What are the criteria for predicting improvement in normal pressure hydrocephalus (NPH) with shunting?

Updated: Jun 04, 2018
  • Author: Stephen L Nelson, Jr, MD, PhD, FAACPDM, FAAN, FAAP; Chief Editor: Jasvinder Chawla, MD, MBA  more...
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Answer

Criteria exist for predicting improvement with shunting in NPH, but they are controversial.

  • If gait disturbance precedes mental deterioration, the chance of improvement is 77%. Patients with dementia and no gait disturbance rarely respond to shunting.

  • Focal impingement of corpus callosum on MRI indicates unstable ICP and is associated with a good response to shunting.

  • Initial OP of CSF greater than 100 mm H2 O predicts better response.

  • Response to a single LP or to controlled CSF drainage via lumbar subarachnoid catheter (ELD) has some value in predicting outcome.

  • Cerebral blood flow of 32 mL/100 g per minute or greater predicts clinical improvement after shunt.

  • CSF pressure of 180 mm H2 O with frequent Lundberg B waves on continuous CSF pressure monitoring is associated with good prognosis after shunting. Lundberg B waves represent an accentuation of physiological phenomena, reflecting arterial waves. They represent fluctuating ICP waves of 4-8 per minute frequency and 20-30 mm Hg (260-400 mm H2 O) amplitude. Occasionally they can occur in normal sleep.

  • Large ventricles with flattened or invaginated sulci (entrapped sulci) suggest that hydrocephalus is not due to atrophy alone. These patients have good prognosis with shunting.

  • If isotopic cisternography shows persistent ventricular activity on a late scan (42-72 h), the probability of improving with shunting is 75%.


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