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Introduction: Idiopathic Normal Pressure Hydrocephalus (iNPH) is a complex and often misdiagnosed syndrome, whose major challenge is to identify which patients will benefit from surgery. Previous studies reported a variability in positive surgery response. The role of tap test(TT) in screening patients suitable for shunting is controversial. The primary aim of this study was to describe the clinical/instrumental features and their longitudinal progression after surgery in iNPH patients. Secondarily, we aimed to investigate the response of the three iNPH domains and the best time of outcome assessment after TT.Methods: Patients compatible with iNPH underwent a 3-T-MRI and an inpatients program with TT including standardized clinical evaluations, neuropsychological assessments and instrumental gait analysis pre- and after-(24-h and 72-h) TT. The multidisciplinary team selected candidates for surgery. Patients were evaluated 6- and 12-months after surgery.Results: A total of 154 consecutive patients were included from 2015 to 2018, 76 with an iNPH diagnosis (43 underwent surgery, 35 were evaluated after 6-months). Clinical and instrumented quantitative gait measures and urinary symptoms improved over time along with some neuropsychological functions. Concerning pre- and post-TT analyses, the three iNPH domains showed a different response after TT, the delayed motor assessment was more appropriate than the early one and the instrumental measures highlighted the motor improvement.Conclusion: iNPH patients improved after surgery, when accurately selected. A multidisciplinary team focused on this disease and a standardized protocol helped in achieving a correct diagnosis and management of iNPH. Our results could impact the management of this disease. [ABSTRACT FROM AUTHOR]

Idiopathic normal pressure hydrocephalus, secondary chronic hydrocephalus, and other cerebrospinal fluid (CSF) disorders are often challenging to diagnose. Since shunt surgery is usually the only therapeutic option and carries significant morbidity, optimal patient selection is crucial. The tap test is the most commonly used prognostic test to confirm the diagnosis but lacks sensitivity. The lumbar infusion study (LIS) appears to be a better option, offering additional information on brain dynamics without increasing morbidity. However, this technique remains underused. In this narrative review, supported by the extensive experience of several European expert centers, we detail the physiological basis, indications, and CSF dynamics parameters that can be measured. We also discuss technical modalities and variations, including one versus 2 needles, patient positioning, and the site of CSF measurement, as well as in vivo shunt testing. Finally, we discuss the limitations and morbidity associated with the LIS. This review aims to assist teams wishing to incorporate LIS into their screening tools for chronic hydrocephalus and other CSF disorders. [ABSTRACT FROM AUTHOR]

Idiopathic normal pressure hydrocephalus (iNPH) refers to a complex brain disorder characterized by ventricular enlargement and the classic Hakim's triad of gait and balance difficulties, urinary incontinence, and cognitive impairment. It predominantly affects older patients in the absence of an identified cause. As the elderly population continues to increase, iNPH becomes a growing concern in the complex spectrum of neuro-geriatric care, with significant socio-economic implications. However, unlike other well-structured management approaches for neurodegenerative disorders, the management of iNPH remains largely uncodified, leading to suboptimal care in many cases. In this article, we highlighted the challenges of current practice and identify key points for an optimal structuration of care for iNPH. Adopting a global approach to iNPH could facilitate a progressive shift in mindset, moving away from solely aiming to cure an isolated neurological disease with uncertain outcomes to providing comprehensive care that focuses on improving the daily life of frail patients with complex neurodegenerative burdens, using tailored goals. [ABSTRACT FROM AUTHOR]

Ventriculoatrial shunt is routinely performed under general anesthesia and is used to treat various kinds of hydrocephalus. Idiopathic normal pressure hydrocephalus patients are generally elderly and can have high comorbidities; in such patients, avoiding general anesthesia and limiting opioid administration could be beneficial. We started to perform ventriculoatrial shunt under locoregional anesthesia, in order to make this procedure more truly "minimally invasive". Demographic data, American Society of Anesthesiologists (ASA) score and vital signs, Ramsay sedation scale, and procedural duration were collected. All procedures were performed combining sedation with cervical plexus and scalp block. After internal jugular vein cannulation, a catheter was inserted and connected with a programmable valve and then with the ventricular catheter. Outcome was assessed by the Idiopathic Normal Pressure Hydrocephalus Grading Scale and complications were recorded at 3-month follow-up. Ten consecutive patients were enrolled; the mean age was 74 years, 8 were male, ASA score median value was 3. Opioids were administered only in 4 patients, in 6 patients the value of Ramsay scale was 5. The average duration of surgery was 59.5 minutes. No procedure was converted to general anesthesia. Our preliminary experience with ventriculoatrial shunt under locoregional anesthesia demonstrates that this technique is feasible, is not associated with an increase in operating times or complications, can avoid general anesthesia, and helps to limit opioid administration in the elderly. It can therefore represent a valid option in order to improve treatment quality in these complex patients. [ABSTRACT FROM AUTHOR]

Idiopathic normal pressure hydrocephalus (iNPH) is a chronic neurologic syndrome that affects the elderly population in a context of concomitant medical conditions. The aim of this study was to understand the significance of comorbidities using 4 validated and specific clinical scores: Cumulative Illness Rating Scale (CIRS), American Society of Anesthesiologists (ASA) score, Comorbidity Index (CMI), and Charlson Comorbidity Index (CCI). From 2015 until 2019, the Bologna PRO-Hydro multidisciplinary team selected 63 patients for shunt surgery. All comorbidity scores were collected during preoperative anesthesia evaluation. Positive shunt response was defined as an improvement in overall disability (assessed with modified Rankin Scale [mRS]), in risk of fall (assessed with Tinetti Permormance Orientated Mobility Assessment, Tinetti) and in INPH specific symptoms (assessed with INPH Grading Scale, INPHGS). Patients with elevated values of CIRS had worse performance in gait and balance at Tinetti scale, both before (P = 0.039) and after surgery (P = 0.005); patients with high values of CMI had inferior values of Tinetti at baseline (P = 0.027) and higher mRS after surgery (P = 0.009); ASA 2 patients had better postoperative Tinetti scores than ASA 3 patients (P = 0.027). A positive or negative shunt response was not significantly correlated with patients' preoperative comorbidity scores. Patients with multiple comorbidities have a worse preoperative condition compared to patients with less concomitant diseases, and the proposed comorbidity scores, CIRS in particular, are useful clinical tools for the anesthesiologist. Comorbidities, though, do not impact overall postoperative outcome. [ABSTRACT FROM AUTHOR]

Diagnosing idiopathic normal pressure hydrocephalus (iNPH) still remains a clinical challenge. The callosal angle (CA) is a widely used neuroradiologic marker for iNPH. However, the relationship of the CA to clinical features has not been well investigated. We hypothesize that iNPH symptoms might better correlate with a variant of the CA (anterior callosal angle [ACA]). We aim to establish the validity of the ACA measurement for the diagnosis of iNPH and compare it with current radiologic parameters. The multidisciplinary BOLOGNA PRO-HYDRO Study Group performed a retrospective review of consecutive iNPH patients. Magnetic resonance imaging studies for these patients were collected, as well as magnetic resonance imaging studies from Alzheimer disease and healthy control patients. The CA, ACA, and Evans Index were measured by 2 blinded members of the study team based on magnetic resonance images for each of these populations. The ACA shows high accuracy, sensitivity, and specificity in distinguishing iNPH patients from healthy control and Alzheimer disease patients. The optimal pathologic diagnostic cut-off value for the ACA is 119 degrees. The diagnostic accuracy of the ACA is not significantly different from the CA. The ACA could be a valid radiologic parameter in the diagnostic armamentarium for iNPH. [ABSTRACT FROM AUTHOR]

The natural history and the outlook of patients with hydrocephalus are dramatically affected using cerebrospinal fluid shunts. The several issues related with a long-standing shunt should suffice to justify all the possible attempts to free the patient from it. This study focused on the role of secondary endoscopic third ventriculostomy (ETV) in the achievement of shunt removal in cases of shunt malfunction, and to identify patients who could benefit most from the procedure. In the period of 2006–2015, ETV was attempted in 47 patients >6 months old with ventriculoperitoneal shunt malfunction who presented with increased ventricle size compared with the previous neuroradiological examinations; simultaneously the shunt was removed or ligated. The overall success rate of secondary ETV was 74% (shunt-free patients with normalized intracranial pressure and absence of symptoms attributable to hydrocephalus) in patients with a long shunt duration (up to 30 years). The number of previous shunt revision procedures (P = 0.026) and lower age (P = 0.017) correlate with the likelihood of secondary ETV failure, a score of 80 as ETV success score (calculated for both pediatric and adult patients, even if the score was meant for the pediatric population) correlates with secondary ETV success (P = 0.014). Many patients with shunt malfunction can benefit from secondary ETV even after decades of shunting. Age at secondary ETV, the number of previous shunt revisions, and the ETV success score can help to better identify the best candidates for the procedure. [ABSTRACT FROM AUTHOR]