Normal Pressure Hydrocephalus
Normal pressure hydrocephalus(NPH); It is a syndrome that occurs with gait disturbance, dementia and urinary incontinence (incontinence) and is a syndrome characterized by ventriculomegaly (enlargement of the ventricles) where the cerebrospinal fluid (CSF) pressure is not high. The co-occurrence of these three complaints is called the “Dominant” triad, after the person who first described it.
NPH can be divided into two as NPH of unknown etiology or idiopathic NPH, and secondary NPH that develops after pathologies such as head trauma, subarachnoid hemorrhage, meningitis, and tumor.
Waiting impairment is typically the first symptom in NPH. It is seen as apraxic (clumsy), bradykinetic (slowed), parkinsonian (similar to Parkinson's patients), tendency to stick to the ground, difficulty in starting the movement of the feet, slow, broad-based, short mixed steps, difficulty turning around itself. Patients mostly present with a history of falling. There is spasticity in the lower extremities but no weakness in muscle strength.
Dementia is typically of the frontal and subcortical type. It is characterized by the deterioration of all intellectual functions such as memory, recall and comprehension. Inattention and apathy are common. Reading, writing, and simple calculations are rarely impaired.
Urine incontinence is another symptom. While urinary frequency and urgency are observed in the early stages of the disease, urinary and even stool incontinence may be seen as the disease progresses. Detrusor muscle overactivity is seen in urodynamic studies.
Patients vary greatly in the form of symptoms, severity of disease, and progression of symptoms, and the diagnosis of NPH does not require the full classical triad.
Gait disturbance plus one supplement feature is sufficient for diagnosis. Typically, gait and balance disorders occur before or at the same time as the onset of dementia and urinary incontinence. Examination of imaging tests to be performed in patients who suggest the presence of NPH will make a decision about the treatment process.
The patient Computed tomography (CT) and magnetic resonance imaging (MRI) examinations are requested.
Seeing the enlarged ventricle structure and CSF that has passed into the brain tissue outside the ventricle are supporting findings for the diagnosis. Ventricular dimensions are generally not as enlarged as in classical hydrocephalus. Moreover, with advancing age, atrophy (shrinking) of the brain tissue occurs and the ventricles seem to be enlarged compared to younger age.
Radioisotope cisternography, positron emission tomography, CSF flow void MR, Phase Contrast MRI, MRI spectroscopy is not used in routine applications, although it is not used in routine applications.
CSF drainage from the waist (lumbar puncture) procedure is still used in patients with NPH, both diagnostically and therapeutically and/or as a guide to treatment. However, it is an important detail to firstly examine the head with imaging methods and then decide for a lumbar puncture (LP). If there is a mass in the brain or cerebellum tissue or pathologies that may carry a risk, LP application should definitely be avoided.
Normal CSF pressure is typically detected in the lumbar puncture in NPH. CSF drainage with LP supports the diagnosis in NPH patients. In the lumbar tap test, the patient is followed after 20-50 ml of CSF is emptied at once. In addition, temporary lumbar CSF drainage and 5-day continuous CSF drainage are other methods used to evaluate the clinical response. It is difficult for their relatives.
However, surgical treatment is recommended for patients whose complaints improve after CSF drainage.
The treatment in NPH is the surgical treatment of CSF into another area within the head. This area can be peritoneum (intra-abdominal membrane), pleura (lung membrane), or heart.
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