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Introduction: Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS)., Methods: A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models., Results: The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS., Discussion: Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals., (Published by Elsevier Inc.)

Background: The purpose of the current study was to investigate the incidence of postoperative medical complications and 3-month mortality in patients  ≥ 70 years old with hip fracture following hip arthroplasty (HA) and independent risk factors associated with postoperative medical complications and 3-month mortality during the Coronavirus Disease 2019 (COVID-19) pandemic., Methods: A multicenter retrospective study was conducted, patients  ≥ 70 years old with HA for hip fracture under general anesthesia were included during COVID-19 and before COVID-19 pandemic. The outcome was defined as postoperative medical complications and 3-month mortality. The baseline characteristics and risk factors were collected, multivariable logistic regression was used to identify independent risk factors for postoperative medical complications and 3-month mortality., Results: A total of 1096 patients were included during COVID-19 pandemic and 1149 were included before COVID-19 pandemic in the study. Patients  ≥ 70 years with hip fracture for HA had longer fracture to operation duration (7.10 ± 3.52 vs. 5.31 ± 1.29, P < 0.001), and the incidence of postoperative medical complications (21.90% vs. 12.53%, P < 0.001) and 3-month mortality (5.20% vs. 3.22%, P = 0.025) was higher during COVID-2019 pandemic. Multivariate logistic regression analysis showed that dementia (OR 2.73; 95% CI 1.37-5.44; P = 0.004), chronic obstructive pulmonary disease (COPD) (OR 3.00; 95% CI 1.92-4.71; P < 0.001), longer fracture to operation duration (OR 1.24; 95% CI 1.19-1.30; P < 0.001) were associated with increased risk for postoperative medical complications. COPD (OR 2.10; 95% CI 1.05-4.17; P = 0.035), dementia (OR 3.00; 95% CI 1.11-7.94; P = 0.031), postoperative medical complications (OR 4.99; 95% CI 2.68-9.28; P < 0.001), longer fracture to operation duration (OR 1.11; 95% CI 1.04-1.19; P = 0.002) were associated with increased risk for 3-month mortality., Conclusions: In conclusion, we found that postoperative medical morbidity and 3-month mortality in patients with hip fracture underwent HA were 21.90% and 5.20%, respectively, during the COVID-19. COPD, dementia and longer fracture to operation duration were associated with negative outcome in patients with hip fracture underwent HA during the COVID-19., (© 2023. The Author(s).)

Background: Optimal periprocedural oral anticoagulant (OAC) therapy before catheter ablation (CA) for atrial fibrillation (AF) and the safety profile of OAC discontinuation during the remote period (from 31 days and up to 1 year after CA) have not been well defined., Methods and results: The RYOUMA registry is a prospective multicenter observational study of Japanese patients who underwent CA for AF in 2017-2018. Of the 3,072 patients, 82.3% received minimally interrupted direct-acting OACs (DOACs) and 10.2% received uninterrupted DOACs. Both uninterrupted and minimally interrupted DOACs were associated with an extremely low thromboembolic event rate. Female, long-standing persistent AF, low creatinine clearance, hepatic disorder, and high intraprocedural heparin dose were independent factors associated with periprocedural major bleeding. At 1 year after CA, DOAC was continued in 55.9% of patients and warfarin in 56.4%. The incidence of thromboembolic and major bleeding events for 1 year was 0.3% and 1.2%, respectively. Age ≥73 years, dementia, and AF recurrence were independently associated with major bleeding events. Univariate analyses revealed that warfarin continuation and off-label overdose of DOACs were risk factors for major bleeding after CA., Conclusions: High intraprocedural dose of heparin was associated with periprocedural major bleeding events. At 1 year after CA, over half of the patients had continued OAC therapy. Thromboembolic events were extremely low; however, major bleeding occurred in 1.2%. Age ≥73 years, dementia, and AF recurrence were independently associated with major bleeding after CA.

Purpose: Atrial fibrillation is associated with an increased risk of cognitive impairment. It is unclear whether the restoration of sinus rhythm with catheter ablation may modify this risk. We conducted a systematic review of studies comparing cognitive outcomes following catheter ablation with medical therapy (rate and/or rhythm control) in atrial fibrillation., Methods: Searches were performed on the following databases from their inception to 17 October 2021: PubMed, OVID Medline, Embase and Cochrane Library. The inclusion criteria comprised studies comparing catheter ablation against medical therapy (rate and/or rhythm control in conjunction with anticoagulation where appropriate) which included cognitive assessment and/or a diagnosis of dementia as an outcome., Results: A total of 599 records were screened. Ten studies including 15,886 patients treated with catheter ablation and 42,684 patients treated with medical therapy were included. Studies which compared the impact of catheter ablation versus medical therapy on quantitative assessments of cognitive function yielded conflicting results. In studies, examining new onset dementia during follow-up, catheter ablation was associated with a lower risk of subsequent dementia diagnosis compared to medical therapy (hazard ratio: 0.60 (95% confidence interval 0.42-0.88, p < 0.05))., Conclusion: The accumulating evidence linking atrial fibrillation with cognitive impairment warrants the design of atrial fibrillation treatment strategies aimed at minimising cognitive decline. However, the impact of catheter ablation and atrial fibrillation medical therapy on cognitive decline is currently uncertain. Future studies investigating atrial fibrillation treatment strategies should include cognitive outcomes as important clinical endpoints., (© 2022. The Author(s).)

Background: Hemiarthroplasty is a common treatment for displaced femoral neck fractures, but limited Canadian data are available about hemiarthroplasty failure. We evaluated the frequency and predictors of hemiarthroplasty failure in Manitoba., Methods: In this retrospective multicentre province-wide study, billing and joint registry databases showed 4693 patients who had hemiarthroplasty for treatment of femoral neck fracture in Manitoba over an 11-year period (2005-2015), including 155 hips with subsequent reoperations (open or closed) for treatment of hemiarthroplasty failure. Hospital records were reviewed to identify modes of hemiarthroplasty failure, comorbidities and reoperations. Data were analyzed using χ 2 test and Poisson and γ regression models., Results: During our study period, 155 hips (154 patients [3%]) underwent 230 reoperations. Of these, 131 hips (85%) initially had an uncemented unipolar modular implant. Indications for first-time reoperation included periprosthetic femur fracture (49 hips [32%]), dislocation (45 hips [29%]), acetabular wear (28 hips [18%]) and infection (26 hips [17%]). There were 46 hips (30%) that had 2 or more reoperations. Reoperation for dislocation was associated with presence of dementia; acetabular wear was associated with absence of dementia. Time from hemiarthroplasty to reoperation was associated inversely with age at hemiarthroplasty, dislocation and dementia and was directly associated with acetabular wear. The risk of having 2 or more reoperations was associated independently with dislocation, infection, and alcohol abuse., Conclusion: Hemiarthroplasty for femoral neck fracture in Manitoba had a low frequency of failure. Risk factors for multiple reoperations included dislocation, infection and alcohol abuse., Competing Interests: Competing interests: T. Tung and E. Trepman received fellowship support from the Concordia Foundation, DePuy Synthes, and Smith & Nephew. T. Gascoyne, E. Bohm, C. Burnell, D. Hedden, and T. Turgeon have received institutional funding from DePuy, Smith & Nephew, Zimmer Biomet, Hip Innovation Technology, and Össur. E. Bohm is a consultant to Stryker Canada and declares receiving payment for expert testimony from the Government of British Columbia. He is also an editorial board member of The Bone and Joint Journal. C. Burnell reports travel reimbursement from Hip Innovation Technology. D. Hedden was a paid consultant for Smith & Nephew. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Information regarding fracture in patients with transcatheter aortic valve replacement (TAVR) is limited. We investigated the prevalence and impact of fracture in patients with severe aortic stenosis who had undergone TAVR. Of 913 consecutive patients with symptomatic, severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute between October 2013 and April 2020, 633 women were enrolled. The primary endpoint was all-cause mortality following TAVR. Patients with a history of fracture displayed smaller body mass indices, increased frailty, a higher prevalence of osteoporosis, and stroke history. Notably, 61.7% of patients with a history of fracture reported to have not taken any osteoporosis medications. Estimated all-cause mortality survival rates post-TAVR were significantly lower in patients with fractures than those without fractures. In the multivariate analysis, history of fracture was independently associated with all-cause mortality following TAVR. Furthermore, fracture prevalence was significantly greater in those who had a higher clinical frailty scale score were slower in the 5-m walk test, had more severe dementia as per the revised Hasegawa dementia scale, and performed poorly in the hand grip strength test. History of fracture was an independent predictor for all-cause mortality in patients undergoing TAVR. In addition, our study demonstrated that osteoporotic fracture may be under-treated in this population. History of fracture may be one of the phenotypes of frailty given its significant relationship with frailty markers in this population., (© 2021. Japanese Association of Cardiovascular Intervention and Therapeutics.)

Background: Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group., Objective: To evaluate the relationship between dementia status and cataract surgery., Methods: Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery., Results: Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88)., Conclusion: US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.

Background: The strategy for cardiovascular surgery in dementia patients is controversial, so we aimed to investigate whether preoperative dementia and its severity might affect the outcomes of cardiovascular surgery by evaluating with the Mini-Mental State Examination (MMSE). Methods and Results: The study group comprised 490 patients undergoing cardiovascular surgery. Their preoperative cognitive status was evaluated using the MMSE, and analysis was performed to compare the patients with MMSE score <24 (dementia group, n=51) or MMSE score 24-30 (non-dementia group, n=439). Furthermore, the effect of the severity of dementia was analyzed with a cut-off MMSE score of 19/20. Risk factors for surgical outcomes were explored using multivariate logistic regression analysis. Hospital mortality was 11.8% in the dementia group and 2.1% in the non-dementia group (P=0.002). Regarding the postoperative morbidities, the incidence of cerebrovascular disorder (P=0.001), pneumonia (P=0.039), delirium (P=0.004), and infection (P=0.006) was more frequent in dementia group. Among the patients with MMSE <20, hospital mortality was as high as 25%, and the rate of delirium was 58%. Multivariate logistic regression analysis revealed that MMSE score <24 (P=0.003), lower serum albumin (P=0.023) and aortic surgery (P=0.036) were independent risk factors for hospital death., Conclusions: Preoperative dementia affects the outcomes of cardiovascular surgery with regard to hospital death and delirium. The surgical indication for patients with MMSE <20 might be difficult, but surgery with an appropriate strategy should be considered for patients with MMSE <24.

Objective: This study was designed to verify the association between dementia and mortality in the elderly undergoing hip fracture surgery, and assessed the mortality of patients with dementia after hip fracture surgery., Material and Methods: PubMed, Embase, and Web of Science were searched until April, 2018 without language restrictions. Two reviewers selected related studies, assessed study quality, and extracted data independently. Risk ratios (RRs) with 95% confidence intervals (CI) were derived using random-effects model throughout all analyses. The endpoints included 30-day, 6-month, 1-year, and more than 1-year mortality. This meta-analysis was performed following PRISMA statement and carried out by using stata14.0 software., Results: Dementia significantly increased postoperative mortality of patients suffered from hip fracture in 30-day [RR = 1.57, 95% CI (1.29, 1.90), P<0.00], 6-month [RR = 1.97, 95% CI (1.47, 2.63), P<0.00], 1-year [RR = 1.77, 95% CI (1.54, 2.04), P<0.00], and more than 1-year follow up [RR = 1.60, 95% CI (1.30, 1.96), P<0.00] respectively. The mortality of dementia patients after hip fracture surgery in 30-day [ES = 12%, 95% CI (8%, 15%)], 6-month [ES = 32%, 95% CI (17%, 48%)], 1-year [ES = 39%, 95% CI (35%, 43%)], and more than 1-year follow up [ES = 45%, 95% CI (32%, 58%)]., Conclusions: Our meta-analysis demonstrated that the mortality of patients with dementia suffered from hip fracture surgery is 12%, 32%, 39%, and 45%, and dementia increased 1.57, 1.97, 1.77, and 1.60-fold mortality in patients undergoing hip fracture surgery in 30-day, 6-month, 1-year, and more than 1-year follow up respectively.

Objective: Truncal vagotomy is associated with a decreased risk of subsequent Parkinson disease (PD), although the effect of vagotomy on dementia is unclear. In response, we investigated the risk of dementia in patients who underwent vagotomy., Setting: Population-based cohort study., Participants: A total of 155 944 patients who underwent vagotomy (vagotomy cohort) and 155 944 age-matched, sex-matched and comorbidity-matched controls (non-vagotomy cohort) were identified between 2000 and 2011., Primary and Secondary Outcome Measures: All patient data were tracked until the diagnosis of dementia, death or the end of 2011. The cumulative incidence of subsequent dementia and HRs were calculated., Results: The mean ages of the study patients in the vagotomy and non-vagotomy cohorts were 56.6±17.4 and 56.7±17.3 years, respectively. The overall incidence density rate for dementia was similar in the vagotomy and non-vagotomy cohorts (2.43 and 2.84 per 1000 person-years, respectively). After adjustment for age, sex and comorbidities such as diabetes, hypertension, hyperlipidaemia, stroke, depression, coronary artery disease and PD, the patients in the vagotomy cohort were determined to not be at a higher risk of dementia than those in the non-vagotomy cohort (adjusted HR=1.09, 95% CI 0.87 to 1.36). Moreover, the patients who underwent truncal vagotomy were not associated with risk of dementia (adjusted HR=1.04, 95% CI 0.87 to 1.25), compared with the patients who did not undergo vagotomy., Conclusion: Vagotomy, either truncal or selective, is not associated with risk of dementia., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Surgical intervention in older people with dementia is becoming increasingly common as the population ages and the number of people with dementia continues to rise. People with dementia have unique needs that require sensitive management at all stages of hospitalisation for surgery. This article sets out a suggested pathway for the care of these patients, in the form of a flow chart. It discusses recognition and assessment of dementia and delirium, issues of capacity and consent, interventions required for optimum care of older people with dementia and peri-operative management. It explores the role of family and friends in achieving integrated care.

Normal pressure hydrocephalus, a reversible cause of dementia, and frontotemporal dementia, an irreversible process, may present with or complicate psychiatric illness. Recognition of these neurological disorders in patients presenting with behavioral symptoms affects key treatment decisions and prognosis.

Object: For several decades, clinicians have predicted intraparenchymal brain pressure or brain tissue compression indirectly based on the degree of distortion of the midline structures (midline shift) and ventricle wall (ventriculomegaly) observed on conventional MRI. However, this method has several limitations. Diffusion tensor imaging (DTI) is a novel MRI technique that can provide information about the microstructural properties of compressed tissue. In this study, the authors evaluated whether DTI can precisely define the degree of tissue compression in patients with chronic subdural hematoma (CSDH)., Methods: The study sample consisted of 18 patients (mean age 71 years, 10 men and 8 women) with unilateral CSDH and 12 age-matched volunteers. Diffusion tensor imaging results were acquired before and after the surgical irrigation in the CSDH group. Subdural pressure during the operation was also measured. Fractional anisotropy (FA) values were evaluated at several locations, including the gray matter., Results: The FA values of the gray matter, especially in the caudate nucleus and putamen, were increased in the patients with CSDH compared with the control group. The change in FA data before and after surgery (ΔFA) correlated with the degree of tissue compression evaluated by measurement of the subdural pressure. Furthermore, the increased FA values in patients with CSDH decreased after surgery., Conclusions: These findings indicate that FA values of the gray matter, especially in the caudate nucleus and putamen, may be important markers of tissue compression. The assessment of FA values of the gray matter will result in a new, less-invasive diagnostic technique to evaluate the degree of brain compression.

Spiroplasma spp. are important phyto and insect pathogens, and candidate causal agent/s of transmissible spongiform encephalopathies (TSE) in man and animals. These filterable wall-less bacteria are widely distributed in nature with an unspecified environmental reservoir. In this study we showed by scanning electron microscopy that spiroplasma form biofilm on an assortment of hard surfaces including mica, nickel and stainless steel. Spiroplasma were stuck to the surfaces by fibrillar threads consistent with curli fibers (an amyloid protein found in bacterial biofilms). After a lengthy time in cultures (6 weeks), spiroplasma in biofilm bound to mica disks lost their spiral shapes and formed coccoid forms interconnected by long (>2 μm) branched membranous nanotubules, therein representing direct conjugate connections between the cells. The affinity of spiroplasma biofilms for mica and nickel, and the membrane communications suggest that soil could be a reservoir for these bacteria. The persistence of clay bound spiroplasma in soil could serve as the mechanism of lateral spread of TSEs by ingestion of soil by ruminants. Spiroplasma binding to stainless steel wire supports bacterial contamination of surgical instruments following surgery on dementia patients as a mechanism of iatrogenic transmission of TSEs, especially with resistance of spiroplasma in biofilms to drying or exposure to 50% glutaraldehyde. The discovery of biofilm formation by spiroplasma addresses questions regarding environmental persistence of these organisms in nature and suggests novel mechanisms of intercellular communication and transmission., (Copyright © 2012 Elsevier Inc. All rights reserved.)

There are currently 25 million people with dementia worldwide, and this number is rising. Dementia has been highlighted as a major priority for health care and research because of the enormous economical and health burden associated with it. Consultations with people with dementia and carers have highlighted that timely well-targeted information services are a key priority for enabling them to 'live well with dementia'. Despite this, the evidence base for the optimal design and delivery of an information provision service is limited. Findings from randomised controlled trials and other studies have indicated that information provision does confer some benefit in carer outcomes and in the symptoms and well-being of people with dementia. However, there is limited understanding of the optimal design of such a service because of the variety of approaches that have been evaluated, the wide range of settings and locations and the lack of a clear conceptual framework. The existing evidence base supports the importance of an optimised information provision service and strongly indicates the need for a large-scale RCT to identify the most effective and cost-effective design for people with dementia and their carers., (© 2011 Blackwell Publishing Ltd.)

Introduction:  Atrial fibrillation (AF) adversely impacts mortality, stroke, heart failure, and dementia. AF ablation eliminates AF in most patients. We evaluated the long-term impact of AF ablation on mortality, heart failure (HF), stroke, and dementia in a large system-wide patient population., Methods:  A total of 4,212 consecutive patients who underwent AF ablation were compared (1:4) to 16,848 age/gender matched controls with AF (no ablation) and 16,848 age/gender matched controls without AF. Patients were enrolled from the large ongoing prospective Intermountain AF study and were followed for at least 3 years., Results:  Of the 37,908 patients, mean age 65.0 ± 13 years, 5,667 (14.9%) died, 1,296 (3.4%) had a stroke, and 1,096 (2.9%) were hospitalized for HF over >3 years of follow-up. AF ablation patients were less likely to have diabetes, but were more likely to have hypertension, HF, and significant valvular heart disease. AF ablation patients had a lower risk of death and stroke in comparison to AF patients without ablation. Alzheimer's dementia occurred in 0.2% of the AF ablation patients compared to 0.9% of the AF no ablation patients and 0.5% of the no AF patients (P < 0.0001). Other forms of dementia were also reduced significantly in those treated with ablation. Compared to patients with no AF, AF ablation patients had similar long-term rates of death, dementia, and stroke., Conclusions:  AF ablation patients have a significantly lower risk of death, stroke, and dementia in comparison to AF patients without ablation. AF ablation may eliminate the increased risk of death and stroke associated with AF., (© 2011 Wiley Periodicals, Inc.)

The goal of this study was to characterize long-term social and functional outcomes in adults treated for idiopathic normal pressure hydrocephalus (NPH). Data for 252 patients treated medically or surgically for idiopathic NPH were obtained through the Hydrocephalus Association Database Project. Data on post-surgical outcomes including improvement in symptoms, the need for in-home care, ability to drive, and employment status were analyzed. Most patients (73.7%) surveyed were treated with a shunt, an endoscopic third ventriculostomy (ETV), or both. More patients who underwent surgery reported driving and being employed compared to those who did not have surgery. Most shunt patients had improvements in gait (81.1%), urinary incontinence (55.9%), and dementia (64.4%). Overall, shunt patients reported more dramatic improvements in quality of life as compared to ETV patients (72.2% versus 55.6%). Treating idiopathic NPH with cerebrospinal fluid diversion facilitates a return to independence through improved functional and social outcomes., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Molecular imaging is a field born out of the happy marriage of molecular biology and radiology. The first installment of this two-part series on molecular imaging demonstrated basic principles for practitioners in the field of the neurosciences. This installment seeks to provide some illustrative examples, insights, and specific applications to the neurosciences. The fields of functional neurosurgery including the treatment of neuropsychiatric disorders, novel treatments and imaging of tumors, neuroregenerative medicine, and nanotechnology in vascular disorders are covered. Finally, we give some parting thoughts on the future of molecular imaging, including advances in the imaging of neurodegenerative disorders., (Published by Elsevier Inc.)

Background: Cognitive decline, slow psychomotor regression and confusion, especially in the elderly, often result in medical consultation. Frequently, these rather unspecific symptoms are interpreted as signs of beginning dementia. When mental regression is joined by tremor or motor deficits, neurodegenerative disease is commonly considered and the need for neuroimaging is underestimated. Chronic subdural haematoma (CSH) is known to be the most frequent type of intracranial bleeding, appearing mostly in the elderly after minor trauma with unspecific symptoms. The aim of this retrospective study was the identification of the leading clinical symptoms in patients with the diagnosis CSH who had been treated surgically in our Neurosurgical Department., Patients and Method: 356 patients with symptomatic CSH (225 male, 131 female; mean age 68.3 years), who were admitted to our Neurosurgical Department between 1992 and 2003, were included in the study. We reviewed the charts documenting preoperative clinical status, radiological signs, history of trauma, operative complications, postoperative clinical status, days of hospitalisation as well as gender and age., Results: The primary surgical procedure performed in 343 patients (96.4%) was burr-hole trepanation. The leading preoperative symptoms were mnestic deficits (cognitive decline, confusion) in 192 patients (55.8%), followed by headache in 150 patients (45.5%) and motor deficit in 144 patients (41.1%). Furthermore, we found a statistically significant correlation (p<0.005) between the thickness of the left-sided haematoma and the symptoms aphasia and psychosyndrome., Conclusion: The leading clinical symptoms identified in our cohort were mnestic deficits, headache and motor deficit, signs that mostly appear at the beginning of demential diseases. Thus, CSH should be taken into account as an important differential diagnosis for demential and neurodegenerative diseases and neuroimaging should be demanded. Once a CSH is detected this way, the patient should be transferred to a neurosurgical department where an easy standard procedure may potentially lead to early recovery.

Objectives: Normal-pressure hydrocephalus (NPH) syndrome is treatable by implantation of a cerebrospinal fluid (CSF) shunt. However, diagnosis of NPH by clinical and radiological findings alone is unreliable, and co-existing structural dementia can contribute to low success rates after shunt implantation. The aim of our study was to investigate whether long-term results after shunt implantation in NPH improve when surgical candidates are selected by continuous intraventricular pressure monitoring (CIPM)., Patients and Methods: Ninety-two consecutive patients who were admitted with suspected NPH received CIPM for 48 h including an intraventricular steady-state infusion test to determine the resistance outflow. With positive CIPM, shunt implantation was performed and the patients were prospectively followed up for 1 to 10 years (median 6.5 years)., Results: CIPM was negative in 37 patients. Fifty-five patients had a positive CIPM and received CSF shunt. 96.1% of them improved from gait disturbance, 77.1% from cognitive impairment and 75.7% from urinary dysfunction. Clinical improvement remained during long-term follow-up in all but 3 patients who showed a decline at 4, 5 and 7 years, respectively. CIPM-related complications (ventriculitis) occurred in only one patient., Conclusion: CIPM is a safe and valuable tool to establish a reliable diagnosis of NPH and to identify promising surgical candidates.

Background: The regional cerebral blood flow (rCBF) and cerebral metabolism in patients with idiopathic normal pressure hydrocephalus (iNPH) remain to be studied in detail., Purpose: Using single-photon emission computed tomography (SPECT), we compared the characteristic rCBF patterns in iNPH patients who did, or did not, respond to shunt operations., Materials and Methods: We studied 24 consecutive iNPH patients: 14 men and 10 women aged 68 to 88 years (mean 77.5 years). Using the Japanese normal pressure hydrocephalus grading scale, they were divided into responders and non-responders to shunt operations. Follow-up ranged from 10 to 36 months (mean 25 months). We obtained baseline single-photon emission computed tomography (SPECT) data on three-dimensional stereotactic surface projections (3D-SSP) before and after shunt operations, and compared rCBF in responders and non-responders., Results: On statistical maps, responders manifested significantly lower rCBF in the basal frontal lobes and cingulate gyrus (anterior-dominant)., Conclusions: The preoperative measurement of rCBF by 3D-SSP SPECT may help to identify iNHP patients expected to exhibit a good response to shunt operations.

Bilateral and symmetric globus-pallidus hyperintensities are observed on T1-weighted MRI in most of the patients with chronic liver failure, due to manganese accumulation. We report a 53-year-old man, with rapid onset parkinsonism-dementia complex associated with accumulation of manganese in the brain, secondary to liver failure. A brain MRI was performed and a high signal on T1-weighted images was seen on globus-pallidus, as well as on T2-weighted images on the hemispheric white-matter. He was referred to a liver-transplantation. The patient passed away on the seventh postoperative day. Our findings support the concept of the toxic effects of manganese on the globus-pallidus. The treatment of this form of parkinsonism is controversial and liver-transplantation should not be considered as first line treatment but as an alternative one.

Symptomatic interhemispheric arachnoid cysts (ACs) are extremely rare lesions seen more frequently in the elderly. Only 13 cases of symptomatic interhemispheric ACs in the elderly have previously been reported. Herein, we describe a 70-year-old female with symptoms of vertigo, memory and behavior disturbances. Magnetic resonance imaging (MRI) revealed a giant arachnoid cyst (AC) on the interhemispheric fissure, which was exerting a mass effect and displacement on the corpus callosum and anterior cerebral vessels, with a massive midline shift. The patient was treated with a cysto-peritoneal shunt. Reports to date have reviewed the pathology, clinical presentation, radiology and surgical management of interhemispheric symptomatic arachnoid cysts in elderly patients.

Object: Many tests have been proposed to help choose candidates for shunt insertion in cases of suspected normal-pressure hydrocephalus (NPH). It is unclear what sensitivity and specificity a prospective test must have to improve outcomes, compared with the results of automatic shunt insertion., Methods: The authors adapted the decision analysis model used in a companion article to allow for application of a screening test. Using the reported sensitivities and specificities of several such tests, they evaluated the effects such tests would have on the expected outcome of an average 65-year-old patient with moderate dementia. They also evaluated the cost-effectiveness of a theoretical screening test with superior sensitivity and specificity., Conclusions: Although external lumbar drainage comes quite close, none of the screening tests reported to date have sufficient sensitivity and specificity to improve expected outcome in an average candidate, compared with the results of automatic shunt placement in cases of suspected NPH. In addition, even a theoretically improved test would need to be considerably less expensive than prolonged lumbar drainage to be cost-effective in clinical practice.

Object: The average 65-year-old patient with moderate dementia can look forward to only 1.4 quality-adjusted life years (QALYs), that is, longevity times quality of life. Some of these patients suffer from normal-pressure hydrocephalus (NPH) and respond dramatically to shunt insertion. Currently, however, NPH cannot be diagnosed with certainty. The authors constructed a Markov decision analysis model to predict the outcome in patients with NPH treated with and without shunts., Methods: Transition probabilities and health utilities were obtained from a review of the literature. A sensitivity analysis and Monte Carlo simulation were applied to test outcomes over a wide range of parameters. Using shunt response and complication rates from the literature, the average patient receiving a shunt would gain an additional 1.7 QALYs as a result of automatic shunt insertion. Even if 50% of patients receiving a shunt have complications, the shunt response rate would need to be less than 5% for empirical shunt insertion to do more harm than good. Authors of most studies have reported far better statistics., Conclusions: In summary, many more patients with suspected NPH should be considered for shunt insertion.

Spontaneous intracranial hypotension (SIH) is known to cause postural headache, often combined with auditory, and vestibular symptoms, nausea, vomiting, and diplopia. We report a 63-year-old male patient who for the first time developed a depressive episode followed by acute manic symptoms during the course of SIH, both relieved after treatment of the underlying organic disturbance.

Object: Neuropsychiatric changes following surgery for chronic subdural hematomas (CSDHs) were analyzed in 26 patients (21 men and five women) by using the Mini-Mental State Examination (MMSE) and the Hasegawa Dementia Scale-Revised (HDS-R) to determine factors that potentially contribute to neuropsychiatric recovery., Methods: Burr hole irrigation was performed in every patient to treat the CSDH. The patients' profiles, including age and sex, neuroimaging findings (such as hematoma volume and thickness, as well as midline shift), and preoperative and postoperative scores on the MMSE, HDS-R, and activities of daily living (ADL) scale were recorded. According to preoperative MMSE scores, eight patients (30.8%) were classified as mentally healthy and 18 (69.2%) as suffering from dementia before surgery. Nine of the 18 patients with dementia recovered to a normal psychological state following surgery. Surgery improved not only the patients' independence in ADL (p = 0.0026), but also their neuropsychiatric functions such as orientation and calculation, as estimated by scores on the MMSE (p = 0.0002) and the HDS-R (p = 0.0008). Factors affecting neuropsychiatric status on admission were midline shift (p = 0.0398) and ADL score (p = 0.0124); factors that could be used to predict neuropsychiatric recovery after surgery were patient age (p = 0.0027) and ADL score (p = 0.0193). The results of a logistic regression analysis demonstrated that significant predictors of neuropsychiatric recovery after surgery include the following: patient age (p = 0.0049, odds ratio [OR] = 0.842) and preoperative ADL (p = 0.0056, OR = 0.471), MMSE (p < 0.0001, OR = 1.895), and HDS-R (p = 0.0073, OR = 1.303) scores. Results of subgroup analyses demonstrated that patients younger than 74 years of age and those who had preoperative scores lower than 5 on the converted ADL scale, higher than 10 on the MMSE, or higher than 9 on the HDS-R on admission were found to have a significantly better recovery of neuropsychiatric functions after surgery., Conclusions: Dementia is reversible in many patients with CSDH, and surgery can improve not only independence in ADL, but also neuropsychiatric functions. Patients who are younger and/or those who have lower preoperative ADL scores and/or higher preoperative MMSE or HDS-R scores will achieve a good recovery with regard to neuropsychiatric functions after surgery. Estimations of neuropsychiatric function based on MMSE and HDS-R scores were found to be useful in predicting functional outcomes in patients with CSDH.

Normal pressure hydrocephalus (NPH) is an important diagnosis to keep in mind, i.e. the possibility that NPH and not a neurodegenerative disease causes the patient's symptoms with ataxia, urinary incontinence and dementia. Clinical improvement, sometimes a complete reversal of the symptoms, may be seen after a simple surgical procedure. This prospective study was performed by testing eight consecutively shunted patients with a walking test and a cognitive test battery pre- and postoperatively. Improvement 3-4 months after the shunting procedure suggests that NPH was present in six of eight patients. Walking ability was improved after surgery, also in patients with severe dementia. Severe dementia caused by NPH is hardly reversible, though cognitive tests may indicate some improvement. However, early surgical treatment of NPH in patients not suffering from a dementia according to the Mini Mental Status Test may bring improvement in some cognitive functions. Patients with both clinical and radiological signs of normal pressure hydrocephalus should be offered a shunting procedure.

Normal pressure hydrocephalus (NPH), which may either be idiopathic or occur secondarily, is responsible for approximately 6% of the cases of dementional syndromes in the elderly. Although its diagnosis still remains a problem, every attempt should be made to identify patients with clinical symptoms arising from NPH, since the placement of a shunt can result in a much improved quality of life. Candidates for surgical treatment must be selected with care, since the transient peri-operative morbidity may be as high as 7%.

The authors report a patient with progressive cognitive and gait decline in association with sarcoid meningitis. The patient had evidence of active inflammation as determined by cerebrospinal fluid examination and was steroid dependent. Magnetic resonance imaging and radionucleotide cisternography were complementary in establishing the diagnosis of communicating hydrocephalus, and suggested that the patient would be shunt responsive.

Background and Purpose: MR studies have shown hippocampal atrophy to be a sensitive diagnostic feature of Alzheimer's disease (AD). In this study, we measured the hippocampal volumes of patients with a clinical diagnosis of normal pressure hydrocephalus (NPH), a potentially reversible cause of dementia when shunted. Further, we examined the relationship between the hippocampal volumes and cortical AD pathologic findings, intracranial pressure, and clinical outcomes in cases of NPH., Methods: We measured hippocampal volumes from 37 patients with a clinical diagnosis of NPH (27 control volunteers and 24 patients with AD). The patients with NPH underwent biopsy, and their clinical outcomes were followed for a year., Results: Compared with those for control volunteers, the findings for patients with NPH included a minor left-side decrease in the hippocampal volumes (P < .05). Compared with those for patients with AD, the findings for patients with NPH included significantly larger hippocampi on both sides. Although not statistically significant, trends toward larger volumes were observed in patients with NPH who had elevated intracranial pressure, who benefited from shunting, and who did not display cortical AD pathologic findings., Conclusions: Measurements of hippocampal volumes among patients with a clinical diagnosis of NPH have clear clinical implications, providing diagnostic discrimination from AD and possibly prediction of clinical outcome after shunting.

The number of perianesthesia patients with dementia increases yearly. Understanding the physiology and functional impairments of these patients will improve the perianesthesia nurse's ability to create a safe environment, communicate effectively, and reduce discomfort.

Although dementia is described as one of the constituent characteristics of normal pressure hydrocephalus (NPH), alongside gait disturbances and urinary incontinence, there is a rather limited number of controlled studies concerning neuropsychological deficits in the disease. A wide range of psychopathologically relevant symptoms have been described, but the common features of most cases include mental and motor slowing, apathy, emotional indifference, anosognosia, memory and attentional impairment. A number of other functional deficits such as dyslexia, dysgraphia, acalculia, apraxia can also frequently be found. Some emphasis is put on the work of J. de Mol (Brussels) which appears to be most important for the study of neuropsychological symptoms in NPH patients. The methodological standard of a number of studies has been found to be rather low, and yet a sound neuropsychological investigation may be of utmost importance for the diagnosis and neurosurgical outcome assessment. Concerning morphological correlates of the functional deficits in NPH, various hypotheses have been formulated, but it is argued that symptoms can neither be described as predominantly "diffuse" in nature, nor can they be reduced to unilocular dysfunctions. Recommendations for future research strategies are formulated.

While reversible cases of dementia are rare once detected, the patient may benefit from treatment. This paper examines the cost-effectiveness of computerized tomography (CT) scanning as a screening test for potentially reversible dementia. A systematic review was carried out to identify the proportion of patients with dementia above and below the age of 65 years with a theoretically treatable condition and the proportion of these patients who would benefit from neurosurgery. Information was combined with epidemiological and financial data relating to Scotland to model the costs and benefits of implementing a national screening program. Subdural hematoma, normal pressure hydrocephalus, and brain tumours are rare conditions treatable by neurosurgery. A scanning and treatment program for Scotland would cost 4.6 million Pounds per annum. Of 531 reversible cases detected, 136 would benefit from neurosurgery, 369 would not benefit, and 26 would die as a result of surgery. Treating normal pressure hydrocephalus reduces overall quality-adjusted survival. The most cost effective screening strategy is to scan all patients but treat only subdural hematomas, gaining 178 quality-adjusted life-years (QALYs) at a cost of 14,171 Pounds per QALY for patients aged 65 at the time of the scan. The corresponding figures for patients above and below 65 years are 9,000 Pounds and 23,000 Pounds, respectively. CT scanning appears cost-effective in dementia patients under 65 years. It should be undertaken selectively in more elderly patients. Surgical treatment of normal pressure hydrocephalus may reduce quality adjusted survival and should only be undertaken within clinical trials.

An 85-year-old man presented with the clinical triad (gait instability, dementia, and bladder and bowel incontinence), the ventriculomegaly, and the normal CSF pressure that characterize normal-pressure hydrocephalus (NPH). Diagnostic uncertainty was raised by an unusually rapid onset and a lack of initial response to CSF tap tests. Additionally, periodic sharp waves on EEG suggested the possibility of Creutzfeldt-Jakob disease, and positron emission tomography (PET) demonstrated a pattern of cerebral hypometabolism typical of Alzheimer's disease. Nevertheless, the diagnosis of NPH was supported by delayed improvement following CSF tap tests, and it was confirmed by a dramatic clinical recovery after CSF shunting, resolution of the EEG and PET abnormalities, and a normal brain biopsy. NPH remains one of the few reversible causes of dementia, and the presence of its core features, regardless of rate of onset or ancillary test results, warrants careful consideration of therapeutic intervention.

Objective: A common finding of computed tomography in a case of normal-pressure hydrocephalus (NPH) is periventricular radiolucency (PVL). We analyzed PVL for patients with hydrocephalus, using dynamic computed tomographic and xenon-computed tomographic techniques to differentiate NPH from similar diseases., Methods: Dynamic computed tomography was evaluated as a method of diagnosing NPH in 14 patients with computed tomographic findings of both PVL and ventricular dilatation. Of the 14 patients, varying degrees of clinical improvement after shunt surgery were observed in 10 (shunt-effective group) but not in the remaining 4 (shunt-ineffective group). The difference in arrival time between PVL and thalamus, the difference in peak time between PVL and anterior cerebral artery, and cerebral blood flow in PVL by xenon-computed tomographic study were analyzed., Results: The difference in arrival time between PVL and thalamus was significantly longer in the effective group than among the remaining patients. There was no significant difference in PVL/cerebral blood flow and the difference in peak time between PVL and the anterior cerebral artery between the two groups., Conclusion: Dynamic computed tomographic analysis of the difference in arrival time between PVL and thalamus is useful for diagnosing NPH and predicting response to shunting.

We report a unique case of thalamic dementia caused by tentorial dural arteriovenous malformation (AVM), which was successfully treated by surgical occlusion of the straight sinus after attempts to occlude the dural AVM by endovascular procedures had failed. The tentorial dural AVM was fed by bilateral posterior meningeal arteries and occipital arteries, with early retrograde venous drainage into the straight sinus, inferior sagittal sinus, basal vein of Rosenthal, and dural veins in the falx cerebri. The venous ischemia in bilateral thalamus was revealed as low-density areas in computed tomographic scans, as high-intensity areas in T2-weighted magnetic resonance images, and as decreased cerebral blood flow and increased cerebral blood volume in single-photon positron emission computed tomography. Because this patient was not amenable to cure by endovascular embolization, an open surgical approach, surgical occlusion of the draining venous channel (the straight sinus), was performed. Postoperatively, dural AVM in angiography and venous ischemia in bilateral thalamus were resolved, as revealed by magnetic resonance imaging and single-photon positron emission computed tomography. Dementia caused by bilateral thalamic ischemia was also resolved. This case clearly illustrates the pathophysiological mechanism of venous ischemia in the bilateral thalamus to cause reversible dementia.

We describe two patients with dural fistulas who presented with dementia and diffuse white matter signal changes on MR that significantly improved after surgery. One patient had preoperative embolization.