INNOVATIONSin spine & treatment Volume 2, number 5

Normal-pressure hydrocephalus produces Alzheimer-like symptoms, but is treatable

Easily mistaken for Alzheimer’s disease, pathology are at present unknown; include apathy, inattention and poor Parkinson’s disease or age-related senility however, it is regarded to be a type of reasoning ability. in general is the condition known communicating hydrocephalus involving appears late in the as normal-pressure hydrocephalus (NPH). impaired CSF resorption at the arachnoid illness, consisting of increased frequency NPH occurs when an accumulation villi. Characteristic is enlargement of the and urgency. Ultimately, patients may of (CSF) causes an ventricles and a resultant strain placed exhibit “frontal lobe incontinence,” where increase in . upon the surrounding lumbosacral motor they become indifferent to their recurrent Recent population-based studies have fibers. In this situation, the CSF pressure urinary symptoms. estimated that NPH each year develops rises but is offset by gradually falling in approximately 5.5 out of every 100,000 intracranial pressure. Eventually, the CSF Test as soon as possible people over the age of 65. This relatively pressure becomes steady at a level of Today, when patients present with this small rate of occurrence is nonetheless approximately 150 to 200 mmH2O, which symptom triad, it is advised that they be significant because it implies that at least is at the high end of the normal range. scheduled as soon as possible for a CT some patients confined to nursing homes The classic signs of increased or MRI examination of the brain to assess may not need to be there owing to the intracranial pressure include the ventricles for appropriateness of size fact that they do not actually suffer from , , or altered and for CSF flow dynamics. CT scans Alzheimer’s disease but, rather, from consciousness, but none of these is are useful in that they can reveal the undiagnosed NPH – a condition that typically seen in NPH patients. Instead, ventricular enlargement. MRI studies are usually is treatable. they experience (and present with) the of value because they can demonstrate If appropriately treated, the NPH aforementioned triad of symptoms: gait at least some degree of transependymal symptoms usually most improved are difficulties, mental decline and urinary migration of CSF surrounding the those of gait, and urinary incontinence. ventricles on the T2/FLAIR sequence. incontinence. The ability to walk with With NPH, though, gait disturbance is One of the most determinative tests surer footing and function with a less often progressive due to the expansion of available for diagnosing NPH is a lumbar clouded mind are both important from the , particularly at the puncture. This relatively simple procedure the standpoint of reducing the risk of level of the , and this in involves extraction of at least 30 mL of fall injury, which is, of course, a major turn leads to traction on the surrounding CSF from the lumbar spine. If NPH is concern for the elderly. (Approximately fibers. As a result, patients commonly present, the patient’s gait will temporarily 3% to 6% of falls in old age result in a experience unsteadiness and impaired show noticeable improvement about an fracture of the pelvis, arm, rib or face, balance, especially on stairs and curbs. hour later. according to findings.) Further, their gait may mimic that which The clinical improvement seen with a is typical of Parkinson’s disease – short, test also has predictive Triad of symptoms shuffling steps and stooped, forward- value – chiefly, it will suggest whether NPH manifests in two varieties. leaning posture. and tiredness the patient is likely a good candidate for The first is a form that arises due to may also manifest. treatment with a surgically implanted sub-arachnoid hemorrhage, , As to dementia, here it is predominantly ventriculoperitoneal . cranial or central frontal-lobe in nature. Memory problems Ventriculoperitoneal shunts are . are thus usually the main problem, and employed to drain excess CSF and More prevalent is the second form of it is this that can lead to the misdiagnosis discharge it into the abdomen where NPH, which is of an idiopathic nature. of Alzheimer’s disease. Other symptoms it can then be absorbed. With one of Its cause and exact mechanism of spun from the frontal-lobe deficiency these shunts in place, the ventricles usually reduce in size after about three Milwaukee, Waukesha and neighboring or four days. A 2004 study concluded Wisconsin communities so often refer to that idiopathic NPH patients, if me their NPH-suspected patients. correctly identified as candidates for Please consider utilizing me as just the procedure, will in most instances such a resource for your own NPH- be helped. Specifically, the researchers suspected patients. You and they will found that 86% of patients experienced appreciate my accessibility and eagerness improvements in either gait or continence to help – not just in terms of diagnosis or both. and treatment but with respect to answers Shekhar A. Dagam, MD Significantly, ventriculoperitoneal to even the most vexing questions about Fellowship: Stereotactic Radiosurgery, shunting is a moderately conservative and this condition. I’m very sure that your Mayo Graduate School of Medicine / straightforward intervention. There are at patients will find my help invaluable – University of Pittsburgh, PA present two types of shunt available for and that they will be so satisfied with the Residency: Neurological Surgery, Mayo this purpose. One is a simple mechanical attention they receive that they will return Graduate School of Medicine, Rochester, MN valve device with more or less a single, to you happy and more willing than ever MD: With Distinction, George Washington permanent CSF flow setting. The other to continue trusting you with their ongoing University School of Medicine, Washington, DC is a high-tech programmable valve to care. BS: Chemistry, University of California at Berkeley, CA permit fine postoperative adjustments to For further information about NPH, my the CSF flow as warranted by symptom approaches to treatment and information Advanced, comprehensive solutions for... improvements. about my other neurology-specific n Chronic & acute neck & back pain There is no hard-and-fast upper surgical services, please call me at n Arm & leg pain age limit with regard to the viability of (414) 385-7150. n Spine disorders & degenerative conditions n Cervical & lumbar radiculopathy candidates for this procedure. As long as n Spinal the patient is generally deemed operable, n Herniated disc this surgery remains an option. Studies n Compression fractures n Spinal-cord tumors & AVMs suggest that the shunt has a longevity of n Brain tumors, aneurysms & AVMs one or more decades. n Microvascular nerve-compression disorders n & Parkinson’s disease n Hydrocephalus n Conclusions n Carpal tunnel syndrome Older adults are more prone to NPH. NPH is sometimes misdiagnosed as Leading-edge spine & brain procedures... Alzheimer’s disease, Parkinson’s disease n All minimally invasive & open spine or senility. The reason for this is that it is n Complex spine reconstruction n Surgery for relief of spine pain of a chronic nature and patients typically n Craniotomy present with a classic triad of Alzheimer’s/ n Removal/resection of spine & brain tumors ® ® Parkinson’s symptoms: gait , urinary n CyberKnife & Gamma Knife radiosurgery n AVM & aneurysm repair incontinence and dementia. n Epilepsy & Parkinson’s surgery CT and MRI scans can greatly aid in n Awake brain mapping the diagnosis of NPH by characterizing n Nerve decompression n Pain pumps & nerve stimulators enlargement of the ventricles despite the n Carotid endarterectomy presence of normal-range fluid pressure. n Shunt insertion & revision More definitive is a lumbar puncture test. Committed, caring & convenient... NPH symptoms can be reduced with surgical placement of a n Friendly, caring doctor & staff n Individualized care & attention ventriculoperitoneal shunt in appropriate n Detailed & frequent physician-to-physician candidates. This reduction of symptoms communication is key to the diminution of fall risk and n Early morning appointments available n Appointments seen promptly to enabling patients to continue living n Most insurance accepted & filed independently. Diagnosis and treatment of NPH is a mainstay of my practice, a skill set acquired years ago during my training at the Mayo Clinic. I believe it is very important that NPH be detected as early as possible so that patients can 2801 West Kinnickinnic River Parkway, Suite 550 be appropriately treated and, ideally, Milwaukee, WI 53215 (414) 385-7150 | Fax: (414) 315-7159 continue to lead satisfying lives. This is www.dagamneurosurgery.com but one reason why physicians across ©pbo 2011