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December 09, 2020Research

Protocolizing the Work-up for Idiopathic Normal Pressure Hydrocephalus Improves Outcomes

Lealani Mae Y. Acosta, Kassandra Stubblefield, Trisha Conwell, Kiersten Espaillat, Heather Koons, Peter Konrad, John Fang, View ORCID ProfileHoward Kirshner, Thomas Davis
First published December 9, 2020, DOI: https://doi.org/10.1212/CPJ.0000000000001018
Lealani Mae Y. Acosta
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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Kassandra Stubblefield
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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Trisha Conwell
2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, 37212,USA
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Kiersten Espaillat
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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Heather Koons
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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Peter Konrad
3Department of Neurosurgery, West Virginia University Rockefeller Neuroscience Institute, Morgantown, WV 26506, USA
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John Fang
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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Howard Kirshner
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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  • ORCID record for Howard Kirshner
Thomas Davis
1Department of Neurology, Vanderbilt University Medical Center, Nashville, 37212,USA
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Citation
Protocolizing the Work-up for Idiopathic Normal Pressure Hydrocephalus Improves Outcomes
Lealani Mae Y. Acosta, Kassandra Stubblefield, Trisha Conwell, Kiersten Espaillat, Heather Koons, Peter Konrad, John Fang, Howard Kirshner, Thomas Davis
Neurol Clin Pract Dec 2020, 10.1212/CPJ.0000000000001018; DOI: 10.1212/CPJ.0000000000001018

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ABSTRACT

Background: The work-up for idiopathic normal pressure hydrocephalus (INPH) can be difficult to coordinate and determining appropriate patients for ventriculoperitoneal shunting can be challenging, so we hypothesized that implementing a formalized protocol can improve patient selection for shunt. In conjunction with neurology and neurosurgery, we instituted a standardized means of assessing patients whose presentation is concerning for INPH and compared their work-up with similar patients seen without the protocol (i.e., “pre-protocol” or PP) regarding baseline characteristics, assessment, and outcomes.

Methods: Twenty-six PP patients were compared with 40 protocol patients on measures, including baseline deficits, work-up, neurosurgical evaluation, and response to shunt.

Results: Average age was similar between groups and percentage of patients who had a decline in gait, cognition, and/or incontinence was not statistically different (p>0.05). Significantly more protocol patients underwent high-volume lumbar puncture (HVLP; 97.5%; PP, 61.5%; p<0.001) and received formalized gait assessment with The Gait Scale (90%; PP, 0%, p<0.001) and standardized cognitive testing (95%; PP, 38.5%; p<0.001). Significantly more protocol patients had no improvement after HVLP (33.3%; PP 6.25%, p<0.045); subsequently, fewer got shunted (57.5%; PP, 84.6%; p<0.030). More protocol patients who were shunted reported gait improvement (100%; PP, 72.7%; p=0.009), though there was no difference in cognition (59.2%; PP, 82.6%, p=0.108) or incontinence (18.2%; PP, 39.1%, p=0.189).

Conclusions: Implementing an INPH protocol leads to standardized and more extensive assessment and better patient selection for and subsequent outcomes from shunting, specifically regarding gait.

  • Received August 28, 2020.
  • Accepted October 22, 2020.
  • © 2020 American Academy of Neurology

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