Article on Nursing
ARTICLE ON NURSING 4
Theknowhow to predict the result after shunt replacement in patientswith idiopathic normal-pressure hydrocephalus (NPH) poses achallenge. This is because up to now no combination of tools orsingle diagnostic tool has proved competent of dependably predictingwhether the condition of a patient with supposed NPH will advanceafter shunting practice. According to a research conducted, 120patients were involved with the aim to spot CSF hydrodynamicscriteria capable of selecting patients with idiopathic NPH, theresearch focused on the assessment between intracranial elastance(IE) and CSF-outflow resistance (R-out) to distinguish patients whowould experience improvement after shunt replacement and they thatwill not experience. According to several studies, carried out whenresearchers select an R-out cutoff level this may increase ofdeselecting patients who would benefit from shunt placement. Someauthors suggest analysis of CSF pulse pressure amplitude duringlong-term monitoring of ICP. Their criteria for shunt treatment are:mean ICP wave amplitude ≥ 4 mm Hg during at least 70% of ICPrecording time, ≥ 5 mm Hg during at least 40%, or ≥ 6 mm Hgduring at least 10% of the time. Using these criteria, they obtain,as the best result, a positive predictive value of 90% and a negativepredictive value of 100%.
Long-termintraventricular ICP monitoring, including periods of sleep, wascarried out in all patients. Different CSF dynamics parameters wereevaluated, and the authors considered a CSF waveform amplitudeincrease of more than 3 times from resting conditions to REM phase ofsleep the most reliable indicator in predicting surgical outcomes.This finding strongly suggested the possibility that a decrease inintracranial compliance (that is, the intracranial volume bufferingcapacity) could play an important role in the genesis and developmentof idiopathic NPH.
Accordingto the outcomes from different articles and tests carried out,idiopathic NPH is treatable with a very good outcome when theselection criterion is based CSF pulse pressure parameters. Anincrease in ventricle size as well as the presence of cognitiveimpairment, gait disturbance, and urinary incontinence may beassociated with several brain diseases different from "true"NPH. Indeed, in a strict pathogenetic sense, this disease should berepresented by a pure reversible hydrodynamic alteration, which isable per se to produce the ventricular enlargement and the clinicaltrial. Correction of the hydrodynamic alteration will produceclinical improvement as well as a reduction in ventricle size. Areduction in ventricular size is not an absolute prerequisite forclinical improvement, even though it never appears to arise in theabsence of a good outcome. This partial discrepancy between expectedand actual postoperative results may have 2 explanations: 1)insufficient therapeutic activity of the currently available CSFshunting devices to adequately control the pathogenetic mechanismsunderlying both ventricular enlargement and clinical history, and 2)irreversible structural alterations in the brain parenchymaassociated with reversible changes in brain function. The lattercondition seems to depend not on patient age rather it probablydepends on the availability of the extracellular space to be refilledby fluid coming from the intravascular space as a consequence of theextrathecal displacement of the intraventricular volume due to CSFshunting. CSF hydronamics parameter automatically measured by acomputerized intraventricular infusion test at constant flow, may behighly predictive of a good outcome. Several authors have recentlyproposed endoscopic third ventriculostomy in the treatment ofidiopathic NPH. There is no reasonable explanation of itseffectiveness.
NPHpatients need much attention and care. The nursing implication ofthis case is for the nurse to administer the right medication as wellas looking after the patient in case the patient is not comfortablethe nurse can call the doctor in charge. Additionally, thepractitioner ought to be very close to the patient to give themmotivation and encouragement needed for these patients. From thisarticle I understand how technology is applicable in such a scenariowhere CSF is measured by use of technology and how technology can aidNPH treatment. Though NPH is said to be untreatable, with the correctinformation and right tools needed, then a patient can be treated.Lastly, I have learnt how the operations that take place whenpreparing and selecting a patient with idiopathy normal-pressurehydrocephalus for shunt placement.
Article Reviewed:Kiefer M, Eymann R, Steudel WI: Outcome predictors fornormal-pressure hydrocephalus. ActaNeurochir Suppl 96: 364–367,2006