Innovations in Treatment: Normal Pressure Hydrocephalus

Recognizing the Symptoms of NPH Normal Pressure Hydrocephalus (NPH) most often occurs in patients over the age of 60 and it presents with symptoms similar to Alzheimer’s, dementia and Parkinson’s disease. There are three (triad) classic symptoms that are associated with NPH. They include: Abnormal Gait – Often this is the first symptom to become apparent and in almost all cases the most pronounced. Patients present with a wide-based, slow shuffling step that could lead to imbalance and frequent falling. Mild Dementia – Often presents as short-term memory loss and difficulty in dealing with simple routine tasks. Patients may also show a loss of interest in daily activities. Urinary Incontinence – Often times the last apparent symptom, patients may experience frequent urgency, to a complete loss of bladder control. It should be noted that some patients might only display one or two of these classic symptoms. If NPH is suspected, a very thorough history and neurological examination along with a variety of diagnostic tests are recommended.

Dr. Gail Rosseau, CINN neurosurgeon, is one of the physicians in the country utilizing newly established guidelines to diagnose NPH. Rosseau treats the disorder with a new, high-tech shunt, which features a programmable valve. The valve allows the physician to adjust spinal fluid pressure magnetically in an office setting. Dr. Rosseau’s NPH patients report that the treatment has given them a new outlook on life.

Normal Pressure Hydrocephalus (NPH), an adult illness that typically occurs in people over age 60, is characterized by an accumulation of cerebral spinal fluid that causes the ventricles to enlarge and stretch the nerve tissue of the brain. The condition, which often goes undiagnosed or misdiagnosed as dementia, is treatable and can often be seen using magnetic resonance imaging (MRI) or computerized tomography (CT). NPH causes three primary symptoms, including difficulty walking, impaired bladder control and memory loss. Because the symptoms can be easily confused with those of Alzheimer’s disease and dementia, many patients never get the proper referral or care for a condition that is treatable with surgery.

Patient Case Study: BETTY — Age 84

History: Betty began having dizzy spells and started losing her balance in 1995. She sought help from several of the nation’s leading medical institutions. None of the physicians recommended a CT scan or MRI.

The symptoms disappeared as quickly as they started only to return in a worse form in 1997. Betty was bent over, using a walker and experiencing memory loss. She found it impossible to hook the clasps on her clothing.

Evaluation: At the urging of a friend, Betty and her husband Robert drove to Chicago from Springfield, IL to be seen by Dr. Leonard Cerullo, who suggested her symptoms pointed to NPH and recommended an MRI. Dr. Cerullo introduced Betty to Dr. Gail Rosseau, one of the neurosurgeons in the country treating NPH utilizing the new guidelines. In addition to an MRI, Betty had a spinal tap and sonogram. Betty’s MRI combined with the test results, her gait problems, and memory loss, confirmed she had NPH and that a shunt could improve her condition. Dr. Rosseau recommended surgery to implant a shunt and remove the excess fluid on the brain.

Surgery: The surgical procedure to implant a ventricular peritoneal (VP) shunt usually requires less than an hour in the operating room. After the patient is placed under general anesthesia, the scalp is shaved and the patient is scrubbed with an antiseptic from the scalp to the abdominal area. These steps are taken in order to reduce the chances of an infection. Incisions are then made on the head and in the abdomen to allow the neurosurgeon to pass the shunt’s tubing through the fatty tissue just under the skin. A small hole is made in the skull, opening the coverings between the skull and brain to allow the ventricular end of the shunt to be passed through the brain and into the lateral ventricle. The abdominal (peritoneal) end is passed into the abdominal cavity through a small opening in the lining of the abdomen where the excess cerebrospinal fluid (CSF) is eventually absorbed. The incisions are then closed and sterile bandages are applied.

Potential Complications: Potential complications may include infection of the surgical wound or of the CSF (meningitis), bleeding into the brain or ventricles, or a seizure. A shunt infection may be indicated by fever, redness or swelling along the shunt track. Fortunately, these complications are uncommon and can be managed successfully in most cases. “The treatment of adults with normal pressure hydrocephalus carries greater risks compared to the treatment of children with hydrocephalus,” Rosseau says. “That’s why the procedure should only be considered if the degree of disability or the progression of the disorder warrants it.”

The most common problem with shunt systems is that they can become obstructed. This can occur hours or years after the operation, sometimes multiple times. Subdural hematoma is the most serious complication that can occur following insertion of a shunt.

Post Surgery: Betty was walking unassisted two days after surgery. “The programmable valve shunt we used features 18 different programmable pressure settings,” says Rosseau. “This allows us to adjust the pressure magnetically as many times as necessary, without the risk of another surgery. We can make very fine adjustments to ensure the best resolution of symptoms. All of this is done in the office with no discomfort to the patient,” Rosseau says.

“I have a new outlook on life since mine was almost taken away from me,” says Betty. “So many people have this condition and it goes undiagnosed for so long – sometimes forever. Patients should explore all their options, because there is always hope.”