'Normal'-pressure hydrocephalus and the saga of the treatable dementias

Article Abstract:

The case history of a 74-year-old woman who was eventually diagnosed with normal-pressure hydrocephalus (NPH) is reviewed, illustrating the difficulties of diagnosing and understanding the clinically significant aspects of dementing illnesses. Normal-pressure hydrocephalus is defined as increased cerebrospinal fluid within enlarged ventricles of the brain. NPH occurs without an increase in spinal fluid pressure or blockage of the normal flow of spinal fluid. (Cerebrospinal fluid is contained in the spinal cord and ventricles, which are small cavities inside the brain.) The patient had a rather lengthy history of progressive cognitive deterioration, spanning four years, along with urinary incontinence and poor balance. She was not taking any medications and had no prior history of cardiovascular disease, high blood pressure, or head trauma. A general physical exam was normal, except for neurological findings which included mild dementia with memory impairment. No improvement resulted from the removal of cerebrospinal fluid and her memory and incontinence continued to worsen. A magnetic resonance imaging test (MRI) was performed and disclosed ventricular abnormalities that indicated a diagnosis of NPH. This was followed by the surgical placement of a ventriculoperitoneal shunt (a device that provides drainage of fluid from the brain into the abdominal cavity, where it is absorbed). The patient began to improve steadily and gradually resumed her normal activities. Subsequent follow-up tests over the next two years showed continued improvement. The case pointed out the lack of accurate and straight-forward nomenclature for the diagnosis of NPH. An over-emphasis on Alzheimer's disease may lead to oversights in detecting treatable dementias. The fact that this older patient recovered to an extent that was not anticipated demonstrated the resilience of the brain in an aging person.

Case studies, Complications and side effects

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Normal-pressure hydrocephalus: saga or swamp?

Article Abstract:

A recent article in "The Journal of American Medical Association" reviewed a case history of normal-pressure hydrocephalus (NPH) which was entitled "'Normal'-pressure Hydrocephalus and the Saga of the Treatable Dementias". Normal-pressure hydrocephalus is defined as increased cerebrospinal fluid within enlarged ventricles of the brain without an increase in spinal fluid pressure or blockage of normal flow of spinal fluid. (Cerebrospinal fluid is contained in the spinal cord and the ventricles, small cavities within the brain.) The syndrome may occur in conjunction with trauma, brain tumors, or other conditions which may have a negative impact upon the brain. Often the actual cause of NPH is unknown. This reviewer emphasizes that NPH is a rare condition, occurring in only about 1.6 percent of all cases of dementia. One of the focuses of the previous article was that the condition is often both under-diagnosed and if discovered, under-treated. This author does not directly dispute this assertion, but submits that given the current state of medical technology, little in the way of treatment is actually effective for most cases of NPH. The automatic referral of all patients who appear to be suffering from dementia for a computerized tomography (CT) scan is not justified. In particular, the observation of ventricular enlargement associated with NPH is not necessarily a basis for recommending surgery. In fact, even if the diagnosis is confirmed, surgical procedures often do not improve the condition or the symptoms of dementia. Although no negative criticism of the article's accuracy or validity is made, this reviewer cautions against increased optimism regarding the general reversibility of dementias which are accompanied by these symptoms.

editorial

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Fetal Surgery for Myelomeningocele and the Incidence of Shunt-Dependent Hydrocephalus

Article Abstract:

Intrauterine surgery to correct fetal spinal defects can improve the baby's health but increases the risk of premature birth. Intrauterine surgery means the doctors perform surgery on the baby before it is born. This requires making incisions in the mother's abdomen and uterus. In a study of 52 fetuses with spinal defects, 29 received intrauterine surgery. Fewer of these babies required treatment after they were born, but half of the mothers went into premature labor compared to only 9% in the other group. The babies who had intrauterine surgery also weighed less than the others.

Risk factors, Fetus, Surgery, Premature birth, Fetal surgery, Myelomeningocele, Meningomyelocele

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