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idiopathic_normal_pressure_hydrocephalus_outcome

Idiopathic normal pressure hydrocephalus outcome

Patients often present to the neurosurgeon frustrated and desperate after a long preoperative course. It is important to acknowledge the uncertainty regarding Idiopathic normal pressure hydrocephalus diagnosis and response to shunting when counseling patients. Comorbid conditions interfere with the ability to assess progression of iNPH and the effectiveness of the shunt. Patient caregivers play a large role in decision-making and clinical course, and should be included when counseling patients 1).

A 2001 meta-analysis of outcomes reported the Idiopathic normal pressure hydrocephalus treatment to have a 29% rate of significant improvement and a 6% significant complication rate 2).

A study in 2005 revealed greater improvements, with 75% of patients (n = 132) seeing postoperative improvements within 24 months of surgery 3), 68% of patients experiencing “very good” or “good” outcomes in a prospective study 4), and 69%–84% of patients seeing improvements by 1 year after surgery in a prospective multicenter study 5).

Studies that have established fixed protocols for follow-up have shown that short- and long-term periods after shunting are determined by many factors. Whereas short-term results were more likely to be influenced by shunt-associated risks, long-term results were independent of factors inherent to the shunt procedure and shunt complications, i.e., death and morbidity related to concomitant cerebrovascular and vascular diseases 6).

In 2013 a total of 64 studies of 3,063 patients were reviewed. Positive improvement following shunt insertion was reported in an average of 71 % of patients with an average 1 % mortality. Results from studies published in the last 5 years showed 82 % improvement following shunt insertion, mortality of 0.2 %, and combined common complications rate of 8.2 % 7).

Analysis of the efficacy of shunts for possible iNPH conducted in Japan indicated a significant improvement in the mRS grade between baseline and outcome within 1 year, regardless of the surgical technique, and shunt intervention was found to be effective 8).


Clinically, patients presenting with early or severe dementia have worse outcome, while those with a primary gait disturbance feature have better results 9) 10)

A growing body of evidence suggests that longer durations of preoperative symptoms may correlate with worse postoperative outcomes following cerebrospinal fluid diversion for treatment of idiopathic normal pressure hydrocephalus (iNPH).

Outcomes after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus (INPH) are variable due to a lack of reliable, quantitative outcome data and inconsistent methods of selecting shunt candidates.


Clinical improvement of patients with iNPH can be sustained for 5-7 years in some patients, even if shunt revision surgery is needed multiple times. With earlier diagnosis and treatment and the increasing lifespan of the ageing population, the need for long-term follow-up after shunt surgery may be greater than it was in the past. Monitoring, identification and treatment of shunt obstruction is a key management principle 11).

Gait and Incontinence

Postoperative improvement of Gait and Urinary incontinence is obtained at an early stage 12) 13). In contrast, Dementia tends to improve gradually from after the third postoperative month. The family satisfaction increases as the symptom of Dementia improve. The satisfaction of the medical personnel tends to remain high after the first postoperative month 14).

Independent predictors

Independent predictors of improvement are the presence of gait impairment as the dominant symptom and shorter duration of symptoms 15).

Caregiver Burden

Shunt operations reduced the caregiver burden of iNPH patients 16). 17).

Thirty-seven patients (median age 70 years, range 50-89 years) with Idiopathic normal pressure hydrocephalus were evaluated before and 6 months after surgery. Symptoms and signs were assessed by the iNPH scale, activities of daily living (ADL) with the Functional Independence Measure (FIM) and Assessment of Motor and Process Skills (AMPS), autonomy and participation with Impact on Participation and Autonomy (IPA), and caregiver burden with the Caregiver Burden Scale (CBS). HRQOL was evaluated with the EQ-5D (EuroQol Group-5 Dimension health survey).

Twenty-four patients (65%) improved clinically (iNPH scale score) and 31 (86%) improved their HRQOL after surgery, almost to the same level as found in the normal population. The patients became more independent in physical and cognition, and participation and autonomy improved. The caregiver burden was decreased among caregivers to male patients but remained unchanged on the overall group level. After shunt surgery, patients with iNPH showed improvement in most aspects of social life, they became more independent, and their quality of life returned to nearly normal 18).

References

1)
Subramanian HE, Mahajan A, Sommaruga S, Falcone GJ, Kahle KT, Matouk CC. The subjective experience of patients undergoing shunt surgery for idiopathic normal pressure hydrocephalus. World Neurosurg. 2018 Jul 4. pii: S1878-8750(18)31425-6. doi: 10.1016/j.wneu.2018.06.209. [Epub ahead of print] PubMed PMID: 29981467.
2)
Hebb AO, Cusimano MD: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:1166–1186, 2001
3) , 15)
McGirt MJ, Woodworth G, Coon AL, Thomas G, Williams MA, Rigamonti D. Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005 Oct;57(4):699-705; discussion 699-705. PubMed PMID: 16239882.
4)
Meier U, Kiefer M, Neumann U, Lemcke J: On the optimal opening pressure of hydrostatic valves in cases of idiopathic normal-pressure hydrocephalus: a prospective randomized study with 123 patients. Acta Neurochir Suppl 96:358–363, 2006
5)
Wikkelsø C, Hellström P, Klinge PM, Tans JT: The European iNPH Multicentre Study on the predictive values of resistance to CSF outflow and the CSF Tap Test in patients with idiopathic normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 84:562–568, 2013
6)
Klinge P, Marmarou A, Bergsneider M, Relkin N, Black PM. Outcome of shunting in idiopathic normal-pressure hydrocephalus and the value of outcome assessment in shunted patients. Neurosurgery. 2005 Sep;57(3 Suppl):S40-52; discussion ii-v. Review. PubMed PMID: 16160428.
7)
Toma AK, Papadopoulos MC, Stapleton S, Kitchen ND, Watkins LD. Systematic review of the outcome of shunt surgery in idiopathic normal-pressure hydrocephalus. Acta Neurochir (Wien). 2013 Oct;155(10):1977-80. doi: 10.1007/s00701-013-1835-5. Epub 2013 Aug 23. Review. PubMed PMID: 23975646.
8)
Nakajima M, Miyajima M, Ogino I, Akiba C, Kawamura K, Kurosawa M, Kuriyama N, Watanabe Y, Fukushima W, Mori E, Kato T, Sugano H, Karagiozov K, Arai H. Shunt Intervention for Possible Idiopathic Normal Pressure Hydrocephalus Improves Patient Outcomes: A Nationwide Hospital-Based Survey in Japan. Front Neurol. 2018 Jun 7;9:421. doi: 10.3389/fneur.2018.00421. eCollection 2018. PubMed PMID: 29942280; PubMed Central PMCID: PMC6004916.
9)
Bugalho P, Alves L, Ribeiro O. Normal pressure hydrocephalus: a qualitative study on outcome. Arq Neuropsiquiatr. 2013 Nov;71(11):890-5. doi: 10.1590/0004-282×20130173. PubMed PMID: 24394877.
10)
Poca MA, Mataró M, Matarín M, Arikan F, Junqué C, Sahuquillo J. Good outcome in patients with normal-pressure hydrocephalus and factors indicating poor prognosis. J Neurosurg. 2005 Sep;103(3):455-63. PubMed PMID: 16235677.
11)
Pujari S, Kharkar S, Metellus P, Shuck J, Williams MA, Rigamonti D. Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008 Nov;79(11):1282-6. doi: 10.1136/jnnp.2007.123620. Epub 2008 Mar 20. PubMed PMID: 18356257.
12)
Savolainen S, Hurskainen H, Paljärvi L, Alafuzoff I, Vapalahti M: Five-year outcome of normal pressure hydrocephalus with or without a shunt: predictive value of the clinical signs, neuropsychological evaluation and infusion test. Acta Neurochir (Wien) 144:515–523, 2002
13) , 14)
Takeuchi T, Goto H, Izaki K, Tamura S, Sasanuma Z, Maeno K, Kikuchi Y, Tomii M, Koizumi Z, Watanabe Z, Numazawa S, Ito Y, Ohara H, Kowada M, Watanabe K. Postoperative patterns of improvement of symptoms and degrees of satisfaction in families of patients after operations for definite idiopathic normal pressure hydrocephalus: a long-term follow-up study]. No Shinkei Geka. 2007 Aug;35(8):773-9. Japanese. PubMed PMID: 17695775.
16)
Kazui H, Mori E, Hashimoto M, Ishikawa M, Hirono N, Takeda M. Effect of shunt operation on idiopathic normal pressure hydrocephalus patients in reducing caregiver burden: evidence from SINPHONI. Dement Geriatr Cogn Disord. 2011;31(5):363-70. doi: 10.1159/000328625. Epub 2011 May 27. PubMed PMID: 21625136.
17) , 18)
Petersen J, Hellström P, Wikkelsø C, Lundgren-Nilsson A. Improvement in social function and health-related quality of life after shunt surgery for idiopathic normal-pressure hydrocephalus. J Neurosurg. 2014 Oct;121(4):776-84. doi:10.3171/2014.6.JNS132003. Epub 2014 Jul 18. PubMed PMID: 25036194.
idiopathic_normal_pressure_hydrocephalus_outcome.txt · Last modified: 2018/07/08 17:22 by administrador