134. DOI: 10.1002/ana.25847. |web = Incomplete site citation. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. ©2020. |cd = Incomplete carrier citation. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. ©2020. |db = Incomplete database citation. ©2020. |corporate_literature = Incomplete citation of company literature. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. 2020. legislative_document = Incomplete citation of legislative document. 2020. s. 703-711. ISSN 0364-5134.
- ↑
„ {{{1}}} “ - ↑ {{#switch: article |book = Incomplete publication citation. 2010. pp. 80-91. |collection = Incomplete citation of contribution in proceedings. . 2010. pp. 80-91. {{ #if: |978-80-7262-438-6} } |article = Incomplete article citation. . Diagnostic Intracranial Pressure Monitoring and Surgical Management in Idiopathic Normal Pressure Hydrocephalus. 2010, year 2010, pp. 80-91, ISSN 0148-396X. DOI: 10.1227/01.neu.0000363408.69856.b8. |web = Incomplete site citation. . ©2010. |cd = Incomplete carrier citation. . ©2010. |db = Incomplete database citation. ©2010. |corporate_literature = Incomplete citation of company literature. . 2010. legislative_document = Incomplete citation of legislative document. 2010. s. 80-91. ISSN 0148-396X.
- ↑ {{#switch: article |book = Incomplete publication citation. , Maria MATARÓ and Maria Del Mar MATARÍN2004. pp. 855-866. |collection = Incomplete citation of contribution in proceedings. , Maria MATARÓ and Maria Del Mar MATARÍN. 2004. pp. 855-866. {{ #if: |978-80-7262-438-6} } |article = , Maria MATARÓ and Maria Del Mar MATARÍN. 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. 2004, year 2004, pp. 855-866, ISSN 0022-3085. DOI: 10.3171/jns.2004.100.5.0855. |web = Incomplete site citation. , Maria MATARÓ and Maria Del Mar MATARÍN. ©2004. |cd = Incomplete carrier citation. , Maria MATARÓ and Maria Del Mar MATARÍN. ©2004. |db = Incomplete database citation. ©2004. |corporate_literature = Incomplete citation of company literature. , Maria MATARÓ and Maria Del Mar MATARÍN. 2004. legislative_document = Incomplete citation of legislative document. 2004. s. 855-866. ISSN 0022-3085.
- ↑ {{#switch: article |book = Incomplete publication citation. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI2020. pp. 703-711. |collection = Incomplete citation of contribution in proceedings. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. 2020. pp. 703-711. {{ #if: |978-80-7262-438-6} } |article = MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. Normal Pressure Hydrocephalus Associated with Alzheimer's Disease. 2020, year 2020, pp. 703-711, ISSN 0364-5134. DOI: 10.1002/ana.25847. |web = Incomplete site citation. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. ©2020. |cd = Incomplete carrier citation. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. ©2020. |db = Incomplete database citation. ©2020. |corporate_literature = Incomplete citation of company literature. MÜLLER‐SCHMITZ, Katharina, Natalia KRASAVINA‐LOKA and Tugba YARDIMCI. 2020. legislative_document = Incomplete citation of legislative document. 2020. s. 703-711. ISSN 0364-5134.
- ↑
„ {{{1}}} “ - ↑ {{#switch: article |book = Incomplete publication citation. 2010. pp. 80-91. |collection = Incomplete citation of contribution in proceedings. . 2010. pp. 80-91. {{ #if: |978-80-7262-438-6} } |article = Incomplete article citation. . Diagnostic Intracranial Pressure Monitoring and Surgical Management in Idiopathic Normal Pressure Hydrocephalus. 2010, year 2010, pp. 80-91, ISSN 0148-396X. DOI: 10.1227/01.neu.0000363408.69856.b8. |web = Incomplete site citation. . ©2010. |cd = Incomplete carrier citation. . ©2010. |db = Incomplete database citation. ©2010. |corporate_literature = Incomplete citation of company literature. . 2010. legislative_document = Incomplete citation of legislative document. 2010. s. 80-91. ISSN 0148-396X.
- ↑ {{#switch: article |book = Incomplete publication citation. , Maria MATARÓ and Maria Del Mar MATARÍN2004. pp. 855-866. |collection = Incomplete citation of contribution in proceedings. , Maria MATARÓ and Maria Del Mar MATARÍN. 2004. pp. 855-866. {{ #if: |978-80-7262-438-6} } |article = , Maria MATARÓ and Maria Del Mar MATARÍN. 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. 2004, year 2004, pp. 855-866, ISSN 0022-3085. DOI: 10.3171/jns.2004.100.5.0855. |web = Incomplete site citation. , Maria MATARÓ and Maria Del Mar MATARÍN. ©2004. |cd = Incomplete carrier citation. , Maria MATARÓ and Maria Del Mar MATARÍN. ©2004. |db = Incomplete database citation. ©2004. |corporate_literature = Incomplete citation of company literature. , Maria MATARÓ and Maria Del Mar MATARÍN. 2004. legislative_document = Incomplete citation of legislative document. 2004. s. 855-866. ISSN 0022-3085.
- ↑ {{#switch: article |book = Incomplete publication citation. and George SAVULICH2016. |collection = Incomplete citation of contribution in proceedings. and George SAVULICH. 2016. {{ #if: |978-80-7262-438-6} } |article = Incomplete article citation. and George SAVULICH. The effect of shunt surgery onneuropsychological performance in normal pressure hydrocephalus: a systematic review and meta-analysis. 2016, year 2016, ISSN 0340-5354. DOI: 10.1007/s00415-016-8097-0. |web = Incomplete site citation. and George SAVULICH. ©2016. |cd = Incomplete carrier citation. and George SAVULICH. ©2016. |db = Incomplete database citation. ©2016. |corporate_literature = Incomplete citation of company literature. and George SAVULICH. 2016. legislative_document = Incomplete citation of legislative document. 2016. ISSN 0340-5354.