title: Clinical outcomes after ventriculoatrial shunting for idiopathic normal pressure hydrocephalus.
abstract: BACKGROUND
  Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder that classically presents with a triad of progressive gait impairment, urinary incontinence, and cognitive deterioration. Treatment predominantly involves ventriculoperitoneal (VP) shunting, but one alternative is ventriculoatrial (VA) shunting. This study sought to describe and evaluate the clinical outcomes of patients with iNPH primarily treated with VA shunting.
  
  
  METHODS
  A retrospective review of patients with iNPH who were treated with VA shunting at a single institution, from 2003 to 2013, was performed.
  
  
  RESULTS
  58 patients with iNPH underwent primary VA shunting at a median age of 74 (IQR: 70-80) years. The most common comorbidities included hypertension (n=39, 67%) and diabetes mellitus (n=11, 19%). Median duration of symptoms prior to VA shunting was 24 (IQR: 12-36) months. All patients had gait impairment, 52 (90%) had cognitive decline, and 43 (74%) had urinary incontinence. Forty-three (74%) patients had all three symptoms. At a median last follow-up of 16 (IQR: 7-26) months, median iNPH score improved from 6 to 3 (p<0.0001), mini mental status exam (MMSE) tended to increase from 26 to 29 (p=0.082), timed up-and-go (TUG) improved from 18 to 13s (p<0.0001), and Tinetti score improved from 19 to 25 (p<0.0001) after VA shunting. 78% of patients had improvement in at least one of their symptoms with 66% of patients having improvement in gait, 53% having improvement in their cognition, and 52% having improved urinary incontinence. A total of 21 patients (36%) had improvement in all 3 symptoms.
  
  
  CONCLUSIONS
  There were significant improvements in functional outcomes as evaluated via the iNPH score, TUG, and Tinetti score, while improvement in MMSE trended toward significance. Patients also had improvement of clinical symptoms related to gait, urinary function and cognition. These results suggest that VA shunting can be an effective primary treatment alternative to VP shunting for iNPH.
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Ann
authors.initials: A
authors.lastname: Liu
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Eric W
authors.initials: EW
authors.lastname: Sankey
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Ignacio
authors.initials: I
authors.lastname: Jusué-Torres
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Mira A
authors.initials: MA
authors.lastname: Patel
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States. Electronic address: belder4@jhmi.edu.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Elder
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: C Rory
authors.initials: CR
authors.lastname: Goodwin
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Jamie
authors.initials: J
authors.lastname: Hoffberger
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lu
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
authors.forename: Daniele
authors.initials: D
authors.lastname: Rigamonti
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002557:Cerebrospinal Fluid Shunts / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria; D006801:Humans; D006850:Hydrocephalus, Normal Pressure / Q000175:diagnosis* / Q000601:surgery*; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Cerebrospinal fluid shunt; Cognitive dysfunction; Gait; Idiopathic normal pressure hydrocephalus; Outcomes; Ventriculoatrial shunt