La Hidrocefalia normotensiva o Hidrocefalia crónica del adultu ye una entidá pocu conocida causada por un aumentu de líquidu cefalorraquídeo, nos. Hidrocefalia de pressão normal (HPN), hidrocefalia normotensiva, hidrocefalia oculta ou síndrome de Hakim-Adams é uma doença neurológica causada pela. Transcript of Hidrocefalia Normotensiva. Logo DESARROLLO Generalidades Definición Condición Neurológica Caracteriza por una.
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T he indications for placing shunts in patients with NPH syndrome are still controversial, because surgery in these fragile patients does not always lead to a good outcome or improve quality of life.
Several authors have investigated the predictive values of distinct symptoms and ancillary methods for improving prognoses. The following factors have traditionally been associated with unfavorable outcome: To our knowledge, no study has been focused on the outcome in patients with NPH who show accepted markers of poor prognosis prior to surgery.
In a recent paper, 24 members of our department studied the influence of several known prognostic factors in patients with a confirmed diagnosis of NPH. We found that the factors clearly related to better neuropsychological and functional recovery after shunt procedures included the presence of a complete clinical triad, obliterated or normal cortical sulci size, and periventricular lucencies. Age, symptom duration, degree of preoperative dementia, and ventricular dilation were not definitively related to neuropsychological or functional changes after surgery when these factors were evaluated by an independent neuropsychologist; however, clinical or radiological factors classically associated with a poor prognosis are increasingly found in patients with suspected NPH or in those who have a mixed-type dementia NPH associated with other neurodegenerative disorders such as Alzheimer disease or vascular dementia.
Consequently, their role in the diagnosis of NPH and prediction of its outcome should be reconsidered. The main objective of this paper was to challenge the widespread belief that patients with the classic symptoms or signs of bad outcome cannot improve after shunt procedures, especially when more than one of these signs are present.
To achieve this goal, we describe the clinical and neuropsychological outcome 6 months after shunt surgery in a pilot study of a subgroup of patients with NPH who simultaneously presented the following four factors traditionally considered to be markers of poor prognosis in addition to old age: These patients were also included in a study of 43 patients recently published by us. Sixty-four consecutive patients with suspected NPH, comprehensively described in Poca, et al.
Two patients died of unrelated causes pulmonary neoplasm and cardiac infarct before the follow-up assessment. Of the remaining 56 patients with NPH who had received shunts, we selected a subgroup with four of the factors traditionally considered to be markers of poor prognosis: In addition, we considered patients older than 64 years only because age is considered one of the most significant variables in neurological recovery and can preclude aggressive treatment.
Twelve patients met these criteria. Figure 1 summarizes the selection criteria of patients included in the present study. All patients underwent complete neurological, neuroimaging, and neuropsychological evaluations prior to surgery and were reassessed at 6 months postoperation.
Tables 1 and 2 show the clinical and demographic description of the 12 patients who met the poor prognosis selection criteria and the rest of the 44 patients who composed the good prognosis group. Algorithm demonstrating patient selection in this study. The disease affects three main areas—gait, sphincter control, and cognitive functioning—which were evaluated according to the NPH scale Table 3. The maximum score 15 points indicates normal functioning in the three domains. The neuropsychological examination included tests of verbal and visual memory, speed of mental processing, and frontal lobe functioning as well as a brief screening test for dementia.
Patients were administered the WMS, 35 which consists of seven subtests: Also administered were the TMT, Parts A and B, 28 to evaluate motor speed, visual scanning, attention, and mental flexibility; a word fluency task consisting of naming as many animals as possible during 1 minute; and the MMSE, 8 which provides a global measure of the severity of cognitive impairment.
Patients’ functional behavior and changes in daily life activities were evaluated using several rating scales: The decision to implant a shunt was based on continuous ICP monitoring and CSF dynamics studies the R out was determined by Katzman and Hussey’s 14 constant rate infusion test.
We registered mean ICP and the presence and percentage of the total recording time of A waves ICP elevations at least 20 mm Hg above the resting line, with abrupt onset and end, and lasting between 5 and 20 minutes and B waves 0.
Accordingly, each patient received one of the following classifications: Independently of the R out values, patients with active or compensated hydrocephalus were selected for shunt placement. Clinically, the patient showed a predominance of gait alterations and urinary incontinence, with subtle recent memory deficit and no other symptomatology.
Computerized tomography scans left and ICP readings right from a patient with Normktensiva 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. After shunt placement, this patient experienced marked improvement abnormal but independent and stable gait, normotensivva sphincter control, and fewer self-reported memory problems—all of which persist to date, 8 years after the shunt was inserted.
Category:Normal pressure hydrocephalus – Wikimedia Commons
A differential low-pressure valve system was implanted in all patients. In five patients, this valve was combined with normotenssiva infraclavicular gravity-compensating accessory NMT Neurosciences Implants S. A low-pressure diaphragm valve American Heyer-Schulte Corp. A Delta valve with a performance level of 0. Although different types of shunt were used in this series, all of them were included in the low-pressure category of normoteniva.
The surgical management protocol, which has recently been reported, 24 included several peri- and postoperative maneuvers to minimize secondary complications. Briefly, one dose each hidricefalia sulfamethoxazole mg and trimethoprim mg were used as prophylactic antibiotic agents during induction of anesthesia, followed by a further three doses every 12 hours.
The head and body were washed twice once in the ward and again after induction of anesthesia. The surgical field was then painted with Betadine solution and covered with Betadine-soaked gauze strips for at least 3 minutes. The dura mater was opened by coagulation and as far as possible the size of the hole was limited to the diameter of the ventricular catheter. To hidrocefalai the catheter’s lumen and prevent infection, an intraventricular bolus of vancomycin 20 mg was administered in all patients.
When the surgical procedure was finished, moderate abdominal compression was applied using a girdle and was maintained normotensica the day for 2 to 3 weeks.
In the subgroup of patients with a differential-pressure valve and no antisiphon or gravity-compensating accessory, the beds were kept flat for at least 7 to 9 days, after which ambulation was begun.
At discharge, the patients were advised to try to maintain this bed position at home until the first follow-up examination, which was routinely performed approximately 3 months later.
In this subgroup of patients, ambulation was started on the 3rd day after shunt insertion. Outcome was independently assessed by the neurosurgeon and neuropsychologist 6 months after the shunt procedure by using the NPH scale. If discrepancies were found between the evaluations of the neurosurgeon and the neuropsychologist, the patient was reevaluated and the final normotenskva was agreed on by consensus. Neuropsychological tests and quality-of-life scales were administered to the patients while they were in the hospital for presurgical studies, and again 6 months later.
Because a small change in the NPH scale score represents a substantial change in the patient’s functional status, we defined moderate improvement as a onepoint increase and hicrocefalia improvement as an increase of two or more points. Improvements in neuropsychological and behavioral features were analyzed using the percentage of change between baseline and postoperative scores. Complications in the early postoperative period 1st month after shunt placement and at 6 months after shunt insertion were evaluated by the neurosurgeon in charge of the patient.
Nonparametric analyses were used. The Wilcoxon matched-pairs signed-rank test was used to compare presurgical and postsurgical data. A percentage of change between baseline and postoperative conditions was also calculated as follows: Statistical significance was noted at a probability level less than or equal to 0.
Before treatment, 10 patients had hirocefalia complete clinical triad, one patient had cognitive dysfunction only, and another patient had gait hidrocsfalia cognitive disturbances but no sphincter incontinence. All patients had some level of nomotensiva impairment Table 4. Five patients had active hydrocephalus Fig. According to the NPH scale, 11 patients showed clinical improvement defined as an increase of 1 or more points on the NPH scale. Gait improved in all of the patients who had presented with gait abnormalities at the baseline assessment, sphincter dysfunction improved in nine of 10 patients who had presented with sphincter incontinence at the presurgical assessment, and cognitive impairment improved in four patients.
No worsening was observed in any patients Table 5 and Nrmotensiva. Bar graphs demonstrating baseline conditions and hidrocefaila conditions after surgery according to the NPH scale. Light gray barsbefore surgery; dark gray bars6 months after surgery. No statistically noemotensiva improvement was found in the cognitive normotrnsiva Table 6.
At the baseline assessment, six patients were completely dependent on others for daily life activities Grade 4 on the SLSfive patients required some supervision SLS Grade 2and one patient was independent for daily life functioning SLS Grade 1.
Good outcome in patients with normal-pressure hydrocephalus and factors indicating poor prognosis
Six months after shunt placement, only one patient remained totally dependent SLS Grade 4seven patients required supervision SLS Grades 2 and 3and four patients were independent for daily life activities SLS Grades 0 and 1; Table 4.
We compared the poor prognosis group with the rest of the sample, which comprised 44 patients with NPH who had undergone shunt placement. The comparisons between the poor prognosis group and the good prognosis group for percentage of change in each clinical and neuropsychological variable showed no significant differences; however, a tendency emerged toward more improvement in patients with poor prognosis in gait functioning NPH gait: There was no treatment-related death.
Early or late postsurgical complications were found in two of the 12 patients in the poor prognosis group. Subacute subdural hematoma was diagnosed in a patient before discharge from the hospital. Evacuation of the subdural collection was performed without sequelae. One additional patient had an asymptomatic subdural collection self-limiting hygroma during the months after shunt placement.
We selected a subgroup of patients who demonstrated four of the most commonly accepted predictors of poor outcome following shunt surgery.
All patients had idiopathic hydrocephalus, cortical atrophy, long disease evolution, and dementia; in addition, all were old. A highly significant improvement was seen in gait and sphincter functioning as well as in almost all daily life activity and functional scales.
Many authors have reported a slight or moderate improvement in patients with NPH following shunt placement; 10, 34 more recently, however, authors have found a high proportion of good results when exhaustive diagnostic and treatment protocols were applied.
We believe these results to be related to the diagnostic and treatment protocols used in this study. The diagnostic criteria used in these patients relies on continuous ICP monitoring. In our experience, continuous ICP monitoring is mandatory when, despite compatible clinical and radiological data, the tap test is negative or the R out is within a normal range.
The percentage of B waves that patients with NPH can demonstrate is highly variable; in the present series, we found wide variation in the percentage of B waves in patients who improved after shunt procedures.
Several other authors support the view that continuous ICP monitoring is the most useful diagnostic test in evaluating NPH. Although different types of shunt were used in this series, all of them included a valve in the low pressure category.
Eleven of the 12 implanted valves were also combined with an antigravity device, which probably reduced the number of subdural collections in these patients. Moreover, the surgical management protocol included other maneuvers before, during, and after shunt placement that could also have influenced the low complication rate and, consequently, the percentage of improvement after shunt insertion.
In our group of patients, cognition improved little in comparison to gait and sphincter changes. Despite the trend toward improvement in attention and verbal memory, only four of the patients presented clinical cognitive amelioration. In addition, in some of the tests that indicated a tendency toward improvement, such as the associate memory subtest of the WMS, we cannot avoid or rule out a possible retest effect, given that the same stimuli were used in the two presentations.
Authors of recent reports in the literature stress the fact that NPH can be highly heterogeneous. All of our patients presented cortical atrophy, which was one of the selection criteria.
The presence of cortical atrophy, dementia, and old age may well raise the probability of the coexistence of other brain diseases.
This factor would explain the poor improvement in cognition in comparison to gait and sphincter changes. Most authors agree about the importance of selecting for shunt placement patients who are very likely to respond.
Many investigators have tried to elucidate which factors are associated with a favorable outcome in this patient population; however, an effective means of predicting shunt responsiveness remains elusive. Nnormotensiva of this factor and the potential risks of the treatment, some authors still question whether the benefits of shunt insertion outweigh the risks.