From the Guidelines
Normal pressure hydrocephalus (NPH) after stroke is a serious complication that can lead to significant morbidity and mortality if left untreated, with potential complications including gait disturbance, urinary incontinence, and cognitive decline. The prognosis for NPH after stroke varies significantly depending on several factors, including the duration of symptoms before treatment, advanced age, significant comorbidities, and extensive cerebrovascular disease 1. Early diagnosis and treatment with ventriculoperitoneal (VP) shunt surgery generally offers the best outcomes, with approximately 60-80% of patients showing improvement in at least one symptom domain 1. Some key points to consider in the management of post-stroke NPH include:
- Gait disturbance typically responds best to shunting, followed by urinary symptoms, while cognitive improvements may be less dramatic
- Factors that negatively affect prognosis include longer duration of symptoms before treatment, advanced age, significant comorbidities, and extensive cerebrovascular disease
- Without treatment, NPH typically progresses gradually, leading to worsening symptoms and increased disability
- Regular follow-up is essential after shunt placement to monitor for potential shunt complications such as infection, obstruction, or overdrainage, which occur in approximately 30% of cases
- Physical therapy and cognitive rehabilitation are important adjuncts to surgical management to maximize functional recovery It is essential to note that the management of elevated intracranial pressure (ICP) in patients with intracerebral hemorrhage (ICH) is often performed, but the decision to monitor and treat elevated ICP is unclear due to limited published data 1. However, in the context of post-stroke NPH, early diagnosis and treatment with VP shunt surgery is the most effective way to improve outcomes and reduce morbidity and mortality.
From the Research
Normal Pressure Hydrocephalus Post Stroke Possible Complications
- Normal pressure hydrocephalus (NPH) is a potentially reversible syndrome characterized by enlarged cerebral ventricles, cognitive impairment, gait apraxia, and urinary incontinence 2
- The management of NPH is difficult due to uncertain diagnosis and significant risk associated with shunt surgery 3
- Possible complications of NPH include severe gait disturbance, intellectual impairment, and bladder disturbances 4, 5
Prognosis
- Patients with severe preoperative symptoms have a higher risk of poor quality of life and severe gait disturbance after shunt surgery 5
- Disease duration from onset to shunt surgery is not significantly associated with postoperative symptom severity or unimproved symptoms 5
- The tap test scores can accurately predict shunt efficacy, and indications for shunt surgery should be carefully assessed in each patient with NPH 5
- Acetazolamide administration test may be useful in selecting patients for shunt operation, as it can indicate the response to shunt surgery 6
Treatment Options
- Shunt surgery is a common treatment option for NPH, but it carries significant risks and uncertainties 3, 5
- Acetazolamide may be an alternative to shunting in some cases, with clinical response observed even in severe cases 4
- Non-invasive MRI methods, such as arterial spin-labeling (ASL), may offer new avenues to understand and treat NPH 2