Beruflich Dokumente
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CSF Hydrodynamics
Obstructive hydrocephalus Communicating hydrocephalus Normal pressure hydrocephalus Idiopathic intracranial hypertension benign intracranial hypertension, pseudotumor cerebri
CSF Hydrodynamics
NPH Surgery
ICP monitoring
Often used in conjunction with ELD Elevated ICP suggests another source Use of frequency of A and B waves controversial
High volume LP
High positive predictive value Low specificity Positive test suggests shunt responsiveness but negative test is not helpful.
Haan & Thomeer, 1988; Kahlon et al, 2002; Malm et al, 1995; Walchenbach et al, 2002; Wikkelso et al, 1986.
Haan & Thomeer, 1988; Marmarou,Young et al, 2005; Walchenbach et al, 2002; Williams et al, 1998.
CSF Ro
Outflow resistance measurement Multiple methods used to determine with different threshold values May improve identification in patients with negative tap test
Boon et al, 1997; Borgeson et al, 1979; Kahlon et al, 2002; Malm et al, 1995; Meier & Bartels, 2001; Takeuchi et al, 2000.
Recommended Algorithm
Surgical Treatment
Medical clearance Choice of device and configuration Complications
Hematoma (intracerebral and subdural) Subdural hygroma Shunt infection Shunt malfunction Seizure
Devices
Differential pressure valves Flow-limiting valves Programmable valves Antisiphon devices
Results
Shunt insertion added an average of 1.7 QALYs Empirically shunting all potential patients is better than the natural history for all published rates of shunt response and complications
Based on recent published data, only ELD is close to threshold sensitivity but still not sufficient
Initial evaluation
Neuropsychological standardized dementia workup performed at the Memory Disorders Clinic (MDC) of the Alzheimers Disease Center at the University of Pennsylvania
Includes taped gait assessment and review of urinary symptomatology Patients reviewed and discussed by cognitive neurologists
Follow-up
Regular neurosurgical follow-up including monthly CT scans and possible valve adjustments for 3 months Patients will have repeat evaluation at the MDC 3, 6, and 12 months post-operatively to objectively test for changes
Will include repeat neuropsychological battery and taped gait assessment for blinded review
Analysis
Correlate clinical response with:
Pre-operative clinical data
History Exam, neuropsychological, laboratory, and imaging findings
Histopathological data
CSF
Routine chemistry, tau, abeta, isoprostanes
Cortex
Plaques and tangles Neurodegenerative disease proteins Biochemical analysis Electron microscopy
Valve Adjustments* Subject ID NPH-02 NPH-03 NPH-04 NPH-05 NPH-06 NPH-07 NPH-08 NPH-09 NPH-10 NPH-11 NPH-12 NPH-13 NPH-14 1-Month 2-Month 3-Month Follow-up Follow-up Follow-up 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.5 1.5 1.0 1.0 1.0 1.0 1.5 1.0 0.5 1.0 1.0 8/11/06 8/11/06 1.0 1.0 1.0 8/25/06 9/15/06 9/15/06 9/15/06 1.0 8/11/06 1.0 1.5 8/11/06 1.5 8/25/06 2.0 8/25/06 8/11/06 4+ Month Follow-up
* Initial Valve setting was 1.5 for all subjects # Symptom improvement is patient reported, not clinically measured
NPH-02
1*
NPH-04
2 2# 1#
Dizziness Chest Pain Seizure Heightened emotions Swelling at scalp incision site Headache
Acknowledgements
Roy Hamilton, MD Sunil Patel, MD Joanna Lopinto, RN Anuj Basil, MD Joel Bauman, MD Eric Jackson, MD
LP vs VP shunt
Complications LP: iatrogenic Chiari, overdrainage VP: ICH Revision rate Shunt evaluation
Alternative Treatments
Subtemporal decompression Sagittal sinus shunt Optic nerve sheath fenestration
IIH Conclusions
CSF diversion surgery effective but technically challenging VP shunt with stereotactic guidance may have best outcome, but trial needed Shunt does not always relieve visual problems