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1.
Neurol Med Chir (Tokyo) ; 59(12): 498-503, 2019 Dec 15.
Artículo en Inglés | MEDLINE | ID: mdl-31619602

RESUMEN

This study consisted of 29 patients with idiopathic normal pressure hydrocephalus (iNPH) who underwent lumbosubarachnoid-lumboepidural (L-L) shunting under local anesthesia in accordance with our surgical indications of L-L shunting. (1) CSF absorption within the lumbar epidural space and shunt clearance were confirmed in all patients after operation. (2) Shunt responders (R) were 25 of 29 cases (86.2%) 3 months after surgery. Among the R, symptom exacerbation was confirmed in three patients (12%) within the follow-up period (mean, 25.1 months). In each of these patients, shunt function were maintained and remained unchanged even with pressure resetting, the cause being an intracranial/extracranial disease other than iNPH. (3) The initial pressure setting for this method was 8 cmH2O, with gradual change to higher pressures, such that the setting for Patient 11 and thereafter became 20 cmH2O. (4) As postsurgical complications, subcutaneous cerebral spinal fluid collection (SCC) was confirmed in five patients (17.2%). In high-pressure resetting and follow-up observation, SCC was not observed in all patients. Epidural catheter displacement was confirmed in three patients (10.3%). No recurrence was noted after the secure fixation of the catheter at the fascia insertion portion and 2 days' postsurgical bed rest. Hence, L-L shunting is an effective shunt therapy for iNPH.


Asunto(s)
Anestesia Local , Derivaciones del Líquido Cefalorraquídeo/métodos , Hidrocéfalo Normotenso/cirugía , Anciano , Anciano de 80 o más Años , Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Comorbilidad , Espacio Epidural , Femenino , Estudios de Seguimiento , Humanos , Hidrocéfalo Normotenso/diagnóstico por imagen , Región Lumbosacra/diagnóstico por imagen , Masculino , Complicaciones Posoperatorias/etiología , Espacio Subaracnoideo , Evaluación de Síntomas , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
2.
Neurol Med Chir (Tokyo) ; 59(7): 281-286, 2019 Jul 15.
Artículo en Inglés | MEDLINE | ID: mdl-31118357

RESUMEN

A total of 482 operated idiopathic normal pressure hydrocephalus (iNPH) patients were divided into those aged <80 years at the time of surgery (group A: 400 cases; and male-to-female ratio, 259:141) and ≥80 years (group B: 82 cases; male-to-female ratio, 43:39) and comparatively investigated based on the following variables: (1) temporal changes in shunt efficacy rates, and (2) temporal changes in each symptom, including the patient's fall frequency and preoperative modified Rankin Scale (mRS) score and during follow-up at 3, 6 months, 1-4 years postoperatively. (1) The shunt efficacy rates at 3 months and 4 years postoperatively were 93% and 82%, respectively, in group A and 92.3% and 70.7%, respectively, in group B. This demonstrates a decrease in shunt efficacy at 4 years postoperatively, regardless of the persistence of shunt function or adjustments in setting pressure. This trend was particularly observed in group B. In group A, 41 (9.8%) cases had decreased efficacy rate, compared with 21 (25.6%) cases in group B, which occurred due to complications with an extracranial or intracranial disease. (2) Gait disturbance (G) and urinary incontinence (U) showed signs of improvement in the early postoperative stage, while dementia (D) and mRS score began to gradually improve from 6 months postoperatively. Patient's fall frequency tended to become higher until 6 months postoperatively than the preoperative rate. In group A, symptom improvement was comparatively maintained until 4 years postoperatively, while in group B, all symptoms and mRS tended to gradually deteriorate beginning at 3 years postoperatively.


Asunto(s)
Derivaciones del Líquido Cefalorraquídeo , Hidrocéfalo Normotenso/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Hidrocéfalo Normotenso/complicaciones , Masculino , Persona de Mediana Edad , Evaluación de Síntomas , Factores de Tiempo , Resultado del Tratamiento
3.
Neurol Med Chir (Tokyo) ; 47(7): 299-306; discussion 306, 2007 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-17652915

RESUMEN

This study was conducted to elucidate the pathologic conditions of cerebral circulatory disorders in idiopathic normal pressure hydrocephalus (iNPH). Among 44 possible iNPH patients, 40 patients underwent shunt surgery based on diagnostic flow charts plotted by the Southern Tohoku method and were evaluated to be shunt-effective at the end of the first post-surgical month. The cerebral blood flow (CBF) was measured by N-isopropyl-((123)I)-P-iodo-amphetamine single photon emission computed tomography (mean, mCBF; cortical region, cCBF; thalamus-basal ganglia region, tbCBF on autoradiography [ARG] method) and the perfusion patterns of the cerebral cortex were measured based on three-dimensional stereotactic surface projection (3D-SSP) Z-score images, before and 1 month after the surgery in all 40 subjects. The mCBF rose significantly from 32.1 +/- 2.74 ml/100 g/min before surgery to 39.8 +/- 3.02 ml/100 g/min after surgery (p < 0.03). Investigation of the change of CBF revealed reductions in the cCBF (3 cases), tbCBF (9 cases), and cCBF + tbCBF (28 cases), with the reduced-cCBF group totaling 31 cases and the reduced-tbCBF group totaling 37 cases. Investigation of cerebral cortex hypoperfusion by 3D-SSP Z-score revealed 31 cases with hypoperfusion (frontal lobe type [19 cases], occipitotemporal lobe type [5 cases], mixed type [7 cases]) and nine cases with cortical normoperfusion (N). The pattern of reduction of the cortical blood flow on ARG method was favorably correlated with the pattern of hypoperfusion of the cerebral cortex on 3D-SSP Z-score images before surgery. A reduction of blood flow was found in the thalamus-basal ganglia region of all N type cases. The blood flow improved in 19 of 31 (61.3%) cases of the reduced-cCBF group and in 32 of 37 (86.5%) cases of the reduced-tbCBF group. All of the cases without detectable improvement exhibited increased blood flow in non-reduction areas. Investigation of the hypoperfusion patterns of the cerebral cortex on 3D-SSP Z-score images, revealed a reduction or disappearance of the hypoperfusion site in 19 of 31 (61.3%) cases, either no-change or a shift of the hypoperfusion site in 12 of 31 (38.7%) cases, and a correlation between the pattern of cortical blood flow reduction on ARG method and the pattern of cerebral cortex hypoperfusion on 3D-SSP Z-score images after surgery. Cerebral circulatory disorders in iNPH manifest as either of two pathophysiological conditions: the "circulatory disorder of the cerebral cortical region" and the "circulatory disorder of the thalamus-basal ganglia region." Various patterns develop according to the disease stage.


Asunto(s)
Derivaciones del Líquido Cefalorraquídeo , Circulación Cerebrovascular/fisiología , Trastornos Cerebrovasculares/fisiopatología , Hidrocéfalo Normotenso/complicaciones , Anciano , Trastornos Cerebrovasculares/complicaciones , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos Cerebrovasculares/terapia , Árboles de Decisión , Femenino , Humanos , Hidrocéfalo Normotenso/fisiopatología , Hidrocéfalo Normotenso/cirugía , Masculino , Persona de Mediana Edad , Tomografía Computarizada de Emisión de Fotón Único
4.
No Shinkei Geka ; 35(8): 773-9, 2007 Aug.
Artículo en Japonés | MEDLINE | ID: mdl-17695775

RESUMEN

PURPOSE: To clarify the patterns of improvement of pre- and post-operative symptoms and family satisfaction in patients with definite idiopathic normal pressure hydrocephalus (iNPN) who responded well to shunt intervention. SUBJECTS AND METHODS: The subjects included 40 patients definitively diagnosed with iNPH and who were followed up for one year or longer (age, 61-85; male-to-female ratio, 18: 22). The study focused on (1) preoperative clinical symptoms, (2) improvements in symptoms at 1, 3, 5, and 12 months after surgery, and the satisfaction of the families based on medical results of the Zarit caregiver burden interview, and infomation through questionnaires to medical personnel. RESULTS: (1) The major symptoms were gait disturbance (G, n=38), dementia (D, n=10), and urinary incontinence (U, n=23). G and D appeared as initial symptoms in 30 and 10 cases, respectively. (2) The rates of postoperative improvement at 1, 3, 5, and 12 months were 94.7%, 94.7%, 97.4%, and 94.7% for G, 43.8%, 62.5%, 71.9%, and 84.4% for D, and 78.3%, 86.96%, 86.96%, and 91.3% for U, respectively. G and U cases improved during the postoperative early stage, and D improved gradually from after the third postoperative month. The family satisfaction before surgery and at 1, 3, 5, and 12 months after surgery was 72.5 +/- 12.8, 68.1 +/- 15.4, 55.7 +/- 9.6, 52.9 +/- 11.4, and 47.3 +/- 7.9 points, respectively. The rate of improvement in satisfaction was higher for D. The satisfaction of the medical personnel was 88 percent (+) at 1 month and tended to remain high for 12 months. CONCLUSION: (1) Preoperative gait disturbance is a major initial symptom in definitively diagnosed iNPN. (2) Postoperative improvement of G and U is obtained at an early stage. In contrast, D tends to improve gradually from after the third postoperative month. The family satisfaction increases as the symptom of D improve. The satisfaction of the medical personnel tends to remain high after the first postoperative month. This study investigated the results of quantitative analyses of the patients symptoms.


Asunto(s)
Familia/psicología , Hidrocéfalo Normotenso/psicología , Hidrocéfalo Normotenso/cirugía , Satisfacción del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Cuidadores/psicología , Femenino , Estudios de Seguimiento , Humanos , Hidrocéfalo Normotenso/fisiopatología , Masculino , Cuerpo Médico/psicología , Persona de Mediana Edad , Periodo Posoperatorio , Encuestas y Cuestionarios , Resultado del Tratamiento
5.
No Shinkei Geka ; 33(6): 579-84, 2005 Jun.
Artículo en Japonés | MEDLINE | ID: mdl-15952306

RESUMEN

PURPOSE: To compare the cerebrospinal fluid (CSF) outflow resistance values (Ro) with epidural pressure (EDP) monitoring and lumbar subarachnoid CSF pressure (L-CSFP) monitoring. SUBJECTS AND METHODS: The subjects were 14 patients with possible iNPH (age: 59-74 years old, ratio of male and female 8:6). All the patients were subjected to an infusion test by a single bolus injection method (1 ml/sec., deltaV: 5 ml, t2: 2 min) as prescribed in the Standard of SINPHONI. EDP was monitored by continuous monitoring and the L-CSFP values By intermittent simple glass tube method (SINPHONI) were measured simultaneously. The Ro (RoEDP, RoL-CSFP) calculated from both methods, (1) the correlation of Ro and (2) the Ro threshold in a shunt effective group (E: nine cases) and a non effective group (NE, five cases) were compared. RESULTS: (1) Although a favorable correlation was found between both Ro measurements (r=0.784), the RoEDP was always higher than the RoL-CSFP. (2) The mean Ro values in the E and NE groups were 36.8 +/- 15.7 mmHg/ml/min, and 10 +/- 2.05 mmHg/ml/min for Ro-EDP, 22.1 +/- 13.95 mmg/ml/min and 6.4 +/- 1.7 mmHg/ml/min for RoL-CSFP, respectively. The approximate thresholds in the E and NE groups were 15 mmHg/ml/min for RoEDP and 10 mmHg/ml/min for RoL-CSFP. CONCLUSION: (1) Although the RoEDP is always higher than the RoL-CSFP, a favorable correlation is found between the RoEDP and RoL-CSFP, (2) The Ro thresholds of the E and NE groups in the infusion test are about 15 mmHg/ml/min for RoEDP and 10 mmHg/ml/min for RoL-CSFP. (3) After this, Ro calculation ought to execute by standard of SINPHONI and the Ro threshold of the E and NE groups is about 10 mmHg/ml/min.


Asunto(s)
Presión del Líquido Cefalorraquídeo/fisiología , Hidrocéfalo Normotenso/fisiopatología , Presión Intracraneal/fisiología , Anciano , Espacio Epidural , Femenino , Humanos , Hidrocéfalo Normotenso/cirugía , Vértebras Lumbares , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Derivación Ventriculoperitoneal
6.
No To Shinkei ; 57(4): 306-12, 2005 Apr.
Artículo en Japonés | MEDLINE | ID: mdl-15948403

RESUMEN

PURPOSE: The purpose of this study was to investigate the significance of the shunt-effect evaluation of SPECT in idiopathic normal pressure hydrocephalus (iNPH). SUBJECTS AND METHODS: The subjects were 15 patients with possible iNPH, aged 62-83 (mean 75.3, the ratio of males to females to 6:9), who were treated at our department during the period from June to September, 2004. All patients received the lumbar tap test (LTT) at the outpatient section before surgery. An L-P shunt was conducted on patients whose the LTT positive or negative with cerebrospinal fluid outflow resistance value (Ro) was 10 mmHg/ml/min. or higher patients. As for SPECT, a 3D-SSP Z-score, as well as an mCBF, was conducted before and after the LTT and within one month after surgery. Comparisons were made for (1) the shunt effect, (2) mCBF before and after the LTT and after surgery, (3) mean cerebral blood flow increase rate (mIR) after the LTT, and (4) 3D-SSP before and after surgery. RESULTS: (1) The shunt was effective for all the patients. (2) The mCBF levels was 30.8 +/- 4.02 ml/100 g/min. before the LTT, 37.1 +/- 100 g/min. after the LTT, and 38.6 +/- 3.4 ml/100 g/min. after surgery. A significant increase in mCBF was observed both after the LTT and after surgery (p < 0.05). (3) The mean mIR after the LTT was 21.2 +/- 8.01%, with all the patients showing 10% or higher. (4) The ischemic patterns in the SD-SSP Z-score before surgery were the frontal type (F: 10 cases, 66.7%), the occipitotemporal type (OT: 3 cases, 20%), and the mixed type (M: 2 cases, 13.3%), but not the parietal localized type. The post-operative course showed no-change in 4 cases, disappearance-reduction in 9 cases, and shift to OT in 2 cases. CONCLUSION: The evaluation factors in the measurement of the cerebral blood flow for evaluation of the shunt effect were the following two items. (1) The mIR of mCBF after the LIT was 10% or higher. (2) As for the preoperative cerebral ischemic patterns, there were many F cases and no parietial localized types found.


Asunto(s)
Presión del Líquido Cefalorraquídeo/fisiología , Derivaciones del Líquido Cefalorraquídeo , Hidrocéfalo Normotenso/cirugía , Tomografía Computarizada de Emisión de Fotón Único , Anciano , Anciano de 80 o más Años , Circulación Cerebrovascular , Femenino , Humanos , Hidrocéfalo Normotenso/fisiopatología , Masculino , Persona de Mediana Edad
7.
No Shinkei Geka ; 30(5): 495-501, 2002 May.
Artículo en Japonés | MEDLINE | ID: mdl-11993172

RESUMEN

PURPOSE: To clarify the usefulness of glycerol-induced cerebral blood flow measurement (G-CBF) as a method for prognostic evaluation of an asymptomatic unruptured cerebral aneurysm (AUCA). SUBJECTS AND METHODS: Fifty-three patients (age: 26-72 years; ratio of males to females, 23: 30; 56 AUCAs) who were found to have an AUCA(s) on brain checkup at our hospital and then received treatment (direct or intravascular surgery) were the subject of our study. The patients underwent the N-type psychofunction test (NPT) and G-CBF. As the control group, G-CBF was also performed on 50 subjects (age: 36-73 years; ratio of males to females, 27; 23), who were found, by brain checkup, to have no intracranial disease. We investigated (1) the occurrence of post-treatment complications (symptoms/psychofunctional disorders) in the treated group, and compared (2) G-CBF between the complication-developing group, the non-complication-developing group, and the control group. RESULTS: (1) Complications were observed in 9 patients (17%), including convulsions in 2 patients, hemiparalysis in 1, disorientation in 3. Psychofunctional disorders (less than 80 points on the NPT score) were observed in all of the 9 patients developing complications, but could be determined as higher brain dysfunctions only in the 3 patients with disorientation. (2) The mean cerebral blood flow (mCBF) before glycerol administration was 34.17 +/- 4.82 ml/100 g/min in the complication-developing group, 32.41 +/- 7.29 ml/100 g/min in the non-complication-developing group, and 31.98 +/- 5.04 ml/100 g/min in the control group, showing no significant intergroup differences. The mean increased rate of cerebral blood flow (mIR) after glycerol administration was 7.05 +/- 3.96%, 23.63 +/- 5.5%, and 30.64 +/- 13.08%, respectively, showing a significantly lower increase in the complication-developing group (p < 0.01), particularly low in the frontal lobe. Paradoxical flow reactivity was observed in 2 patients, both of whom were in the complication-developing group. CONCLUSIONS: (1) The complication-developing group showed a significantly lower pre-treatment mIR (less than 10%), particularly low in the frontal lobe, (2) Paradoxical flow reactivity was observed only in the complication-developing group. (3) G-CBF was very useful for prognostic evaluation prior to the treatment of AUCA.


Asunto(s)
Circulación Cerebrovascular , Glicerol , Aneurisma Intracraneal/cirugía , Adulto , Anciano , Femenino , Humanos , Aneurisma Intracraneal/fisiopatología , Masculino , Persona de Mediana Edad , Pronóstico
8.
No Shinkei Geka ; 32(3): 247-55, 2004 Mar.
Artículo en Japonés | MEDLINE | ID: mdl-15148799

RESUMEN

PURPOSE: To improve the diagnostic precision of the lumbar tap test (LTT). SUBJECTS AND METHODS: Thirty one patients (mean age, 65.4 years; male to female ratio, 12:19) suspected of having idiopathic normal pressure hydrocephalus (INPH) were used in the study. They underwent LTT (20-30 ml of cerebrospinal fluid was drained through a puncture with a 18 G needle; evaluation within 3 days after LTT). Based on changes in symptoms after LTT, including dementia (evaluated according to the duration of time needed to accomplish No. 7 items in the N method psychofunction test) and gait disturbance (evaluated according to the duration and the number of steps needed to walk 4 m in a straight line), mean cerebral blood flow (mCBF) monitored with 133Xe-CT, and electroencephalographic topography (EEG-T). The patients were divided into symptom-improved [LTT (+)] and no change [LTT(-)] groups. Changing patterns of EEG-T and mCBF after LTT and the efficacy of V-P shunt at 1 month after shunt administration (effective: E; non-effective: NE) were analyzed and compared. Changing patterns of EEG-T and mCBF after LTT were categorized as improvement of both parameters (type A), that of mCBF only (type B), that of EEG-T only (type C), and no change in either parameter (type D). RESULTS: (1) Twenty patients were classified as LTT(+) and eleven as LTT(-). (2) The false positive rate was 25% (5/20) for LTT(+); the false negative rate was 27.3% (3/11) for LTT (-). (3) In all the patients, in relation to changing patterns of EEG-T and mCBF, 100% of type A patients (9/9), 75% of type B (6/8), 42.9% of type C (3/7), and 0% of type D (0/7) responded to shunting. (4) Increased rates (IR) of mCBF in 17 patients with improvement of mCBF were 24.2 +/- 10.6% in E patients and 8.9 +/- 5.2% in NE patients, demonstrating a significantly higher percentage in E patients (p < 0.005). The borderline of IR between E and NE was around 15%. CONCLUSION: (1) Although quantitative evaluation of symptoms (dementia and gait disturbance) before and after LTT, 27.3% of false negative and 25% of false positive were recognized. (2) According to changing patterns of EEG-T and mCBF after LTT, all type A patients responded to shunting (E), whereas type D patients were all categorized as NE. (3) When the IR of mCBF was 15% or more after LTT, such patients all responded to shunting. (4) The diagnostic precision of LTT in efficacy evaluation is improved when this test is combined with EEG-T and mCBF, in addition to quantitative evaluation of symptoms.


Asunto(s)
Circulación Cerebrovascular , Electroencefalografía/métodos , Hidrocéfalo Normotenso/diagnóstico , Punción Espinal/métodos , Anciano , Femenino , Humanos , Hidrocéfalo Normotenso/fisiopatología , Hidrocéfalo Normotenso/cirugía , Masculino , Derivación Ventriculoperitoneal
9.
Neurol Med Chir (Tokyo) ; 53(9): 638-43, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-24067779

RESUMEN

The objective of the study is to introduce the surgical procedure of the lumbosubarachnoid-lumboepidural (L-L) shunting performed as treatment for idiopathic normal-pressure hydrocephalus (iNPH) and its follow-up. The subjects were five patients with probable iNPH (aged 78-85 years; mean age 81 years; four males and one female) who were judged to be at high risk from general or lumbar anesthesia due to their systemic complications and age. The L-L shunt operation was performed for all the patients under local anesthesia using Codman-Hakim Programmable Valve(®) (Codman & Shurtleff, Inc., Raynham, Massachusetts, USA). The initial pressure for all patients was set at 8 cmH2O. The evaluation of shunt efficacy and the lumbar epidural space cerebrospinal fluid (CSF) absorption test (injection of contrast media into epidural space) were performed both on the operation day and during follow-up period (9-12 months). The shunt operation was judged to be effective in four out of five patients (regarded as shunt responders), whereas no improvement in symptoms was seen in one patient (regarded as shunt nonresponder) where the shunting had no effect after the initial pressure was changed to 4 cmH2O. The lumbar epidural space CSF absorption test both on the operation day and during the follow-up period confirmed absorption in all patients. The L-L shunting is useful for patients with probable iNPH who are at high risk from general or lumbar anesthesia due to their systemic complications and age. CSF was continuously absorbed in the lumbar epidural space during postoperative follow-up period. A longer follow-up is required to establish this surgical procedure.


Asunto(s)
Derivaciones del Líquido Cefalorraquídeo/métodos , Hidrocéfalo Normotenso/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Hidrocéfalo Normotenso/diagnóstico por imagen , Hidrocéfalo Normotenso/etiología , Masculino , Radiografía , Resultado del Tratamiento
10.
Neurol Med Chir (Tokyo) ; 48 Suppl: S1-23, 2008.
Artículo en Inglés | MEDLINE | ID: mdl-18408356

RESUMEN

With the rapid aging of Japanese society, medical care of the elderly has become an important social issue. Among various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, normal pressure hydrocephalus (NPH), especially of idiopathic type (iNPH), is becoming noteworthy. The Guidelines for management of iNPH in Japan are created in compliance with the evidence-based medicine methods and published in 2004. This English version is made to show the diagnosis and treatment of iNPH with reference to the socio-medical background in Japan and to promote the international research on iNPH. They propose three diagnostic levels; possible, probable, and definite. They indicate the diagnostic importance of high convexity tightness and dilated sylvian fissure with mild to moderate ventriculomegaly on coronal magnetic resonance imaging. The cerebrospinal fluid tap test is regarded as an important diagnostic test because of its simplicity to perform and high predictability of the shunt efficacy. The use of programmable valves at shunt surgeries is recommended. Flowcharts for diagnosis, preoperative assessment, and prevention for complications of shunt surgery are made to promote a wide use of them.


Asunto(s)
Hidrocéfalo Normotenso , Neurocirugia , Actividades Cotidianas , Anciano , Envejecimiento/fisiología , Acueducto del Mesencéfalo/patología , Ventrículos Cerebrales/patología , Derivaciones del Líquido Cefalorraquídeo , Demencia/diagnóstico , Demencia/epidemiología , Trastornos Neurológicos de la Marcha/diagnóstico , Trastornos Neurológicos de la Marcha/epidemiología , Humanos , Hidrocéfalo Normotenso/diagnóstico , Hidrocéfalo Normotenso/epidemiología , Hidrocéfalo Normotenso/cirugía , Complicaciones Intraoperatorias/prevención & control , Japón , Imagen por Resonancia Magnética , Pruebas Neuropsicológicas , Neurocirugia/instrumentación , Neurocirugia/métodos , Cuidados Preoperatorios , Índice de Severidad de la Enfermedad , Punción Espinal , Incontinencia Urinaria/diagnóstico , Incontinencia Urinaria/epidemiología
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