Elsevier

Surgical Neurology

Volume 53, Issue 3, March 2000, Pages 201-207
Surgical Neurology

Hydrocephalus
The Dutch Normal-Pressure Hydrocephalus Study: How to select patients for shunting? AN ANALYSIS OF FOUR DIAGNOSTIC CRITERIA

https://doi.org/10.1016/S0090-3019(00)00182-8Get rights and content

Abstract

BACKGROUND

Comparison of the predictive value of four “diagnostic tests” for the outcome of shunting in patients with normal-pressure hydrocephalus (NPH).

METHODS

Ninety-five NPH patients who received shunts were followed for 1 year. Gait disturbance and dementia were quantified by an NPH scale and handicap by a modified Rankin scale. Primary outcome measures were differences between the preoperative and last scores on both the NPH scale and the modified Rankin scale. Clinical and computed tomographic (CT) findings typical of NPH, absence of cerebrovascular disease, and a resistance to outflow of cerebrospinal fluid (CSF) ≥ 18 mmHg/ml/minute were designated as a positive test outcome; clinical and CT findings compatible with NPH, presence of cerebrovascular disease, and an outflow resistance < 18 mmHg/ml/minute as a negative test outcome.

RESULTS

For each of the four tests the percentage of patients classified as improved was significantly greater for those with positive than with negative test results. Measurement of CSF outflow resistance was the only significant prognostic factor for the improvement ratio in NPH scale and CT in the modified Rankin scale according to multivariate logistic regression analysis. The accurate predictive value of the combination of typical clinical and CT findings was 0.65, that of the positive test results of outflow resistance, clinical and CT findings was 0.74.

CONCLUSION

The best strategy is to shunt NPH patients if their outflow resistance is ≥ 18 mmHg/ml/minute or, when the outflow resistance is lower, if their clinical as well as their CT findings are typical of NPH.

Section snippets

Measurement of gait disturbance and dementia

Gait disturbance was quantified by a gait scale that evaluates the presence of 10 features of gait and measures the number of steps and seconds required for a 10-meter walk (range, 2–40). Dementia was assessed by means of a dementia scale comprising the 10-word test, digit span forwards and backwards, trail making, and finger tapping (range, 4–40). Both scales are described in detail elsewhere [14]. To create one neurological outcome measure the scores for gait and dementia were added, yielding

Results

A summary of the primary outcome measures for the negative and positive outcome of each test is given in Table 1. The proportion of patients classified as improved was significantly greater for those with positive than with negative test results. The highest percentage of shunt responders in the NPH scale was found for patients with an Rcsf measurement ≥ 18 mmHg/ml/minute. CT yielded the largest difference between positive and negative test outcomes in the Rankin scale. The number of patients

Clinical and computed tomographic findings

Because only patients with a diagnosis of NPH were eligible for our study, the classification of their clinical and CT findings as compatible with or typical of NPH requires explanation. Both the clinical and CT diagnoses of NPH are notoriously difficult. The gait disturbance, for instance, has specific features such as a wide-based, apraxic gait with small steps and feet appearing glued to the floor. On the other hand, NPH gait resembles in many ways the aspecific senile gait disorder with

Acknowledgements

This study was supported by grants from the Dr. Ed. Hoelen Stichting and an anonymous foundation.

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