What is hydrocephalus?
Hydrocephalus is a condition characterized by abnormal accumulation of cerebrospinal fluid (CSF) in cavities called ventricles in the brain. CSF circulates around the brain and spinal cord. The task of CSF is to provide physical support to the brain, to remove waste materials and to allow the distribution of important substances in the central nervous system (CNS). Daily CSF production in a healthy adult is about 500cc. is When the CSF flow path is blocked, or when there is a problem in absorption, fluid begins to accumulate, the ventricles enlarge, the pressure in the head increases, and hydrocephalus occurs.
What is Normal Pressure Hydrocephalus?
NPH is an accumulation of CSF that causes enlargement of the ventricles but does not increase the intracranial pressure very little or not at all. It is often seen in the elderly. It is accompanied by symptoms characterized by movement disorder, mild dementia and urinary incontinence. It may be one or all of these symptoms. In most of the patients, the factor causing blockage in the CSF absorption pathways is unknown.
Causes of Normal Pressure Hydrocephalus?
In most of the cases, the underlying cause cannot be determined, that is, it is idiopathic. NPH may occur as a result of head trauma, previous subarachnoid hemorrhage, tumors or cysts, subdural hemorrhage, bleeding during surgery, meningitis or other brain infections.
What are the symptoms of NPH?
Gait Disorders: It can be found in different tables from a mild balance problem to the inability to stand and walk. Steps are often broad-based, short-stepped, and slow. Patients with NPH have a problem in lifting their feet and climbing stairs. They fall often. They also have difficulty turning around. They walk very slowly and with many steps. Balance problem and difficulty in walking are the first and most common complaints.
Mild dementia: Includes decreased interest in daily activities, forgetfulness, difficulty coping with routine tasks, and near-term memory impairment. Because the cognitive symptoms observed in NPH are not very severe, they are often neglected and considered as a natural process of aging. The ability to speak is often not impaired. They are often unaware of the problems they have and may even deny it. In some cases, cognitive changes can only be detected by neuropsychological evaluation.
Impairment in bladder control: While it is manifested by frequent toileting in mild cases, bladder control is completely impaired in advanced cases. Rarely, disc hijacking may occur. Some patients never develop bladder problems.
Since NPH patients are often over 60 years old and such symptoms are thought to be normal in this age group, people generally think that they have to live with these problems and try to adapt themselves to these changes in their bodies.
NPH symptoms can also mimic some other health problems that may occur in the bereaved. For example, cognitive symptoms seen can be evaluated as early-stage Alzheimer’s disease. Likewise, balance and walking problems can be considered as Parkinson’s disease. It should be kept in mind that some patients may accompany NPH in these diseases.
When patients first consult a doctor, symptoms may persist for months or even years. Symptoms of hydrocephalus increase over time. The rate of increase varies and patients often go to the doctor when their loss of function reaches the critical point. The longer the onset of symptoms and the more severe the symptoms, the later will be the response to treatment. As a general rule, it can be said that the earlier the diagnosis is made, the more successful the treatment will be.
Presence of all 3 symptoms in the same patient is not absolutely necessary for diagnosis.
Lumbar Puncture
It helps to measure the approximate CSF pressure and also helps to analyze from the liquid. Under local anesthesia, a thin needle is inserted into the lower part of the waist and CSF up to 50 cc is emptied. In this way, a temporary improvement in symptoms is desired. If there is a significant improvement in the symptoms, albeit temporarily, after this procedure, then it can be said that the surgical treatment will be successful. If the response to the lumbar puncture is negative or not clearly understood, further investigations are required.
Treatment alternatives used today
The most commonly used and generally the only possible treatment option today is the surgical placement of a system called sent, which connects the CSF channels with other parts of the body where absorption can be achieved. The most commonly used site for this purpose is the peritoneum in the abdomen, and the system used is called ventriculoperitoneal shunt. After the surgery, all parts of the suspension system will remain under the skin and nothing will be seen from the outside.
In patients with aquaduct stenosis, a surgical intervention called endoscopic third ventriculostomy may be an alternative to stenting. In this approach, an alternative CSF flow path is made with the help of an endoscope due to the narrowing of the aqueduct. The narrowing of the aquadac can be detected by MRI. The results of the endoscopic approach differ in adults. In some of the patients who underwent third ventriculostomy, it may be necessary to put a stent after the symptoms can improve.
Who are eligible patients for the stemming procedure?
Although many tests and studies have been developed for this purpose, there is no single factor that can predict the success of the spinning process. The following findings suggest that the outcome will be better following stent insertion:
Gait disturbance is the first to appear and predominant symptom
There is a known cause of NPH such as trauma or bleeding
In imaging methods Ventricular dimensions are disproportionately larger than the Subarachnoid space where CSF is located
CSF draining via lumbar puncture or lumbar catheter provides a dramatic temporary improvement
Measured intracranial or spinal CSF pressure is at the upper limits
Minimal evidence of small blood vessel disease affecting the brain
It is important to know that recovery from hydrocephalus symptoms after stabbing is possible.
Although everyone expects a full recovery after surgery, this may not always be possible. Significantly reducing the existing complaints after the surgery, getting rid of the dependence on others, and most importantly, preventing the further progression of neurological symptoms is a satisfactory response for the patient and their relatives.
What is the Success Rate of Sant Operation?
Gait disturbance, mild dementia and bladder control problems may improve within a few days after the operation or may require weeks to months for improvement. Unfortunately, there is no way to predict how quickly and to what extent this improvement will occur. In those who have improvement, these improvements are usually within the first weeks. This improvement can be mild or very dramatic. The clinical regression in patients whose symptoms improved after the operation suggests central dysfunction or the development of one of the following complications.
What happens if NPH is not treated?
Patients with NPH often present with progressive symptoms and there is no reason to believe that these symptoms will resolve on their own and the clinical deterioration will stop on its own. No one can predict how quickly existing symptoms will progress. The more severe the symptoms and the longer they have been present, the less likely the response to treatment will be. As a general rule, the earlier the diagnosis and treatment, the better the recovery. If the symptoms are very mild, the patient can be followed up for a while without an emergency surgery.
