The value of the cerebrospinal fluid tap test for predicting shunt effectiveness in idiopathic normal pressure hydrocephalus

Masatsune Ishikawa, Masaaki Hashimoto, Etsuro Mori, Nobumasa Kuwana, Hiroaki Kazui, Masatsune Ishikawa, Masaaki Hashimoto, Etsuro Mori, Nobumasa Kuwana, Hiroaki Kazui

Abstract

Background: The cerebrospinal fluid (CSF) tap test (TT) has been regarded as an important test for the prediction of shunt effectiveness in patients with suspected idiopathic normal pressure hydrocephalus (iNPH). Although its specificity and sensitivity are reportedly high, there remains some disagreement over this point. Herein, the TT as a test for predicting shunt effectiveness was investigated in our multicenter prospective study named SINPHONI and strategies to increase its predictability were examined.

Methods: One hundred suspected iNPH patients with the following entry criteria were enrolled in the study: (1) 60 to 85 years old, (2) one or more of the NPH triad signs, (3) ventriculomegaly (Evans index > 0.3), (4) high convexity tightness in coronal-section MRI, and (5) no antecedent disorders. Changes in NPH triad symptoms were assessed using the iNPH grading scale and other measures before and after removal of 30 ml lumbar CSF. A positive response to TT was pre-defined by specific improvements on the grading and other scales. A ventriculoperitoneal shunt was performed with a programmable valve. The sensitivity and specificity of the TT was calculated with a contingency table. A decision tree analysis was performed to increase the predictability of the TT.

Results: Among 100 patients, 80 were shunt responders. A statistically-significant variable between shunt responders and non-responders was CSF pressure. The changes in single variables in the iNPH grading scale after TT showed high specificity with low sensitivity. In contrast, change of the total score in the iNPH grading scale showed a relatively high sensitivity of 71.3% with specificity of 65%. A decision tree analysis revealed that using the iNPH grading scale total score and pre-shunt CSF pressure ≥ 15 cmH20, sensitivity increased to 82.5%, without a decrease in specificity.

Conclusions: The sensitivity and specificity of the TT for predicting shunt responsiveness were optimum when improvement on any iNPH grading scale was combined with CSF pressure ≥ 15 cmH20. To increase the sensitivity of the TT, further effort is necessary.

Trial registration: This study is registered with ClinicalTrials.gov, with the number NCT00221091.

Figures

Figure 1
Figure 1
Decision tree analysis for selecting shunt responders. At the first step, 57 shunt responders (SR) among 64 patients with improvement of any domain in iNPHGS [GS-Total-change (+)] group were selected as positive cases. At the second step, nine SR were selected from the 36 patients without improvement in iNPHGS [GS-Total-change (-)] group with the variable of CSFP greater than 15 cm H20. This resulted in 82.5% of 80 SR patients being identified in two steps.

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