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• W1966990943 abstract "A 73-year-old right-handed man with a history of diabetes, hyperlipidemia, coronary artery disease, and asthmatic obstructive lung disease came to our institution because of a 2-year history of gradual worsening of gait and balance. One year previously, he had undergone coronary artery bypass grafting without perioperative complications. Subsequently, his gait worsened, and his feet felt “glued to the floor.” During the 2 years before the current examination, he also noticed urinary urgency, occasional incontinence, and impotence. His wife noticed that he had had some mental slowing and forgetfulness during the preceding 18 months. Review of systems revealed no history of tremor, speech change, difficulty with use of his arms, or weakness. Five months before the current assessment, a neurologist had noted parkinsonism; amantadine hydrochloride and carbidopa-levodopa were prescribed separately but yielded no benefit. On initial consultation, the patient had normal mental status and cranial nerve functions. Motor examination showed generally preserved strength, reduced ankle jerks, and flexor plantar responses bilaterally. Muscle tone was mildly spastic in the legs. Sensory examination showed mild hypoesthesia to pinprick in both hands (fingertips) and feet (up to the ankles); other sensory modalities were normal. His gait was wide-based, and external anal sphincter tone was mildly reduced. Parkinsonian signs included shuffling gait, slowed walking, and postural instability. 1.Which one of the following is the most likely clinical diagnosis? a.Alzheimer's disease (AD)b.Cauda equina syndrome (CES)c.Vitamin B12 deficiencyd.Parkinson's diseasee.Normal-pressure hydrocephalus (NPH) AD is the most common degenerative cause of senile dementia and can manifest with deterioration of gait and balance late in its course.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar A parkinsonian syndrome of akinesia, rigidity, and flexed posture may be seen in patients with AD.2Molsa PK Manilla RJ Rinne UK Extrapyramidal signs in Alzheimer's disease.Neurology. 1984; 34: 1114-1116Crossref PubMed Google Scholar The cardinal features of AD are memory deficits with or without aphasia, apraxia, and agnosia.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar In our patient, the cognitive complaints were mild, and the Mini-Mental State Examination showed normal findings; thus, the diagnosis of AD was unlikely. Moreover, parkinsonian signs in AD are primarily seen in those with severe dementia.2Molsa PK Manilla RJ Rinne UK Extrapyramidal signs in Alzheimer's disease.Neurology. 1984; 34: 1114-1116Crossref PubMed Google Scholar CES can produce leg weakness, gait instability, bowel, bladder, and sexual dysfunction, sensory loss (usually in a radicular distribution), and hyporeflexia or areflexia in the lower extremities.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar Early loss of reflexes and leg weakness soon thereafter, as well as early bowel or bladder involvement, are common in CES; these findings were not observed in our patient. Furthermore, CES does not manifest with parkinsonian signs. The mild bladder and sexual dysfunction in our patient, as well as the reduced external anal sphincter tone, is most likely related to diabetic autonomie neuropathy. The distal hypoesthesia and reduced ankle jerks can also be due to a concomitant diabetic polyneuropathy. Hypoactive ankle jerks are a common finding in elderly persons and are often nonlocalizing. Deficiency of vitamin B12 is a common cause of not only gait instability but also recurrent falls because of its effects on the spinal cord (particularly the posterior and lateral columns) and the peripheral nerves.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar Although the hypoactive reflexes, wide-based gait, and distal sensory loss may be due to vitamin B12 deficiency, the absence of the hallmarks of this disorder, including posterior column signs (decreased vibration and position sense) and lateral column signs (weakness with or without hyperreflexia and the Babinski sign), makes this diagnosis less likely (albeit still possible) in our patient. Parkinson's disease usually manifests with resting tremor, rigidity, bradykinesia, postural instability, and shuffling gait.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar The asymmetry of signs and symptoms, as well as responsiveness to levodopa, helps to confirm the diagnosis. Although our patient had shuffling gait and postural instability, several factors make Parkinson's disease unlikely, including symmetric involvement of his legs, early abnormalities of bladder and sexual function, and lack of response to levodopa. NPH manifests with the classic triad of a slowly progressive gait disorder, urinary incontinence, and impairment of mental function.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar, 3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar Affected persons commonly describe their walking impairment as feeling as if their feet are glued to the floor, which is also referred to as a “magnetic gait” or gait apraxia.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar, 4Wikkelso C Andersson H Blomstrand C Lindqvist G Svendsen P Normal pressure hydrocephalus: predictive value of the cerebrospi-nal fluid tap-test.Acta Neurol Scand. 1986; 73: 566-573Crossref PubMed Scopus (158) Google Scholar A wide-based gait may be noted. Although weakness and tiredness of the legs are frequent complaints, objective motor weakness is seldom present.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar As NPH worsens, the steps become shorter and more shuffling, and ambulation arrests (freezing) and difficulties in turning (dyspraxia) occur; thus, signs of Parkinson's disease are mimicked.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar, 3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar Myelopathy might also be suggested by the leg spasticity, reduced anal tone, and bladder and sexual dysfunction in our patient, but this diagnosis is less likely because of the absence of a sensory level, Babinski sign, and weakness. A conus lesion usually manifests with prominent early signs of bowel and bladder dysfunction, which were not found in our patient. On the basis of the foregoing considerations, NPH seemed the most likely cause of our patient's gait disturbance. Clinically, we could not rule out a concomitant myelopathy or sensory ataxia, especially in light of the fact that gait impairment in elderly patients is often multifactorial.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar, 3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar 2.Which one of the following tests is most likely to help in the diagnosis of the suspected neurologic problem in this patient? aElectromyography (EMG)b.Blood test including vitamin B12 levelsc.Somatosensory evoked potentials (SEPs)d.Magnetic resonance imaging (MRI) of the lumbosacral spinee.MRI of the brain EMG is most helpful in cases in which gait impairment is associated with prominent peripheral nerve or lower motor neuron signs (that is, weakness with atrophy of muscles, cramping or fasciculations, normal or reduced muscle tone, loss of reflexes, and radicular or peripheral nerve distribution of hypoesthesia).1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar Because EMG detects only large-fiber abnormalities (which clinically manifest as loss of vibration sense, position sense, and reflexes), a normal result does not rule out small-fiber neuropathy (which clinically manifests as loss of the sense of pain and temperature as well as autonomie dysfunction). The distal loss of pain perception in our patient is not a feature of NPH; it is most likely related to small-fiber diabetic polyneuropathy. Our patient's EMG findings were normal, probably because of the mild degree of neuropathy and the predominance of small-fiber involvement. Useful blood tests in cases of gait instability with signs of polyneuropathy include vitamin B12, folate, vitamin E, thyroid function tests, liver enzymes, rapid plasma reagin, fasting blood glucose, and serum protein electrophoresis. All these tests showed normal results in our patient. SEPs are most helpful in detecting dorsal column pathway dysfunction as a cause of gait ataxia, especially if findings on MRI of the spinal cord or brain (or both) and EMG are normal. Our patient's tibial SEPs were normal. MRI of the lumbosacral spine is useful in suspected cases of CES, especially in relationship to degenerative changes (of the disks or vertebrae) and neoplastic processes (such as carcinomatous meningitis or focal neoplasm). The MRI of the lumbosacral spine was unremarkable in our patient. Although all the aforementioned tests may be useful in narrowing the differential diagnoses, the most helpful one is the brain imaging in confirming NPH. The typical finding is a communicating hydrocephalus, with ventriculomegaly being out of proportion to the degree of cortical atrophy (Fig. 1).3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar, 5George AE Holodny A Golomb J de Leon MJ The differential diagnosis of Alzheimer's disease: cerebral atrophy versus normal pressure hydrocephalus.Neuroimaging Clin N Am. 1995 Feb; 5: 19-31PubMed Google Scholar A prominent cerebrospinal fluid (CSF) flow void in the cerebral aqueduct is also a possible finding; it is seen as a dark signal in the aqueduct of Sylvius on T2-weighted MRI.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar This finding, however, is not a universally accepted means of confirming NPH. In addition to the foregoing tests, an MRI scan of the upper part of the spinal cord may be useful in suspected cases of myelopathy because cervical spondy-losis in conjunction with compression of the spinal cord can mimic NPH.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar Because of the increased tone in the legs, cervical spine MRI was performed in our patient and showed a normal spinal cord. Spasticity is not a feature of NPH (tone is usually normal) and could possibly be related to the sub-cortical white matter changes seen on our patient's MRI due to small-vessel ischemie disease. Leukoencephalopathy (or subcortical white matter changes) has reportedly been frequently associated with NPH.6Krauss JK Regel JP Vach W Droste DW Borremans JJ Mergner T Vascular risk factors and arteriosclerotic disease in idiopathic normal-pressure hydrocephalus of the elderly.Stroke. 1996; 27: 24-29Crossref PubMed Scopus (198) Google Scholar Alternatively, with the cervical and lumbar MRIs showing normal findings, the spasticity could have been due to thoracic spinal cord involvement. Because clinical signs were not localizable to the thoracic cord, performing MRI at this level was deemed unnecessary. 3.On the basis of the history, neurologic examination, and magnetic resonance imaging findings, which one of the following choices is best at this point? a.Avoid lumbar puncture (LP) to prevent hemiation of cerebellar tonsilb.Lumbar puncturec.Neuropsychometric testingd.Follow-up in 6 monthse.Emergency surgical treatment of hydrocephalus Hydrocephalus is either communicating (nonobstructive) or noncommunicating (obstructive).1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar Intracranial pressure (ICP) is increased in the noncommunicating (obstructive) type and usually manifests with headache and papilledema. In such cases, computed tomography (CT) or MRI of the brain should be done to rule out a major structural lesion of the brain that could put the patient at risk of hemiation of cerebellar tonsil if pressure is released from below, as in LP. In contrast, NPH is a type of communicating hydrocephalus with normal CSF pressure and is not associated with this risk. Because our patient has the features of NPH, the easiest way to confirm that the CSF pressure is normal is by doing a single LP or a series of LPs. Neuropsychometric testing should be considered if, after NPH has been confirmed by MRI and LP, the patient exhibits cognitive impairment, inasmuch as severe dementia of more than 2 years’ duration is thought to predict a poor response to treatment.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar Our patient had normal findings on a Mini-Mental State Examination; therefore, neuropsychometric testing was deferred. If the only feature a patient manifests is subtle gait impairment, objective assessment of a response to treatment would be difficult. In such cases, the physician may choose observation and follow-up of the patient at 4- to 6-month intervals to gauge the progression of the disorder. Because our patient already had incontinence and severe gait impairment, treatment was thought to be warranted at that point, in order to increase the possibility of reversal of deficits. In NPH, the symptoms are chronic, and the ICP is normal; thus, emergent intervention is unnecessary. Although a single LP may be adequate to confirm NPH, some physicians choose to perform three serial LPs on 3 consecutive days. For each procedure, enough fluid is removed to decrease the opening pressure by 50%. Variables that can be monitored are the opening and closing pressures, speed and quality of ambulation for a fixed distance before and after each LP (with videotaping), and pre- and post-LP neuropsychometric testing. Chemical study, cytology, and cultures of the CSF are done. Our patient underwent three serial LPs; the opening pressure in the first LP was 178 mm (normal). Initially, pre-LP time to walk 25 feet (7.6 m) was 11 seconds, and post-LP time (30 minutes after LP) was 9 seconds. On the second day, pre-LP time was 9.5 seconds, and post-LP time was 8 seconds. By the third day, pre-LP time was 6.47 seconds, and post-LP time was 6.14 seconds. The patient thought that his balance and speed improved progressively, not only after each LP but also subjectively up to 5 days after the last LP. Aside from increased speed of ambulation, his walking became less shuffling, with longer stride, higher step height, and better heel strike. Results of all tests on the CSF were normal. 4.On the basis of the patient's clinical response to the cerebrospinal fluid tests after lumbar puncture, which one of the following is most appropriate? a.Trial of acetazolamideb.Trial of corticosteroidsc.No therapy for nowd.Ventriculoperitoneal shuntinge.Ventriculoatrial shunting No effective medical treatment is available for NPH.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar Acetazolamide and diuretics might have a role in idiopathic intracranial hypertension (pseudotumor cerebri), especially when loss of vision has not occurred, but they are ineffective in NPH. Corticosteroids may also benefit some cases of pseudotumor but are most helpful in reducing increased ICP from vasogenic edema (that is, tumors). The subjective and objective improvement in gait after the LP in our patient is predictive of an increased possibility of responding to a shunt operation.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar, 4Wikkelso C Andersson H Blomstrand C Lindqvist G Svendsen P Normal pressure hydrocephalus: predictive value of the cerebrospi-nal fluid tap-test.Acta Neurol Scand. 1986; 73: 566-573Crossref PubMed Scopus (158) Google Scholar Therefore, offering him no therapy is not clinically prudent. The most commonly performed therapeutic procedures are ventriculoperitoneal and lumboperitoneal shunting.7Adams RD Fisher CM Hakim S Ojemann RG Sweet WH Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure: a treatable syndrome.N Engl J Med. 1965; 273: 117-126Crossref PubMed Scopus (1051) Google Scholar, 8Philippon J Duplessis E Dorwling-Carter D Horn YE Comu P Lumboperitoneal shunt and normal pressure hydrocephalus in elderly subjects.Rev Neurol (Paris). 1989; 145: 776-780PubMed Google Scholar These procedures are equally effective, and the choice depends primarily on the neurosurgeon's preference and skills. Ventriculoatrial shunting is an alternative, although it may be more technically difficult and in certain cases may have more complications, including sudden death from arrhythmia.9Brasey DL Fankhauser H de Tribolet N Normal-pressure hydrocephalus in adults: analysis of results and complications following ventriculo-cardiac derivation.Schweiz Med Wochenschr. 1988; 118: 919-923PubMed Google Scholar Our patient had a ventriculoperitoneal shunt placed 5 months after his initial visit; dramatic improvement was noted postoperatively. 5.Which one of the following is the most common potential complication for our patient as a result of the surgical procedure? a.Intracranial hemorrhageb.Extracranial infectionc.Intracranial infectiond.Seizurese.Pulmonary hypertension In a retrospective multicenter study of 166 patients, the rate of severe and moderate shunt-related complications was 28%, most being due to intracranial hemorrhage.10Vanneste J Augustijn P Dirven C Tan WF Goedhart ZD Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review.Neurology. 1992; 42: 54-59Crossref PubMed Google Scholar Extracranial infections also accounted for a large number of complications (22%), whereas intracranial infections were less common (5%). Both hemorrhage and infection often necessitate shunt removal and revision. Seizures and ischémie strokes each accounted for 4% of the complications. About 8% of patients with complications died, particularly those who had cerebral hemorrhage or extracranial infections. In another study, pulmonary hypertension resulted from chronic embolization of distal pulmonary vasculature from the proteinaceous debris accumulated at the catheter tip used in ventriculoatrial shunting.11Pascual JMS Prakash UBS Development of pulmonary hypertension after placement of a ventriculoatrial shunt.Mayo Clin Proc. 1993; 68: 1177-1182Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar This complication, however, is not associated with ventriculoperitoneal shunting. Our patient had no perioperative complications; he experienced sustained reversal of his gait impairment and incontinence. NPH was first described in 1965 in patients who had gait disturbance or urinary urgency, with or without dementia.1Adams RD Victor M Principles of Neurology. 5th ed. McGraw-Hill, New York1993Google Scholar The syndrome of NPH may follow subarachnoid hemorrhage, meningitis, head trauma, Paget's disease of the skull, and mucopolysaccharidosis of the méninges.13Raftopoulos C Deleval J Chaskis C Leonard A Cantraine F Des-myttere F et al.Cognitive recovery in idiopathic normal pressure hydrocephalus: a prospective study.Neurosurgery. 1994; 35: 397-404Crossref PubMed Scopus (142) Google Scholar At least 30% of cases are idiopathic (actual percentage is most likely much higher) and have traditionally been attributed to disturbed CSF hydrodynamics, particularly reduced CSF absorption at the level of the arachnoid villi or basal cistern.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar, 4Wikkelso C Andersson H Blomstrand C Lindqvist G Svendsen P Normal pressure hydrocephalus: predictive value of the cerebrospi-nal fluid tap-test.Acta Neurol Scand. 1986; 73: 566-573Crossref PubMed Scopus (158) Google Scholar, 10Vanneste J Augustijn P Dirven C Tan WF Goedhart ZD Shunting normal-pressure hydrocephalus: do the benefits outweigh the risks? A multicenter study and literature review.Neurology. 1992; 42: 54-59Crossref PubMed Google Scholar More recently, the theory of a vascular leukoencephalop-athy was proposed, with the concept that white matter lesions reduce periventricular tissue strength and elastic properties and thus predispose the ventricles to dilate under CSF pulse pressure.6Krauss JK Regel JP Vach W Droste DW Borremans JJ Mergner T Vascular risk factors and arteriosclerotic disease in idiopathic normal-pressure hydrocephalus of the elderly.Stroke. 1996; 27: 24-29Crossref PubMed Scopus (198) Google Scholar Systemic hypertension is frequently associated with NPH. It is thought to lead to ventricular enlargement because of decreased CSF absorption due to increased superior sagittal sinus venous pressure and because of increased intraventricular pulse pressure from the choroid plexus.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar Other possibilities include congenital hydro-cephalus becoming symptomatic in elderly persons and increasing age. The diagnosis is confirmed by CT or MRI of the brain and LP.13Raftopoulos C Deleval J Chaskis C Leonard A Cantraine F Des-myttere F et al.Cognitive recovery in idiopathic normal pressure hydrocephalus: a prospective study.Neurosurgery. 1994; 35: 397-404Crossref PubMed Scopus (142) Google Scholar Characteristic imaging findings include ventricles that are widened disproportionate to the degree of cortical atrophy, wide temporal horns, periventricular hypodensity around the frontal horns, and flattening of the cortical sulci. MRI may also show a CSF flow void in the aqueduct of Sylvius5George AE Holodny A Golomb J de Leon MJ The differential diagnosis of Alzheimer's disease: cerebral atrophy versus normal pressure hydrocephalus.Neuroimaging Clin N Am. 1995 Feb; 5: 19-31PubMed Google Scholar and is more sensitive than CT in detecting other abnormalities, especially leukoencephalopathy.6Krauss JK Regel JP Vach W Droste DW Borremans JJ Mergner T Vascular risk factors and arteriosclerotic disease in idiopathic normal-pressure hydrocephalus of the elderly.Stroke. 1996; 27: 24-29Crossref PubMed Scopus (198) Google Scholar Not all patients with NPH benefit from surgical intervention. Factors that predict a poor surgical outcome include more than a 2-year history of dementia, onset of dementia before gait abnormality, alcohol abuse, and aphasia.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar, 12Graff-Radford NR Godersky JC Jones MP Variables predicting surgical outcome in symptomatic hydrocephalus in the elderly.Neurology. 1989; 39: 1601-1604Crossref PubMed Google Scholar Several tests have been developed to select surgical candidates. The CSF tap test involves measurement of gait pattern (and psychometric functions) before and after draining 30 to 50 mL of CSF.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar, 4Wikkelso C Andersson H Blomstrand C Lindqvist G Svendsen P Normal pressure hydrocephalus: predictive value of the cerebrospi-nal fluid tap-test.Acta Neurol Scand. 1986; 73: 566-573Crossref PubMed Scopus (158) Google Scholar Improvement in either measurement after LP correlates with a positive response to shunting. A modification involves continuous CSF drainage for 2 to 5 days. On CT or MRI, extensive cortical atrophy, atrophy of the medial temporal lobes, aqueductal stenosis, and Arnold-Chiari malformation may predict a poor surgical outcome, whereas a CSF flow void on MRI may predict a good result.3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar Cerebral blood flow studies showing a low frontal-to-posterior ratio may predict a favorable response to surgical treatment. Other predictive tests have been used, including cistemography, infusion manometric studies, and cine-MRI techniques, which have shown variable results. Despite all these available tests, the most cost-effective ones are the brain MRI and CSF tap test. The natural course of untreated NPH is progressive deterioration. Surgical treatment to divert CSF (shunting) is best done during the first 2 years after onset of signs or symptoms. The success rate of CSF diversion ranges from 25 to 80%3Graff-Radford NR Godersky JC Petersen RC A clinical approach to symptomatic hydrocephalus in the elderly.in: Morris JC Handbook of Dementing Illnesses. Marcel Dekker, New York1994: 377-391Google Scholar, 9Brasey DL Fankhauser H de Tribolet N Normal-pressure hydrocephalus in adults: analysis of results and complications following ventriculo-cardiac derivation.Schweiz Med Wochenschr. 1988; 118: 919-923PubMed Google Scholar and may depend on several factors, including the skill of the surgeon, severity of deficits, and adequacy of presurgical predictive screening. Although cognitive deficits in NPH are commonly thought to be irreversible and predict a poor response to surgical treatment, remarkable improvement in cognition has been noted after shunting.13Raftopoulos C Deleval J Chaskis C Leonard A Cantraine F Des-myttere F et al.Cognitive recovery in idiopathic normal pressure hydrocephalus: a prospective study.Neurosurgery. 1994; 35: 397-404Crossref PubMed Scopus (142) Google Scholar" @default.
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