Gait Apraxia and Hakim's Disease: A Historical Review.

In 1965, Prof. Salomón Hakim described, for the first time, a condition characterized by normal pressure hydrocephalus and gait alterations. During the following decades, definitions such as "Frontal Gait", "Bruns' Ataxia" and "Gait Apraxia" have been frequently used in pertinent literature in the attempt to best define this peculiar motor disturbance. More recently, gait analysis has further shed light on the typical spatiotemporal gait alterations that characterize this neurological condition, but a clear and shared definition of this motor condition is still lacking. In this historical review, we described the origins of the terms "Gait Apraxia", "Frontal Gait" and "Bruns' Ataxia", starting with the first works of Carl Maria Finkelburg, Fritsch and Hitzig and Steinthal during the second half of the 19th century and ending with Hakim's studies and his formal definition of idiopathic normal pressure hydrocephalus (iNPH). In the second part of the review, we analyze how and why these definitions of gait have been associated with Hakim's disease in the literature from 1965 to the present day. The definition of "Gait and Postural Transition Apraxia" is then proposed, but fundamental questions about the nature and mechanisms underlying this condition remain unanswered.

From hysteria to gait dementia: History of the concept of astasia-abasia.

Paul Blocq (1860-1896) and his teacher Jean-Martin Charcot (1825-1893) introduced the expression "astasia-abasia" into medical terminology in 1888 to designate a pathology they believed to be caused by hysteria. This condition makes it impossible to remain erect and to walk, whereas the ability to move the legs while lying down remains normal. At the turn of the 20th century, and now almost exclusively, this motor disturbance is recognised as a syndrome with multiple possible organic causes, and now described as "higher-level gait disorder". After briefly mentioning earlier descriptions by other authors, I will review Charcot's Tuesday lessons in 1889 that covered astasia-abasia and elucidated the beginnings of the breakdown into organic aetiologies: medial-frontal and corpus callosum tumors, damage to the cerebellar vermis, lacunar state as described by Pierre Marie (1853-1940), Parkinson's disease, and Parkinson-plus syndrome. The long history of astasia-abasia reveals a cluster of neurologists, often emerging from oblivion herein and all of whom, through the precision of their clinical examinations and their pathophysiological findings, helped advance the understanding of the mechanisms by which human beings are the only erect, constantly bipedal mammals, whether immobile or walking.

Gait Apraxia with Exaggerated Upper Limb Movements as Presentation of AARS2 Related Leukoencephalopathy.

A 55-year-old male presented with apraxia of gait with exaggerated upper limb movement with relative preservation of cognition and mild spasticity of limbs. His investigations reveal posterior-predominant leukodystrophy in brain magnetic resonance imaging (MRI) and compound heterozygous mutations in mitochondrial alanyl-transfer RNA synthetase 2 (AARS2) by next generation sequencing. His asymptomatic brother also has MRI changes with subtle mild pyramidal signs. AARS2 mutation is a rare cause of mitochondrial encephalopathy which may give rise to leukodystrophy with premature ovarian failure, infantile cardiomyopathy, lung hypoplasia and myopathy. Gait apraxia as primary presenting feature of this rare variant of mitochondrial encephalomyopathy is hitherto un-reported.

Gait apraxia evaluation in normal pressure hydrocephalus using inertial sensors. Clinical correlates, ventriculoperitoneal shunt outcomes, and tap-test predictive capacity.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a neurological condition with gait apraxia signs from its early manifestation. Ventriculoperitoneal shunt (VPS) is a surgical procedure available for treatment. The Cerebrospinal fluid Tap Test (CSF-TT) is a quick test used as selection criterion for VPS treatment. Its predictive capacity for VPS outcomes is still sub judice. This study is aimed to test the hypothesis that wearable motion sensors provide valid measures to manage iNPH patients with gait apraxia. METHODS: Forty-two participants of the Bologna PRO-Hydro observational cohort study were included in the analyses. The participants performed the Timed Up and Go (TUG) and the 18 m walking test (18mW) with inertial sensors at baseline, three days after the CSF-TT, and six months after VPS. 21 instrumental variables described gait and postural transitions from TUG and 18mW recordings. Furthermore, participants were clinically assessed with scales (clinical variables). We tested the hypothesis by analysing the concurrent validity of instrumental and clinical variables, their individual- and group-level responsiveness to VPS, and their predictive validity for VPS outcomes after CSF-TT. RESULTS: The instrumental variables showed moderate to high correlation with the clinical variables. After VPS, most clinical and instrumental variables showed statistically significant improvements that reflect a reduction of apraxic features of gait. Most instrumental variables, but only one clinical variable (i.e., Tinetti POMA), had predictive value for VPS outcomes (significant adjusted R2 in the range 0.12-0.70). CONCLUSIONS: These results confirm that wearable inertial sensors may represent a valid tool to complement clinical evaluation for iNPH assessment and prognosis.

Circumscribed supplementary motor area injury with gait apraxia including freezing of gait and shuffling gait: a case report.

Clinical findings in cases of injury circumscribed with SMA is no consensus. We report the case of a 60-year-old male with circumscribed SMA injury who showed freezing of gait, and shuffling gait. Twenty-one days after onset, the patient showed difficulties with the left leg swing in gait initiation (freezing of gait). In steady-state gait, the stride of the left leg swing was short (shuffling gait). Thirty-four days after onset, this phenomenon was not observed during gait. Circumscribed SMA injury can cause gait apraxia, including freezing and shuffling gait, such as in extensive SMA injury in the medial frontal cortex.

High Periventricular T1 Relaxation Times Predict Gait Improvement After Spinal Tap in Patients with Idiopathic Normal Pressure Hydrocephalus.

PURPOSE: The diagnosis of idiopathic normal pressure hydrocephalus (iNPH) can be challenging. Aim of this study was to use a novel T1 mapping method to enrich the diagnostic work-up of patients with suspected iNPH. METHODS: Using 3T magnetic resonance imaging (MRI) we prospectively evaluated rapid high-resolution T1 mapping at 0.5 mm resolution and 4 s acquisition time in 15 patients with suspected iNPH and 8 age-matched, healthy controls. T1 mapping in axial sections of the cerebrum, clinical and neuropsychological testing were performed prior to and after cerebrospinal fluid tap test (CSF-TT). T1 relaxation times were measured in 5 predefined periventricular regions. RESULTS: All 15 patients with suspected iNPH showed gait impairment, 13 (86.6%) showed signs of cognitive impairment and 8 (53.3%) patients had urinary incontinence. Gait improvement was noted in 12 patients (80%) after CSF-TT. T1 relaxation times in all periventricular regions were elevated in patients with iNPH compared to controls with the most pronounced differences in the anterior (1006 ± 93 ms vs. 911 ± 77 ms; p = 0.023) and posterior horns (983 ± 103 ms vs. 893 ± 68 ms; p = 0.037) of the lateral ventricles. Montreal cognitive assessment (MoCA) scores at baseline were negatively correlated with T1 relaxation times (r < -0.5, p < 0.02). Higher T1 relaxation times were significantly correlated with an improvement of the 3­m timed up and go test (r > 0.6 and p < 0.03) after CSF-TT. CONCLUSION: In iNPH-patients, periventricular T1 relaxation times are increased compared to age-matched controls and predict gait improvement after CSF-TT. T1 mapping might enrich iNPH work-up and might be useful to indicate permanent shunting.

Axial Impairment Following Deep Brain Stimulation in Parkinson's Disease: A Surgicogenomic Approach.

BACKGROUND: Postoperative outcome following deep brain stimulation (DBS) of the subthalamic nucleus is variable, particularly with respect to axial motor improvement. We hypothesized a genetic underpinning to the response to surgical intervention, termed "surgicogenomics". OBJECTIVE: We aimed to identify genetic variants associated with clinical heterogeneity in DBS outcome of Parkinson's disease (PD) patients that could then be applied clinically to target selection leading to improved surgical outcome. METHODS: Retrospective clinical data was extracted from 150 patient's charts. Each individual was genotyped using the genome-wide NeuroX array tailored to study neurologic diseases. Genetic data were clustered based on surgical outcome assessed by comparing pre- and post-operative scores of levodopa equivalent daily dose and axial impairment at one and five years post-surgery. Allele frequencies were compared between patients with excellent vs. moderate/poor outcomes grouped using a priori defined cut-offs. We analyzed common variants, burden of rare coding variants, and PD polygenic risk score. RESULTS: NeuroX identified 2,917 polymorphic markers at 113 genes mapped to known PD loci. The gene-burden analyses of 202 rare nonsynonymous variants suggested a nominal association of axial impairment with 14 genes (most consistent with CRHR1, IP6K2, and PRSS3). The strongest association with surgical outcome was detected between a reduction in levodopa equivalent daily dose and common variations tagging two linkage disequilibrium blocks with SH3GL2. CONCLUSION: Once validated in independent populations, our findings may be implemented to improve patient selection for DBS in PD.

Clinical and genetic characteristics of adolescent and adult Krabbe disease / 中华神经科杂志

Objective:To investigate the clinical and genetic characteristics of patients with late-onset subtypes (adolescent or adult) of Krabbe disease.Methods:The clinical data of 7 patients with Krabbe disease admitted to Shanghai Jiao Tong University Affiliated Sixth People′s Hospital and Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from September 2006 to June 2021 were analyzed and Sanger sequencing of the galactosylceramidase (GALC) gene (NM_000153) and detection of the activity of GALC were conducted. A total of 61 cases of Krabbe disease reported in domestic literature were reviewed and summarized.Results:Among the 7 patients with Krabbe disease, there were 4 males and 3 females. All of them had lower limb weakness or walking difficulty as the initial symptoms, and presented as spastic paraplegia. The symptoms were relatively mild in patients with late onset. There were 4 out of 5 patients undergoing magnetic resonance imaging examination, who showed abnormal signals: 2 had brain atrophy and the remaining 2 had white matter lesions. A total of 5 GALC gene mutations were detected by genetic analysis. Among these, c.1901T>C (p.L634S), c.908C>T(p.S303F) and c.461C>A(p.P154H) are known variants, while c.50_51insTT (p.M17Ifs) and c.1130delT(p.L337X) are novel variants reported for the first time in this paper.Conclusions:Krabbe disease is a rare neurodegenerative disease with phenotypic heterogeneity, which is inherited in an autosomal recessive mode. The severity of clinical manifestations of Krabbe disease is correlated with the age of onset.

The clinical characteristics and risk factors of frozen gait in Parkinson's disease / 中国医师杂志

Objective o investigate the clinical characteristics and relevant risk factors of freezing gait in patients with Parkinson's disease (PD).Methods A total of 570 consecutive PD patients were registered basic information and evaluated by Unified Parkinson's Disease Rating Scale (UPDRS) and New Freezing of gait questionnaire (NFOG-Q).They were divided into the PD with freezing gait group (188 cases) and non-freezing gait group.Results UPDRS score in each part (UPDRS-Ⅰ,UPDRS-Ⅱ,UPDRS-Ⅲ,UPDRS-Ⅳ) and Hoehn & Yahr stage of the PD freezing gait group was significantly higher than that of the non frozen gait group (P ＜ 0.05).Conclusions PD patients with frozen gait group experience more rapid PD progression than those without freezing of gait.The appearance of FOG is associated with the mental behavior and emotion,treatment complication,disease severity,and course of PD.

Effects of gait training with rhythmic auditory stimulation on gait ability in elderly stroke patients / 中华老年医学杂志

Walking disorder is the most common sequela in patients with hemiplegia after stroke.More than half of stroke patients can not walk independently after discharge,and still present a gait asymmetry and slow pace,and other abnormalities.Then,the fall risk is increased.With security concerns,patients are more afraid to walk independently and can not complete the walk in community environment.Therefore,gait rehabilitation is considered as the main goal of stroke rehabilitation.Rhythmic auditory stimulation(RAS)is a new rehabilitation method to improve stroke gait.By elucidating the mechanism of RAS and their effects on stroke gait,the aim of this paper is to explore the effective RAS treatment method for hemiplegic patients,so that RAS is not only used in gait training,but also in real-time assessment of gait in any environment for chronic stroke patients.

Clinical significance of smooth pursuit eye movement in PD patients / 中华老年心脑血管病杂志

Objective To study the clinical significance of smooth pursuit eye movement (SPEM) in primary PD patients.Methods Thirty-two PD patients admitted to our hospital served as a PD group and 30 subjects underging physical examination in our hospital served as a control group in this study.The added SPEM value,types of PD patients,and tremor fraction were recorded.The added SPEM values in different types of PD patients were compared between the two groups.The influencing factors for added SPEM values were analyzed by multivariate linear regression analysis.The added SPEM values were analyzed by ROC curve analysis in PD patients.Results The added SPEM value was significantly lower in PD group than in control group (0.80±0.11 vs 0.91± 0.13,P=0.001).The added SPEM value was significantly different in 3 types of PD patients (P=0.027).The added SPEM value was significantly lower in PD patients with dominant tremor than in those with posture unstable gait (0.7±0.1 vs 0.8±0.1,P＜0.01).The added SPEM value was negatively related with the tremor fraction (P =0.000).The sensitivity and specificity of added SPEM value in diagnosis of PD were 79.2 ％ and 87.5 ％ respectively.The area under the ROC curve was 0.807 (95％ CI.:0.641-0.973,P =0.010).Conclusion The SPEM function is significantly poorer in PD patients with dominant tremor than in those without tremor.The added SPEM value can thus used as a rather good indicator for differential diagnosis of dominant tremor from that of non-dominant tremor in PD patients.

The Timed Up and Go Test as a Diagnostic Criterion in Normal Pressure Hydrocephalus.

INTRODUCTION: Normal-pressure hydrocephalus (NPH) is a disease characterized by gait disturbance, urinary incontinence, and dementia. Our objectives were to define an average value of the test for the population, check the specificity and test sensitivity as evaluation criteria and diagnostic testing, and correlate with other already used more frequently. METHODS: A study conducted at the Neurosurgery Division of the Hospital do Servidor Público Estadual de São Paulo in which a group of 30 patients with NPH was submitted to the Mini-Mental State Test Examination, Time Up and Go (TUG), test and Japanese scale for NPH before the Tap Test 3 hours and 72 hours after the Tap Test. After being subjected to ventriculoperitoneal shunt, patients were evaluated 3 months, 6 months, and 12 months after surgery. A control group was used composed of 30 individuals of the same age and who had no diagnosis of NPH who were submitted to the TUG test to determine an average, which was compared with that of patients with NPH. RESULTS: TUG did not show good correlation with other tests used, but there was excellent specificity (0.967) and sensitivity (0.933) for cut-off value of 16.5 seconds for the diagnosis of NPH. CONCLUSIONS: TUG is a good test for the diagnosis of NPH because there is very good specificity and sensitivity, with a mean value of 16.5 seconds as the cut-off.

Three Cases of Gait Improvement after Rehabilitation Management in Corticobasal Syndrome

Corticobasal syndrome (CBS) is characterized by asymmetric dystonia, and myoclonus accompanied by higher cortical features including apraxia, alien limb phenomena, cortical sensory loss. Here, we report treatment course of 3 CBS patients. Asymmetric dystonia was seen in the first and second cases, a cortical sensory loss was seen in the third case and left lower limb apraxia was common in all cases. In the first and second cases, we performed an alcohol block on the obturator nerve and injected botulinum toxin into the lower leg to reduce dystonia. In the third case, patient was treated with a robotic assisted gait training, whole body therapeutic pool and gait training with laser pointer visual cueing. After appropriate treatment for patients, all 3 cases showed improvement in gait.

Clinical manifestations in eight patients with multiple dilated Virchow-Robin spaces in striatum / 中华神经科杂志

Objective To investigate the clinical feactures of patients with numerous dilated Virchow-Robin space in basal gangalia.Methods Eight patients with cribriform state in striatum in brain MRI at Peking Union Medical College Hospital from March 2013 to October 2013 were enrolled.The clinical data including age,gender,common vascular risk factors and clinical manifestations were analyzed.Cognitive functions,balance and gait disturbance,as well as activity of daily living were assessed.Results All of the eight patients are male,aged from 69 to 80.All the patients had a history of hyperlipidemia,while 7 of them had hypertension.The primary complaint was either gradual motor function decline or memory impairments (3/8),or dizziness (1/8).The other 4 of them were diagnosed as stroke or transient ischemic attack.Among the 8 patients,four had mild deterioration in activity of daily living function (Barthel index 65-85).Cognitive impairment was common (8/8,the Montreal Cognitive Assessment scores 19-27),while word recall was the mostly affected cognitive domain (8/8).Gait and balance dysfunction were found in three patients (3/8,Tinetti scores ≤ 24).Conclusions Man is more likely to have predisposition to cribriform state in striatum.Mild cognitive impairments and gait abnormality are common clinical manifestations of the disease.

Clinical and MRI characterization of MS patients with a pure and severe cognitive onset.

BACKGROUND AND OBJECTIVE: Cognitive and behavioural symptoms are common in multiple sclerosis (MS), but they are rarely the inaugural and predominant manifestation of the disease. Our objective is to characterize the clinical and radiological features of cognitive-multiple sclerosis (cog-MS), defined as MS subjects who entered into the disease with cognitive symptoms, which subsequently remain the predominant manifestation. METHODS: We describe the disease course, and clinical and radiological features of 18 subjects with a cognitive form of MS. RESULTS: Memory loss and behavioural changes were the primary symptoms at disease onset. They remained prominent and led to severe cognitive impairment during disease course. The main associated manifestations were depression, pathological laughing and/or crying, urinary incontinence and gait disturbance suggestive of high-level gait disorder. Motor, sensory or cerebellar abnormalities were uncommon. During disease course, superimposed neurological relapses occurred in 61% of cases. Brain MRI revealed multiple periventricular lesions that were extensive and confluent in half of cases, and a severe atrophy measured as an increase in the third ventricular width compared to age-matched healthy controls. Gadolinium-enhancing lesions were common (72%). The mean diagnosis delay from disease onset was 2 years. A principal component analysis on the neuropsychological results revealed that verbal memory assessment is complementary to global cognitive functioning evaluation in these patients with severe cognitive deficit. Verbal memory deficit was associated with high EDSS. CONCLUSIONS: cog-MS patients might represent a challenging diagnosis, which needs to be individualized for an early management.

Gait analysis in cerebral palsy children / 中国组织工程研究

BACKGROUND:Abnormal gaits are very common in children with cerebral palsy, and how to improve the gait is the focus of rehabilitation therapy. OBJECTIVE:To analyze the biomechanical parameters of gaits in cerebral palsy children and to observe the effects of brace control on the exercise capacity of dyskinetic cerebral palsy children. METHODS:In this paper, we compared the biomechanical parameters of children with cerebral palsy and normal children in the initial process of walking and during walking. Biomechanical parameters in the initial process of walking include spatial and temporal parameters, kinematic and kinetic parameters of the range of motion of the knee and ankle. Biomechanical parameters during walking include spatial and temporal parameters. With the aid of hand brace, dyskinetic cerebral palsy received postural control, gait training, and sling exercise therapy for 3 months. The Gross Motor Function Measure (GMFM-88) assessment and video control were conducted for evaluation of therapeutic efficiency. RESULTS AND CONCLUSION:Biomechanical parameters in the initial process of walking showed significant differences between children with cerebral palsy and normal children except for the peak of ground reaction force at frontal axis with the right foot to start walking. Biomechanical parameters during walking showed that the stance phase and bipedal stance phase were prolonged, while the step length and stride length were shortened in the children with cerebral palsy compared with the normal children. For cerebral palsy children with brace control, the GMFM-88 scores were significantly decreased after treatment, involuntary movements were reduced shown on the video, the neck and body were stable, and life skil s were improved. Children with epilepsy and cognitive impairment or who had imaging changes in the basal ganglia showed a little improvement, and children with dance-athetoid type and dystonia type had a better progress than those with athetoid spasm.

Hidrocefalia de pressão normal: visão atual sobre a fisiopatologia, diagnóstico e tratamento / Normal pressure hydrocephalus: current view on pathophysiology, diagnosis and treatment

Introdução: A hidrocefalia de pressão normal (HPN), descrita em 1964 por Salomón Hakim, é uma doença insidiosa que acomete, sobretudo, idosos e manifesta-se através da tríade clínica de distúrbios da marcha, demência e incontinência urinária, associada a achados radiológicos de ventriculomegalia e achados laboratoriais de pressão liquórica normal. Objetivo: apresentar as principais hipóteses relacionadas à fisiopatologia, diagnóstico por imagem e tratamento da HPN empregadas atualmente. Métodos: a revisão da literatura foi realizada através das bases de dados MEDLINE e PubMed, onde foi utilizado o recurso MeSH(Medical Subject Headings) para a seleção de artigos dos últimos seis anos. Resultados: tanto as bases fisiopatológicas quanto os critérios diagnósticos da HPN ainda não estão totalmente estabelecidos. O principal tratamento consiste na derivação liquórica. Conclusões: é fundamental que o diagnóstico da HPN seja realizado precocemente e que os pacientes com maiores chance de responder à derivação liquórica sejam identificados.

Introduction: The normal pressure hydrocephalus (NPH), described in 1964 by Salomón Hakim, is an insidious disease that affects mainly elderly people and is manifested by the clinical triad of gait disorders, dementia and urinary incontinence associated with radiological findings of ventriculomegaly and laboratory findings of normal CSF pressure. Objective: present the main hypotheses related to the pathophysiology, imaging diagnosis and treatment of NPH in practice today. Methods: the literature review was conducted through MEDLINE and PubMed, where was used the MeSH resource (Medical Subject Headings) for the selection of articles from the last 6 years. Results: both the pathophysiology and diagnostic criteria of NPH has not beenfully established. The main treatment consists of the CSF shunt. Conclusion: it is essential that the diagnosis of NPH be realized early and that patients with higher chance to improve after CSF shunt are identified.

Hidrocefalia de pressão normal: visão atual sobre a fisiopatologia, diagnóstico e tratamento / Normal pressure hydrocephalus: current view on pathophysiology, diagnosis and treatment

A hidrocefalia de pressão normal (HPN), descrita em 1964 por Salomón Hakim, é uma doença insidiosa que acomete, sobretudo, idosos entre 60 e 80 anos e manifesta-se por meio da tríade clínica de distúrbios da marcha, demência e incontinência urinária, associada a achados radiológicos de ventriculomegalia e achados laboratoriais de pressão liquórica normal. Apesar de representar cerca de 5% das causas de demência, ficando atrás da doença de Alzheimer e demência vascular, ao contrário dessas causas a HPN é uma das poucas causas reversíveis de demência, e é por essa reversibilidade que torna fundamental o conhecimento da doença por parte de todos os médicos que cuidam dos pacientes dessa faixa etária. O artigo foi realizado a fim de apresentar as principais hipóteses relacionadas a fisiopatologia, diagnóstico e tratamento da HPN empregadas atualmente. A revisão da literatura foi realizada por meio das bases de dados Medline e PubMed, sendo utilizado o recurso MeSH (Medical Subject Headings) para a combinação dos descritores (hidrocefalia de pressão normal, história, epidemiologia, etiologia, fisiopatologia, diagnóstico e terapia) e seleção de artigos dos últimos seis anos. Tanto as bases fisiopatológicas quanto os critérios diagnósticos da HPN ainda não estão totalmente estabelecidos, porém as principais hipóteses envolvem distúrbios da hemodinâmica e complacência cerebral. O principal tratamento consiste na derivação liquórica, mediante a derivação ventriculoperitoneal e da terceira ventriculostomia endoscópica, sendo fundamental que o diagnóstico da HPN seja realizado precocemente e que os pacientes com maiores chances de responder à derivação liquórica sejam identificados.

The normal pressure hydrocephalus (NPH), described in 1964 by Salomón Hakim, is an insidious disease that affects mainly elderly people between 60 and 80 years and is manifested by the clinical triad of gait disturbances, dementia and urinary incontinence associated the radiological findings of ventriculomegaly and laboratory findings of normal cerebrospinal fluid pressure. Despite representing about 5% of the causes of dementia, behind Alzheimer?s disease and vascular dementia, unlike these causes NPH is one of the few reversible causes of dementia, and it is this reversibility that makes crucial the knowledge of the disease by of all physicians who care of patients in this age group. The paper was developed in order to present the main hypotheses related to the pathophysiology, diagnosis and treatment of NPH in practice today. The literature review was conducted through Medline and PubMed, where was used the MeSH resource (Medical Subject Headings) for the combination of keywords (normal pressure hydrocephalus, history, epidemiology, etiology, pathophysiology, diagnosis and therapy and selection of articles from the last six years. Both the pathophysiology and diagnostic criteria of NPH has not been fully established, but the main hypotheses involve disturbances of cerebral hemodynamics and complacency. The main treatment consists of CSF shunt through the ventriculoperitoneal shunt and endoscopic third ventriculostomy and it?s essential that the diagnosis of NPH be realized early and that patients with higher chance to improve after CSF shunt are identified.