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tricular system in comparison to the degree of cortical atrophy judged by the CT and MRI appearance Various unwieldy formulas have been designed to assess this ratio Some guidelines relating the ventricular span to the outcome of treatment are given below MRI may show some degree of transependymal egress of water surrounding the ventricles, but this is not always the case, and this sign is sometimes dif cult to differentiate from the periventricular white matter change that is ubiquitous in the elderly Monitoring of CSF pressure over a prolonged period may show intermittent rises of pressure, possibly corresponding to the A waves of Lundberg, but this is not practical in most cases According to Katzman and Hussey, the infusion of normal saline into the lumbar subarachnoid space at a rate of 076 mL/min for 30 to 60 min provokes a rise in pressure (300 to 600 mmH2O) that is not observed in normal individuals Theoretically, this test should quantitate the adequacy of CSF absorption, but it too has yielded unpredictable results Whether derivatives of these infusion and pressure trend monitoring tests are valuable is doubtful in our view Drainage of large amounts of CSF (20 to 30 mL or more) by lumbar puncture often results in clinical improvement in stance and gait for a few days, although this change is usually not evident for many hours or more after the spinal tap As mentioned, objective improvement in gait after spinal drainage is one practical way to select patients for shunt operations when the clinical picture is not entirely clear but the test is by no means infallible When there has been doubt as to the effects of lumbar puncture we have admitted the patient to the hospital and inserted a lumbar drain for 3 days, draining approximately 50 mL of CSF daily and observing the response in gait and mentation It is worthwhile to quantify the speed and facility of gait two or three times before the lumbar.

Figure 30-3 CT scan of a patient with normal-pressure hydrocephalus There is enlargement of all the ventricles, particularly of the frontal horns of the lateral ventricles (left), which is roughly disproportionate to the cortical atrophy (right) Various formulas have been devised to quantitate this disporportion, but they are dif cult to apply and they are only variably accurate

changed Training material will be needed to make the transition to the BI 70 environment consistent and straightforward

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puncture or drainage and to perform this testing at periodic intervals for several days after the procedure in order to be certain that improvement is genuine Even more persuasive is a de nite improvement followed days later by worsening of gait As a group, patients who have a sustained response to drainage of CSF by shunting, as described below, have had the rst two elements of the clinical triad (only half of our successfully treated patients have been incontinent), and their lateral ventricular span at the level of the anterior horns was in excess of 50 mm (a true dimension calculated from CT scans), equivalent to approximately 18 mm on the usual CT lm, and at the same time, relatively little cerebral atrophy Treatment of Hydrocephalus in Adults The development of ventricular shunt tubing with one-way valves opened the way to successful treatment of hydrocephalus The valve can be set at a desired opening pressure, allowing the CSF to escape directly into the bloodstream (ventriculoatrial shunt), peritoneal cavity (ventriculoperitoneal shunt), or pleural space whenever the pressure level is exceeded Gratifying success can be obtained, often a complete or nearly complete restoration of mental function and gait, by the placement of such shunts Regarding NPH, the most consistent improvement has been attained in that minority of patients in whom a cause could be established (subarachnoid hemorrhage, chronic meningitis, or tumor of the third ventricle) As already noted, other predictors of success are considerable enlargement of the ventricles in comparison to the degree of cortical atrophy, CSF pressures above 155 mmH2O, and improvement after spinal puncture, but none of these is entirely dependable Deviations from the characteristic syndrome such as the occurrence of dementia without gait disorder or the presence of apraxias, aphasias, and other focal cerebral signs should lead one to a diagnosis other than NPH Fisher, on analyzing successfully shunted cases, noted that almost without exception gait disturbance was an early and prominent symptom Uncertainties of diagnosis increase with advancing age owing to the frequent association of degenerative dementia and vascular lesions However, in Fisher s experience, age alone does not exclude the existence of NPH as a cause of gait disorder, and long duration of symptoms does not preclude a salutary outcome from shunting In patients who are averse to the shunting procedure or who have medical conditions that make the surgery inadvisable, it is sometimes possible to produce a reasonable improvement in gait for several months by repeating the spinal puncture and drainage of large amounts of uid every few weeks or months The potential failure of shunting must be anticipated in patients who do not conform to the typical syndrome or whose disease has advanced to the stage of long-standing incontinence or dementia In some instances, a lack of improvement is explained by inadequate decompression, which justi es a revision of the shunt with a valve that drains at lower pressures Overdrainage, in contrast, causes headaches that may be chronic or orthostatic and may be associated with small subdural collections of uid These uid collections, or hygromas, consisting of CSF and proteinacious uid derived from blood products, are generally innocuous and do not require drainage unless they enlarge or cause focal neurologic symptoms or, rarely, seizures Some surgeons prefer to insert an externally programmable valve that allows adjustments if the ventricles do not reduce in size or if the opposite, overdrainage, occurs Although shunting is relatively simple as a surgical procedure, it is associated with complications, the main ones being a postop-.

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