Cerebral hydrocephalus

Cerebral hydrocephalus

The condition of cerebral hydrocephalus, or also known as Normal Pressure Hydrocephalus (NPH) in medical terms, is the accumulation of fluid in the brain ventricles. It is a disease that commonly occurs in the elderly and is easily treatable with relatively good results. However, there is a caveat that it must be diagnosed early, as correct diagnosis from the beginning will lead to appropriate treatment and give the patient a chance to recover from permanent disability in the future. It is estimated that approximately 15-20% of elderly people who are left to fend for themselves in elderly care facilities or with their caregivers at home suffer from this disease without treatment, which often arises from a misconception that the disease cannot be treated in old age. The actual number of patients in Thailand is likely much higher than this, as the number of these patients has increased in today's society where grandchildren are separated from their grandparents and the elderly are left to fend for themselves or are abandoned in hospitals or nursing homes.

What are brain ventricles?

The brain ventricles are fluid-filled spaces in the center of the brain that are surrounded by brain tissue. These spaces contain cerebrospinal fluid (CSF), which is a clear liquid that helps cushion the brain and spinal cord from injury.

The cerebrospinal fluid (CSF)

You may be surprised why, when talking about fluid in the brain, instead of calling it "brain fluid," it is referred to as "spinal fluid." Some may think that it is a typo, but in reality, both terms can be used interchangeably. However, in medical terminology, the term "spinal fluid" is preferred over "brain fluid." This is because the brain and the spinal cord develop from the same embryonic cells, and the spinal cord is like an extension of the brain that extends outside the skull and runs down along the spinal bones. This means that there is a part of the brain that extends down into the spinal cord, and the fluid in the brain can flow out into the spinal cord as well. Therefore, the fluid in the brain is the same as the fluid in the spinal cord.

Symptoms of hydrocephalus

Symptoms of hydrocephalus can be divided into two cases. The first case is the acute, where patients will visit a doctor with severe headaches, nausea, vomiting, and loss of consciousness if the edema from excessive fluid is severe. In the second case, which is the chronic type, patients may not have symptoms like those in the first group, or if they do, they are often mild, and come and go, with blurred vision. What is similar in both groups is that the accumulation of fluid in the brain's cavities causes high pressure within the skull and brain. However, there is another group of patients who believe that their condition is a development from the second case. They have chronic hydrocephalus, but the brain has adapted to the high pressure, so the pressure within the cavities is not as high as it should be. When measuring the pressure in the cavities, the value obtained is often close to that of a normal person. Therefore, in medical terms, this group is called "normal pressure hydrocephalus".

Symptoms of low-pressure hycrocephalus

Patients who sees a doctor often have one or more of the following symptoms:

Difficulty walking or gait apraxia, such as having trouble standing up after sitting down and needing to hold on to something or taking short, slow steps because of a fear of falling. As a result, we may see patients walking with their legs apart to help with balance. Walking often becomes slower, and if something interrupts the rhythm of walking, it becomes more difficult to maintain balance, forcing the patient to stop and start again. Abnormal walking is more noticeable when we ask the patient to turn around to change direction, as they have to pivot on one leg, similar to making a "circle" to draw a circular shape. Another distinctive feature is that walking resembles having an electromagnet that sucks the patient's feet to the floor, making it difficult to lift their feet and walk, similar to being stuck to the ground. This can be very tiring for the patient when walking, even though there is no problem with muscle strength or weakness. The gait may be similar to Parkinson's disease, but patients with this disease do not have rigidity or tremors. Patients who come to the doctor early in the course of the disease with only difficulty walking are the group that will benefit most from treatment.

Dementia may begin with forgetting recent events, such as not remembering what was eaten in the morning, but long-term memory, such as remembering friends and siblings, is usually not a problem (except in the later stages). This is different from Alzheimer's disease, which affects both short and long-term memory.

Urinary incontinence is a condition where patients have difficulty controlling their urination. They may feel the urge to urinate and are unable to make it to the bathroom in time, often resulting in leakage. For those with severe cases, they may experience urinary leakage without realizing it beforehand. As a solution, family members often use adult diapers, but leaving them on for too long can cause bowel incontinence as well.

It is important to note that not all patients with this condition exhibit all three symptoms. Conversely, patients often begin with abnormal walking patterns that can last for years before the onset of memory loss or urinary incontinence finally occurs.

Judging from all three symptoms, it can be difficult to distinguish from the normal aging of elderly individuals who do not have this disease. For example, relatives often assume that our elderly loved ones are simply experiencing typical difficulties with walking as they age, or that their hearing loss is just a natural part of getting older. It is also common for elderly individuals to experience difficulty with urination when they become immobile, and for their brains to deteriorate, resulting in memory loss. These assumptions can lead to neglect and missed opportunities for effective treatment. Eventually, the patient may become disabled and bedridden, leading to pressure sores and infections. The worst part is that at the end of their life, patients may not be able to recognize their loved ones due to severe brain damage from the disease.

When should we suspect that our relative has NPH (normal pressure hydrocephalus)?

The best way to diagnose this disease is to suspect that an elderly patient with at least one of the three symptoms mentioned above may have this disease and gradually consult a doctor. The most appropriate physician to evaluate this group of patients should be a neurologist. The doctor will always perform tests to differentiate related diseases such as Alzheimer's disease, dementia, Parkinson's disease, brain damage from diabetes or stroke, spinal cord injury, stomach ulcers, abnormal urination, etc. If the doctor can distinguish these diseases, they may suspect that the patient may have NPH.

(In some cases, it may not be possible to differentiate these diseases.)

If the doctor still suspects that the patient may have NPH, they may conduct additional tests such as CT scans, MRI, spinal taps to drain fluid, or tests involving the injection of water into the spinal canal.

Hydrocephalus can be treated

One of the important aspects of diagnosing this disease is that it is a condition that can lead to a treatable or preventable form of dementia.

Generally, when a doctor diagnoses us or our relatives with a condition such as dementia, it is considered bad news for both the patient and the family because there is currently no effective treatment that can cure brain deterioration or stop the progression of the disease altogether. At best, it can only be delayed for longer periods of time, but ultimately it will end in amnesia, inability to care for oneself, and death.

However, for the condition of dementia (including difficulty walking) caused by hydrocephalus, this is the only condition that can be treated or prevented from worsening, and patients have a high chance of improving their quality of life. The most important aspect of this treatment is “quick diagnosis”. When doctors are sure (or suspect and see a high likelihood) that a patient may have brain edema from hydrocephalus, they will recommend treatment with surgery to insert a drain into the brain, which is a quick and easy procedure that takes less than an hour and has low risks, but can yield relatively good results. Alternatively, it may not significantly improve, but it can delay the progression of the deterioration for a longer period of time, in order to maintain the patient's quality of life for as long as possible.