Maggie McKay (Host): What is hydrocephalus and NPH? And why do we need to know? Dr. Seun Omofoye, Neurosurgeon at Tidelands Health, is here to answer those questions and more. Welcome to the Better Health Podcast from Tidelands Health. I'm Maggie McKay. Thank you so much for being here today.

Seun Omofoye, MD: Thank you for having me, Maggie.

Host: Let's just start off with what is hydrocephalus and NPH?

Seun Omofoye, MD: Yeah, so hydrocephalus is a buildup of spinal fluid in the brain. So the brain makes spinal fluid and when that builds up in the brain and it's not drained, then that's hydrocephalus. And an NPH or normal pressure hydrocephalus is a subtype of hydrocephalus in general, and that's more common in, in older patients, and it's a type of hydrocephalus that the pressure in the brain is normal, and that's why it's called normal pressure hydrocephalus, and that differentiates it from other type of hydrocephalus, which we commonly see in children that has a high pressure in the brain or if it's due to other causes in the brain, such as if you have a brain tumor that's increasing pressure in the brain that can cause hydrocephalus or bleeding in the brain that's also blocking the flow of spinal fluid in the brain, it can cause hydrocephalus and sometimes even some traumatic brain injuries can cause hydrocephalus as well. But NPH or normal pressure hydrocephalus is called idiopathic normal pressure hydrocephalus, meaning there's no specific known cause for it. It's just something that happens in older patients.

Host: What are the symptoms of NPH?

Seun Omofoye, MD: Yeah, so there are three classic symptoms of NPH. The first category is in terms of movement, mainly balance, difficulties, difficulty walking. So patients with NPH will have a lot of difficulty walking, difficulty getting their feet up off the floor. It's called a magnetic gait, feeling like your feet is stuck to the floor.

And we can see a lot of falls in those patients. That's the first category. The second set of symptoms is cognition. So patients will have memory difficulties, difficulty kind of thinking clearly, some confusion episodes. Sometimes you can see mood changes and things like that. And the last category is urinary symptoms. So, this usually starts out with urinary frequency. Patients feeling like they have to urinate more frequently than they used to. And if that goes on, it can get to the point where they're starting to have urinary incontinence, where they're not able to control their bladder. They're urinating on themselves.

So those are the three classic symptoms and there's a mnemonic that we learned in medical school for it; it's called wet, wobbly, and wacky. And that just means they're urinating and balance difficulties and confusion.

Host: Do you have to have all three or can you just have one and still have it?

Guest: Yeah. So, classically, you should have all three to meet the category for normal pressure hydrocephalus based on symptoms. But we also look at imaging. So if you get a CAT scan of that patient's brain, or if we get an MRI of their brain, we can see that the chambers where the spinal fluid made in the brain, which is called the ventricles, are enlarged.

So if you have that finding on your MRI or CAT scan of the brain and you have some of those symptoms it could fit with NPH. But classically we see all three. But in some patients, they may start out with one, and then over time they develop the other symptoms. So if you're catching it early you could have maybe just balance difficulties and you know later on that can progress to where you start to have the memory difficulties and then urinary symptoms as well.

Host: You mentioned an MRI. Is there anything else to know about how you diagnose NPH?

Seun Omofoye, MD: Yeah, so first step is the symptoms. If you have all three symptoms, that's usually what gives a clinician, or the provider or the physician an indication that you might have NPH. So if somebody has those three symptoms, then typically they get a CAT scan first or some providers might go straight to an MRI. And if you have that enlarged ventricles in the brain, the fluid space in the brain are enlarged, then we confirm that diagnosis.

Host: Dr. Omofoye, how do you treat NPH?

Seun Omofoye, MD: Yeah, good question. So, the main treatment really is to drain the spinal fluid because what causes it is the fact that there's excess buildup of spinal fluid in the brain. Because our brain normally makes about 20 cc's of spinal fluid every hour, and then reabsorbs that fluid back.

That fluid kind of cushions the brain and also takes away some waste products from the brain. But for some reason, in older patients, in some older patients, the brain is not reabsorbing the fluid as fast as it's making it, so the fluid backs up. So the main treatment is to drain the fluid. And the way we do that is to put in a shunt.

Technical term for it is, or the most common type is to put in a ventriculoperitoneal shunt, which means we're basically draining the fluid from the brain into the abdomen, into the peritoneum. So there's a small tube that we do a surgery to treat this, and we insert a small tube into the brain, into that fluid space in the brain.

The tube is tunneled under the skin. It goes kind of around the side of the neck, over the collarbone, over the ribs and it drains into the abdomen. And that's really the main treatment for it.

Host: That sounds pretty complicated. What is recovery like?

Seun Omofoye, MD: Yeah, so, recovery is actually pretty quick for the shunt. So typically patients they come in for the surgery, it's only about an hour long surgery. And patients are able to go on the next day if there are no complications, if everything goes well. But before we recommend patients get this procedure done, get the shunt done; typically we do a test, we do a trial first to see whether they're going to benefit from the shunt. And, that involves patients come into the hospital, usually they're admitted to the hospital and we have physical therapy and speech therapy do an evaluation on the patient.

They assess their balance, their walking, they time patients to see how fast they're able to move from point A to point B, and speech therapy, do a cognitive evaluation, test their memory, their thinking, and then we do a procedure that's called a lumbar drain, which is a small drain that goes in the back, in the spine, similar to having a spinal tap done, and that tube is attached to a drainage bag, and then we drain about 10 cc's of spinal fluid every hour for 2 days while the patient is in the hospital.

And after that procedure is done, we take the drain out and the physical therapy and speech therapy, they repeat the same tests to see whether there's an improvement. And if there's an improvement, if we notice the patient's balance is better, their walking is better, their memory is better and the patients also notice while they're in the hospital while they're draining the fluid, that their urinary frequency or incontinence improves; then at that point we recommend putting the shunt in.

Host: So can hydrocephalus or NPH ever go away for good, or is it always kind of with you?

Seun Omofoye, MD: Yeah, typically once you have those symptoms, the three symptoms we described and, um, you have the findings noticed an MRI; typically this is a progressive process. So, in most patients, this continues to get worse. So for patients who start out with just having balance difficulties or difficulty walking, it typically progresses to the point where they're now having to use a cane or having to use a rolling walker to maintain their balance.

And if it goes untreated, some patients can actually end up just needing a wheelchair and lose ability to walk. And similarly, with memory difficulties as well, that can also worsen to the point where patients start having a lot of short term memory difficulties and the urine as well can start out with frequency first and then get to the point where patient essentially incontinent and they have to start wearing pads and things of that nature to prevent them urinating themselves.

Host: And so, but if they have the treatment, then it's all good, right?

Seun Omofoye, MD: That's another good question. So with the treatment, so once you have the shunt placed, there is about 80, 70 to 80 percent success rate with that. So patients, most of the patients get a benefit, meaning all their symptoms improve. Sometimes this can sort of relapse, so, some patients who have the shunt placed, they may notice they have a benefit for about a year, two years, three years, and then the symptoms start coming back.

Because of this fact, we usually put in a programable shunt. So, what that means is that the shunt has a valve that's attached to it. And that can be adjusted using a magnet. So there's a magnetic device that we can put next to the patient's head and change the setting of the shunt. And that gives us the ability to drain more or drain less spinal fluid.

So for patients who, let's say they have the surgery, they're doing great, and then the fluid, they start having some of that symptoms come back a year or two after the surgery; we can reduce the setting of that shunt to drain more spinal fluid and treat it that way.

Host: What's the main cause of this in adults?

Seun Omofoye, MD: Yeah, so we unfortunately, we don't know. We don't have a good specific cause for it. And that's why it's actually, the technical term is INPH which stands for idiopathic normal pressure hydrocephalus. And idiopathic means we don't really know what causes it. We do know it's a degenerative process.

It's just one of those things that happens the older we get, the brain just doesn't function as well and this is most common in patients over the age of 60. And for some reason, the brain just doesn't reabsorb that fluid as much as it's making it. And that's what causes the buildup.

There are, you know, other causes of hydrocephalus like we talked about earlier. So if you have a history of traumatic brain injury, history of stroke, history of some kind of brain surgery or brain tumors, sometimes that affects the dynamics of spinal fluid absorption in the brain and that can cause you to have hydrocephalus, which we term that, if it's bleeding, post hemorrhagic hydrocephalus.

But if we don't know the cause, it's the classic NPH, idiopathic normal pressure hydrocephalus.

Host: With cases of NPH on the rise, why is it so often overshadowed by the more prevalent Alzheimer's or Parkinson's that we hear about so often?

Seun Omofoye, MD: Yeah. It's primarily because you know, it's not a commonly known diagnosis. So a lot of the patients who I see with normal pressure hydrocephalus, it's not as common as Alzheimer's they just don't know about it. A lot of the public we don't know about this diagnosis and even some healthcare providers may not know about it.

And that's why it's sometimes difficult to diagnose and patients go undiagnosed. Actually uh, there was a study from 2007 by the Medicare database that showed that only about 25 percent of patients older than age of 65 who have a diagnosis of NPH receive treatment for it, receive shunt for it.

And that's just because we don't, it's not very commonly known. And a lot of the symptoms can as you can be attributed to other symptoms. So, patients who have balance difficulties, they may think it's just part of getting older, or if they start having urinary incontinence, they don't think about it as a disease process and just think they think it's part of getting old. And same with memory as well. And so often it goes undiagnosed.

Host: In closing, why do they think cases of NPH are on the rise?

Seun Omofoye, MD: I think that's likely because the United States population in general is getting older. And, this is a problem of older patients. And as the whole population is getting older, I think we'll see more cases of it. And it's just important to know the signs of it. And if you're having any of those symptoms of balance, gait difficulties, memory difficulties, confusion, urinary symptoms to talk to your healthcare provider about it. And usually the next step, if you have those three symptoms is to get a scan of your brain to see if you have it. And then typically you get referred to the neurologist or a neurosurgeon to get evaluation for it.

Host: Well, thank you so much for sharing your expertise. Is there anything else you'd like to add that we didn't cover?

Seun Omofoye, MD: No, I think, the main thing is that at Tidelands, you know, Health with our neuroscience program, we have, you know, a multidisciplinary program that we have in the system of treating these patients. So, we usually see the patient either in neurologist first, or if you have all of the symptoms and you have MRI findings and CTs finding for it, you see a neurosurgeon like myself, and we have a process of getting the patients into the hospital to get a lumbar drain trial done with physical therapy, with speech therapy, and then getting patients back on their feet and back to better health.

Host: Thank you so much for your time. This has been so informative.

Seun Omofoye, MD: All right. Thank you, Maggie.

Host: Again, that's Dr. Seun Omofoye, and if you would like to find out more, you can visit tidelandshealth.org or call 1-866-TIDELANDS. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you.

Thanks for listening. I'm Maggie McKay. This is the Better Health Podcast presented by Tidelands Health.