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Alzheimer's Disease Comorbidity in Normal Pressure Hydrocephalus

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Alzheimer's Disease Comorbidity in Normal Pressure Hydrocephalus 778 J Neurol Neurosurg Psychiatry 2000;68:778–781 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.778 on 1 June 2000. Downloaded from SHORT REPORT Alzheimer’s disease comorbidity in normal pressure hydrocephalus: prevalence and shunt response J Golomb, J WisoV, D C Miller, I Boksay, A Kluger, H Weiner, J Salton, W Graves Abstract The explanation for shunt unresponsiveness is The clinical impact of Alzheimer’s disease not well understood but comorbid neurode- pathology at biopsy was investigated in 56 generative pathology such as Alzheimer’s dis- cognitively impaired patients undergoing ease may play an important part. shunt surgery for idiopathic normal pres- Alzheimer’s disease is a common cause of sure hydrocephalus (NPH). Cognition was dementia in elderly people and may therefore measured by means of the global deteriora- be a frequent source of concomitant pathology tion scale (GDS), the mini mental status in older cognitively impaired patients with examination (MMSE) and a battery of six NPH. In two recent retrospective studies, clini- psychometric tests. Gait was assessed using cal improvement was reported in three of five1 objective measurements of velocity and the and two of eight2 shunted patients with ambulatory index (AI). The prevalence of Alzheimer’s disease pathology established by cases exhibiting neuritic plaques (positive biopsy indicating that comorbidity with this biopsies) increased in parallel with demen- disease does not always mitigate against a ben- tia severity from 18% for patients with GDS eficial neurosurgical result. Nevertheless, 3 to 75% for patients with GDS scores>6. Alzheimer’s disease may attenuate the brain’s Patients with positive biopsies were more capacity to recover from the eVects of NPH cognitively impaired (higher GDS and and may contribute to many of its cardinal lower MMSE scores) as well as more gait symptoms including dementia, incontinence, impaired (higher AI scores and slower and gait impairment.3 The extent to which velocities) than patients with negative biop- Alzheimer’s disease pathology may negatively sies. After surgery, gait velocity and AI influence the response to shunt surgery re- Silberstein Aging and scores improved significantly and to a quires prospective investigation using quantita- http://jnnp.bmj.com/ Dementia Research comparable degree for patients with and tive clinical assessment techniques. Center, New York without positive biopsies. Similar propor- In this study we estimated the prevalence of University, University tions of positive and negative biopsy pa- Alzheimer’s disease pathology in 56 cognitively School of Medicine, impaired patients who received ventriculoperi- New York, NY 10016, tients also had improved gait as assessed by USA means of subjective video tape compari- toneal shunts for a diagnosis of idiopathic Department of sons. There were no significant diVerences NPH. The presence of pathology was ascer- Neurology between the biopsy groups in the magni- tained by means of cortical biopsies obtained J Golomb tude of postoperative psychometric change during surgery. The impact of Alzheimer’s dis- on September 29, 2021 by guest. Protected copyright. W Graves or in the proportion of cases exhibiting ease on the clinical presentation of the patients and on their response to shunting was assessed Department of improved urinary control. Alzheimer’s dis- Neurosurgery ease pathology is a common source of through psychometric and quantitative gait J WisoV comorbidity in older patients with idio- evaluations performed at baseline and postop- H Weiner pathic NPH where it contributes to the eratively. clinical impairment associated with this Department of Neuropathology disorder. For patients accurately diagnosed Methods D C Miller with NPH, concomitant Alzheimer’s dis- Within a 55 month period, 117 patients at our ease pathology does not strongly influence institution received shunt operations for a Department of the clinical response to shunt surgery. diagnosis of idiopathic NPH. All patients Psychiatry (J Neurol Neurosurg Psychiatry 2000;68:778–781) I Boksay evidenced prominent signs of dyspraxic gait A Kluger Keywords: normal pressure hydrocephalus; Alzheimer’s instability and MRI or CT disclosing severe J Salton disease; dementia; ventriculo-peritoneal shunt ventricular enlargement in excess of sulcal prominence as interpreted by a neuroradiolo- Correspondence to: gist unaware of the patient’s clinical condition. Dr James Golomb [email protected] Although normal pressure hydrocephalus These patients received a diagnosis of NPH (NPH) is recognised as a potentially reversible because neurological and medical evaluations Received 26 August 1999 cause of intellectual and motor impairment in disclosed no alternative explanation for the gait and in revised form 17 January 2000 older adults, ventricular shunting procedures dysfunction. Specifically, in no patient could Accepted 21 January 2000 do not always result in clinical improvement. the gait impairment be attributed to rheumato- Alzheimer’s disease comorbidity in normal pressure hydrocephalus 779 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.6.778 on 1 June 2000. Downloaded from logical disease, peripheral neuropathy, my- and data presentation, a composite cognitive elopathy, stroke, Binswanger’s disease, Parkin- score equal to the mean of the standardised (Z son’s disease, cerebellar disease, or intracranial transformed) raw scores was calculated. Gait mass. Of the 117 patients, 81 underwent a was evaluated by measuring average velocity structured psychiatric interview preoperatively over a 60 foot distance. Additionally, by and 77 were found to be cognitively impaired viewing pairs of digitised video clips made (global deterioration scale4 (GDS) score of preoperatively and postoperatively, two clini- >3). In all cases, cognitive dysfunction either cians independently recorded subjective im- followed or evolved simultaneously with the pressions of gait change using a seven point onset of a gait disorder. After informed ordinal scale: (+3=dramatic improvement/ consent, 56 of the 77 cognitively impaired resolution of deficit, +2=definite/moderate patients received cortical biopsies during shunt improvement, +1= questionable/mild improve- surgery. Biopsies were obtained when patients, ment, 0=no change, −1=questionable/mild their families, or their referring physicians deterioration, −2=definite / moderate deterio- sought information on the presence of comor- ration, −3=marked deterioration). The raters bid neurodegenerative disease. The biopsy had no previous clinical involvement in the consisted ofa5mm×2 mm wedge of tissue study and were blinded to both the biopsy through the thickness of the cortex obtained result as well as to the presurgical/postsurgical adjacent to the shunt penetration site. Shunts identity of the individual clips. A mean of the were installed right frontally in 18 patients and two rater’s scores was computed and a value of right occipitoparietally in 38 patients. >+2 was conservatively taken as evidence for The biopsy specimens were fixed in 10% postshunt improvement. Finally the ambula- neutral buVered formalin and processed rou- tory index10 (AI), a six point ordinal scale tinely into paraYn for histological examina- assessing functional gait capacity, was adminis- tion. Sections were examined with haematoxy- tered. Baseline velocity and AI scores were lin and eosin stains, with Congo red stains, and available on 43 and 42 patients respectively and with Bielschowsky silver stains. The biopsies 35 completed the psychometric battery. A sub- were evaluated for inflammation, neoplastic set of these patients returned for postoperative cells, amyloid angiopathy, neuritic and diVuse clinical testing (mean follow up=4.3 months). plaques, neurofibrillary tangles, Lewy bodies, A complete set of preoperative and postopera- and other intracellular inclusions. Biopsies tive psychometric results was available for 27 were considered positive for Alzheimer’s dis- patients, velocity measurments for 32, clini- ease pathology if neuritic plaques, in any cian’s impression of gait change (CIGC) number, were present on the Bielschowsky ratings for 33, and AI scores for 34. There were stained sections. no significant GDS, MMSE, sex, or age diVer- Cognition was assessed by means of five psy- ences at baseline between patients with and chometric tests previously found sensitive to without postoperative follow up data. shunt related improvement in a wider sample of patients with idiopathic NPH. The tests, Results which included measures of verbal recall, No biopsy showed inflammation, neoplasm, perceptual processing, psychomotor praxis and neurons with Lewy Bodies, Pick bodies, or glial motor planning consisted of the Guild para- cells with silver positive inclusions. Amyloid http://jnnp.bmj.com/ graph recall test,5 the digit symbol substitution angiopathy and neuropil threads were detected test,6 the trail making test,7 the MeVerd and in only a few specimens and sparse accumula- Moran perceptual speed test,8 and the Purdue tions of neurofibrillary tangles were seen in six. pegboard test.9 to facilitate statistical analysis Neuritic plaques were found in 23 biopsies Clinical characteristics and shunt response on September 29, 2021 by guest. Protected copyright. Biopsy group p Value between group n (AD−/AD+) AD− AD+ contrast Clinical characteristics at baseline: Age (mean (SD)) 33/23 76.15 (7.65) 77.56 (6.54) 0.474 Male/female ratio 33/23 21/12 12/11 0.391 GDS (mean
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