title: Shunt surgery in patients with hydrocephalus and white matter changes.
abstract: OBJECTIVE
  Patients with idiopathic normal pressure hydrocephalus (iNPH) often present with impaired gait and cognition together with ventricular enlargement and normal intracranial pressure. Many have vascular risk factors as well as periventricular and deep white matter changes on MR imaging. Abnormal CSF dynamics, that is, high resistance to outflow or improvement after CSF drainage, indicate good effects of shunt surgery. The authors examined whether the worst-case iNPH patients with extensive vascular white matter disease and normal CSF dynamics would benefit from shunt surgery. These patients also fulfilled the criteria for Binswanger disease. Therefore, a randomized controlled double-blind study was performed.
  
  
  METHODS
  Fourteen consecutive patients fulfilling the above criteria were randomized to receive either open or closed shunts. At 3 months after surgery, the patients with initially ligated shunts had their shunts opened. Clinical evaluation consisting of 7 quantitative psychometric and 6 continuous gait tests was performed preoperatively and 3 and 6 months after surgery.
  
  
  RESULTS
  Patients randomized to receive open shunts had improved motor (30% increase) and psychometric (23% increase) scores 3 months after shunt placement. There were no significant changes between the 3- and 6-month follow-up in these same patients. Conversely, those with initially ligated shunts were unchanged during the first 3-month period, although they improved in both motor (28%) and cognitive (18%) functions following removal of the ligature.
  
  
  CONCLUSIONS
  Patients with enlarged ventricles, hydrocephalic symptoms, and extensive vascular white matter changes benefit from shunt surgery.
authors.affiliation: Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden. magnus.tisell@vgregion.se
authors.forename: Magnus
authors.initials: M
authors.lastname: Tisell
authors.forename: Mats
authors.initials: M
authors.lastname: Tullberg
authors.forename: Per
authors.initials: P
authors.lastname: Hellström
authors.forename: Mikael
authors.initials: M
authors.lastname: Edsbagge
authors.forename: Mats
authors.initials: M
authors.lastname: Högfeldt
authors.forename: Carsten
authors.initials: C
authors.lastname: Wikkelsö
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000473:pathology; D015170:Cerebrospinal Fluid Pressure / Q000502:physiology; D015897:Comorbidity; D015140:Dementia, Vascular / Q000175:diagnosis / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D020233:Gait Disorders, Neurologic / Q000209:etiology; D006801:Humans; D006850:Hydrocephalus, Normal Pressure / Q000175:diagnosis / Q000601:surgery*; D007091:Image Processing, Computer-Assisted; D008026:Ligation; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000706:statistics & numerical data; D009483:Neuropsychological Tests / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000209:etiology; D011594:Psychometrics; D017287:Ventriculoperitoneal Shunt