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iNPH with parkinsonism: response to lumbar CSF drainage and ventriculoperitoneal shunting

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Abstract

Objectives

To evaluate clinical response after external lumbar drainage (ELD) and ventriculoperitoneal shunting (VPS) in a cohort of patients with idiopathic normal pressure hydrocephalus associated with parkinsonism (iNPH-P), considering parkinsonism as clinical primary outcome.

Methods

Patients underwent long-term 72-h intracranial pressure-controlled CSF ELD. Clinical motor response before and after ELD was evaluated using changes in UPDRS-ME as outcome measure. A standardized cognitive assessment was also performed. iNPH-P patients who underwent VPS were clinically followed-up after surgery.

Results

Fourteen iNPH-P patients (age: 69.3 ± 11.6 years) were studied. The time of evaluation after ELD removal was 3.5 ± 1.8 days. We observed a significant motor improvement after the drainage in eight (57.1%) patients. Percent clinical motor response was 18.4 ± 6.7%. Twelve (85.7%) patients underwent VPS. Nine patients were examined after surgery at 31.6 ± 7 months. Four (44.4%) patients presented a clinically detectable improvement in motor response after VPS. No significant changes in cognitive performances were detected.

Conclusions

A clinically detectable motor response on parkinsonian signs was observed in a consistent part of iNPH-P patients few days after ELD as well as over two and half years after VPS. Parkinsonism should be considered as outcome measure for the clinical management of patients with iNPH-P.

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Data availability statement

Data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Hakim S, Adams AR (1965) The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci 2:307–327

    CAS  PubMed  Google Scholar 

  2. Jaraj D, Rabiei K, Marlow T, Jensen C, Skoog I, Wikkelsø C (2014) Prevalence of idiopathic normal-pressure hydrocephalus. Neurology 82:1449–1454

    PubMed  PubMed Central  Google Scholar 

  3. Currà A, Pierelli F, Gasbarrone R et al (2019) The ventricular system enlarges abnormally in the seventies, earlier in men, and first in the frontal horn: a study based on more than 3,000 scans. Front Aging Neurosci 11:294

    PubMed  PubMed Central  Google Scholar 

  4. Missori P, Currà A (2015) Progressive cognitive impairment evolving to dementia parallels parieto-occipital and temporal enlargement in idiopathic chronic hydrocephalus: a retrospective cohort study. Front Neurol 6:15

    PubMed  PubMed Central  Google Scholar 

  5. Halperin JJ, Kurlan R, Schwalb JM, Cusimano MD, Gronseth G, Gloss D (2015) Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 85:2063–2071

    PubMed  PubMed Central  Google Scholar 

  6. Grasso G, Torregrossa F, Leone L, Frisella A, Landi A (2019) Long-Term efficacy of shunt therapy in idiopathic normal pressure hydrocephalus. World Neurosurg 129:e458-463

    PubMed  Google Scholar 

  7. Giannini G, Palandri G, Ferrari A et al (2019) A prospective evaluation of clinical and instrumental features before and after ventriculo-peritoneal shunt in patients with idiopathic Normal pressure hydrocephalus: the bologna PRO-hydro study. Parkinsonism Relat Disord 66:117–124

    PubMed  Google Scholar 

  8. Mihalj M, Dolić K, Kolić K, Ledenko V (2016) CSF tap test—obsolete or appropriate test for predicting shunt responsiveness? A systemic review. J Neurol Sci 362:78–84

    PubMed  Google Scholar 

  9. Malm J, Kristensen B, Karlsson T, Fagerlund M, Elfverson J, Ekstedt J (1995) The predictive value of cerebrospinal fluid dynamic tests in patients with the idiopathic adult hydrocephalus syndrome. Arch Neurol 52:783–789

    CAS  PubMed  Google Scholar 

  10. Marmarou A, Bergsneider M, Klinge P, Relkin N, Black PM (2005) The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery 57(3 Suppl):S17–S28

    PubMed  Google Scholar 

  11. Wikkelsø C, Hellström P, Klinge PM, Tans JTJ, European iNPH Multicentre Study Group (2013) The European iNPH Multicentre Study on the predictive values of resistance to CSF outflow and the CSF Tap Test in patients with idiopathic normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 84:562–568

    PubMed  Google Scholar 

  12. Walchenbach R, Geiger E, Thomeer RT, Vanneste JA (2002) The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 72:503–506

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Schniepp R, Trabold R, Romagna A et al (2017) Walking assessment after lumbar puncture in normal-pressure hydrocephalus: a delayed improvement over 3 days. J Neurosurg 126:148–157

    PubMed  Google Scholar 

  14. Molde K, Söderström L, Laurell K (2017) Parkinsonian symptoms in normal pressure hydrocephalus: a population-based study. J Neurol 264:2141–2148

    PubMed  PubMed Central  Google Scholar 

  15. Broggi M, Redaelli V, Tringali G et al (2016) Normal pressure hydrocephalus and parkinsonism: preliminary data on neurosurgical and neurological treatment. World Neurosurg 90:348–536

    PubMed  Google Scholar 

  16. Kang K, Jeon JS, Kim T et al (2016) Asymmetric and upper body Parkinsonism in patients with idiopathic normal-pressure hydrocephalus. J Clin Neurol Seoul Korea 12:452–459

    Google Scholar 

  17. Akiguchi I, Ishii M, Watanabe Y et al (2008) Shunt-responsive parkinsonism and reversible white matter lesions in patients with idiopathic NPH. J Neurol 255:1392–1399

    PubMed  Google Scholar 

  18. Relkin N, Marmarou A, Klinge P, Bergsneider M, Black PM (2005) Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 57(3 Suppl):S4–S16

    PubMed  Google Scholar 

  19. Evans WA (1942) An encephalographic ratio for estimating ventricular enlargment and cerebral atrophy. Arch Neurol Psychiatry 47:931–937

    Google Scholar 

  20. Postuma RB, Berg D, Stern M et al (2015) MDS clinical diagnostic criteria for Parkinson’s disease. Mov Disord 30:1591–1601

    PubMed  Google Scholar 

  21. Kubo Y, Kazui H, Yoshida T et al (2008) Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus. Dement Geriatr Cogn Disord 25:37–45

    PubMed  Google Scholar 

  22. Folstein MF, Folstein SE, McHugh PR (1975) ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198

    CAS  PubMed  Google Scholar 

  23. Dubois B, Slachevsky A, Litvan I, Pillon B (2000) The FAB: a frontal assessment battery at bedside. Neurology 55:1621–1626

    CAS  PubMed  Google Scholar 

  24. Uttl B, Graf P (1997) Color-word stroop test performance across the adult life span. J Clin Exp Neuropsychol 19:405–420

    CAS  PubMed  Google Scholar 

  25. Marra C, Gainotti G, Scaricamazza E, Piccininni C, Ferraccioli M, Quaranta D (2013) The multiple features target cancellation (MFTC): an attentional visual conjunction search test. Normative values for the Italian population. Neurol Sci 34:173–180

    CAS  PubMed  Google Scholar 

  26. Carlesimo GA, Caltagirone C, Gainotti G (1996) The Mental Deterioration Battery: normative data, diagnostic reliability and qualitative analyses of cognitive impairment. The Group for the Standardization of the Mental Deterioration Battery. Eur Neurol 36:378–384

    CAS  PubMed  Google Scholar 

  27. Novelli G, Papagno C, Capitani E, Laiacona M (1986) Tre test clinici di ricerca e produzione lessicale. Taratura su sogetti normali. [Three clinical tests to research and rate the lexical performance of normal subjects.]. Arch Psicol Neurol Psichiatr 47:477–506

    Google Scholar 

  28. Yamada S, Ishikawa M, Miyajima M, SINPHONI-2 Investigators (Appendix) et al (2017) Disease duration: the key to accurate CSF tap test in iNPH. Acta Neurol Scand 135:189–196

    CAS  PubMed  Google Scholar 

  29. El Ahmadieh TY, Wu EM, Kafka B et al (2019) Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients. J Neurosurg 132:306–312

    PubMed  Google Scholar 

  30. Ko PW, Lee HW, Kang K (2017) Frontal assessment battery and cerebrospinal fluid tap test in idiopathic normal-pressure hydrocephalus. Eur Neurol 77:327–332

    PubMed  Google Scholar 

  31. Pujari S, Kharkar S, Metellus P, Shuck J, Williams MA, Rigamonti D (2008) Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol NeurosurgPsychiatry 79:1282–1286

    CAS  Google Scholar 

  32. Curran T, Lang AE (1994) Parkinsonian syndromes associated with hydrocephalus: case reports, a review of the literature, and pathophysiological hypotheses. Mov Disord 9:508–520

    CAS  PubMed  Google Scholar 

  33. Lenfeldt N, Larsson A, Nyberg L et al (2008) Idiopathic normal pressure hydrocephalus: increased supplementary motor activity accounts for improvement after CSF drainage. Brain 131:2904–2912

    PubMed  Google Scholar 

  34. Haslinger B, Erhard P, Kämpfe N et al (2001) Event-related functional magnetic resonance imaging in Parkinson’s disease before and after levodopa. Brain 124:558–570

    CAS  PubMed  Google Scholar 

  35. Ouchi Y, Nakayama T, Kanno T, Yoshikawa E, Shinke T, Torizuka T (2007) In vivo presynaptic and postsynaptic striatal dopamine functions in idiopathic normal pressure hydrocephalus. J Cereb Blood Flow Metab 27:803–810

    CAS  PubMed  Google Scholar 

  36. Nakayama T, Ouchi Y, Yoshikawa E, Sugihara G, Torizuka T, Tanaka K (2007) Striatal D2 receptor availability after shunting in idiopathic normal pressure hydrocephalus. J Nucl Med 48:1981–1986

    CAS  PubMed  Google Scholar 

  37. Haan J, Thomeer RT (1998) Predictive value of temporary external lumbar drainage in normal pressure hydrocephalus. Neurosurgery 22:388–391

    Google Scholar 

  38. Marmarou A, Young HF, Aygok GA et al (2005) Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients. J Neurosurg 102:987–997

    PubMed  Google Scholar 

  39. Panagiotopoulos V, Konstantinou D, Kalogeropoulos A, Maraziotis T (2005) The predictive value of external continuous lumbar drainage, with cerebrospinal fluid outflow controlled by medium pressure valve, in normal pressure hydrocephalus. Acta Neurochir (Wien) 147:953–958

    CAS  Google Scholar 

  40. Espay AJ, Narayan RK, Duker AP, Barrett ET, de Courten-Myers G (2008) Lower-body parkinsonism: reconsidering the threshold for external lumbar drainage. Nat Clin Pract Neurol 4:50–55

    PubMed  Google Scholar 

  41. Governale LS, Fein N, Logsdon J, Black PM (2008) Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Neurosurg 63(4 Suppl 2):379–384

    Google Scholar 

  42. Lenfeldt N, Hauksson J, Birgander R, Eklund A, Malm J (2008) Improvement after cerebrospinal fluid drainage is related to levels of N-acetyl-aspartate in idiopathic normal pressure hydrocephalus. Neurosurgery 62:135–141

    PubMed  Google Scholar 

  43. Tarnaris A, Toma AK, Chapman MD et al (2009) The longitudinal profile of CSF markers during external lumbar drainage. J Neurol Neurosurg Psychiatry 80:1130–1133

    CAS  PubMed  Google Scholar 

  44. Leinonen V, Menon LG, Carroll RS et al (2011) Cerebrospinal fluid biomarkers in idiopathic normal pressure hydrocephalus. Int J Alzheimers Dis 2011:312526

    PubMed  PubMed Central  Google Scholar 

  45. Lenfeldt N, Hansson W, Larsson A, Birgander R, Eklund A, Malm J (2012) Three-day CSF drainage barely reduces ventricular size in normal pressure hydrocephalus. Neurology 79:237–242

    PubMed  Google Scholar 

  46. Singer OC, Melber J, Hattingen E et al (2012) MR volumetric changes after diagnostic CSF removal in normal pressure hydrocephalus. J Neurol 259:2440–2446

    PubMed  Google Scholar 

  47. Ivkovic M, Reiss-Zimmermann M et al (2015) MRI assessment of the effects of acetazolamide and external lumbar drainage in idiopathic normal pressure hydrocephalus. Fluids Barr CNS 12:9

    Google Scholar 

  48. Mahr CV, Dengl M, Nestler U et al (2016) Idiopathic normal pressure hydrocephalus: diagnostic and predictive value of clinical testing, lumbar drainage, and CSF dynamics. J Neurosurg 125:591–597

    CAS  PubMed  Google Scholar 

  49. Yang F, Hickman TT, Tinl M et al (2016) Quantitative evaluation of changes in gait after extended cerebrospinal fluid drainage for normal pressure hydrocephalus. J Clin Neurosci 28:31–37

    PubMed  Google Scholar 

  50. Gallina P, Lastrucci G, Caini S, Di Lorenzo N, Porfirio B, Scollato A (2018) Accuracy and safety of 1-day external lumbar drainage of CSF for shunt selection in patients with idiopathic normal pressure hydrocephalus. J Neurosurg 1:1–7

    Google Scholar 

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Author notes

  1. Giovanni Mostile, Giacomo Portaro these authors have equally contributed to this work.

Authors and Affiliations

  1. Department “G.F. Ingrassia”, Neurology Clinic, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy

    Giovanni Mostile, Giacomo Portaro, Antonina Luca, Roberta Manna, Roberta Terranova, Alessandra Nicoletti & Mario Zappia

  2. Department “G.F. Ingrassia”, Neurosurgery Clinic, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy

    Francesco Certo, Roberto Altieri & Giuseppe Maria Vincenzo Barbagallo

Authors
  1. Giovanni Mostile
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  2. Giacomo Portaro
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Corresponding author

Correspondence to Mario Zappia.

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The authors declare that they have no conflict of interest.

Ethics approval

this retrospective study was approved by the Local Ethics Committee. It strictly included standardized clinical information recorded during patients’ diagnostic work-up and follow-up visits.

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Written informed consent was obtained.

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Mostile, G., Portaro, G., Certo, F. et al. iNPH with parkinsonism: response to lumbar CSF drainage and ventriculoperitoneal shunting. J Neurol 268, 1254–1265 (2021). https://doi.org/10.1007/s00415-020-10267-x

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  • DOI: https://doi.org/10.1007/s00415-020-10267-x

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