Normal Pressure Hydrocephalus

A Simple Guide to Normal Pressure Hydrocephalus
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What is Normal Pressure Hydrocephalus?
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Normal Pressure Hydrocephalus(NPH) is an abnormal accumulation of cerebrospinal fluid in the cavities of the brain.

Who is at risk of getting Normal Pressure Hydrocephalus?
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Normal Pressure Hydrocephalus occurs in adults of 55 years old and above.

The accumulation of cerebrospinal fluid is gradual leading to enlargement of the cavities in the brain called ventricles.

This in turn stretches the nerve tissues of the brain giving rise to 3 main neurological disturbances in the brain which is characteristic of NPH.

What are the causes of Normal Pressure Hydrocephalus?
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In most cases the cause is unknown.

In the remaining cases, the secondary causes can be found:

1. Brain infection can cause damage to brain tissues and the resulting cell damage can increase fluid in the brain

2. Stroke may damage brain cells resulting in damaged brain tissues and increase fluid in the brain

3. Trauma and head injury may damage brain cells similar to above

4. Brain tumors are another cause of increased fluid in the brain


What are the Symptoms of Normal Pressure Hydrocephalus?
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Onset is slow and gradual but typically the following symptoms are present:

Gait disturbance
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Difficulty in walking or balancing

Cognitive impairment
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mild dementia

Urinary Incontinence
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Problems with bladder control and hence incontinence

How is the diagnosis of Normal Pressure Hydrocephalus confirmed?
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1.History of the above 3 symptoms

2.Physical examination shows the neurological deficits:
difficulty in walking

mild dementia

urinary incontinence

3.MRI of brain shows the presence of enlarged ventricles in the brain

What is the Treatment of Normal Pressure Hydrocephalus?
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NPH cannot be cured but its symptoms can be controlled.

Treatment is by surgery using a shunt to divert the excessive fluid in the brain to the peritoneal cavity.

What are the complications of Normal Pressure Hydrocephalus?
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1. Dementia

2. Disabilty

3. Disturbed urinary and bowel function.

What is the prognosis of Normal Pressure Hydrocephalus?
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With early diagnosis and treatment, symptoms can be partially or fully reversed leading to resumption of a normal life.

With the use of the shunt, symptoms may disappear within days or at most a few months.

There is dramatic improvement in the first week in mild cases.

Some adjustments of the valve are often needed before the correct setting is obtained for the individual.

A Simple Guide to Headache

A Simple Guide to Headache

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What is Headache?

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Headache is a very common complaint, not an illness.

It literally means pain in the head.

What are the Common Types of Headaches?

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Tension headache:

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as defined by the International Headache Society is characterised by:

1.bilateral location

2.pressing/tightening (non-pulsating) quality

3. mild to moderate in intensity

4. not aggravated by routine physical activity like walking or climbing stairs.

It is the most common headache and may be associated with contractions of head and neck muscles due to physical or mental stress. The headache is made worse by changes in the environment, drugs, or factors unique to the individual.

It can also be classified into 2 side types:

episodic (<>

chronic (> 14 days a month on average and <>

Treatment can be divided into:

pharmaceutical

non pharmaceutical

Pharmaceutial:

can be divided into acute and prophylactic.

In acute treament simple painkillers is usually effective.

In prophylactive treatment,antidepressants like amitriptyline usually help in the prevention of tension headache.

Medicines should always be given at low doses and titrated up to therapeutic doses to minimise side effects.

Non-pharmaceutical:
1. rest

2. removal of aggravating factors.

3. relaxation exercises

Migraine:

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is defined as a heavy throbbing pain usually over one side of the scalp, forehead and about the eye, caused by abnormally dilated blood vessels.

Migraine may be accompanied by nausea, vomiting or sensitivity to loud noises or bright lights.

It is also triggered by certain factors unique to the individual such as:

1.menstruation,

2.alcohol,

3.anxiety,

4.loud noises,

5.bright lights

A validated 3 items questionaire covering

1. disability

2. nausea

3. sensitivity to lights

should given to every patient to screen the severity of the migraine.

Treatment again is divided into:

phamaceutical

non-pharmaceutical.

Pharmacetical:

can be divided into acute and prophylactic.

In acute treament simple painkillers like paracetamol is usually effective in mild cases.

Non-steroidal anti-inflamatory drugs should be tried if paracetamol fails.

If NSAIDs are ineffective then migraine-specific drugs like triptans or ergotamine which act to constrict blood vessel should be tried.

In some cases anti-emetic drugs like stemetil to prevent vomiting is given together with the migraine medication.

In prophylactic treatment, the goals are to:

1. reduce frequency,severity and duration

2.improve function and reduce disability

3.improve responsiveness to treatment of acute attacks

Medicines used include:

betablockers

Calcium channel blockers

Serotonin receptor antagonists

Antidressants

Anticonvulsants

Angiotensin blockers

NSAIDs

Non-pharmaceuticals:

1.resting in a cool, dark and quiet room.

2.relaxation exercises

3.Solving the triggering factors also help.

4.Oestogen containing oral cotraceptives should avoided in menstrual migraine.

During pregnancy or lactation treatment should be non-pharmaceutical when possible. If necessary paracetamol is the safest drug for women during pregnancy or lactation.

Cluster headaches

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is defined as pain which occurs in runs with tearing pain over the forehead or behind the eye(s) with flushing of the face.

There are aura of stars,flashing lights etc associated with this headache.

The cause is beleived to be due to histamine release from ingestion of certain foods like cheese, seafood,alcohol etc.

It is more common in males.

Treatment is by

1.strong painkillers

2.avoidance of food triggers

3.rest.

What are Secondary headaches?

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Secondary headaches refer to headaches associated with a known medical illness.

It is diagnosed by its close relation to a disorder that is known to cause headache.

The headache improves or disappear after successful treatment or spontaneous resolution of the causative illness.
1.Sinus headaches:

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are due to acute sinus inflammation attacks.

Pain is over the frontal forehead and the upper cheeks.

It may be associated with fever and heavy mucus production.

Treatment is by

1.antibiotics for the sinus infection,

2.antihistamines to reduce mucus production

3.painkillers

4.rest.

2.Referred headaches:

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these are caused by by referred pain from disorders of structures around the head. Common ones are

1. earaches,

2. toothache causing pain over an entire part of the face and

3. temporomandibular joint dysfunction from mechanical pain from the jaw joint.

4. temporal arteritis, a rare inflammatory blood vessel condition causing persistent headache at the temporal artery. There is possible complication of blindness secondary to anterior ischemic optic neuropathy. The headache usually resolves or improves with 3 days of high dose steroid treatment.

3.Meningitis / Encephalitis headaches:

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caused by infection of the brain tissue (encephalitis) or the membranes surrounding the brain (meningitis).

Headache is the most common symptom. The pain is diffuse and progressive with fever, a painful stiff neck and other symptoms such as drowsiness, seizures and neurological problems including weakness and numbness.

This type of headache needs immediate hospital treatment.

4.Cerebrovascular Accidents (haemorrhagic stroke):

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a stroke happens when a blood vessel in the brain is blocked or bursts.

Bleeding in the brain causes a sudden severe headache.

There is also associated loss of consciousness and other neurological signs such as weakness, numbness and seizures.

This type of headache needs immediate hospital treatment.

5.Brain Tumour:

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is rare and causes a gradual headache lasting for weeks.

It is localised and associated with nausea, vomiting, loss of appetite and loss of weight.

It is worse in the morning and aggravated by coughing or leaning forward.

By the time neurological symptoms appear such as seizures, numbness, weakness or blindness, the brain tumour has already grown to an advanced stage.

Treatment includes surgery, chemotherapy or radiotherapy.

6. Other causes of secondary headaches are:

a.post traumatic headache following a head injury

b.whiplash injury

c.cerebral venous thrombosis

d. idiopathic intracranial hypertension

e. hydrocephalus

f. sleep apnea

g.cardiac cephalgia

h.acute glaucoma

Simple Treatment of Headache

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Consume a painkiller.

Lie down in a dark, quiet room.

Use muscle relaxation techniques or a gentle massage.

For tension headaches, try a warm bath.

For migraines, put an ice bag or cold towel on your temple.

If the headache do not improve, go for a complete investigation of the headache.

What are the investigations done in Headache?

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You should be investigated for your headache if the headache has:

1. associated fever and and change in mental state.

2. numbness of part of the body or with paralysis.

3. associated fits.

4. sudden onset of severe headache

5. lasted for more than a day even after taking painkillers.

6. increased headache frequency.

7. appeared different from your usual type

8. been precipitated by coughing,sneezing,bending

9. associated with stiff neck and vomiting

10.appeared for the first time in middle age

Common tests:

Blood tests - for infections,raised ESR, bleeding disease

MRI of brain- to exclude brain tumours, bleeding in the brain

Lumbar puncture - used only if there is suspected infection of brain or meninges