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Sunday, 1 December 2013

Hydrocephalus - Diagnosis

Hydrocephalus, also known as "water in the brain" is defined as complex and multifactorial neurological disorders of accumulation of cerebrospinal fluid (CSF) in the cavity of brain of that can lead to intracranial pressure inside the side, resulting of brain trauma, stroke, infection, tumor, etc.
According to Dr. Michael Kiefer and the research team, in the study of the Differential Diagnosis and Treatment of Normal-Pressure Hydrocephalus suggested that
B.1. Diagnosis according to patient impairement
1. For patient of Gait impairment, differential diagnosis include the Characteristics of Externally rotated posture of the feet, Particular difficulty turning on the body’s long axis and Absence of apraxia.

2. For patients with Cognitive deficits/dementia, aside from reactive depression (without depressive thought content), patients with NPH generally do not have any psychiatric abnormalities. Thus, changes of mood, personality, and behavior steer the differential diagnosis toward a neurodegenerative disorder of another type. An objective examination should be performed with the aid of specific psychometric tests for the assessment of subcortical frontal lobe deficits.

Some suitable tests of this type are :
2.1 The grooved pegboard test
2.2. The Stroop test
2.3. The digit span test
2.4. The trail-making A/B test
2.5. The Rey auditory-verbal learning test
3. For patients with Incontinence 
Disturbances of bladder function in NPH result from detrusor hyperactivity owing to the partial or total absence of central inhibitory control. Patients initially suffer from increased urinary frequency (e42e44); later developments are urge incontinence and, finally, permanent urinary incontinence. Fecal incontinence is rare in NPH (2) and should arouse suspicion of another type of neurodegenerative disease. If present in a patient with NPH, it implies severe frontal subcortical dysfunction.
CSF shunting can improve bladder dysfunction in as many as 80% of iNPH patients if performed early, but in no more than 50% to 60% if performed in an advanced stage of the disease (e15, e20, e45).
4. NPH and other neurodegenerative disorders
 Findings that make NPH less likely      
4.1. Asymmetrical findings    
4.2. Cortical deficits, e.g., aphasia, apraxia, paresis     
4.3. Progressive dementia without gait disturbance     
4.5. Lack of progression of symptoms
B.2. General Diagnosis and tests 
1.  Computerized tomography (CT) or magnetic resonance imaging (MRI)
Either computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain is necessary—yet, alone, never sufficient to establish the diagnosis of NPH.
2. Invasive diagnostic testing
The aim of the tests is needed to raise the prognostic accuracy above 80%
2.1. Spinal tap test: lumbar puncture with the removal of 30 to 70 mL of CSF. This can be repeated on two or three consecutive days
2.2. Continuous spinal drainage of 150 to 200 mL of CSF per day for 2 to 7 days (1– 2)
If the number of steps taken in a 10 m gait test, and the time needed to walk 10 m, are reduced by at least 20%, and/or psychometric tests show an improvement of at least 10%.
3. Other invasive tests
Long-term ICP measurement for 24 to 72 hours is performed in no more than a few centers. Special pressure waves and brain pulse amplitudes are measured Such techniques are not recommended for routine use, both because their predictive value has not yet been sufficiently documented and because they require specialized equipment and expertise.