Dottorato in TECNOLOGIE INNOVATIVE NELLE MALATTIE DELLO SCHELETRO,
DELLA CUTE E DEL DISTRETTO ORO-CRANIO-FACCIALE

Titolo della tesi: CLINICAL OUTCOMES OF SHUNTING IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS: A PROSPECTIVE OBSERVATIONAL STUDY

STUDY DESIGN: This is a multi-center, prospective observational study. OBJECTIVE: This study aimed to evaluate the clinical outcomes of shunting in idiopathic normal pressure hydrocephalus following a new uniform protocol. BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH), characterized by the triad of dementia, gait disturbance and urinary incontinence, all potentially reversible following ventricular-peritoneal shunt (VPS). However, difficulties in differential diagnosis with neurodegenerative diseases result in delay and/or lack of treatment, thus preventing recovery with dramatic consequences in terms of clinical deterioration and growing socio-economic costs. The European Multicenter Study on iNPH reported a good correlation between a newly developed assessment scale and the clinical improvement, providing a promising tool for the diagnostic process. However, additional clinical-radiological markers and prospective/randomized studies, could improve the diagnostic process, especially the differential diagnosis with other neurodegenerative diseases. METHODS: This study is designed according to the STROBE guidelines. Demographical, clinical, surgical, and radiological data were collected from May 2016 to June 2019. Gait, balance and incontinence data based on iNPH European scale were collected before and after one, six and twelve months of treatment with a VPS. The neuropsychological tests included: the Rey Auditory Verbal Learning Test, the Grooved Pegboard and the Stroop test. Clinical symptoms and changes of the Stoke Volume, as measured by phase-contrast cine MRI were used to evaluate improvement after VPS surgery. RESULTS: Eighty-one consecutive patients met inclusion criteria. Mean age was 73.1 years (59–86) and mean follow-up was 31.2 months (13-50). The gait (58.5±14.3 to 70.1±13.4, p<0.001), the balance (66.7±21.5 to 71.7±22.1, p=0.001) and continence domain (69.9±20.5 to 76±20, p=0,002) scores showed a statistically significant improvement over follow-up. The neuropsychological scales significantly improved postoperatively and at the last follow-up. The overall improvement after 12 months was present in 90% of patients. No intraoperative complications were recorded. An overall complication rate of 9.9% and a reoperation rate of 8.6% were recorded, respectively. CONCLUSIONS: Surgical treatment by VPS for iNPH improves symptoms in most patients, when accurately selected. A uniform protocol and a multidisciplinary team dedicated on this disorder is needed to achieve an early and correct diagnosis of iNPH. Follow-up with stroke volume measurement is needed for early diagnosis of shunt malfunction or need for valve adjustment. KEYWORDS: idiopathic normal pressure hydrocephalus; hydrocephalus; ventriculoperitoneal shunt; iNPH; cerebrospinal fluid; VPS; dementia; neurodegenerative diseases