Evidence based management of normal pressure hydrocephalus: Lessons and future directions
Mahajan A, Macki M, Kaur M, Novikova M, Shatz R, and Schwalb J. Evidence based management of normal pressure hydrocephalus: Lessons and future directions. Movement Disorders 2018; 33:S410-S412.
Objective: To present the methodology and management tree of patients referred to the Henry Ford NPH conference for an evaluation from 2003 to 2017. Background: The diagnosis of idiopathic NPH may prove to be more challenging. Currently, a clinical triad of cognitive impairment, (Figure presented) gait disability and urinary incontinence, along with a radiological evidence of ventriculomegaly is widely accepted to be sufficient to consider a work up for NPH. Given the prevalence of comorbidities that may confound the clinical picture, an accurate diagnosis is essential for an effective patient centric management plan. (1, 2) To the appropriately selected patient population, timely surgical intervention may provide good clinical benefit. Methods: All patients presented in the multi-disciplinary NPH conference at Henry Ford Health System are prospectively registered in Research Electronic Data Capture (REDCap). The REDCap database was queried for all patients without a previous diagnosis of NPH from 2003-2017. Patients with at least radiographic evidence of ventriculomegly or clinical features of ataxia were discussed in the NPH conference. Our management algorithm with results can be seen in Figure 1-3. An Anticholinergic Cognitive Burden (ACB) score was calculated for each patient. Results: Out of the 316 patients without obstructive hydrocephalus, 149 patients (47%) were identified with alternative diagnoses not necessitating a LP. We further identified 87 patients (28%) with treatable causes, out of which 52% improved with treatment. Of the 142 patients who underwent LP, 40 patients did not improve clinically. Finally, 102 patients were referred for a surgical shunt. ACB score calculated between the non-operative and shunted cohorts did not statistically significantly differ (0.75 vs 0.84, respectively, p=0.672). Conclusions: Our methodology offers a systematic process to assess patients with suspected NPH for appropriate clinical management. Recognition of treatable causes in this patient population is imperative. In our cohort, cervical stenosis, Parkinson's disease and sleep disorders constituted 64% of this subsection. Our data suggests that the prevalence of sleep apnea in patients presenting with a presentation suggestive of NPH is underappreciated. A key confounder to the clinical picture in the elderly is polypharmacy. Our study is unique in that a mean ACB score was taken into account.