| Part I:The natural course and prognostic factors of idiopathic normal pressure hydrocephalus:a retrospective cohort study of 42 cases in 5 years follow upAim:This study is to investigate natural course and prognostic factors of iNPH patients in long-term follow up.Methods:All 42 iNPH patients who were diagnosed in Huashan Hospital during Jan 2006-Dec 2011 and undergone no operation were evaluated. Clinical data were extracted from medical history, follow ups were performed 3 months,1 year,3 years,5 years after diagnosis. Clinical progression or improvement were confirmed according to change in NPHGS. Survival analyses were performed in Kaplan-Meier method, log-rank tests were performed to investigate the prognostic value of clinical parameters by SPSS.Results:Initial symptom was gait disturbance in 17 cases (40.5%), cognitive impairment in 12 cases (28.6%) and urinary incontinence 1 case(2.4%), in other 12 cases (28.6%) patients initiated with more than 2 symptoms. Median follow up was 3.2 years with the longest of 7.8 years. During the follow up,12 deaths and 17 progression occurred. The 5-year overall survival(OS) and progression free survival(PFS) rate was 68.0 ±9.1% and 26.0±12.0%, respectively. The 5 years OS of patients with complete Hakim triad was 54.6±13.1%, significantly lower than 84.8± 10.0% in those without (p=0.028).Conclusion:iNPH dramatically worsen the quality of life of elder people. In those who undergo no operation,5-year OS and PFS are 68.0% and 26.0% respectively. The progression rate of gait disturbance, cognitive impairment and urinary are nearly the same. INPH patients with complete Hakim triad has shorter OS.Part II:The therapeutic effect of ventriculoperitoneal shunt:a retrospective cohort study of 67 cases in 5 years follow upAim:This study is to investigate symptom improvement and prognostic factors of iNPH patients after ventriculoperitoneal shunt (VPS) in long-term follow up.Methods:All 67 iNPH patients who were diagnosed in Huashan Hospital during Jan 2006-Dec 2011 and undergone VPS were evaluated. Clinical data were extracted from medical history, follow ups were performed 3 months, 1 year,3 years,5 years after VPS. Clinical progression or improvement were confirmed according to change in NPHGS. Survival analyses were performed in Kaplan-Meier method, log-rank tests were performed to investigate the prognostic value of clinical parameters by SPSS. Results:Initial symptom was gait disturbance in 28 cases (41.8%), cognitive impairment in 13 cases (19.4%) and urinary incontinence 4 case (6.0%), in other 22 cases (32.8%) patients initiated with more than 2 symptoms. Median follow up was 4.2 years with the longest of 7.9 years. During the follow up,17 deaths and 45 progression occurred. The 5-year OS and 5-year improvement rate was 76.5±6.0% and 68.5±6.0%, respectively. The 5-year improvement rate of patients with complete Hakim triad was 77.1±7.1%, had a trend to be higher than 59.0±9.5% in those without (p=0.070). The 5-year OS rate of patients with hypertension was 69.0±10.6%, had a trend to be lower than 80.7±7.2% in those without (p=0.115). Surgical complication rate is 6.0%, including 2 (3.0%) subdural effusion and 2 (3.0%) central nervous system infection.Conclusion:In iNPH patients who underwent VPS,5-year OS and improvement rate are 76.5±6.0% and 68.5±6.0%, respectively. VPS can effectively promote improvement and delay progression in the course of iNPH patients. But in the same time, VPS do render harmful complications like subdural effusion and central nervous system infection to iNPH patients.Part III:Ventriculoperitoneal shunt versus conservative follow up iniNPH:a retrospective cohort study of 109 cases in 5 years follow upAim:This study is to investigate symptom improvement and prognostic factors of iNPH patients in long-term follow up.Methods:All 109 iNPH patients diagnosed in Huashan Hospital during Jan 2006-Dec 2011 who and undergone VPS or no operation were evaluated. Clinical data were extracted from medical history, follow ups were performed 3 months,1 year,3 years,5 years after VPS/diagnosis. Clinical progression or improvement were confirmed according to change in NPHGS. Survival analyses were performed in Kaplan-Meier method, log-rank tests were performed to investigate the prognostic value of clinical parameters by SPSS.Results:Median follow up was 4.0 years with the longest of 7.9 years. The 5-year OS is 76.5±6.0% in surgical group and 68.0±9.1% in conservative group(p=0.313).5-year PFS rate is 26.0±12.0%. Surgical complication rate is 6.0%, including 2 (3.0%) subdural effusion and 2 (3.0%) central nervous system infection.Conclusion:VPS can effectively promote improvement and delay progression in the course of iNPH patients. But in the same time, VPS do render harmful complications like subdural effusion and central nervous system infection. VPS do not prolong life expectancy.iNPH:a retrospective cohort study of 109 cases in 5 years follow upAim:This study is to investigate symptom improvement and prognostic factors of iNPH patients in long-term follow up.Methods:All 109 iNPH patients diagnosed in Huashan Hospital during Jan 2006-Dec 2011 who and undergone VPS or no operation were evaluated. Clinical data were extracted from medical history, follow ups were performed 3 months,1 year,3 years,5 years after VPS/diagnosis. Clinical progression or improvement were confirmed according to change in NPHGS. Survival analyses were performed in Kaplan-Meier method, log-rank tests were performed to investigate the prognostic value of clinical parameters by SPSS.Results:Median follow up was 4.0 years with the longest of 7.9 years. The 5-year OS is 76.5±6.0% in surgical group and 68.0±9.1% in conservative group(p=0.313).5-year PFS rate is 26.0±12.0%. Surgical complication rate is 6.0%, including 2 (3.0%) subdural effusion and 2 (3.0%) central nervous system infection.Conclusion:VPS can effectively promote improvement and delay progression in the course of iNPH patients. But in the same time, VPS do render harmful complications like subdural effusion and central nervous system infection. VPS do not prolong life expectancy.Part IV:The prognostic value of clinical, biochemical and neuroimaging parameters in idiopathic normal pressure hydrocephalus patients after ventriculoperitoneal shunt:a prospective cohort studyAim:To investigate the prognostic value of clinical, biochemical and imaging parameters in idiopathic normal pressure hydrocephalus (iNPH) patients after ventriculoperitoneal shunt.Methods:Collect iNPH patients diagnosed in Huashan Hospital during Jul 2012-Aug 2013 who aggreed to anticipate this program. Detailed clinical data were well collected, special sequences including cine PC MRI were scanned, anatomical parameters like callosal angle (CA) and CSF dynamical parameters like CSF velocity at aqueduct. CSF tap tests were performed. Biochemical markers like TNF a and TGFβ1 in CSF were analyzed by ELISA in sandwich enzyme linked immunosorbent assay. Clinical progression or improvement was confirmed according to change in NPH grading scale (NPHGS). Student’s t test and logistic regression analyses were performed, ROC were drawn to investigate the prognostic value of clinical parameters by SPSS.Results:In 15 patients,9(60.0%) improved after VPS,6(40.0%) did not. The sensitivity(SE) and specificity(SP) of tap tests in predicting surgical outcome were 33.3% and 83.3%, respectively. TNF a and TGβ1 level in CSF of the study group were 11.5±2.2 and 3694.2±367.7pg/ml in average, respectively. CA and Evan’s index were 92.2±16.5° and 0.37 ±0.05, respectively. Take 0.35 as cutoff value, the prognostic sensitivity and specificity of Evan’s index were 88.8% and 50.0%, respectively. At aqueduct, CSF velocity fluctuated in sine wave synchronizing with cardiac cycle. Pre-operative peak caudal and rostral CSF velocity in aqueduct is 6.6±3.6cm/s and 8.0±2.2cm/s, respectively. In patients with improvement, peak rostral CSF velocity (PRV)is 9.1± 2.2 cm/s, significantly higher than 6.3±0.9 cm/s in those without (p=0.013). Take 7.575cm/s as cutoff value, the prognostic SE and SP of PRV were 100.0% and 77.8%, respectively. In patients with improvement, there is a 2.06±0.9 cm/s decrease in PRV, in patients without improvement there is an increase of 0.15±1.4 cm/s in PRV (p=0.002).Conclusion:In iNPH patients, lateral ventricles are not significantly narrowed after VPS. Tap test can not satisfy clinical need in selecting patients for VPS. At aqueduct, CSF velocity fluctuates in sine wave synchronizing with cardiac cycle. The PRV is higher in patients improved after VPS, and 7.575cm/s is good cutoff value in predicting surgical outcome with SE and SP of 100.0% and 77.8%, respectively. |
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