Usually assessments are based on gait and balance, bladder control, and neuropsychological testings. Many neurosurgeons expressed their confusion regarding worsening after initial improvement or frequent unexplained changes ups and downs during post-shunt follow ups.
In a guideline article by Prof. Marmou with others; “Outcome of shunting in NPH and the value of assessment in shunted patients”. Prof. Marmou guideline was there is no validated, universally accepted scale for assessment of treated or untreated NPH. So there is a universal neurosurgical non-agreement regarding measuring outcome post-shunt.
Added to what mentioned above, it is well known that shunt function is notoriously unpredictable.
What are your personal observations with your patients?
Professor Gordon,
I am very vey thankful to you for giving attention to this very precious differentiating point.
Idiopathic normal-pressure hydrocephalus Results of shunting in 62 patients
http://thejns.org/doi/abs/10.3171/jns.1980.52.3.0371?journalCode=jns
Comparison between the lumbar infusion and CSF tap tests to predict outcome after shunt surgery in suspected normal pressure hydrocephalus
http://jnnp.bmj.com/content/73/6/721.full.pdf
Predicting the response to ventriculoperitoneal shunt in patients with Normal Pressure Hydrocephalus
http://clok.uclan.ac.uk/2391/1/Balamurali_MDthesisfinal.pdf
Clinical Diagnosis of Ventriculoperitoneal Shunt Failure Among Children With Hydrocephalus
http://journals.lww.com/pec-online/pages/articleviewer.aspx?year=2008&issue=04000&article=00001&type=abstract
@ jetty: Thank you too much for the important links mentioned above. The most NPH detailed was the third one which is giving precious comprehensive knowledge.
The problem is that the different testings available at the time being are crude and not sensitive enough to achieve optimal CSF pressure adjustment without possibility of serious risks. So most neurosurgeons would rationally prefer some under drainage which is safer. This compromise is not the optimal treatment as patients might suffer significant symptoms when adjusted above optimal. The dynamic changing nature of CSF is another problem they are facing. It looks as if the optimal point is escaping easily from them in some patients. Optimal adjustment would also logically help to prolong shunt life.
I am not denying the great researches which are going on to improve hydrocephalus understanding and management. Hydrocephalus researchers and experts have used to declare these problems and controversies very frankly and honestly. I am trying to share.
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