Question Title: Brain Injury after NPH dx

Forum: Neurology Forum
Topic: Hydrocephalus

In mid June, my fil took a fall in a parking lot, which resulted in multipule subdural hematomas. Although my mil was not given much hope, they took my non-responsive fil into surgery. He came out of surgery, and remarkably within the week was able to independently move his body (while in bed), open his eyes to make eye contact, wiggle his toes, squeeze a hand to provide yes/no answers. He was on a vent. The shunt was removed during the surgery. It has not been replaced. The dr.s are not treating the NPH because they say that the CT scans do not show enlarged ventricles and that his bur hole is depressed. I am not sure if he has had an MRI or not.

Since his cranial drain was removed after surgery, my fil has steadily declined. He is no longer able to provide any response to stimulation. (Although, my husband, who is there right now, told me last night that he was getting pupilary response and that his dad raised his arm when my husband massaged his head.) The sub-acute center that he is in now has said that there is no hope and that he should be transfered to a nursing home.

My questions are: Could the NPH be causing his decline? Could he have a problem with the NPH yet still have normal-sized ventricles and a depressed burr hole? (My own daughter has hydrocephalus secondary to a chromosome abnormality and at 2 1/2, before she was shunted, had an absolutely sunk-in soft spot. An eye exam revealing papilledema and an MRI provided evidence for the dx.) If NPH were the culprit of my fil's further decline, wouldn't a lumbar drain provide some relief (so that they wouldn't have to provide further insult to the brain) and perhaps an answer? I realize that the dr.s may be dealing with a quality of life issue. . .why try if his quality of life wouldn't significantly improve? But shouldn't the family be imformed if this is the case. . . so that the family can make the decision?

We do have family their on the scene, who don't seem to question what's going on, and perhaps if we lived closer, we would have more information and no need to question. It's very frustrating to live as far away as we do and not have direct contact with the dr.s.

Thanks for any help that you can provide.

Joanna
_______
_______
Dear Joanna,

You are correct, the classic clinical triad for NPH is gait ataxia, dementia and incontinence. Patients can have marked recovery when the diagnosis is correct, which sounds like the case with your father. When a shunt stops functioning, a patient or his family will note a return of these symptoms. Shunts may fail by disconnection, kinking, infection and physically pulling out of abdominal cavity, for instance. A patient may also become symptomatic if the shunt isn't draining enough CSF. If this is the case, the valve should be changed to a lower pressure valve to allow more drainage.

The problem with your father is that he fell and had the subdural hematomas, and the shunt was removed. The surgeons were probably worried about the shunt overdraining, which could allow the brain to be a bit more 'slack' and could cause worsening or return of the subdural hematomas. It is a bit of a tradeoff. If your father has had a return of the previous symptoms, the surgeon may consider replacing the shunt, but the risk is overdrainage and a return of the subdurals, putting him right back where he started. This isn't the simplest situation to manage.

Speak to your father's surgeon and have him explain why the shunt hasn't been replaced. It may be because of the subdurals your father had. The ideal would be to balance enough CSF drainage and not cause further subdural bleeding and more problems. Unfortunately there are no easy answers here.

Good luck.

[Neurology Forum]      [Neurology Forum Archives]