​Kembara Xtra - Medicine - Hydrocephalus

​Kembara Xtra - Medicine - Hydrocephalus 
Hakim first identified normal pressure hydrocephalus (NPH) as a clinical triad of gait instability, incontinence, and dementia (mnemonic: wet, wobbly, wacky) in 1957. The condition has two types: idiopathic and obstructive, the latter of which is typically brought on by physical trauma such as post-trauma, meningitis, or subarachnoid hemorrhage. It is also characterized

Precautions: Idiopathic NPH (iNPH) is most common in those over 60; it is extremely rare in people under 40. Patients over 60 who fall to the ground should be evaluated for NPH.
More than 10% of study participants exhibited NPH results.


Epidemiology 

The secondary type can develop at any age, although the iNPH form primarily affects elderly people who are at least 40 years old.
● estimated to play a role in 6% of dementia cases overall
Incidence
between 1.1% and 2.2%. Uncertain diagnosis hinders obtaining correct data (2).
The prevalence increases from 1.3% in the over-65 age group to 5.9% in those who are 80 years and older. It is believed that 2,000,000 people in Europe and 700,000 people in the United States are affected (as opposed to 400,000 people with multiple sclerosis).


Pathophysiology and Etiology 

Idiopathic hydrocephalus is a communicative condition of reduced CSF absorption (not overproduction), not overproduction. The predominant notion in iNPH contends that suboptimal venous compliance compromises baseline CSF evacuation by subarachnoid granulations.
Scarring is probably present in secondary NPH.
● There is a pressure gradient between the ventricular system and subarachnoid space as a result.
In response to a higher pressure set point, CSF synthesis declines (albeit it still exceeds the amount of CSF absorbed).
Elevated pressure causes the ventricles to dilate and the brain parenchyma to constrict, which disrupts the normal flow of blood to the brain and causes ischemia alterations that result in tissue loss and damage.
● Some people think that the idiopathic form results from immature subarachnoid granulations that have consistently failed to remove enough CSF throughout childhood.
● Several factors could cause secondary NPH, including:
- Head injury (most often)
- Subarachnoid bleeding
- Chronic meningitis (tuberculosis, syphilis) - Paget disease of the skull - Resolved acute meningitis
RISK ELEMENTS
Head injury, subarachnoid hemorrhage, meningitis, or encephalitis are causes of the secondary type.

Diagnosis 
The secret to an early diagnosis is a thorough history and examination.

Gait instability typically first shows up in the past, then mentation abnormalities, and finally urinary incontinence. The past is typically insidious and progressive.
Behavioral alterations observed frequently: Many times the physical results are preceded by depression, mania, or psychotic symptoms, which frequently do not respond well to conventional therapy.
Difficulty starting motion: Feet seem "glued to the floor." Wide-based and shuffling gait; turning looks to be done "en bloc."
With subcortical dementia of NPH, inattention, forgetfulness, and lack of spontaneity are frequently observed.
Urinary urgency was first, then lack of restraint, and then outright incontinence.
A minimum of three to six months of symptom persistence and progression.
A distant trauma or infection points to a secondary as opposed to an idiopathic form.
No behavioral, neurological, or other medical problems (including structural causes of CSF flow restriction) can account for the symptoms
It is crucial to have a qualified informant who is familiar with the patient's premorbid status because memory impairment may be present.
Frontal lobe function is adversely impacted more than memory function (early identification may be possible with objective testing).
Parkinson's disease symptoms like bradykinesia and stiffness are frequently seen.

Clinical examination findings include: decreased step height and length; decreased walking speed (cadence); widened standing base; swaying of the trunk during walking; decreased fine motor speed and accuracy; impaired recall for recent events; impaired ability to perform multistep tasks or interpret abstractions; and useful "get up and go" testing (standing from a chair, walking 10 steps, turning, and returning to start).

Alzheimer disease (which may be a concomitant illness in as many as 75%) is the differential diagnosis.
Parkinson disease, chronic alcoholism, intracranial infection, multi-infarct dementia, subdural hematoma, cancerous meningitis, collagen vascular diseases, depression, syphilis, vitamin B12 insufficiency, and urologic conditions are only a few of the conditions that are mentioned.
Case report pointing to Lyme disease as a potential source of comparable imaging and clinical traits (curable with antibiotic therapy)


Laboratory Results 
Initial examinations (lab, imaging)
Complete blood count, vitamin B12, folate, thyroid-stimulating hormone (TSH), syphilis serology, and metabolic profile

Blood alcohol content and drug abuse analysis
Urine testing
Imaging is crucial for CSF analysis, which includes an opening pressure of less than 245 mm H2O (a value higher than this excludes iNPH by definition).
– As opposed to ventricular enlargement seen in other forms of dementia where brain atrophy is present, computed tomography (CT) or magnetic resonance imaging (MRI) (preferred imaging study) show ventriculomegaly (particularly lateral and 3rd ventricles) with preservation of the cerebral parenchyma. Recent research has demonstrated that a tight convexity, or restricted subarachnoid space, correlates with possible or confirmed iNPH.
– When comparing NPH to other conditions, T1-weighted MRI images combined with the Evans index (the ratio of the width of the lateral ventricles to the maximum internal diameter of the skull) and the callosal angle provide acceptable accuracy (AUC = 0.96). Evans index greater than 0.3 suggests NPH (1).
Diagnostic procedures and other CSF removal help determine the precise diagnosis and forecast surgical treatment outcomes.
High-volume (30 to 70 mL) spinal tap to remove CSF ("tap test") Comparison of gait analysis before and after CSF removal should be performed within 24 hours (a 20% improvement indicates a positive test), especially when combined with concurrent executive function improvement.


No medicine is notably useful for management.
The use of carbonic anhydrase inhibitors (acetazolamide) in conjunction with repeated lumbar punctures has only been reported anecdotally.
Levodopa may be used to rule out Parkinson's disease (NPH will show little to no improvement to dopamine agonist).


Referral 
Consultation with a neurologist or a neurosurgeon is useful in suspected situations when other treatable medical disorders have been ruled out.
Recent cohort studies have shown that clinical improvement occurs after shunt surgeries. At one year after the surgery, gait stability, cognitive scores, and urine continence parameters all improved.

Further Treatments 

Gait training and the use of ambulation aids are advised, but their effectiveness is limited.

Surgical Techniques 
The only available treatment is to implant a ventricle-atrial or ventricle-peritoneal shunt from a lateral ventricle that drains into the right atrium or peritoneal cavity through a tunnel under the skin. Recent research has shown that using a lumbar-peritoneal shunt is noninferior since it is technically simpler and linked to less problems.
Patients with symptoms that have been present for less two years are more likely to have improvement after shunting. Age has not been found to have a deleterious impact on shunting response. Patients who had symptoms for many years but were previously undetected have shown improvement.
 Endoscopic third ventriculostomy is becoming more popular because it eliminates shunt-related postoperative problems like late shunt infection and blockage.

Admission for a scheduled surgical procedure

Follow-Up Evaluation and environment modification for fall hazards
A determination of your capacity to drive safely in a motor vehicle
patient observation

 Conduct additional cognitive tests to assess the dementia's condition after treatment.
Improvements in walking speed and incontinence can both be quantified.

Prognosis 
Deterioration occurs over time in natural history. Inability to walk, stand, sit, or turn over in bed causes the patient's axial skeletal stability to deteriorate.

Complications 
In addition to the standard surgical risks, complications in patients undergoing surgery include cerebral infarcts, bleeding, infection, and seizures. This is because NPH is a disorder that affects people over 65.
Misalignment of the shunt, particularly when symptoms return following successful shunt implantation and infections of the urinary tract, skin deterioration, pressure ulcers, and infections as movement impairment worsen also part of the complications.

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