← Becker’s Healthcare Podcast
Loading summary
Transcript16 lines
- [00:00]
A
This is Laura Dearda with the Becker's Healthcare Podcast. I'm thrilled today to be speaking with Dr. Matthew Potts, who's a neurosurgeon at Northwestern Medicine. Today we're going to talk a little bit about normal pressure hydrocephalus, especially in light of Billy Joel's recent diagnosis of normal pressure hydrocephalus. We wanted to talk a little bit with Dr. Potts about what that means about, you know, the diagnosis and treatment and why it's important for people to really be keeping an eye out for these symptoms, and then, you know, what clinicians can do at the same time to really work with their patients and help them do whatever they can to keep a great quality of life. So, Dr. Potts, it's a pleasure to have you on the podcast today.
- [00:43]
B
Thank you very much. Pleasure is mine.
- [00:46]
A
Now, before we get into our bigger discussion, can you tell us a little bit about yourself and your background?
- [00:51]
B
Sure. I am a neurosurgeon at Northwestern. My primary clinical focus is vascular neurosurgery. But over the years, I've taken on an interest in hydrocephalus and normal pressure hydrocephalus in particular.
- [01:08]
A
Fantastic. Well, you know, let's get right into it. What are some of the main symptoms and warning signs of normal pressure hydrocephalus.
- [01:16]
B
The classic symptoms that, you know, we learn about in school? It's a triad of three symptoms, obviously, since it's triad of gait abnormalities, cognitive dysfunction, and urinary incontinence.
- [01:34]
A
Absolutely. So those are three of the warning signs. And I can imagine, you know, these are things that patients might notice or might try to ignore any one of those three. And so when you, you know, are talking to patients, how do you, I guess, get through to them or really kind of talk about some of the risks and dangers of the condition so that they'll be able to, you know, connect with you and understand what is happening.
- [02:03]
B
Yeah, you know, when I meet patients, they typically have already seen a neurologist, certainly a primary care provider, and they've already been given a potential diagnosis of normal pressure hydrocephalus. The challenge with this population is that those symptoms, gait problems, cognitive dysfunction, urinary dysfunction, those are very common in older patients. And it's the older patients where we primarily see idiopathic normal pressure hydrocephalus. And there's a lot of causes of those things well beyond normal pressure hydrocephalus. And so the first steps, when I meet somebody who, again, has already been given a presumptive diagnosis, is to really Tease out the symptoms that they're having and try to understand, do these really fit with that classic triad, and are there potentially other explanations for each of their symptoms?
- [03:10]
A
That makes a lot of sense. And it's really helpful to understand how the process typically goes. And so you have the conversation and you're looking at whether, you know, these symptoms are connected and the diagnosis. You know, you need to move on to treatment. What are some of the available treatments or cures when a patient does have normal pressure hydrocephalus?
- [03:32]
B
So, ultimately, the treatment that we have for normal pressure hydrocephalus is what we call a shunt. Shunt basically is a tube that drains cerebral spinal fluid out of the brain, or in some cases, from pockets around the spine and drains it into somewhere else in the body to basically remove some of that fluid, relieve a little bit of the pressure. And if somebody truly has normal pressure hydrocephalus, that will improve their symptoms.
- [04:12]
A
Got it. That's helpful to know. Now, for someone that's going through the treatment, could they recover? And especially in Billy Joel's case, could he potentially recover and return to performing?
- [04:23]
B
So it's very possible. It depends on a few things. It depends on how long somebody has had those symptoms and how severe those symptoms are. Normal pressure hydrocephalus, the vast majority of patients have gait difficulties. That's for most patients, sort of the hallmark symptom. And the cognitive difficulties, the urinary difficulties, oftentimes will progress later. So if you catch somebody very early on, when it's primarily gait difficulties and they don't have significant cognitive dysfunction or urinary dysfunction, I think their chances of having significant improvement are very high. When somebody's been dealing with these issues for years and they're difficult, you know, it's to the point where they can no longer walk, where they have very severe cognitive dysfunction, it's less clear how well they're going to improve. Now, typically when we offer a shunt to a patient, we've already done some sort of test to determine if they're going to respond to a shunt. And as I said before, the biggest challenge is really trying to figure out is this truly normal pressure hydrocephalus and not something else. But usually the last step in the workup, once we've sort of determined that the symptoms really fit, that there's not some other condition going on that can explain these symptoms. Usually we do some sort of test to temporarily remove cerebral spinal fluid and basically see if patient symptoms improve. The easiest symptom to look at is gait imbalance. And we have different ways of sort of objectively measuring somebody's balance in their gait. And we have two ways that we can test this. One is simply with what's called a high volume lumbar puncture. We do a lumbar puncture, we remove 30 to 50 cc of cerebral spinal fluid. Prior to that, we do some sort of formal gait and balance test, and then we repeat that test, usually a few hours later. And what you're looking for is, do they get better? Is their gait faster? Are they able to turn faster? Are they more balanced? Sometimes you might need to repeat that test later in the day, the next day. Some people advocate for repeating it over a few days to be really certain. You know, if initially somebody's not improving, you want to give them the best chance at seeing if they can improve. The other way that we can do this, it's a little more intensive for the patient, but we actually bring them into the hospital again. We do sort of a baseline gait and balance test, and then we place what's called a lumbar drain. That's a drain, that small drain that goes through the lumbar region in the back into a cerebral spinal fluid cistern below the level of the spinal cord. And we basically drain 5 to 10 ccs per hour for the next several days. So patients have to be in the hospital for this. But on each subsequent day, we repeat those gait and balance tests, and again, we're looking to see, do patients get better? Sometimes, Particularly for patients that have significant cognitive dysfunction, we can also do baseline cognitive testing and then repeat that a few days into one of these tests. And, you know, those are the objective things. Oftentimes, though, we get a lot of subjective feedback from patients and their families. And, you know, if somebody's truly responding to that CSF drainage, their families will say, hey, you know, my mom is just so much brighter. And, you know, she seems like she's back to her old self. And patients will sometimes say, I feel like I feel so much more steady on my feet. And so that subjective feedback is also very important when we're evaluating these patients. And typically, if they respond to one of these tests, a high volume lumbar puncture or a trial of lumbar drainage, typically we can assume they will then also respond to a shunt, and we can recommend that and proceed with that surgery. It gets a little trickier if they don't respond. And I think oftentimes we tell patients the likelihood of you benefiting from a shunt is very low if you didn't benefit when we drain csf. But there have been studies where they ultimately shunted everybody, they included, and then they kind of looked at what were their CSF drainage tests. And there are some patients who actually will improve with a shunt, even if they didn't improve initially with our test of CSF drainage.
- [09:23]
A
That's really helpful to understand. And you know, what a great outcome once the patients are able to feel a bit more like themselves and show up a bit more familiarly to their families. So I think that's amazing. Amazing outcome and definitely seems like great to have that possibility. Is there anything else that people should know? Both patients as well as clinicians?
- [09:46]
B
We have a great treatment. So once somebody lands in a neurosurgeon's office, I think if they have normal pressure hydrocephalus, that's going to get diagnosed and they're going to get the treatment they need. Again, the challenge is making that initial diagnosis. You know, whether it's a primary care provider or a neurologist, it's having the suspicion that normal pressure hydrocephalus could be going on, and it's doing the appropriate initial workup. The sort of bare minimum workup is some imaging of the brain, CT scan can show you that the ventricles are enlarged. Ideally, you have an MRI, because not only does it show you that the ventricles are enlarged, but it looks at the brain in other ways and can help kind of narrow the diagnosis. There are. There are lots of different sort of measurements we can do to look at the size of the ventricle, how the ventricles are shaped, to look at CSF outside of the ventricles. And there are some other kind of more advanced imaging studies that can help make that diagnosis. But bare minimum, we need some imaging of the brain to confirm that they actually have a buildup of cerebral spinal fluid. And, you know, I think a lot of times patients, you know, for example, if their primary issue is gait, you know, patients who are older can also have degenerative spine disease. They can also have peripheral neuropathy. There's these other things, and they may actually have both those things and normal pressure hydrocephalus, but those other things are more common, so they end up kind of going down those pathways. Similarly for cognitive dysfunction and urinary dysfunction, I think one particular challenge is with cognitive dysfunction in elderly patients, There's a lot of reasons for that. And dementia is probably more prevalent than normal pressure hydrocephalus. And so I think oftentimes it's easy for somebody to just be given a diagnosis of dementia or Alzheimer's, something like that, when in fact, if it's just normal pressure hydrocephalus, that is actually a treatable form of dementia. So if that diagnosis is missed, you miss out on the chance to help them. So I think the biggest message and the biggest impact that having a discussion of normal pressure hydrocephalus, having it be something that's now in the media and the news, I think the biggest impact is going to be awareness and that patients, primary care providers, general neurologists, are going to become more aware of this and think about it next time they see a patient that has some of the possible NPH symptoms and hopefully then, you know, refer them to neurosurgeons to, to get the treatment that they need.
- [12:38]
A
That's amazing to hear. Dr. Potts, thank you so much for being here today. I really appreciate your expertise in what a great conversation, an important one too, as you know, this type of research and treatment evolves. Thanks again for your time and I look forward to connecting with you again soon.
- [12:54]
B
Of course. Thank you very much.