Shunt-responsive idiopathic normal pressure hydrocephalus patient with delayed improvement after tap test

Kyunghun Kang, Sung Kyoo Hwang, Ho-Won Lee, Kyunghun Kang, Sung Kyoo Hwang, Ho-Won Lee

Abstract

The cerebrospinal fluid tap test (CSFTT) is recommended as a key step in the diagnosis of idiopathic normal pressure hydrocephalus (iNPH). While there is no generally accepted evaluation period for ascertaining a CSFTT responder, a substantial number of patients are evaluated only once within 24 hours of the test for improvement in gait. We report an iNPH patient with a favorable response to shunt surgery, who was first judged a non-responder by this standard, though subsequently was judged a responder in virtue of repetitively testing gait over 7 days. A 68-year-old man presented with progressive impairment of gait, balance, and memory. He was diagnosed as iNPH with an Evans' ratio of 0.35. At first hospitalization, change in gait was evaluated 24 hours after the CSFTT. He didn't show any significant improvement and was judged as a non-responder. However, at the second CSFTT, we repetitively tested his change in gait over seven days. Forty-eight hours after the tap, he showed significant improvement in his gait. He was then confirmed as a responder. After the operation, the gait difficulties were almost fully resolved. Further studies developing the standard procedure of the CSFTT should be considered.

Keywords: Cerebrospinal fluid shunts; Normal pressure hydrocephalus; Predictive value of tests.

Figures

Fig. 1
Fig. 1
A : Preoperative brain MRI; T2-weighted axial images show the lateral ventricular enlargement with CSF signal void in the cerebral aqueduct. Thinning of the corpus callosum with enlargement of the temporal horns of the lateral ventricles is also demonstrated in T2-weighted coronal image. B : Postoperative brain CT image still shows the lateral ventricular enlargement. However, after the operation he improved gradually. The gait difficulties were almost fully resolved, and the balance problem disappeared after 1 month. CSF : cerebrospinal fluid.

References

    1. Adams RD, Fisher CM, Hakim S, Ojemann RG, Sweet WH. Symptomatic occult hydrocephalus with "normal" cerebrospinal-fluid pressure.a treatable syndrome. N Engl J Med. 1965;273:117–126.
    1. Choi SH, Na DL, Lee BH, Hahm DS, Jeong JH, Yoon SJ, et al. Estimating the validity of the Korean Version of Expanded Clinical Dementia Rating (CDR) Scale. J Korean Neurol Assoc. 2001;19:585–591.
    1. Damasceno BP, Carelli EF, Honorato DC, Facure JJ. The predictive value of cerebrospinal fluid tap-test in normal pressure hydrocephalus. Arq Neuropsiquiatr. 1997;55:179–185.
    1. Evans WA. An encephalographic ratio for estimating ventricular enlargement and cerebral atrophy. Arch Neurol Psychiatry. 1942;47:931–937.
    1. Ishikawa M, Hashimoto M, Kuwana N, Mori E, Miyake H, Wachi A, et al. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 2008;48(Suppl):S1–S23.
    1. Ishikawa M, Hashimoto M, Mori E, Kuwana N, Kazui H. The value of the cerebrospinal fluid tap test for predicting shunt effectiveness in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS. 2012;9:1.
    1. Kahlon B, Sundbärg G, Rehncrona S. Comparison between the lumbar infusion and CSF tap tests to predict outcome after shunt surgery in suspected normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 2002;73:721–726.
    1. Kang Y, Na DL, Hahn S. A validity study on the Korean Mini-Mental State Examination (K-MMSE) in dementia patients. J Korean Neurol Assoc. 1997;15:300–308.
    1. Kubo Y, Kazui H, Yoshida T, Kito Y, Kimura N, Tokunaga H, et al. Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus. Dement Geriatr Cogn Disord. 2008;25:37–45.
    1. Lee WC, Seo DH, Choe IS, Park SC, Ha YS, Lee KC. A comparative result of ventriculoperitoneal shunt, focusing mainly on gravity-assisted valve and programmable valve. J Korean Neurosurg Soc. 2010;48:251–258.
    1. Lee WJ, Wang SJ, Hsu LC, Lirng JF, Wu CH, Fuh JL. Brain MRI as a predictor of CSF tap test response in patients with idiopathic normal pressure hydrocephalus. J Neurol. 2010;257:1675–1681.
    1. Lim TS, Yong SW, Moon SY. Repetitive lumbar punctures as treatment for normal pressure hydrocephalus. Eur Neurol. 2009;62:293–297.
    1. Malm J, Kristensen B, Karlsson T, Fagerlund M, Elfverson J, Ekstedt J. The predictive value of cerebrospinal fluid dynamic tests in patients with th idiopathic adult hydrocephalus syndrome. Arch Neurol. 1995;52:783–789.
    1. Marmarou A, Bergsneider M, Klinge P, Relkin N, Black PM. The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005;57(3 Suppl):S17–S28. discussion ii-v.
    1. Podsiadlo D, Richardson S. The timed "Up & Go" : a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148.
    1. Ravdin LD, Katzen HL, Jackson AE, Tsakanikas D, Assuras S, Relkin NR. Features of gait most responsive to tap test in normal pressure hydrocephalus. Clin Neurol Neurosurg. 2008;110:455–461.
    1. Relkin N, Marmarou A, Klinge P, Bergsneider M, Black PM. Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005;57(3 Suppl):S4–S16. discussion ii-v.
    1. Sand T, Bovim G, Grimse R, Myhr G, Helde G, Cappelen J. Idiopathic normal pressure hydrocephalus : the CSF tap-test may predict the clinical response to shunting. Acta Neurol Scand. 1994;89:311–316.
    1. Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly people : Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther. 2002;82:128–137.
    1. Udvarhelyi GB, Wood JH, James AE, Jr, Bartelt D. Results and complications in 55 shunted patients with normal pressure hydrocephalus. Surg Neurol. 1975;3:271–275.
    1. Virhammar J, Cesarini KG, Laurell K. The CSF tap test in normal pressure hydrocephalus : evaluation time, reliability and the influence of pain. Eur J Neurol. 2012;19:271–276.
    1. Walchenbach R, Geiger E, Thomeer RT, Vanneste JA. The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 2002;72:503–506.
    1. Wikkelsø C, Andersson H, Blomstrand C, Lindqvist G. The clinical effect of lumbar puncture in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 1982;45:64–69.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する