PRE- AND POST- SHUNT CEREBRAL PERFUSION MEASURED BY DYNAMIC SUSCEPTIBILITY CONTRAST MRI IN PATIENTS WITH NORMAL PRESSURE HYDROCEPHALUS.

Background: NPH-related dementia is the only surgically manageable dementia. Response to ventricular shunting in NPH is variable. This study aims to establish a possible correlation between the changes in cerebral perfusion with clinical response to shunting. The study group consisted of 20 patients with NPH Methods: diagnoses who underwent ventricular shunting. Pre- and 3-month post- shunt DSC-MRI was done to assess the change in relative cerebral blood ?ow (rCBF). Mean ± SD values of rCBF in frontal grey matter, frontal periventricular white Results: matter, parietal periventricular white matter and hippocampus were 0.91 ± 0.11, 0.61 ± 0.09, 0.47 ± 0.11 and 0.93 ± 0.06 before shunt surgery and 0.98 ± 0.06, 0.70 ± 0.07, 0.54 ± 0.07 and 0.98 ± 0.06 after shunt surgery in NPH patients who responded to shunt surgery; and 0.78 ± 0.17, 0.37 ± 0.14, 0.41 ± 0.11 and 0.89 ± 0.10 before shunt surgery and 0.79 ± 0.14, 0.37 ± 0.19, 0.38 ± 0.09 and 0.84 ± 0.07 after shunt surgery in NPH patients who did not respond to shunt surgery. Therefore, regional rCBF in these regions increased in responders after shunt surgery, with a signi?cant statistical difference (p-value < 0.05) while no signi?cant change was seen in shunt non-responders (p-value > 0.05). There is a correlation between a signi?cant increase in Conclusion: regional rCBF and clinical improvement after shunt surgery

Normal pressure hydrocephalus: an update / Hidrocefalia de pressão normal: uma atualização

ABSTRACT Normal pressure hydrocephalus (NPH) has been a topic of debate since its introduction in publications. More frequent in the elderly population, it is characterized by gait disturbance, urinary urge incontinence and cognitive decline. Therefore, it is a clinical-radiological entity with relatively common findings for the age group, which together may have greater specificity. Therefore, its diagnosis must be careful for an adequate selection of patients for treatment with ventricular shunt, since the symptoms are potentially reversible. The tap test has a high positive predictive value as a predictor of therapeutic response, but a negative test does not exclude the possibility of treatment. Scientific efforts in recent years have been directed towards a better understanding of NPH and this narrative review aims to compile recent data from the literature in a didactic way for clinical practice.

RESUMO A hidrocefalia de pressão normal (HPN) é tema de debate desde sua introdução na literatura. Mais frequente na população idosa, caracteriza-se por distúrbio de marcha, urge-incontinência urinária e declínio cognitivo. Portanto, trata-se de uma entidade clínico-radiológica com achados relativamente comuns para a faixa etária, que em conjunto, podem ter maior especificidade. Sendo assim, seu diagnóstico deve ser criterioso para uma adequada seleção de pacientes para tratamento com a derivação ventricular, uma vez que os sintomas são potencialmente reversíveis. O tap test possui valor preditivo positivo alto preditor de resposta terapêutica, mas um teste negativo não exclui a possibilidade de tratamento. Esforços científicos nos últimos anos têm sido direcionados para melhor entendimento da HPN e essa revisão narrativa se propõe a compilar dados recentes da literatura de forma didática para a prática clínica.

From disease to noninvasive intracranial monitoring / Da doença ao monitoramento intracraniano não invasivo

ABSTRACT Professor Sérgio Mascarenhas was a Brazilian researcher with a vast legacy. His work paved the way for new research possibilities by consolidating the use of innovation and transdisciplinary science. In Medicine, he proposed changes to what had previously been well-accepted concepts, and his contributions have influenced medical practices. Although many authors consider intracranial pressure (ICP) as an unrivaled variable for monitoring and diagnosis of many diseases, its clinical applicability is still the subject of debate in the literature because of the difficulty in standardizing protocols. Mascarenhas's research and the creation of a device for noninvasive monitoring of intracranial compliance are discussed and are shown to have led to the creation of Brain4care, a start-up, and a new perspective on the debate on ICP monitoring.

RESUMO O professor Sérgio Mascarenhas foi um pesquisador com vasto legado. Seu trabalho abriu caminho para novas possibilidades de pesquisa, consolidando o uso da inovação e da ciência transdisciplinar. Na Medicina, ele propôs mudanças no que antes eram conceitos bem-aceitos, e suas contribuições influenciaram a prática médica. Embora muitos autores considerem a pressão intracraniana (PIC) uma variável incomparável para o monitoramento e o diagnóstico de uma série de doenças, sua aplicabilidade clínica ainda é motivo de debate na literatura pela dificuldade de padronização de protocolos. A pesquisa do Professor Mascarenhas e a criação de um dispositivo para o monitoramento não invasivo da complacência intracraniana levaram à criação do Brain4care, uma start-up, e a uma nova perspectiva sobre o debate do monitoramento da PIC.

Feasibility of action observation effect on gait and mobility in idiopathic normal pressure hydrocephalus patients / Viabilidade do efeito de observação da ação na marcha e mobilidade de pacientes com hidrocefalia de pressão normal idiopática

ABSTRACT. Action observation (AO) has been proved to be of benefit in several neurological conditions, but no study has previously been conducted in idiopathic normal pressure hydrocephalus (iNPH). Objective: This study aimed to investigate the feasibility of AO in iNPH patients. Methods: A single-group pretest-posttest design was conducted in twenty-seven iNPH patients. Gait and mobility parameters were assessed using the 2D gait measurement in the timed up and go (TUG) test for two trials before and after immediate AO training. The outcomes included step length and time, stride length and time, cadence, gait speed, sit-to-stand time, 3-m walking time, turning time and step, and TUG. In addition, early step length and time were measured. AO consisted of 7.5 min of watching gait videos demonstrated by a healthy older person. Parameters were measured twice for the baseline to determine reproducibility using the intraclass correlation coefficient (ICC3,1). Data between before and after immediately applying AO were compared using the paired t-test. Results: All outcomes showed moderate to excellent test-retest reliability (ICC3,1=0.51 0.99, p<0.05), except for the step time (ICC3,1=0.19, p=0.302), which showed poor reliability. There were significant improvements (p<0.05) in step time, early step time, gait speed, sit-to-stand time, and turning time after applying AO. Yet, the rest of the outcomes showed no significant change. Conclusions: A single session of AO is feasible to provide benefits for gait and mobility parameters. Therapists may modify this method in the training program to improve gait and mobility performances for iNPH patients.

RESUMO. A observação de ação (OA) teve benefícios comprovados em diversas condições neurológicas, mas nenhum estudo foi conduzido anteriormente em Hidrocefalia de Pressão Normal idiopática (HPNi). Objetivo: O presente estudo teve como objetivo investigar a viabilidade da OA em pacientes com HPNi. Métodos: Um projeto de pré-teste e pós-teste de grupo único foi realizado em 27 pacientes com HPNi. Parâmetros de marcha e mobilidade foram avaliados por meio de parâmetros 2D para a medida da marcha com o teste timed up and go (TUG) com duas tentativas antes e imediatamente depois do OA. Os resultados incluíram comprimento e tempo do passo, comprimento e tempo da passada, cadência, velocidade da marcha, tempo para sentar-e-levantar, tempo de caminhada de 3 metros, tempo de virada e passo, e tempo do teste (TUG). Além disso, o comprimento do passo inicial e o tempo da etapa inicial foram medidos. A OA consistia em assistir 7,5 minutos de vídeos de marcha demonstrados por um idoso saudável. Os parâmetros foram medidos duas vezes para a linha de base para determinar a reprodutibilidade usando o coeficiente de correlação intraclasse (CCI3,1). Os dados entre antes e depois da aplicação imediata de OA foram comparados com o teste t pareado. Resultados: Todos os resultados mostraram confiabilidade teste-reteste moderada a excelente (CCI3,1=0,51 0,99, p<0,05), exceto para o tempo do passo (CCI3,1=0,19, p=0,302), que apresentou confiabilidade pobre. Houve melhorias significativas (p<0,05) no tempo do passo, tempo do passo inicial, velocidade da marcha, tempo sentar-e-levantar e tempo de virar após a aplicação de OA. Os demais resultados não mostraram nenhuma mudança significativa. Conclusões: Uma única sessão de aplicação de OA é viável para proporcionar benefícios aos parâmetros de marcha e mobilidade. Os terapeutas podem modificar esse método no programa de treinamento para obter desempenho de marcha e mobilidade para pacientes com HPNi.

Balance and Stability for Patients with Idiopathic Normal Pressure Hydrocephalus / 中国康复理论与实践

@#Objective:To observe the features of posture control in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods:From May, 2017 to May, 2018, patients with iNPH in our hospital (<italic>n</italic> = 13) and healthy controls (<italic>n</italic> = 15) were measured with sensory organization test on Balance Manager. The balance scores and strategy scores under six conditions were recorded and the comprehensive balance scores were calculated. Results:The balance scores decreased in the patients in the conditions of eyes-open/stable-support, eyes-close/stable-support, eyes-close/unstable-support and eyes-disturb/unstable-support compared with those of the controls (|<italic>Z</italic>| > 2.042, <italic>P</italic> < 0.05), as well as the comprehensive balance scores (<italic>Z</italic> = -3.617, <italic>P</italic> < 0.001); while the strategy scores increased in the conditions of eyes-close/stable-support, eyes-open/unstable-support, eyes-close/unstable-support and eyes-disturb/unstable-support (|<italic>Z</italic>| > 2.333, <italic>P</italic> < 0.05). Conclusion:There are balance disorders in the patients with iNPH, mainly associating with the disorders of proprioceptive and vestibular senses, and application of hip strategy.

Clinical observation of Metazolamide in the treatment of normal pressure hydrocephalus / 中华老年医学杂志

Objective:To study the efficacy and safety of Methazolamide(MTZ)for the treatment of normal pressure hydrocephalus(NPH)patients.Methods:A randomized, double-blind, placebo-controlled, prospective clinical study was conducted in Aviation General Hospital.A total of 35 NPH patients including 29 idiopathic normal pressure hydrocephalus(iNPH)and 6 secondary normal pressure hydrocephalus(sNPH)received drug treatment in our hospital from September 2019 to March 2021.All patients were unsuitable for or refused surgical treatment for some reasons.The patients were divided into drug group(n=18)and control group(n=10), taking oral MTZ or placebo 25 mg twice daily, increasing to 50 mg twice daily after 1 week if there was no discomfort.The 10 m gait score, cognitive function score, brain MRI check were completed before and 1 month after oral administration.The assessment of idiopathic normal pressure hydrocephalus scale(iNPHGS)score were performed 1 month and 3 months after oral administration.The primary efficacy endpoint was iNPHGS score for 3 months treatment and the secondary efficacy endpoint was the assessment of above scales for 1 month treatment.Results:As compared with baseline, the effect of 1 month treatment showed that MOCA scores[(16.2±8.8)and(14.8±8.7)scores, t=-2.68, P=0.02], 10 m gait scores[(22.3±11.2)and(25.6±12.9), t=2.76, P=0.02], iNPHGS scores[(7.3±3.2)and(8.1±3.5), t=4.08, P<0.01]were improved.The effect of 3 month treatment showed that the iNPHGS score(6.1±2.4)was improved compared with baseline( t=5.07, P<0.01)and 1 month( t=4.11, P<0.01). But the above scores of the control group were not significantly improved compared with the baseline(all P>0.05). After 1 month treatment, the 10 m gait score and iNPHGS score in the drug group were improved compared with those in the control group(all P<0.05). After 3 months treatment, the iNPHGS score was improved compared with the baseline level in the control group( t=-4.41, P<0.05). The above 35 patients had no serious adverse reactions such as hypokalemia and acidosis.There was no significant difference in adverse events between the two groups( χ2=0.01, P=1.00). Conclusions:The treatment of MTZ could effectively improve the clinical symptoms of NPH patients with good safety.

Normal pressure hydrocephalus: Diagnostic delay / Hidrocefalia de presión normal: demora en el diagnóstico

Abstract. Introduction: Normotensive hydrocephalus is a differential diagnosis in the evaluation of the dementia syndrome. The diagnostic protocols would allow detecting this pathology that has more effective treatment than other dementias. Objective: To describe a population with clinical suspicion of normal pressure hydrocephalus evaluated in a Colombian psychiatric hospital and discuss the possible reasons for its diagnostic and therapeutic delay. Materials and methods: We conducted a retrospective study of medical records to identify patients with suspected normal pressure hydrocephalus during a 5-year period. Results: Thirty-five patients with suspected normal pressure hydrocephalus underwent diagnostic lumbar puncture and five of them were considered candidates for a peritoneal-venous shunt, but none underwent this surgical procedure. After three to six months of the lumbar puncture, the gait pattern improved in 22.8% of the patients, cognition in 22.8%, and sphincter control in 11.4%. Improvement was not sustained in the long term (1 year) in any of them. Conclusion: This study suggests the poor implementation of the protocols for evaluating patients with cognitive deficits and delays in the diagnosis of normal pressure hydrocephalus. A small number of patients were identified as candidates for treatment. Normal pressure hydrocephalus is a potentially reversible clinical entity with the placement of a peritoneal ventricular shunt, but delays in diagnosis and treatment have deleterious consequences for patients and their families.

Resumen. Introducción. La hidrocefalia normotensiva es un diagnóstico diferencial en la evaluación del síndrome demencial. Los protocolos diagnósticos permitirían detectar esta condición, cuyo tratamiento es más efectivo que el de otras demencias. Objetivo. Describir una población con sospecha clínica de hidrocefalia normotensiva evaluada en un hospital psiquiátrico colombiano y discutir las posibles razones de la demora en el diagnóstico y en la terapia de esta condición clínica. Materiales y métodos. Se hizo un estudio retrospectivo de los registros médicos para detectar pacientes con sospecha de hidrocefalia normotensiva durante un período de cinco años. Resultados. A 35 pacientes con sospecha de hidrocefalia normotensiva se les hizo una punción lumbar diagnóstica. Cinco de ellos se consideraron candidatos para una derivación ventrículo-peritoneal, pero ninguno se sometió a este procedimiento quirúrgico. A los 3-6 meses de la punción lumbar, se observó una mejoría del patrón de la marcha en el 22,8 % de los pacientes, de la cognición en el 22,8 % y del control del esfínter en el 11,4 %. La mejoría no se mantuvo a largo plazo (un año) en ningún paciente. Conclusión. Se encontró una implementación deficiente de los protocolos de evaluación de los pacientes con déficit cognitivos y demoras en el diagnóstico de la hidrocefalia normotensiva, así como un número reducido de pacientes clasificados como candidatos para el tratamiento. La hidrocefalia normotensiva es una condición clínica potencialmente reversible con la colocación de una derivación ventrículo-peritoneal. Los retrasos en el diagnóstico y en el tratamiento tienen consecuencias perjudiciales para los pacientes y sus familias.

Relationships between intracranial compartment volumes and clinical symptoms in patients with idiopathic normal pressure hydrocephalus before and after cerebrospinal fluid shunt surgery / 中华老年医学杂志

Objective To investigate the relationships of intracranial compartment volumes with the severity of clinical symptoms before surgery,and the degree of symptom improvement one year after cerebrospinal fluid(CSF)shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH).Methods Twenty-one patients meeting the diagnosis criteria of international guidelines of iNPH and undergoing CSF shunt surgery in Department of Neurosurgery in our hospital from 2016 to 2017 were included.All patients underwent brain MRI measurement before surgery,and were evaluated by using 3-meter timed up and go test(TUG),minimum mental state examination(MMSE),idiopathic normal pressure hydrocephalus grading scale (iNPHGS) and modified Rankin scale (mRS) before and one year after CSF shunt procedures.The ventricular volume,brain volume,pericerebral CSF volume,total intracranial volume and Evans' index were measured in the pre-operative imaging of the brain.The following four pre-operative intracranial compartment volumes were calculated:the relative ventricular volume,brain volume ratio,pericerebral CSF volume ratio and the ratio of ventricular volume to pericerebral CSF volume.Results The scores of gait,cognitive function and urinary function were improved after surgery in iNPH patients (all P ＜ 0.05).There were no significant difference in the correlation of intracranial compartment volumes(the relative ventricular volume,brain volume ratio,pericerebral CSF volume ratio and the ratio of ventricular volume to pericerebral CSF volume)and Evans' index with the severity of clinical symptoms including gait,cognitive function and urinary function before surgery,and with the degree of symptom improvement one year after surgery in iNPH patients (all P ＞ 0.05).There was no significant difference in intracranial compartment volumes between patients having improvement in mRS,TUG,MMSE and iNPHGS and patients having no improvement one year after surgery in iNPH patients(all P＞0.05).Conclusions Patients with iNPH can benefit from CSF shunt surgery and have improvements of clinical symptoms including gait,cognitive function and urinary function.Preoperative intracranial compartment volumes(the relative ventricular volume,brain volume ratio,pericerebral CSF volume ratio and the ratio of ventricular volume to pericerebral CSF volume)and Evans' index have no correlations with the severity of clinical symptoms before surgery,and have no correlations with the degree of symptom improvement one year after surgery in iNPH patients.For this reason,preoperative intracranial compartment volumes and Evans' index cannot be used to predict whether or not CSF shunt surgery can improve specific clinical symptoms.

Assessment of Relationship between In-hospital Rehabilitation Period after Cerebrospinal Shunt Surgery and Improvement of Gait Disturbance in Idiopathic Normal Pressure Hydrocephalus Patients with Severe Gait Disturbance / The Japanese Journal of Rehabilitation Medicine

Objective：Currently, there is no reliable evidence on the usefulness of rehabilitation for idiopathic, normal-pressure hydrocephalus (iNPH）patients after cerebrospinal shunt surgery. Therefore, in this study we investigated the association between the duration of rehabilitation and outcomes.Methods：We evaluated the changes before and after cerebrospinal shunt surgery and rehabilitation by applying the 3-m timed up-and-go test (TUG), 10-m straight walk test, 180-degree turn, 30-seconds chair-stand test (CS-30), mini-mental state examination (MMSE), and frontal assessment battery (FAB) in 81 patients with iNPH. Clinical outcomes were classified as excellent, good, or unsatisfactory.Results：At discharge, TUG, 180-degree turn, and CS-30 were significantly improved in 38 patients who had been in rehabilitation for ≥2 weeks, compared to those with ＜2 weeks-rehabilitation after shunt surgery. However, there was no significant difference between MMSE and FAB tests in the two groups. Rehabilitation for ≥2 weeks significantly improved the patient outcome, especially for those patients with severe gait disturbance before treatment. In 53 patients whose initial TUG time was ≥13.5 s, rehabilitation for ≥2 weeks was effective, and resulted in an excellent outcome (odds ratio：4.52, 95％ confidence interval：1.22-18.7, P value：0.012).Conclusion：In-hospital rehabilitation after cerebrospinal shunt surgery was useful for patients with iNPH and severe disability in daily activities. Therefore, we suggest that these patients require in-hospital rehabilitation after shunt surgery until sufficient improvement of gait disturbance is achieved, in order to maximize activities of daily living.

Assessment of Relationship between In-hospital Rehabilitation Period after Cerebrospinal Shunt Surgery and Improvement of Gait Disturbance in Idiopathic Normal Pressure Hydrocephalus Patients with Severe Gait Disturbance / The Japanese Journal of Rehabilitation Medicine

Objective：Currently, there is no reliable evidence on the usefulness of rehabilitation for idiopathic, normal-pressure hydrocephalus (iNPH）patients after cerebrospinal shunt surgery. Therefore, in this study we investigated the association between the duration of rehabilitation and outcomes.Methods：We evaluated the changes before and after cerebrospinal shunt surgery and rehabilitation by applying the 3-m timed up-and-go test (TUG), 10-m straight walk test, 180-degree turn, 30-seconds chair-stand test (CS-30), mini-mental state examination (MMSE), and frontal assessment battery (FAB) in 81 patients with iNPH. Clinical outcomes were classified as excellent, good, or unsatisfactory.Results：At discharge, TUG, 180-degree turn, and CS-30 were significantly improved in 38 patients who had been in rehabilitation for ≥2 weeks, compared to those with ＜2 weeks-rehabilitation after shunt surgery. However, there was no significant difference between MMSE and FAB tests in the two groups. Rehabilitation for ≥2 weeks significantly improved the patient outcome, especially for those patients with severe gait disturbance before treatment. In 53 patients whose initial TUG time was ≥13.5 s, rehabilitation for ≥2 weeks was effective, and resulted in an excellent outcome (odds ratio：4.52, 95％ confidence interval：1.22-18.7, P value：0.012).Conclusion：In-hospital rehabilitation after cerebrospinal shunt surgery was useful for patients with iNPH and severe disability in daily activities. Therefore, we suggest that these patients require in-hospital rehabilitation after shunt surgery until sufficient improvement of gait disturbance is achieved, in order to maximize activities of daily living.

Relationships between intracranial compartment volumes and clinical symptoms in patients with idiopathic normal pressure hydrocephalus before and after cerebrospinal fluid shunt surgery / 中华老年医学杂志

Objective@#To investigate the relationships of intracranial compartment volumes with the severity of clinical symptoms before surgery, and the degree of symptom improvement one year after cerebrospinal fluid(CSF)shunt surgery in patients with idiopathic normal pressure hydrocephalus(iNPH).@*Methods@#Twenty-one patients meeting the diagnosis criteria of international guidelines of iNPH and undergoing CSF shunt surgery in Department of Neurosurgery in our hospital from 2016 to 2017 were included.All patients underwent brain MRI measurement before surgery, and were evaluated by using 3-meter timed up and go test(TUG), minimum mental state examination(MMSE), idiopathic normal pressure hydrocephalus grading scale(iNPHGS)and modified Rankin scale(mRS)before and one year after CSF shunt procedures.The ventricular volume, brain volume, pericerebral CSF volume, total intracranial volume and Evans' index were measured in the pre-operative imaging of the brain.The following four pre-operative intracranial compartment volumes were calculated: the relative ventricular volume, brain volume ratio, pericerebral CSF volume ratio and the ratio of ventricular volume to pericerebral CSF volume.@*Results@#The scores of gait, cognitive function and urinary function were improved after surgery in iNPH patients(all P<0.05). There were no significant difference in the correlation of intracranial compartment volumes(the relative ventricular volume, brain volume ratio, pericerebral CSF volume ratio and the ratio of ventricular volume to pericerebral CSF volume)and Evans' index with the severity of clinical symptoms including gait, cognitive function and urinary function before surgery, and with the degree of symptom improvement one year after surgery in iNPH patients(all P>0.05). There was no significant difference in intracranial compartment volumes between patients having improvement in mRS, TUG, MMSE and iNPHGS and patients having no improvement one year after surgery in iNPH patients(all P>0.05).@*Conclusions@#Patients with iNPH can benefit from CSF shunt surgery and have improvements of clinical symptoms including gait, cognitive function and urinary function.Preoperative intracranial compartment volumes(the relative ventricular volume, brain volume ratio, pericerebral CSF volume ratio and the ratio of ventricular volume to pericerebral CSF volume)and Evans' index have no correlations with the severity of clinical symptoms before surgery, and have no correlations with the degree of symptom improvement one year after surgery in iNPH patients.For this reason, preoperative intracranial compartment volumes and Evans' index cannot be used to predict whether or not CSF shunt surgery can improve specific clinical symptoms.

Home physical exercise program: analysis of the impact on the clinical evolution of patients with normal pressure hydrocephalus / Programa de exercícios físicos domiciliares: análise do impacto na evolução clínica de pacientes com hidrocefalia de pressão normal

ABSTRACT Objective: To present a program of home physical exercises for patients with normal pressure hydrocephalus (NPH) and to evaluate adherence, acceptance and applicability; to verify possible changes in patients with NPH in the home physical exercise program, comparing patients with, and without, a ventriculoperitoneal shunt, regarding gait, quality of life, activities of daily living, static and dynamic balance and its impact on the risks of falling. Methods: This was a controlled clinical trial, with assessments in three moments (0, 10 and 18 weeks) at the home, from October 2015 to November 2017. Fifty-two patients (30 women and 22 men) participated in the study. Results: There was a statistically significant improvement with 10 weeks of home physical exercises for the groups with and without ventriculoperitoneal shunt, respectively, in the sub-items: activities of daily living p = 0.032*, p = 0.003*; static balance p < 0.001*, p < 0.001*; functional capacity p < 0.001*, p = 0.027*; and dynamic balance and gait p = 0.009*, p < 0.001*. There was no statistically significant difference for the subitems: quality of life p = 0.695, p = 1.000; and NPH grading scale p = 0.695, p = 1.000, respectively. Conclusion: The developed program of home physical exercise was easily applied and there was good acceptance by most patients with NPH included in the research. There was a statistically significant improvement with the 10 weeks of home physical exercises in the sub-items: activities of daily living, static balance and functional capacity, for both groups. In the sub-item dynamic balance and gait, there was a statistically significant improvement for both groups, but with a higher score for the group with a ventriculoperitoneal shunt. There was no statistically significant difference for the sub-items: quality of life, NPH grading scale and risk of falls, based on the Berg scale.

RESUMO Objetivo: Apresentar um programa de exercícios físicos domiciliares para pacientes com hidrocefalia de pressão normal e avaliar a adesão, aceitação e sua aplicabilidade; verificar possíveis alterações nos pacientes com HPN com o programa de exercícios físicos domiciliares, comparando os pacientes com e sem derivação ventriculoperitoneal, no que diz respeito à marcha, qualidade de vida, atividades de vida diária, equilíbrio estático e dinâmico e sua repercussão nos riscos de queda. Métodos: Trata-se de um Ensaio clínico controlado, com avaliações em três momentos (0.10 e 18 semanas) em nível domiciliar, no período de outubro/2015 a novembro/2017 Participaram do estudo 52 pacientes (30 mulheres e 22 homens). Resultados: Houve melhora estatisticamente significante com as dez semanas de exercícios físicos domiciliares para os grupos sem e com derivação ventriculoperitoneal respectivamente, nos subitens: atividades de vida diária p = 0,032* p = 0.003*, equilíbrio estático p < 0.001*, p < 0.001*; capacidade funcional p < 0.001*, p = 0,027*; equilíbrio dinâmico e marcha p = 0.009*, p < 0.001*. Não houve diferença estatística significante para os subitens: qualidade de vida p = 0,695, p = 1,000 e escala de graduação de HPN p = 0,695, p = 1,000. Conclusão: O programa de exercícios físicos domiciliares desenvolvido mostrou-se de fácil aplicabilidade e houve boa aceitação para a maioria dos pacientes com Hidrocefalia de Pressão Normal inseridos na pesquisa. Houve melhora estatisticamente significante com as dez semanas de exercícios físicos domiciliares nos subitens: atividades de vida diária, equilíbrio estático e capacidade funcional para ambos os grupos. No subitem equilíbrio dinâmico e marcha houve melhora estatisticamente significante para ambos os grupos, mas com escore maior para o grupo com derivação ventriculoperitoneal. Não houve diferença estatisticamente significante para os subitens: qualidade de vida, escala de graduação de Hidrocefalia de Pressão Normal e risco de quedas baseado na escala de Berg.

Salomón Hakim: the man behind normal pressure hydrocephalus / Salomón Hakim: o homem por trás da hidrocefalia de pressão normal

ABSTRACT The illustrious Colombian Professor Salomón Hakim provided the annals of neurology with one of the most brilliant and original bodies of research on record, developing the concept of normal pressure hydrocephalus, as well as proving that ventricular shunting is an effective treatment. Thus, Professor Hakim proved that some of the dementias, at that time considered senile, could be successfully treated. Here the authors present an historical review of his main contributions, which continue to influence the study of dementia to this day.

RESUMO O ilustre professor colombiano Salomón Hakim deixou como legado nos anais da neurologia uma das mais brilhantes e originais séries de pesquisa da história, desenvolvendo o conceito de hidrocefalia de pressão normal, bem como introduzindo a derivação ventricular como tratamento efetivo. Assim, Hakim provou que algumas das demências até então consideradas senis tinham possibilidade de tratamento bem-sucedido. Aqui os autores apresentarão uma revisão histórica de suas maiores contribuições, que continuam a influenciar o estudo de demências até os nossos dias.

Aperfeiçoamento de modelo de estimativa da eficiência de remoção de turbidez da água em floculadores tubulares helicoidais / Model improvement for estimating of water turbidity removal efficiency in helical tubular flocculators

RESUMO Estudos científicos têm demonstrado que os floculadores tubulares helicoidais (FTHs) têm alta eficiência na formação de flocos e baixo tempo de retenção hidráulica, quando comparados aos floculadores comumente usados em tratamento de água e esgoto. No entanto, sua aplicação prática é limitada, pois ainda existe demanda significativa por avanços na compreensão da relação entre a hidrodinâmica da unidade e o processo de floculação, bem como critérios e metodologias para auxiliar em projeto racionais de FTH. Nesse contexto, este estudo teve por objetivo propor um aperfeiçoamento no modelo de estimativa de eficiência de remoção de turbidez apresentado por Oliveira (2014), o qual leva em conta um conjunto de parâmetros geométricos, hidráulicos e hidrodinâmicos relevantes ao processo de floculação nesse tipo de reator, pela incorporação de um dos parâmetros mais representativos de processos de floculação, o gradiente de pressão normal (GPp), como uma de suas variáveis independentes. O desenvolvimento do trabalho empregou dinâmica dos fluidos computacional (CFD) no estudo de 84 configurações de FTH, contemplando regimes de escoamento laminar e turbulento. Como resultado, chegou-se a uma nova versão de modelo de estimativa da eficiência de remoção de turbidez da água que, em relação à versão original: tem menor número de variáveis independentes; apresenta melhor ajuste aos dados experimentais; e é mais simples do ponto de vista operacional.

ABSTRACT Scientific studies have been demonstrating that helical tubular flocculators (HTFs) have high efficiency in floc formation and low hydraulic retention time when compared to flocculators commonly used in water and wastewater treatment. However, its practical application is still limited because there is still a significant demand for advances in the understanding of the relationship between the hydrodynamics of the unit and the flocculation process, as well as for criteria and methodologies in support to the rational design of HTF. In this context, the objective of this study was to propose an improvement in the model of turbidity removal efficiency developed by Oliveira (2014), which takes into account a set of geometric, hydraulic and hydrodynamic parameters relevant to the flocculation process in this type of reactor, by incorporating one of the most representative parameters of flocculation processes, the normal pressure gradient, as one of its independent variables. The development of the work employs computational fluid dynamics (CFD) in the study of 84 HTFs configurations, considering laminar and turbulent flow regimes. As a result, a new model version for estimating water turbidity removal's efficiency in helical tubular flocculators was obtained, which, in relation to the original version, has a smaller number of independent variables, presents better fit to the experimental data and is simpler from the operational point of view.

Normal-pressure hydrocephalus: A critical review / Hidrocefalia de pressão normal: uma revisão crítica

ABSTRACT. Normal-pressure hydrocephalus (NPH) is a potentially reversible syndrome characterized by enlarged cerebral ventricles (ventriculomegaly), cognitive impairment, gait apraxia and urinary incontinence. A critical review of the concept, pathophysiology, diagnosis, and treatment of both idiopathic and secondary NPH was conducted. We searched Medline and PubMed databases from January 2012 to December 2018 using the keywords "normal-pressure hydrocephalus" / "idiopathic normal-pressure hydrocephalus" / "secondary normal-pressure hydrocephalus" / "NPH" / "ventriculoperitoneal shunt". The initial search produced 341 hits. After careful selection, a total of 54 articles were chosen and additional relevant studies were included during the process of writing this article. NPH is an important cause of potentially reversible dementia, frequent falls and recurrent urinary infections in the elderly. The clinical and imaging features of NPH may be incomplete or nonspecific, posing a diagnostic challenge for medical doctors and often requiring expert assessment to minimize unsuccessful surgical treatments. Recent advances resulting from the use of non-invasive MRI methods for quantifying cerebral blood flow, in particular arterial spin-labeling (ASL), and the frequent association of NPH and obstructive sleep apnea (OSA), offer new avenues to understand and treat NPH.

RESUMO. A hidrocefalia de pressão normal (HPN) é uma síndrome potencialmente reversível marcada por ventrículos cerebrais alargados (ventriculomegalia), declínio cognitivo, apraxia da marcha e incontinência urinária. Revisar criticamente o conceito, a fisiopatologia, o diagnóstico e o tratamento da HPN idiopática e secundária. Os autores acessaram as bases de dados Medline e Pubmed entre janeiro de 2012 e dezembro de 2018, utilizando as palavras-chave "normal-pressure hydrocephalus" / "idiopathic normal-pressure hydrocephalus" / "secondary normal-pressure hydrocephalus" / "NPH" / "ventriculoperitoneal shunt". A busca inicial resultou em 341 artigos. Após cuidadosa seleção, 54 estudos foram escolhidos e pesquisas adicionais foram incluídas durante o processo de elaboração do manuscrito. A HPN é uma importante causa de demência potencialmente reversível, quedas frequentes e infecção urinária recorrente em idosos. As características clínicas e de imagem da HPN podem ser incompletas ou inespecíficas, de modo que este se torna um diagnóstico difícil para médicos. Não raro uma avaliação por especialista é necessária, visando minimizar tratamentos cirúrgicos ineficazes. Avanços recentes advindos do uso não invasivo de ressonância magnética para quantificação do fluxo sanguíneo cerebral, em particular arterial spin-labeling (ASL), assim como a usual associação entre HPN e apneia obstrutiva do sono representam novos meios de entender e de tratar a HPN.

Neuropsychiatric manifestations in patient with normal pressure hydrocephalus improved with therapeutic lumbar tapping

Normal pressure hydrocephalus is a communicating hydrocephalus without evident obstruction of the normal pathway of CSF flow. Normal-pressure hydrocephalus is a common cause of reversible dementia and it can also present with various psychiatric symptoms. A 76-year old man was brought to psychiatry OPD with history suggestive of decreased need for sleep for 8 days, disinhibited behaviour, increased libido, increased activity and increased talk for 4 days. On examination patient was noticed to be having increased psychomotor activity with increased talk, mood reported to be happy with elated affect, no content or perceptual disturbances were elicited. Cognitive functions were within normal limits. Personal and social judgement was impaired with grade 0 insight. General physical and systematic examinations were within normal limits. MRI reports showed ventricular enlargement suggestive of normal pressure hydrocephalus. Patient underwent diagnostic and therapeutic lumbar tapping. There was significant improvement in patient’s behavioural symptoms following therapeutic lumbar tapping. Therapeutic lumbar tapping in this case of normal pressure hydrocephalus was effective in the management of manic symptoms. Early identification of organic cause in late onset psychiatric disorders is necessary. Prompt intervention of the organic cause was effective in the management of manic symptoms.

Cerebrospinal Fluid Levels of β-Amyloid 40 and β-Amyloid 42 are Proportionately Decreased in Amyloid Positron-Emission Tomography Negative Idiopathic Normal-Pressure Hydrocephalus Patients

BACKGROUND AND PURPOSE: Cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD) could be misleading in idiopathic normal-pressure hydrocephalus (iNPH). We therefore investigated the CSF biomarkers in 18F-florbetaben amyloid-negative positron-emission tomography (PET) [amyloid PET(−)] iNPH, amyloid-positive PET [amyloid PET(+)] AD, and cognitively normal (CN) subjects. METHODS: Ten amyloid PET(+) AD patients (56.7±5.6 years old, mean±standard deviation), 10 amyloid PET(−) iNPH patients (72.8±4.5 years old), and 8 CN subjects (61.2±6.5 years old) were included. We measured the levels of β-amyloid (Aβ)40, Aβ42, total tau (t-tau) protein, and phosphorylated tau (p-tau) protein in the CSF using enzyme-linked immunosorbent assays. RESULTS: The level of Aβ42 and the Aβ42/Aβ40 ratio in the CSF were significantly lower in AD than in iNPH or CN subjects. The Aβ40 level did not differ significantly between AD and iNPH (p=1.000), but it did between AD and CN subjects (p=0.032). The levels of both t-tau and p-tau were higher in AD than in iNPH or CN subjects. The levels of Aβ42, Aβ40, t-tau, and p-tau were lower in iNPH than in CN subjects, but there was no significant difference after controlling for age. CONCLUSIONS: Our results suggest that the mechanism underlying low CSF Aβ levels differs between amyloid PET(−) iNPH and amyloid PET(+) AD subjects. The lower levels of all CSF biomarkers in iNPH patients might be due to reduced clearances from extracellular fluid and decreased brain metabolism of the periventricular zone in iNPH resulting from glymphatic dysfunction.

Different Outcomes in Two Cases of Idiopathic Normal Pressure Hydrocephalus in the Elderly Living Alone Diagnosed by Internists during Hospitalization / 日本プライマリ・ケア連合学会誌

Idiopathic normal pressure hydrocephalus (iNPH) is a disorder observed in elderly patients causing gait disturbance, urinary incontinence and cognitive impairment. Due to the rapidly aging society, the number of patients with iNPH continues to increase yearly. However, iNPH is often overlooked because of its insidious and variable presentation. In the primary care setting, iNPH can be coincidentally discovered by neuroimaging findings, including disproportionately enlarged subarachnoid space hydrocephalus (DESH). We report two cases of iNPH in the elderly living alone that had different outcomes depending upon the availability of neurosurgery specialists. It is essential for primary care physicians to consult neurosurgeons without delay because prompt diagnosis and treatment can improve the patient's quality of life and prolong their duration of living at home.

Development of the Brazilian Portuguese version of the "Grading scale for idiopathic normal pressure hydrocephalus": cross-cultural adaptation, reliability and validity / Validação da escala de hidrocefalia de pressão normal idiopática para o português brasileiro: aplicação, confiabilidade e validade

ABSTRACT Objective: The current study translated to Portuguese and validated the normal pressure hydrocephalus (NPH) scale originally developed in English as the Grading Scale for Idiopathic Normal Pressure Hydrocephalus. Methods: Following Guillemin's validation protocol, the last version of the Portuguese NPH scale was applied to 121 consecutive patients with a diagnosis of normal pressure hydrocephalus (73 men and 48 women) from the Group of Cerebral Hydrodynamics from July 2010 to March 2012. Results: The mean age was 71.09 years old, ranging from 35 to 92 years. The rate of agreement and reproducibility was high, as confirmed by Cohen's Kappa coefficient, with excellent intraobserver correlation for the NPH scale items individually evaluated: gait (0.80), dementia (0.90) and incontinence (0.87). Conclusions: The Portuguese version of the Grading Scale for Idiopathic Normal Pressure Hydrocephalus was successfully translated and validated for use in Brazilian patients.

RESUMO Objetivos: o presente estudo valida para a língua portuguesa a escala de hidrocefalia de pressão normal (HPN) desenvolvida em língua inglesa como "Escala de classificação para hidrocefalia de pressão normal idiopática". Métodos: Usando o método de Guillemin, uma versão traduzida da escala foi aplicada em 121 pacientes consecutivos com diagnóstico de hidrocefalia de pressão normal (73 homens e 48 mulheres) no Grupo de Hidrodinâmica Cerebral do Hospital das Clínicas da FMUSP de julho de 2010 a março de 2012. Resultados: a média de idade foi de 71,09 anos, variando de 35 a 92 anos. A taxa de concordância e reprodutibilidade foi alta, conforme confirmado pelo coeficiente Kappa, com excelente correlação intraobservador para itens de escala HPN que avaliou a marcha (0,80), demência (0,90) e incontinência (0,87). Conclusões: a versão em português da escala de graduação para pacientes com HPN foi traduzida e validada com sucesso para uso em pacientes brasileiros de ambos os sexos.

Síndrome Neuropsicológico Frontal como Consecuencia de Hidrocefalia de Tensión Normal: estudio de caso / Frontal Neuropsychological Syndrome as a Consequence of Normal Tension Hydrocephalus: a case study

Resumen La manifestación clínica de la Hidrocefalia de Tensión Normal (NPH) implica pérdida del control de esfínter vesical, trastorno de la marcha y deterioro cognitivo. Este estudio buscó describir el estado neuropsicológico funcional de una paciente con NPH a través del análisis sindrómico, aplicando pruebas neuropsicológicas cualitativas y la evaluación de la actividad intelectual. Se evidenciaron dificultades y errores característicos del síndrome frontal severo con predominio de dificultades severas en la regulación y control de la actividad. Se observaron errores sistemáticos derivados de una falta de planeación, de selectividad y de autocrítica, en tareas perceptivas, verbales e intelectuales complejas. En el caso observado, el análisis neuropsicológico cualitativo apoya la afirmación de atrofia cortical con predominio frontal en esta enfermedad.

Abstract The clinical manifestation of Normal Pressure Hydrocephalus (NPH) implies loss of bladder sphincter control, gait disorder and cognitive impairment. The aim of this study is to describe the NPH patient's functional neuropsychological state through a syndromic analysis, applying qualitative neuropsychological tests and assessment of intellectual activity. It is evidenced difficulties and errors, which characterize severe syndrome with self-regulation and control of the activity. In the case of NPH, such syndrome is a consequence of organic frontal damage. Systematic errors derived from a lack of planning, selectivity and self-criticism were observed in complex perceptual, verbal and intellectual tasks. In this case, the qualitative neuropsychological analysis supports the affirmation of a cortical atrophy with frontal predominance in NPH.