An Algorithm to Assess the Rehabilitation Potential in Patients with Chronic Hydrocephalus
In clinical practice, it is often necessary to judge the probability of clinical benefit of invasive ancillary tests given to patients with chronic hydrocephalus before they are performed. The aim of the current study was to establish a screening tool for
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Abstract Objective In clinical practice, it is often necessary to judge the probability of clinical benefit of invasive ancillary tests given to patients with chronic hydrocephalus before they are performed. The aim of the current study was to establish a screening tool for such prediction. Material and Methods A total of 125 patients with chronic hydrocephalus were assessed using a clinical (HHS) and comorbidity (CMI) grading. These patients were shunted and followed-up for at least one year. The statistical tools of ANOVA, CHI-squared, Spearman, Kuskal–Wallis, and Wilcoxen-U-Test were applied. Results The variables discovered to be of use in prediction were age (p = 0.02), anamnesis duration (p = 0.04), CMI (p 10 mm Hg) during 20% of the monitored period. The cutoff level for pathological resistance to outflow (Rout) to indicate shunting was 13 mm Hg/ ml × min. Patients fulfilling minimally one criterion (increased Rout or pathological B-wave pattern) were shunted using adjustable or non-adjustable gravitational shunts. For clinical documentation, we used our modified clinical grading (HHS), Recovery-Index (RI) and Co-Morbidity-Index (CMI) (11). Patients were regarded as shunt responders if RI ³ 3 and/or if (provided given handicap preoperatively) they improved by 2 points or more in the “gait/balance” area of HHS postoperatively. To rule out primary or secondary underdrainage, we used the protocol proposed in the international guidelines (12), with the exception that our first step of the workflow is an “acetazolamide” test (6). If patients improved with azetazolamide, they were diagnosed as underdrained, and shunt revision was performed. Shunt revision due to underdrainage or other hydraulic mismanagement was not an exclusion criterion, but the clinical state at least one year after successful shunt revision was used for analysis. Only when underdrainage was definitively excluded as the reason for lacking improvement after shunting, the patients were considered “non-responders”. Clinical state evaluation and imaging were performed preoperatively, 3 and 12 months postoperatively, and annually thereafter. Patients lacking follow-up for longer than 14 months were excluded as well as patients who refused check-up and patients who had shunt-infections (because shunt infection may affect the patient outcome by itself). In this cohort, the average follow-up was 2.9 ± 1.6 years (range: 1–4 years). The clinical state of the patients at that point in time was considered as the last data point used in this analysis.
Fig. 1 Overall improvement separated based upon the symptoms of all patients and separated based on the studied hydrocephalus etiologies
M. Kiefer and R. Eymann
The statistics that were employed to evaluate the clinical data included the Mann–Whitney U, Spearman, Kruskal– Wallis, ANOVA and c 2-tests at a significance level of p
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