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The CSF tap test in normal pressure hydrocephalus: evaluation time, reliability and the influence of pain
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
2012 (English)In: European Journal of Neurology, ISSN 1351-5101, E-ISSN 1468-1331, Vol. 19, no 2, 271-276 p.Article in journal (Refereed) Published
Abstract [en]

Background:  The cerebrospinal fluid tap test (TT) is a diagnostic tool used to select patients with idiopathic normal pressure hydrocephalus (iNPH) for shunt surgery. The procedure and the evaluation of the TT vary between centres. We aimed to describe the evaluation time after the TT, to assess the variability between repeated measurements, the interrater agreement of the gait tests chosen and finally to investigate whether pain affects the gait performance post-TT.

Methods:  Forty patients (21 men and 19 women) under evaluation for iNPH underwent a TT. Standardized gait analyses were performed before and 2, 4, 6, 8 and 24 h after the TT and repeated twice on every occasion. Independent of each other, two investigators evaluated the quality of gait. At each assessment time, the patients graded headache and back pain on a visual analogue scale.

Results:  Twenty-seven patients (15 men and 12 women) responded to TT. Improvements in gait speed and number of steps were significant at every assessment time post-TT. The variability between two measurements was low (Intra class correlation coefficient = 0.97), and the inter-rater agreement was good with a κ = 0.74. Pain correlated negatively with improvement in gait speed (r = -0.40, P < 0.05).

Conclusions:  We suggest that the TT can be evaluated at any time within the first 24 h and should be repeated if the patient does not initially improve. Gait analysis appears reliable between two evaluators. Further, it is indicated that post-lumbar puncture pain negatively affects the gait and should be minimized.

Place, publisher, year, edition, pages
2012. Vol. 19, no 2, 271-276 p.
National Category
Neurology
Research subject
Neurology
Identifiers
URN: urn:nbn:se:uu:diva-159825DOI: 10.1111/j.1468-1331.2011.03486.xISI: 000299255300018PubMedID: 21801282OAI: oai:DiVA.org:uu-159825DiVA: diva2:447069
Available from: 2011-10-10 Created: 2011-10-10 Last updated: 2017-12-08Bibliographically approved
In thesis
1. Idiopathic Normal Pressure Hydrocephalus: Cerebrospinal Fluid Tap Test and Magnetic Resonance Imaging as Preoperative Prognostic Investigations
Open this publication in new window or tab >>Idiopathic Normal Pressure Hydrocephalus: Cerebrospinal Fluid Tap Test and Magnetic Resonance Imaging as Preoperative Prognostic Investigations
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Idiopathic normal pressure hydrocephalus (iNPH) is a condition with dilated cerebral ventricles but intracranial pressure within normal limits. The symptoms of gait impairment, cognitive decline and urinary incontinence develop gradually. Treatment with shunt insertion results in improvement in eight out of ten patients.

The cerebrospinal fluid tap test (CSF TT) and preoperative magnetic resonance imaging (MRI) are methods used to select patients who may benefit from shunt surgery, but they are performed and interpreted differently in different centers throughout the world. The aim of this thesis was to evaluate the performance of the CSF TT and the underlying mechanisms of improvement in gait function after CSF removal, and to investigate the prognostic value of preoperative MRI scans.

Improvement in gait and changes in cerebral blood flow (CBF) after a CSF TT were investigated in two prospective studies that included 39 and 20 patients, respectively. Gait assessment and perfusion MRI were done before and several times during the first 24 hours after a CSF TT. Perfusion was investigated with pseudo-continuous arterial spin labeling. At the group level, gait function was significantly improved at all investigation times, but only one-third of individual CSF TT responders were improved at all investigation times. In patients with increased CBF in lateral and frontal white matter after the CSF TT, gait function improved more than it did in patients with decreased CBF in these regions. However, in the whole sample, there was no significant increase in CBF after CSF removal.

Preoperative MRI scans were retrospectively evaluated in 109 patients with iNPH who had undergone shunt surgery. The callosal angle was smaller in shunt responders compared with non-responders. The following findings showed the highest association with a positive outcome after shunting: a small callosal angle, wide temporal horns, and occurrence of disproportionally enlarged subarachnoid space hydrocephalus.

In conclusion, CBF in white matter close to the lateral ventricles may play a role in the reversibility of symptoms after CSF removal in patients with iNPH. The CSF TT should be reevaluated if the patient does not initially improve, and preoperative MRI investigations can add prognostic information regarding the selection of shunt candidates.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. 98 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1001
Keyword
normal pressure hydrocephalus, NPH, cerebrospinal fluid disorders, dementia, MRI, CSF tap test, CBF, ASL
National Category
Neurology
Research subject
Neurology; Neurosurgery; Radiology
Identifiers
urn:nbn:se:uu:diva-222779 (URN)978-91-554-8958-8 (ISBN)
Public defence
2014-06-09, Gunnesalen, Akademiska sjukhuset, ing 10, 751 85, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-05-19 Created: 2014-04-14 Last updated: 2014-06-30

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Virhammar, JohanCesarini, Kristina GLaurell, Katarina

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