Welcome
Much of this issue of the newsletter is devoted to an entity that has been the source of debate for decades—normal pressure hydrocephalus. Deciding which patients actually have the disorder, and which ones would benefit from shunting, remains challenging at best. To try to help patients struggling with the possibility of this diagnosis, we have developed a multidisciplinary team that will assess each patient thoroughly, and provide the best possible guidance. Below you will read about the current approach to the diagnosis and treatment of NPH, as well as the roles played by neurology, neurosurgery, neuropsychology and neuro-imaging. I hope you find this informative and helpful.
John Halperin MD
Medical Director, Neurosciences
The Atlantic Neuroscience Institute Invitation to Submit Articles to the NeuroscienceNewsletter Neurosciences at Atlantic Health has grown tremendously in the past several years—hence the periodic updates on the department’s activities through the Neuroscience Newsleter. Our goal is to feature key programs each month, representing both Overlook and Morristown Memorial hospitals.
Articles and contributions come from all neuro related faculty and staff. To submit articles, new items and announcements, please contact Dr. Melvyn Heyes (melvyn.heyes@atlantichealth.org) with your suggestions.
John J. Halperin MD
The New Normal Pressure
Hydrocephalus Center
The ANI is pleased to announce the opening of our multidisciplinary center for the evaluation and treatment of normal pressure hydrocephalus (NPH). Drs. Edward Zampella(Neurosurgery),Pete Saur and Michelle Papka (Memory and Cognitive Disorders Program) and Roger Kurlan (Movement Disorders Program) will collaborate in the new center. NPH is one of those neurological diagnoses never to miss since it can be curable with ventricular shunting. NPH is characterized by the clinical triad of cognitive impairment (dementia), shuffling, unsteady gait, and urinary urgency or incontinence. Brain imaging shows ventricular enlargement out of proportion to cerebral atrophy. It has been estimated that up to 10% of patients with dementia have NPH. Hydrocephalus has been recognized as an illness as far back as the time of Hippocrates, and the benefit to be gained from draining spinal fluid was realized at about the same time. The utilization of an implanted drainage system is a far more recent occurance however.The first shunt systems were developed to treat hydrocephalus of infancy and childhood. Although the general principles of cerebrospinal fluid drainage (diversion) are the same, childhood and adult (normal pressure, NPH, occult) hydrocephalus are very different diseases in terms of both diagnosis and management.
T H E P A S S I O N T O L E A D
Atlantic Neuroscience Institute at Overlook and Morristown Memorial hospitals atlantichealth.org
The symptoms and signs of normal pressure hydrocephalus (NPH) are actually the reason the name for this illness is misleading. The symptoms that this hydrocephalus produces are not those that would typically be associated with acute increased intracranial pressure (ICP) in either the adult or child. The symptom triad of cognitive impairment/dementia, urinary incontinence, gait disturbance seen in patients with NPH is not only different from the headache, coma, decreased heart rate increased blood pressure seen in acute increased ICP - it also overlaps to varying degrees symptoms due to other illnesses frequently seen in patients in patients of the age group where NPH is most commonly seen. Alzheimer’disease, Parkinson’s disease and cervical spondylytic myelopathy can cause symptoms similar to NPH. Many patients may have one or more of these diseases concommittently further complicating the diagnostic process. From a neurosurgeons perspective, there are two main questions to be answered when evaluating a patient referred for evaluation of NPH. Are the patient’s symptoms due to NPH? Will a shunt improve the patients function? With recent improvements in both testing and the technology of the implanted shunt, the diagnosis and treatment of NPH is EASIER than in years past. Neither diagnosis nor treatment is foolproof yet however. Patients with the NPH symptom triad (dementia incontinence/gait disturbance) who have enlarged ventricles on either CT scan or MRI are admitted to the hospital for a 24-48 hour trial of CSF diversion via a lumbar drain. Improvement in any or all of the symptoms, especially gait, is considered indicative of a likely satisfactory outcome with implantation of a shunt. The newer shunts now have a valve system that is programmable with respect to the pressure at which the valve opens and allows CSF to drain. The surgeon can adjust the valve to optimize the pressure in the ventricles and obtain the best possible outcome. Dr. Kurlan points out that many patients with NPH are referred to movement disorders neurologists because their short-stepped, shuffling gait can resemble the gait of patients with Parkinson’s disease. Dr. Saur emphasizes the importance of considering NPH in patients with dementia since it is highly treatable while most dementing conditions are relentlessly progressive. One of our collaborating neuroradiologists, Dr. Neal Horner, notes that there have been advances in brain MRI with special imaging sequences and volumetric measurements to allow more specific diagnosis of NPH. Dr. Papka indicates that cognitive testing is helpful in distinguishing the type of dementia associated with NPH, having a “subcortical” pattern, from the “cortical” pattern typically seen with Alzheimer’s disease. Dr. Zampella is excited that certain clinical tests are showing increasing evidence of being able to predict which patients are expected to improve after shunting. One example is continuous lumbar drainage, in which CSF is slowly drained in the hospital over a 3 day period and documented improvement in measures of cognition and gait is used as a positive predictor of response to shunting. Dr. Zampella also points out the important recent technical advances in shunting for NPH. New programmable valves allow the easy adjustment of pressures so that problems with under- or over-drainage after shunting are markedly reduced. Our new center will utilize all of the latest methods in diagnosis, patient selection for shunting and treatment. Data consistently show that the best shunt responders are diagnosed and treated early in the course of NPH, so early referral is important.
T H E P A S S I O N T O L E A D
For a more complete discussion of the diagnosis of both diagnosis and treatment of NPH, as well as a discussion of the risks and benefits of shunt surgery, an appointment with Dr Zampella can be scheduled by calling 973-285-7800.
To refer a patient to the ANI NPH Center call 908-522-4983.
Edward Zampella, MD
Neuropsychological Assessment
Thursday, August 26, 2010
We are now an ImPACT testing center
Impact testing offers a baseline evaluation to access cognitive function of memory and reaction time. This is an objective evaluation to aid the physician in authorization a safe return to sport participation.
ADDITIONAL HELPFUL INFORMATION:
TODAY SHOW AUGUST 29,2010
Youth football: Is it safe to play? Article by Mark Adickes, M.D.
www.msnbc.com
TODAY SHOW AUGUST 30,2010
ER visits for concussions soar among kid athletes. Article by Lindsey Tanner, Associated Press
www.ap.org
U.S. NEWS AND WORLD REPORT AUGUST 31, 2010
How to Reduce the Risk of Sports Concussions in Young Athletes. Article by Nancy Shute,
U.S. News and World Report
www.usnews.com
SITE INFORMATION ON CONCUSSIONS AND TRAUMATIC BRAIN INJURIES
www.cdc.gov/concussion/headsup
Atlantic Neuroscience Institute Monthly Newletter
Pediatric Neurosurgery at Overlook
The Division of Pediatric Neurosurgery of the Department of Neurosciences at Atlantic Health is responsible for the Craniofacial Center and the Pediatric Movement Disorders Center, as well as all pediatric neurosurgery patients and procedures.
Created in 2006, the Craniofacial Center (CFC) is one of the few, American Cleft Palate and Craniofacial Association (ACPCA) approved teams in New Jersey. The CFC provides comprehensive care to children with congenital or acquired craniofacial defects and their families. Children with cleft palate, craniosynostosis, plagiocephaly, torticollis and other craniofacial defects are evaluated by the team. There are over eighteen specialties that participate in the CFC. Through a multi-disciplinary approach to patient and family-centered care, we provide gold-standard in craniofacial deformity management. The CFC follows over 300 patients with craniofacial diagnoses and is proud to be part of Goryeb Children’s Hospital. We provide complete services - including diagnosis, evaluation and all treatment components for these children. Speech and swallowing evaluations, audiometric testing, electrophysiological testing and sleep studies are available. Children who require outpatient physical or occupational therapy are provided those services through coordinated care at Atlantic Rehabilitation Institute of Morristown (ARI). Craniofacial reconstructive surgery and surgery for craniosynostosis are provided by team surgeons at Goryeb Children’s Hospital. Our team nurses and social workers provide support for the children and their families as they navigate their way through the treatment process. All aspects of neuro-imaging studies are available including 3D reconstructed craniofacial computed tomography (3DCT). The Pediatric ICU team at Goryeb has special expertise in the post-operative care of children undergoing cranial and facial surgery. Infants with Plagiocephaly are cared for through the Plagiocephaly Center of the CFC. Babies are evaluated by the pediatric neurosurgeon, developmental pediatrician, nursing, and a cranial orthotist.
The Pediatric Movement Disorders Center (PMDC) follows the same approach, involves over six specialties and provides care for children with congenital or acquired movement disorders. Children with spasticity, dystonia, hypotonia and mixed movement disorders are seen and evaluated at the Pediatric Outpatient Rehabilitation Department of Atlantic Rehabilitation Institute of Morristown (ARI). Children with cerebral palsy are offered team evaluations and recommendations that are made available to their local caregivers. Rehabilitation services such as physical and occupational therapy and speech and swallowing therapy are available. The team therapists from ARI provide evaluations, recommendations and support for the patient’s local therapists. The participation of pediatric orthopedic surgeons allows children with bony spine, hip or extremity deformities to be seen with the team. Treatment for movement disorders and deformities is coordinated and provided by the team. Services such as Botox or alcohol injections, intrathecal baclofen therapy and pump implantation, as well as test doses or trials, are provided by the PMDC. Selective dorsal rhizotomies (SDR) are offered to some children with spastic diplegia. All aspects of pediatric orthopedic surgery are provided by the excellent pediatric orthopedic surgeons of Goryeb Children’s Hospital.
The Division of Pediatric Neurosurgery is also proud to provide children with comprehensive care for the treatment of brain and spinal cord tumors, epilepsy, Chiari malformations, hydrocephalus, spina bifida, tethered spinal cord, syringomyelia, and traumatic brain injury.
The Division of Pediatric Neurosurgery of the Department of Neurosciences at Atlantic Health is responsible for the Craniofacial Center and the Pediatric Movement Disorders Center, as well as all pediatric neurosurgery patients and procedures.
Created in 2006, the Craniofacial Center (CFC) is one of the few, American Cleft Palate and Craniofacial Association (ACPCA) approved teams in New Jersey. The CFC provides comprehensive care to children with congenital or acquired craniofacial defects and their families. Children with cleft palate, craniosynostosis, plagiocephaly, torticollis and other craniofacial defects are evaluated by the team. There are over eighteen specialties that participate in the CFC. Through a multi-disciplinary approach to patient and family-centered care, we provide gold-standard in craniofacial deformity management. The CFC follows over 300 patients with craniofacial diagnoses and is proud to be part of Goryeb Children’s Hospital. We provide complete services - including diagnosis, evaluation and all treatment components for these children. Speech and swallowing evaluations, audiometric testing, electrophysiological testing and sleep studies are available. Children who require outpatient physical or occupational therapy are provided those services through coordinated care at Atlantic Rehabilitation Institute of Morristown (ARI). Craniofacial reconstructive surgery and surgery for craniosynostosis are provided by team surgeons at Goryeb Children’s Hospital. Our team nurses and social workers provide support for the children and their families as they navigate their way through the treatment process. All aspects of neuro-imaging studies are available including 3D reconstructed craniofacial computed tomography (3DCT). The Pediatric ICU team at Goryeb has special expertise in the post-operative care of children undergoing cranial and facial surgery. Infants with Plagiocephaly are cared for through the Plagiocephaly Center of the CFC. Babies are evaluated by the pediatric neurosurgeon, developmental pediatrician, nursing, and a cranial orthotist.
The Pediatric Movement Disorders Center (PMDC) follows the same approach, involves over six specialties and provides care for children with congenital or acquired movement disorders. Children with spasticity, dystonia, hypotonia and mixed movement disorders are seen and evaluated at the Pediatric Outpatient Rehabilitation Department of Atlantic Rehabilitation Institute of Morristown (ARI). Children with cerebral palsy are offered team evaluations and recommendations that are made available to their local caregivers. Rehabilitation services such as physical and occupational therapy and speech and swallowing therapy are available. The team therapists from ARI provide evaluations, recommendations and support for the patient’s local therapists. The participation of pediatric orthopedic surgeons allows children with bony spine, hip or extremity deformities to be seen with the team. Treatment for movement disorders and deformities is coordinated and provided by the team. Services such as Botox or alcohol injections, intrathecal baclofen therapy and pump implantation, as well as test doses or trials, are provided by the PMDC. Selective dorsal rhizotomies (SDR) are offered to some children with spastic diplegia. All aspects of pediatric orthopedic surgery are provided by the excellent pediatric orthopedic surgeons of Goryeb Children’s Hospital.
The Division of Pediatric Neurosurgery is also proud to provide children with comprehensive care for the treatment of brain and spinal cord tumors, epilepsy, Chiari malformations, hydrocephalus, spina bifida, tethered spinal cord, syringomyelia, and traumatic brain injury.
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