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Well, normal pressure hydrocephalus is a type
of hydrocephalus which occurs in the elderly patient.
Normal refers to the amount of pressure and
it's not high in these patients.
Hydrocephalus means basically water in the head.
Many times when water builds up in the head, pressure builds up.
But in these elderly patients it stays in the normal range, and
the symptoms are imbalance, problems with memory, and
sometimes problems with bladder control.
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Normal pressure hydrocephalus is diagnosed really in three steps.
First, you have to be suspicious of it based on the symptoms.
The triad of symptoms in gate and
in cognition, in memory, and in bladder control.
Once you're suspicious, you have to ask the question,
is fluid building up?
Because that's what hydrocephalus is, and for
that you need an image.
The image can be a CT or an MRI, but we have to see that fluid is
building up to call it a hydrocephalus.
Finally, in the third step we have to found out
if it can be treated by a shunt, if it's normal pressure
hydrocephalus that's treatable by removing fluid.
And we do a trial removal at that stage to make sure you have
NPH that can be treated.
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Normal pressure hydrocephalus does not have
a medical treatment.
There's no medicines for it.
Basically, we try and
drain extra fluid off in a controlled way.
To do that we have to put a shunt in.
And a shunt is basically a tube that runs from the fluid in
the brain, from the ventricle is the fluid space,
down under the skin, and then most often we have it
dripping into the area in the abdominal cavity.
Everything's underneath the skin and it can't be seen.
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Pseudotumor cerebri is a disorder where there's a high
pressure in the head.
And the high pressure is due to veins in the head that
are dilated, and the extra amount of blood in there,
which increases the pressure generally.
This is different from other situations where the pressure
may be normal, as in normal pressure hydrocephalus, or
other situations where the pressure may even be low.
In pseudotumor cerebri,
we have people present really often in young adulthood.
And although males and females can present, often it is in
females and very often it is in people with some extra weight.
Pseudotumor cerebri's a bit of a misnomer.
It was originally described as pseudotumor
because people thought it was tumor, and
that's why the person had the high pressure.
But there's no tumor involved at all.
So we have to remember the word pseudo.
Another perhaps better name for it is intracranial hypertension,
and that means high pressure in the head.
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The diagnosis of pseudotumor cerebri really involves
two elements.
One, we look in the eyes.
With the eye exam we can see if there's any pressure that's in
the head because the eyes often do reflect in something called
papilledema, swelling of the back of the eyes.
We could see that there's pressure in the head.
The second thing is to actually measure
the pressure in the head.
That could be done through a spinal tap or
it's called a lumbar puncture.
Or sometimes we do it through intracranial pressure
monitoring, which is actually a pressure monitor which senses
the pressure right in the head.
If we know there's high pressure and
especially if we see it in the eyes,
then we know the person has pseudotumor cerebri.
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The treatment options for
pseudotumor cerebri run from the medical to the surgical.
First, increased weight can contribute to the high
pressure in your head.
So we ask all patients as possible, and sometimes that
even means surgical procedures to reduce weight.
Another treatment can be medical, and
this a treatment called Diamox.
It's a medicine that reduces the amount of fluid that's
made in the head and reduce the pressure.
Between those two options, pseudotumor can be treated
probably more than half the time.
However, when pressure remains high,
when vision is still endangered, and vision can actually
get severely diminished, or there can even be blindness,
then surgery is needed as an option.
The surgical options are shunting,
which is a tube that runs from the ventricles, again, usually
the peritoneal cavity, usually it's the abdominal cavity, but
it can run other places as well.
But there are other options as well.
Because the pressure can cause blindness,
the pressure actually compresses the nerve going out to the eye.
And the ophthalmologist can do what's called an optic
sheath fenestration.
So they specifically open up the fluid area around the optic
nerve to decompress it.
So that's another additional option, especially if vision is
threatened specifically, which it can be.
The other one is shutting, as I mentioned.
And a third option involves what we call venous stenting,
and this gets back to what pseudotumor cerebri really is.
I mentioned that it's a dilation of the veins,
an increased pressure in the veins.
That is often because there's a blockage somewhere in the veins,
which causes the blood to back up behind it.
We can sometimes see that blockage in the veins in
the back of the head, and
this is a not infrequent cause of pseudotumor cerebri.
In this case, very much like the cardiologist can go up
the vascular tree and use a stent to open up a vessel.
The invasive radiologist can go also up the veins of the body
to the veins back here and
stent them open, and therefore relieve that obstruction and let
the blood flow, the venous blood flow come out more regularly.
So the options are venous stenting, shunting, and
the medical treatments.
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Cerebral spinal fluid leaks have been known for years because
the brain is surrounded by fluid, as is the spinal cord.
And when you get a lumbar puncture,
sometimes the hole back there can leak.
We used to call them lumbar puncture headaches,
LP headaches.
Whenever you stand up, you get very bad headaches.
However, what we also know is these CSF leaks can occur for
many other reasons.
They can present in adults of any age, men and women, and
sometimes it's because of a known trauma,
a trauma to the head, where there may be fluid leaking, or
trauma to the spinal cord.
The trauma could be an accident or it could be surgical trauma.
But also is very interesting is that unfortunately this can
happen without any known trauma, what we consider spontaneously,
and can be very unknown as to where the exact leak is.
So these CSF leaks occur and lower the pressure in the head,
and this is a situation where the CSF pressure is low.
And we call it intracranial hypotension.
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When we have CSF leaks,
sometimes they're quite apparent.
Sometimes fluid is dripping from the nose or
there's a swelling in the back, but that's not often the case.
Sometimes we know by the history that there's a break in
the skull or we can see it on an image.
What we look at in an image is not only for
breaks in the skull, but
sometimes we can see that the brain is actually sagging down
and pulling downward.
And that can cause severe headaches whenever a person
stands up.
It can also cause problems with your nerve control of your face,
your cranial nerves.
It can even make you lethargic and it could be very dangerous.
So the whole brain can sag and we can see that in the MRI.
With an MRI of the spinal cord,
sometimes, unfortunately not frequently enough, we can see
where the leak is coming from on a standard MRI image.
More often, we have to find out if the pressure's low by
measuring the pressure in the head and
determining it's low directly.
And by doing special studies,
and some of them require a tube or catheter going into the spine
to look for where these leaks might be.
We inject dyes or tracers and see how it might
come out of the spinal canal and where the leak might be.
We have to find specifically where the leak is in order
to treat it.
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When a person has a CSF leak,
sometimes we just hope it goes away.
We tell people to lay down for a while, drink some fluids, drink
some caffeine, and sometimes it does go away in a few days.
Obviously, the problems that are more difficult to face is when
they continue,
when there's a leak that does not stop on its own.
In this case, one of the first things that's often tried is
what we call a blood patch.
And it's an empirical blood patch.
It's putting a wad of a person's own blood clot over
the spinal canal to try and close up a leak.
Of course, that only works with leaks that it can find down low
in the bottom of the spinal cord and close up.
Many times these leaks can be up and down the spinal cord, and
we have to go and find them.
So we use what's called a targeted blood patch.
And in this case our invasive radiologist can go up and
look for where the leak is along the spinal canal, find out
the level, and then right through the skin with a needle.
The patient's kept very comfortable,
the patch is made right over the leak.
Those are the main ways that we treat them,
with the addition of actual surgical operation which we
sometimes have to do an open operation to go in and close it.
We hope that we can usually close these up through these
patching techniques.
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