– Tagesanzeiger (German) by Martina Frei | English translation by Quang Thai –
Too much cerebrospinal fluid of the so-called normal pressure hydrocephalus condition leads to symptoms, that resemble Alzheimer and Parkinson.
First signs of this condition appeared two years ago, as Beat H.* fell during a skiing trip and couldn’t get up again by himself. Slowly but certain, his way of walking became unsteady. In addition to that, he battled with incontinence. «My doctor didn’t know what to do with these symptoms», says H.
Also Urs W.* walks more and more unsecure, even with the support of a wheeled walker. He fell frequently, «even while seating, I fell over», the 74 years old man remembers. So eventually, he spent most of his time in bed. Moreover, his short-term memory deteriorated. Now W. is doing better. He went hiking in Graubünden in summer, takes care of his grandchildren and remembers everything again. All this is thank to his third doctor who he consulted after two years of agony and who correctly diagnosed his condition. His family physician and a neurologist did not find the exact diagnosis.
Lennart Stieglitz, a neurosurgeon at the University Hospital of Zürich presumes that both seniors are no isolated incidences. Stieglitz thinks that there may be several hundreds if not over a thousand seniors in the state of Zürich alone, who suffer this form of dementia. With a early and correct diagnosis, these cases could have been averted. Projected for the entire country of Switzerland, there could be as many as over 20’000 such cases with seniors over 65 years of age.
With this kind of disorder, which H. as well as W. are afflicted with, there is an enlargement of the cavity within the brain, where the cerebrospinal fluid flows. This fact can be confirmed with CT- and MRI images. A possible local circulatory disruption in the brain can occur.
According to Stieglitz’s experiences, family physicians do not take this condition of the normal pressure hydrocephalus very often into consideration. A short survey with randomly chosen physicians shows that three are aware of this disease and the other physicians have some or no idea about it. No wonder, because this kind of dementia is not well known. The numbers vary massively, from less than 1 person out of 100’000 and up to six per 100 inhabitants – the older the higher the number.
«The clearist indications are the gaid disorder and the drop of mental abilities», says the behavioral neurologist Karen Wachter, the head the Swiss center for behavioral neurology at the State Hospital Aarau. Both indications can also appear in other diseases, which are far more often diagnoses, for example dementia caused by vascular damages or with Parkinson.
A straddle-legged way of walking
«Are you able to follow a flying bird passing by, without being unsteady while walking?», Stieglitz asks the patients. Those with normal pressure hydrocephalus have often difficulties with it. A straddle-legged way of walking, where the feet are close to the ground as if «glued» to it, is a typical sign. Similarly, a 180° turn can be problematic. Affected patients require at least four steps. Mental abilities such as attention, concentration and agility decrease noticeably.
A crucial test for the diagnosis: doctors release some cerebrospinal fluid from the channel of the spinal cord. If the symptoms improve then the probability is high that the patient suffers from normal pressure hydrocephalus and may benefit from such an invasive procedure. «After that it got immediately better», Beat H. remembers.
«Even with this drainage attempt, there is no one hundred percent certainty», says Luigi Mariani, chief physician of the neurosurgery clinic at the University Hospital of Basel. «There are patients, who respond positively to the drainage and the treatment turned to be futile. And there are others, who didn’t respond well to the drainage attempt and still gained from such a procedure.»
The Treatment is based on a procedure that takes approximately 45 minutes. The neurosurgeon puts a thin tube between the cerebral ventricle and the abdominal cavity. With a valve he will be able to program this shunt through the skin. It should drain as much cerebrospinal fluid as it is required for a recovery. «Around 75 percent of the patients with normal pressure hydrocephalus respond well to this procedure», says Stieglitz. The results are usually better, the fewer secondary disorders a patient has.
In literature there are certainly reports on considerably poorer results. Inquired by the news agency Tagesanzeiger, several geriatricians doubt the benefit of this shunt and the abundance of this disorder. «The difficulty is that these symptoms often don’t have one single root cause. Therefore, it must be thoroughly evaluated who truly benefits from such a shunt surgery. For that, a strong collaboration among the specialists is necessary», argues the geriatrician Sacha Beck, physician in charge of the University Clinic for acutgeriatry at the City Hospital Waid in Zürich.
Who is right? «This discussion is still on-going», says Mariani. «One group believes, the normal pressure hydrocephalus procedure can help many patients if it is screened early enough. The opposing group is convinced that with such a invasive, and to a certain extend, risky treatment, the gain is minimal.» In fact, every fourth shunt has to be checked within five years. One of the complications is blockage of the drainage. However, this leads rarely to infections or cerebral haemorrhage.
«Generally, geriatricians get in contact with patients at a late stage of their conditions», Karen Wachter puts into perspective. «Early treatment improves the symptoms by three quarter of the patients with normal pressure hydrocephalus. Is the disorder already progressive, the benefits are clearly lower.»
In order to figure out who is right a study is needed, where the patients are either treated or only observed, says Mariani. For that the affected patients must be identified. This is what Stieglitz wants to do: with some colleagues he has developed two simple questionnaires for nursing personnel and family physicians, to help them with the diagnosis. The neurosurgeon want to test them shortly. If proved successful, in future patients with normal pressure hydrocephalus will be identified quicker.
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Wissen | Die Demenz, die gar keine ist