Fortunately, NPH can often be treated successfully with a special shunt that drains excess CSF away from the brain to another part of the body, usually the abdominal cavity, where it can be absorbed. The shunt most often placed is a ventriculoperitoneal shunt. Lumboperitoneal shunts and ventriculoatrial shunts also may be used in certain situations. There are a variety of shunt types, including differential pressure valves, flow-regulated valves, anti-siphon devices and, more recently, programmable valves.
The programmable shunt (variable flow valve) has recently been approved for use in the United States. Its major advantage, compared to a fixed-flow valve, is the ability to modify the patient's ICP using a specialized magnetic adjustment device. Additional surgery is unnecessary.
"For most of these patients, the alternative to having a shunt inserted is to accept that they have a progressive dementing illness with no other effective forms of treatment," says Dr. Harold Rekate, M.D., a neurosurgeon at Barrow who specializes in hydrocephalus. "For many candidates, a shunt offers real hope of enjoying life to the fullest."
A shunt operation is not a cure. It does not treat the underlying cause of NPH. It can, however, relieve the symptoms. The shunt remains in place indefinitely. If properly implanted, the shunt is seldom obvious to other people. The earlier the NPH is diagnosed, the better the chances that the surgery will help the patient. In general, people with milder symptoms have better outcomes after this surgery than those with more severe symptoms.
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Endoscopic third ventriculostomy
| Illustration of aqueductal stenosis, yellow arrows indicate
flow of CSF, red arrows indicate blockage.
Another operation sometimes used to treat NPH is endoscopic third ventriculostomy (ETV). During this procedure an endoscope is inserted in the brain to create a small hole in the floor of the ventricles. The hole provides another way for CSF to drain from the brain. Most cases of NPH are classified as communicating hydrocephalus, which requires a shunting procedure rather than ETV.
The ideal candidate for ETV has aqueductal stenosis. Information based on modeling NPH reflects the likelihood that many, if not most, cases of NPH are caused by an obstruction to CSF flow between the spinal subarachnoid space and the cortical subarachnoid spaces. Patients with this form of communicating hydrocephalus are candidates for ETV.
"Normal pressure hydrocephalus is a relatively common and poorly understood condition," says Dr. Rekate. "It is one of the very few surgically treatable causes of dementia in the elderly. The treatment is very effective."
Although NPH is a long-term condition, many people obtain substantial relief through surgical treatment. For those who are not candidates for surgery, treatment consists of measures to relieve disposition and behavioral disturbances, to cope with physical problems such as incontinence and balance difficulties, and to maximize physical, mental, and social functioning.
Medical care should focus on optimizing the individual's health, safety, and quality of life while helping family members cope with the many challenges of caring for a loved one with dementia and other symptoms of NPH.
Individuals diagnosed with NPH should have regular visits with their neurologist or neurosurgeon. These visits allow the doctor to monitor symptoms that may require modifications in the treatment plan.
Shunt operations do not work for everyone with NPH. Many surgeons perform a spinal tap before surgery to test whether the symptoms improve when CSF is removed. In some cases, the person is hospitalized for a few days while CSF is drained slowly through a small tube called a catheter. This is another way of checking whether removing excess fluid will help symptoms.
There are three main types of possible complications: infection, mechanical failure, and obstruction. Although shunts are durable, normal wear and tear can cause various parts to migrate or move. Such cases need surgical repairs. Parts can also fail. Such mechanical failures also must be treated surgically. A patient's own bacterial organisms can often cause a shunt infection. This is a serious condition that requires prompt medical attention.
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