Archivos de la categoría Articulos

UpToDate:Outcome in idiopathic normal pressure hydrocephalus

To date, there is no standard outcome assessment scale for shunt treatment.

In designing such scale, the relative weight of each of the common presentations of the condition from the patient’s or his/her carer’s point of view should be taken into consideration.

Clinical improvement of patients with iNPH can be sustained for 5-7 years in some patients, even if shunt revision surgery is needed multiple times. With earlier diagnosis and treatment and the increasing lifespan of the ageing population, the need for long-term follow-up after shunt surgery may be greater than it was in the past. Monitoring, identification and treatment of shunt obstruction is a key management principle 1).

Gait and Incontinence

Postoperative improvement of Gait and Urinary incontinence is obtained at an early stage 2) 3). In contrast, Dementia tends to improve gradually from after the third postoperative month. The family satisfaction increases as the symptom of Dementia improve. The satisfaction of the medical personnel tends to remain high after the first postoperative month 4).

Independent predictors

Independent predictors of improvement are the presence of gait impairment as the dominant symptom and shorter duration of symptoms 5).

Caregiver Burden

Shunt operations reduced the caregiver burden of iNPH patients 6)7).

Thirty-seven patients (median age 70 years, range 50-89 years) with Idiopathic normal pressure hydrocephalus were evaluated before and 6 months after surgery. Symptoms and signs were assessed by the iNPH scale, activities of daily living (ADL) with the Functional Independence Measure (FIM) and Assessment of Motor and Process Skills (AMPS), autonomy and participation with Impact on Participation and Autonomy (IPA), and caregiver burden with the Caregiver Burden Scale (CBS). HRQOL was evaluated with the EQ-5D (EuroQol Group-5 Dimension health survey).

Twenty-four patients (65%) improved clinically (iNPH scale score) and 31 (86%) improved their HRQOL after surgery, almost to the same level as found in the normal population. The patients became more independent in physical and cognition, and participation and autonomy improved. The caregiver burden was decreased among caregivers to male patients but remained unchanged on the overall group level. After shunt surgery, patients with iNPH showed improvement in most aspects of social life, they became more independent, and their quality of life returned to nearly normal 8).

1) Pujari S, Kharkar S, Metellus P, Shuck J, Williams MA, Rigamonti D. Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008 Nov;79(11):1282-6. doi: 10.1136/jnnp.2007.123620. Epub 2008 Mar 20. PubMed PMID: 18356257.
2) Savolainen S, Hurskainen H, Paljärvi L, Alafuzoff I, Vapalahti M: Five-year outcome of normal pressure hydrocephalus with or without a shunt: predictive value of the clinical signs, neuropsychological evaluation and infusion test. Acta Neurochir (Wien) 144:515–523, 2002
3) , 4) Takeuchi T, Goto H, Izaki K, Tamura S, Sasanuma Z, Maeno K, Kikuchi Y, Tomii M, Koizumi Z, Watanabe Z, Numazawa S, Ito Y, Ohara H, Kowada M, Watanabe K. Postoperative patterns of improvement of symptoms and degrees of satisfaction in families of patients after operations for definite idiopathic normal pressure hydrocephalus: a long-term follow-up study]. No Shinkei Geka. 2007 Aug;35(8):773-9. Japanese. PubMed PMID: 17695775.
5) McGirt MJ, Woodworth G, Coon AL, Thomas G, Williams MA, Rigamonti D. Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005 Oct;57(4):699-705; discussion 699-705. PubMed PMID: 16239882.
6) Kazui H, Mori E, Hashimoto M, Ishikawa M, Hirono N, Takeda M. Effect of shunt operation on idiopathic normal pressure hydrocephalus patients in reducing caregiver burden: evidence from SINPHONI. Dement Geriatr Cogn Disord. 2011;31(5):363-70. doi: 10.1159/000328625. Epub 2011 May 27. PubMed PMID: 21625136.
7) , 8) Petersen J, Hellström P, Wikkelsø C, Lundgren-Nilsson A. Improvement in social function and health-related quality of life after shunt surgery for idiopathic normal-pressure hydrocephalus. J Neurosurg. 2014 Oct;121(4):776-84. doi:10.3171/2014.6.JNS132003. Epub 2014 Jul 18. PubMed PMID: 25036194.

Successful treatment of multiple intracranial meningiomas with the antiprogesterone receptor agent mifepristone (RU486).

Evidence suggests that female sex hormones play a role in the meningioma tumorigenesis. In particular, progesterone, has a receptor (PR) that is highly expressed in the majority of grade I meningiomas. Multiple meningiomas (diffuse meningiomatosis) are less frequent, but have a higher female predominance and a higher PR expression. They are, therefore, attractive candidates for anti-PR therapy.

Touat et al., treated three consecutive women with multiple meningiomas with mifepristone (RU 486).

The treatment was well tolerated, and they observed an important and long-lasting clinical (3/3) and radiological response (2/3) or stabilisation. All the three patients are now stable after five to nine years of treatment.

These encouraging results strongly support a prospective clinical trial in this preselected population 1).

1) Touat M, Lombardi G, Farina P, Kalamarides M, Sanson M. Successful treatment of multiple intracranial meningiomas with the antiprogesterone receptor agent mifepristone (RU486). Acta Neurochir (Wien). 2014 Oct;156(10):1831-5. doi: 10.1007/s00701-014-2188-4. Epub 2014 Jul 31. PubMed PMID: 25078073.

Journal of Neurosurgery: Octubre 2014

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Top Read: Intraventricular thrombolysis in intracerebral hemorrhage requiring ventriculostomy: a decade-long real-world experience.

Intraventricular thrombolysis (IVT) is a promising treatment in facilitating intraventricular clot resolution after intraventricular hemorrhage.

Adult patients with primary diagnosis of nontraumatic intracerebral hemorrhage requiring ventriculostomy from the Nationwide Inpatient Sample from 2002 to 2011, compared demographics and hospital characteristics, comorbidity, inpatient outcomes, and resource utilization measures between patients treated with IVT and those managed with ventriculostomy, but without IVT. Population estimates were extrapolated using standard Nationwide Inpatient Sample weighting algorithms.

34044 patients in the analysis, of whom 1133 (3.3%) received IVT. The thrombolysis group had significantly lower inpatient mortality (32.4% versus 41.6%; P=0.001) and it remained lower after controlling for baseline demographics, hospital characteristics, comorbidity, case severity, and withdrawal of care status (adjusted odds ratio, 0.670; 95% confidence interval, 0.520-0.865; P=0.002). There was a trend toward favorable discharge (home or rehabilitation) among the thrombolysis cohort (adjusted odds ratio, 1.335; 95% confidence interval, 0.983-1.812; P=0.064). The adjusted rates of bacterial meningitis and ventricular shunt placement were similar between groups. The thrombolysis group had longer length of stay and higher inflation-adjusted cost of care, but cost of care per day length of stay was similar to the non-IVT group.

IVT for intracerebral hemorrhage requiring ventriculostomy resulted in lower inpatient mortality and a trend toward favorable discharge outcome with similar rates of inpatient complications compared with the non-IVT group 1).

1) Moradiya Y, Murthy SB, Newman-Toker DE, Hanley DF, Ziai WC. Intraventricular thrombolysis in intracerebral hemorrhage requiring ventriculostomy: a decade-long real-world experience. Stroke. 2014 Sep;45(9):2629-35. doi: 10.1161/STROKEAHA.114.006067. Epub 2014 Jul 24. PubMed PMID: 25061080.

New Classification in Syringomyelia

The term syringomyelia describes many pathogenetically different disorders, and a variety of attempts to group these based on different criteria have been proposed in the literature. As a consequence a lack of consensus regarding classification and terminology exists. This inconsistency extends to the ICD-10 classification of diseases in regards to syringomyelia (G95.0) and hydromyelia (Q06.4).

Blegvad et al., have shown that the use of classifying terminology for fluid-filled cavities in the spinal cord is indiscriminate and inconsistent. Even though a general agreement on the believed pathogenetic mechanism exists, and the general treatment methods are used in accordance with this mechanism, the terminology fails to function as a simple and universal link between theory and treatment.

They propose a new causal concept for an ICD classification with syringomyelia (G95.0) as the only describing terminology, thus abandoning the use of hydromyelia (Q06.4). Syringomyelia is divided into five subgroups according to the associated pathologies. The classification is based on applied diagnostics and serves as a clinical guidance for treatment 1)

1) Blegvad C, Grotenhuis JA, Juhler M. Syringomyelia: a practical, clinical concept for classification. Acta Neurochir (Wien). 2014 Sep 19. [Epub ahead of print] PubMed PMID: 25236931.


Lateral inferior cerebellar peduncle approach

4 patients (3 woman and 1 man) who had a symptomatic dorsolateral brainstem cavernous malformation with radiographic and clinical evidence of hemorrhage, underwent excision via a far lateral suboccipital craniotomy through the foramen of Luschka and with an incision in the cerebellar peduncle.On intraoperative examination, 2 of the 4 patients had hemosiderin staining on the surface of the peduncle. All lesions were completely excised and all patients had a good or excellent outcome (modified Rankin Scale scores of 0 or 1).

Case series of Deshmuk et al., illustrates that intrinsic lesions of the dorsolateral medulla can be safely removed laterally through the foramen of Luschka and the inferior cerebellar peduncle 1).

1) Deshmukh VR, Rangel-Castilla L, Spetzler RF. Lateral inferior cerebellar peduncle approach to dorsolateral medullary cavernous malformation. J Neurosurg. 2014 Sep;121(3):723-9. doi: 10.3171/2014.5.JNS132276. Epub 2014 Jun 27. PubMed PMID: 24972129.