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NeuroNow - A Fluid Approach to CSF Disorders

Spring 2010

A Fluid Approach to CSF Disorders

Date: January 3, 2010

Neurosurgeon Daniele Rigamonti and neurologists David Solomon and Abhay Moghekhar
Neurosurgeon Daniele Rigamonti and neurologists David Solomon and Abhay Moghekhar pose a triple threat for cerebrospinal disorders.

The 80-year-old chemistry professor had gone from being an avid hiker and skier who walked five miles a day and played the flute to someone who could barely get out of a chair and couldn’t think clearly. His decline over a year led his doctor to refer him to the Johns Hopkins Center for Cerebrospinal Fluid Disorders.

Symptoms like the professor’s can be signs of adult hydrocephalus, an abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles. Unusual expansion of those natural spaces can spark a classic triad of symptoms: poor gait and balance, urinary incontinence and cognitive decline — even dementia. The professor appeared to have all three.

Yet because those symptoms may also signal Alzheimer’s disease or other aging-related conditions, says neurologist David Solomon, the center’s co-director, choosing correctly is key. Such subtle distinctions — in either diagnosis or therapy — are the reason for the center’s varied staff, which includes specialists in neurology, neurosurgery, neuroradiology, neuroscience nursing, physical and occupational therapy, geriatrics, neuro-ophthalmology and cognitive testing.

If hydrocephalus is suspected, as in the professor’s case, confirming it takes a neurological exam and magnetic resonance imaging. Should the diagnosis hold, the doctors may recommend surgically implanting a shunt in the patient’s brain. After neurosurgeon Daniele Rigamonti performs this procedure — it drains CSF and redirects it — patients typically find their walking quickly becomes steadier and thinking more lucid.

But not all patients can benefit from the surgery.

“One of our most challenging tasks,” says Solomon, “is figuring out who will do well with a shunt.” That prompted him and colleagues to create a protocol: After center clinicians assess a patient’s gait, balance and cognitive abilities, Solomon inserts a temporary catheter to the patient’s lumbar spine to mimic the shunt’s effect. If a patient’s test performance improves, then a shunt is likely the best step. Roughly half of patients who undergo the trial drainage are offered surgery.

Fortunately for the flute-playing chemist, he was one of those patients. Since his surgery two years ago, he’s steadily improved, says neurologist Abhay Moghekhar, who recently checked the professor again at a routine office visit. His thinking is back to normal; he’s resumed hiking. Recently, he traveled to Antarctica.

“He had been ready to go to a nursing home,” says Solomon. “Now he’s composing music and editing the textbook he wrote.”

Not all cases are as dramatic, notes Solomon, and the shunt’s benefits may be more limited in certain groups. In a patient with both Alzheimer’s disease and hydrocephalus, for example, a shunt may help to steady gait but not improve dementia. “We don’t want the procedure to look like a miracle cure,” says Solomon.

Still, for the right candidate, it offers huge relief.

For more information, call 410-955-7482.

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