Clara

A fantastic comprehensive review article w/ everything you need to know about Idiopathic Normal-Pressure Hydrocephalus just dropped in the NEJM. Hydrocephalus refers to a condition where cerebrospinal fluid accumulates excessively in the brain’s ventricles, resulting in enlarged chambers that contribute to disrupting walking, cognition and bladder control. Johnson and Williams describe in their new New England Journal of Medicine paper that idiopathic normal-pressure hydrocephalus is a common, frequently missed and potentially reversible neurologic condition in older adults. Key Points: -Idiopathic normal-pressure hydrocephalus presents w/ a triad of gait and balance changes, urinary urgency and cognitive slowing, however each feature has an extensive differential diagnosis on its own. - Prognostic testing w/ cerebrospinal fluid drainage or infusion methods improves selection of candidates who are likely to benefit from shunt surgery. - Programmable cerebrospinal fluid shunt systems remain the most effective treatment and can improve gait quality of life and survival when used in appropriately selected folks. My take: Nailing the diagnosis is so important in iNPH, and it is frequently a tricky endeavor for even an experienced clinician. One thing I would add to this article is that a fair number of folks with 'big ventricles' actually have Parkinson's disease, so don't forget considering the possibility of a levodopa trial in select persons who present for shunting. Here are 5 points that resonated w/ me: 1- Recognizing the gait pattern is essential because a wide-based slow shuffling walk frequently precedes memory or bladder issues and can be the earliest clue. 2- Imaging matters ,however it is not enough since enlarged ventricles alone do not confirm the diagnosis and this finding needs to be paired w/ symptoms and w/ testing. 3- A large-volume lumbar puncture can help by temporarily improving walking, which usually signals a higher likelihood of responding to a shunt. 4- Shunt surgery can meaningfully improve daily function, especially the gait and fall risk. Importantly, it should be performed at experienced centers using adjustable valves. 5- Delays in diagnosis can worsen outcomes because waiting too long may reduce the chance of symptom improvement and increase long-term disability. nejm.org/doi/full/10.1056/NE… @NEJM @movedisorder @FixelInstitute @UF @SfNtweets @ParkinsonDotOrg @PdAvengers @DBSThinkTank

To shunt or not to shunt, that is the (NPH) question? The first large randomized trial of shunting for normal pressure hydrocephalus (NPH) just dropped in NEJM, and there was clear benefit for walking, and it favored the group receiving shunts. Spoiler alert: Walking improved, however thinking (cognition) and bladder function did not. Key Points: - NPH is a condition usually presenting in older adults where fluid builds up in the brain and it associated w/ trouble walking, memory and thinking challenges as well as bladder incontinence. - Shunting significantly improved walking speed and balance compared w/ placebo. - No meaningful change in cognition or bladder control observed at 3 months. - Risks included subdural bleeding and headaches, underscoring the need for careful follow up. My take: NPH has always been a tricky area for clinicians when trying to decidr 'to shunt or not to shunt.' Here are 5 points that resonated w/ me: 1- Shunting in well selected persons can restore some walking ability in NPH. 2- Thinking did not improve at 3 months. 3- Incontinence showed no clear benefit. 4- Risks to always discuss w/ people considering shunts should include bleeding and headaches (as not uncommon). 5- Walking gains may possibly reduce falls and boost independence, however we must be careful as sometimes improved walking w/o improved balance, can actually trigger falls. nejm.org/doi/full/10.1056/NE… @FixelInstitute @ParkinsonDotOrg @alzassociation @SfNtweets @SfNtweets @NEJM