Normal Pressure Hydrocephalus and Sleep Apnea

Study Overview
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Brief Summary
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Normal-pressure hydrocephalus is associated with increases in the intracranial pressure during the night sleep. Sleep apnea also increases the intracranial pressure during the apneic spells. When patients are operated the distal part of the shunt is inserted inside the abdominal cavity, which pressure also increases during the sleep apnea episodes. this is particularly important considering that the recumbent position used to sleep further increases the intraabdominal pressure and that impairs the CSF drainage through the shunt system. The purpose of this study is to analyze the intracranial and intraabdominal pressures during the sleep, particularly during the sleep apnea episodes to see which shunt should be used, to which cavity should be drained (peritoneum or heart) and if correcting the sleep apnea has some positive result on the hydrocephalus symptoms.

Detailed Description
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Chronic hydrocephalus in adults, also known as normal pressure hydrocephalus or normal pressure hydrocephalus, occurs with the classic Hakim-Adams triad, gait ataxia, or magnetic gait, urinary incontinence and dementia. Most of the cases have an idiopathic origin and are the only potentially reversible cause of dementia with surgical treatment (by shunting the cerebrospinal fluid or CSF from the lateral ventricles or the thecal sac to the peritoneal cavity or the right atrium), so it is especially important to diagnose it and treat it properly. Unfortunately, and despite all the diagnostic arsenal, the results of treatment using cerebrospinal fluid shunts (lumbo-peritoneal or ventricle-peritoneal), even in the best series, show 20-25% of poor results. These poor results have been attributed to many factors, including associated cerebral vascular pathology problems, co-existing dementia symptoms not always well diagnosed, Parkinson's disease, and, lastly, alterations in ventilatory rhythm. during the night, specifically obstructive sleep apnea or OSA. In reality, the name of normotensive hydrocephalus or hydrocephalus at normal pressure is inaccurate because the intracranial pressure does rise and very markedly during sleep, particularly during the REM phase of sleep. What is no longer so well known is because of such significant increases in intracranial pressure occur. One possible explanation would be that obstructive sleep apnea causes increased intracranial pressure. But it remains to be clarified whether all patients with adult chronic hydrocephalus have sleep apnea, the mechanism of action, and to what extent the treatment of hydrocephalus acts on sleep apnea and vice versa. Another aspect to consider is that the cerebrospinal fluid shunts work by the pressure gradient between the intracranial cavity and the cavity into which the cephalo-spinal fluid is drained66, usually the peritoneal fluid. During sleep apnea, there should be an increase in intra-abdominal pressure, which would result in the ventricle-peritoneal and lumbo-peritoneal shunts working suboptimally precisely at the time of day when they are most needed, that is when intracranial pressure increases. But this correlation has never been investigated or at least there are no publications about it. Therefore, it is necessary to know the relationship between intracranial pressure, sleep apnea, and intra-abdominal pressure at night. With these data, it will be possible to better understand the dynamics of the circulation of the cerebrospinal fluid during the night (when it is more pathological in chronic hydrocephalus in adults), what type of bypass valve is the most indicated (whether or not it must have an anti-system siphon if it must be a gravitational or flow valve) and in which patients the implantation of a ventricle-atrial shunt may be an option to consider.

Official Title
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Normal-pressure Hydrocephalus. Relationship Between Sleep Apnea and Intracranial and Intraabdominal Pressures. Outcome Prognostic Factors in CSF Shunting. Features Guiding to Implant a Ventricle-peritoneal Versus a Ventriculo-atrial Shunt

Conditions
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Normal Pressure Hydrocephalus, Sleep Apnea, Cerebrospinal Fluid Shunt Occlusion

Intervention / Treatment
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* Procedure: CSF shunt diversion


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Clinical condition compatible with normal-pressure hydrocephalus Exclusion Criteria: Cerebral vascular disease Dementia not due to normal-pressure hydrocephalus Parkinson's disease

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Interventional Model Description: Patients diagnosed of normal-pressure hydrocephalus will undergo sleep studies to rule our sleep apnea. Those with sleep apnea will be treated for this condition and we will see if the hydrocephalus symptoms improve
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Normal-pressure hydrocephalus only<br>Patients suffering from normal-pressure hydrocephalus with NO sleep apnea | Procedure: CSF shunt diversion<br>* Clinical response to a CSF shunt insertion<br>|
| Active Comparator: Normal-pressure hydrocephalus with sleep apnea<br>Patients suffering from normal-pressure hydrocephalus with sleep apnea | Procedure: CSF shunt diversion<br>* Clinical response to a CSF shunt insertion<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change of hydrocephalus symptoms with Mini-Mental State Examination | Patients will be evaluated with the Mini_mental State Examination before and after CSF shunting to see the degree of improvement they get from this surgical treatment | 1-2 months | 
| Change of hydrocephalus symptoms with NPH scale after CSF shunt diversion | Patients will be evaluated with the NPH before and after CSF shunting to see the degree of improvement they get from this surgical treatment | 1-2 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Normal pressure hydrocephalus, Sleep apnea, CSF shunt diversion, Ventriculo-peritoneal shunt, Ventriculo-atrial shunt