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Spring/Summer 2011

Reversals of Fortune

In elderly patients properly diagnosed and treated for NPH, improvement is quick -- and dramatic.

By: Christen Brownlee
Date: May 20, 2011

For many doctors, the diagnosis of normal pressure hydrocephalus (NPH) remains a controversial one. Its triad of symptoms—abnormal gait, cognitive decline, and incontinence—might have any number of causes having nothing to do with a buildup of cerebrospinal fluid, including other movement disorders, dementia, and simple aging.

However, for neurologists Abhay Moghekar and Richard O’Brien, geriatrician Sevil Yasar, and neurosurgeon Daniele Rigamonti, proof for NPH is incontrovertible in the videos they take before and after they deliver treatment for this condition. In one typical pretreatment video, an elderly male patient is asked to take a short walk down a hall and around a marker on the floor. To increase the challenge, he counts with each step.

Though the task is simple, it’s clear the patient can barely manage. His feet seem leaden, barely clearing the floor with each tiny step. In the post-treatment video, the patient strides confidently, with no sign that anything was ever amiss.

“I would describe myself as a skeptic,” says O’Brien, “but having seen enough patients now, there are clearly many who do incredibly well after treatment. The issue is correctly diagnosing those patients so they receive the correct care.”

Understanding whether NPH or some other cause is at fault can be tricky, adds Moghekar, but it’s a strong suit at Hopkins. He, O’Brien, Yasar, and Rigamonti evaluate patients together using a number of criteria, including scan images, which need to show enlarged ventricles, and the patients’ performance on movement and cognition tests. Every Monday, the team holds a conference to discuss each patient’s particulars and the next steps.

One of the most important determinants is how patients perform after a test amount of cerebrospinal fluid is removed.The results from this test are often clear-cut. “Either the patient has a response—better gait, better cognition, less incontinence—or no response. Those who respond become candidates for surgery. We know this group of people will benefit from a permanent shunt,” says Rigamonti.

Though the causes of NPH remain hazy, shunts that drain excess cerebrospinal fluid are the standard solution. Rigamonti and his Neurosurgery colleagues have placed hundreds of shunts in NPH patients over the years, with dramatic results for the vast majority. The job isn’t over once the shunt is installed, though. “Strict follow-up is an important part of our care,” says Moghekar.

Such a comprehensive approach is key to why the team’s NPH patients often avoid nursing homes, a fate typical for those with this disease who remain undiagnosed and untreated. “It’s one of the few cognitive and movement disorders that’s reversible,” Moghekar says. Christen Brownlee

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