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Normal Pressure 
 Hydrocephalus (NPH)

Hydrocephalus is an abnormal excessive accumulation of cerebrospinal fluid in the skull.  This fluid is produced in the cavities of the brain called ventricles.  The purpose is to cushion the delicate brain and spinal cord tissue from injuries, and to carry nutrients and other vital elements necessary for proper brain and body functions. 

Cerebrospinal fluid is produced on a daily basis and carried throughout the brain and body through the tiny tubules that compose the fascial system.  Normally, the body produces a certain amount of fluid everyday and that same amount of fluid is picked up by the fascial system and transported out of the brain into the rest of the body.

When an imbalance occurs, an excess of cerebrospinal fluid builds up resulting in the condition known as hydrocephalus, in which there in increased pressure inside the cranium. If not treated, hydrocephalus will create increased pressure in the skull, putting pressure on the brain, which in turn will result in a variety of symptoms and damage to the brain.

Normal Pressure Hydrocephalus is most common in older adults.  It is an accumulation of cerebrospinal fluid in the ventricles of the brain.  The ventricles become enlarged and press on surrounding brain tissue, but it does not cause increased intracranial pressure.

The enlarged ventricles stretch the nerve tissue of the brain, which causes three primary symptoms. Most people suffering form NPH usually exhibit difficulty in walking, dementia, and urinary incontinence. However, not all people will experience all symptoms.

This condition usually appears in people over the age of 60 years.  Ten percent of people diagnosed with dementia and one quarter million Americans diagnosed with symptoms of dementia, Alzheimer's or Parkinson's may actually be suffering from Normal Pressure Hydrocephalus.

Diagnosis of NPH is difficult because the symptoms are similar to many other disorders and are also often considered "normal" factors in aging.  However, these symptoms are far from "normal" and will progress with time. Many cases are never recognized and go completely untreated.

Gait disturbances range from mild imbalance to total inability to stand or walk.  For most patients, the gait is wide based, and the steps short, slow and shuffling.  People may have trouble picking up their feet and therefore may not be able to navigate stairs or curbs.  This is often the most pronounced symptom of NPH and the first to become apparent.

Mild dementia may be defined as short-term memory loss, forgetfulness, difficulty in routine tasks and a loss of interest in daily activities.  Many people will deny that they are having any problems and not every person with NPH will have obvious mental impairment.

Urinary incontinence may also range from mild to severe.  In mild cases, there may be increased frequency or urgency to urinate, sometimes as often as every one to two hours.  However, in severe cases, there may be a complete loss of bladder control.  In very rare cases, fecal incontinence may also be an issue.

To diagnose normal pressure hydrocephalus, the doctors may perform ultrasound, computerized tomography (CT scan), magnetic resonance imaging (MRI), lumbar puncture (spinal tap), continuous lumbar cerebrospinal fluid (CSF) drainage, intracranial pressure (ICP) monitoring, measurement of cerebrospinal fluid outflow resistance or isotopic cisternography, and neuropsychological testing.

Ultrasound is a device, which uses sound waves to produce a picture that outlines the structures within the skull.

A CT Scan creates a picture of the brain by using x-rays and a special scanner.  It is painless and considered safe and reliable.  An x-ray beam passes through he head, which produces a picture of the brain on a computer screen.  This test can show if the ventricles are enlarged or if there is an obvious blockage.

A MRI is a safe painless test that will take 30 minutes or longer to complete.  It uses radio signals and a very powerful magnet to create a picture of the brain.  It can show if the ventricles are enlarged, as well as evaluate the flow of the cerebrospinal fluid and provide information about the surrounding brain tissue.  A MRI can detect how fast CSF moves through a particular area of the brain called the cerebral aqueduct.  MRI's provide more information than CT Scans, therefore are the test usually used in most cases.  However, patients with pacemakers or other metallic implants cannot have MRI scans.

A spinal tap is a painful procedure done under local anesthetic where a thin needle is passed into the spinal fluid space of the low back to estimate CSF pressure and analysis of the fluid.  Up to 50 cc's of fluid are withdrawn through the needle to see if symptoms are temporarily relieved.  Doctors feel that if removal of some of the CSF dramatically improves symptoms, it indicates surgical implant of a shunt may produce greater success.  However, many people who do not respond to a spinal tap may still have NPH and benefit from less fluid in the ventricles of the brain.

Lumbar catheter insertion is a variation of the spinal tap.  It is the same painful procedure described above, but the needle inserts a thin flexible tube into the spinal fluid.  The needle is removed and the catheter allows for continuous recording of spinal fluid pressure or removal of spinal fluid over several days to simulate the effects of a surgical shunt.  Again, it is considered that patients who respond to this procedure would benefit from the surgical implant of a shunt device.

Intracranial pressure monitoring is done in the hospital.  A small pressure monitor is inserted through the skull into the brain or ventricles to measure the intracranial pressure.  The pressure is not always high, therefore pressure monitoring can detect abnormal patterns of pressure waves.

Measuring CSF outflow resistance is a more involved test that requires a specialized hospital setting. This test is used to determine the degree of blockage to CSF absorption back into the bloodstream.  During the test, the patient receives an infusion of artificial spinal fluid while the cerebrospinal fluid pressure is being measured. If the calculated resistance value is abnormally high, then doctors feel the surgical implant of a shunt will give the patient improvement.

Isotopic cisternography is a procedure in which a radioactive isotope is injected into the lumbar subarachnoid space in the lower back through a spinal tap.  This allows the absorption of CSF to be evaluated with periodic scans over a period of up to 96 hours.  This test shows whether the isotope is being absorbed over the surface of the brain or remains trapped in the ventricles.  It is more involved than a CT or MRI.  Doctors have found that this test is not reliable to determine whether or not a patient will respond to the implant of a shunt.

Neuropsychological testing involves asking the patient a series of questions to determine if there is a loss of brain function due to hydrocephalus.

Most doctors choose to treat NPH patients who show a positive response to one of the above tests is to surgically implant a CSF shunt.  A shunt is a device consisting of a catheter and a valve designed to drain CSF fluid away from the brain to allow the enlarged ventricles to return to a normal state.  As the pressure in the ventricle increases from fluid buildup, a one-way valve in the shunt opens and the excess CSF fluid drains into the abdomen where it is absorbed.

If a fixed pressure valve is inserted, the choice of the correct pressure setting is very important. Under-drainage will not improve symptoms, and over-drainage can cause other symptoms or create problems such as subdural hematoma.  The only way to adjust this type of pressure valve is to remove the original shunt and reposition a new one.

New technology is responsible for programmable valve technology.  With a programmable valve on the shunt, the pressure setting can be adjusted, by the doctor, with a special magnetic programmer in his office.  This type of valve can significantly reduce the probability of further surgery.

Many shunts also have a flexible flushing chamber called a reservoir.  This allows the doctor to remove samples of CSF for testing with just a needle and syringe.  The doctor may also inject fluid into the shunt system to test the flow and functioning of the shunt.

Windsong Therapy and Wellness, uses very specialized manual techniques to open the ventricles and improve fluid flow in the brain and spinal column without invasive procedures. We look at the whole body and consider how repetitive stress may be involved in creating the restrictions in the fluid flow, then educate the patient to prevent a recurrence.  A body that is balanced gains strength much more easily and quickly.  We then concentrate on making the patient aware of their body and giving them tasks to do on a daily basis to improve their ability to function as a whole and resume a rewarding life. 

 

Web resources

http://www.lifenph.com/default.htm

 

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This website last updated on 31 July 2010

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