OBJECTIVE Normal pressure hydrocephalus (NPH) is clinically characterized by gait disturbance, cognitive impairment, and urinary incontinence, as well as enlargement of the ventricles. To the best of the authors' knowledge, there have been no previous publications regarding the correlation between bulbar dysfunction and NPH. The primary objective of this study was to compare preoperative and postoperative prevalence of bulbar dysfunction in patients with NPH. Secondary objectives included assessing the results of surgery for swallowing, speech, gait, cognition, and urination, and evaluating the correlation between bulbar dysfunction and triad symptoms. METHODS Fifty-three patients with NPH who underwent shunt placement surgery at Siriraj Hospital were included in the study. Patients were evaluated for gait, cognition, urination, swallowing, and speech before and 6 months after shunt placement. Triad symptoms were assessed using standard methods. Bulbar dysfunctions were assessed using the Swallowing Problem Questionnaire, Thai Articulation Test, Resonation Screening Test (RST), and Thai Nasality Test. The Thai Speech Assessment Program and nasometer were used for objective speech measurement. RESULTS Preoperatively, 86% (43/50) of patients had swallowing problems and 75% (37/49) had speech problems, as measured by the RST. Postoperatively, there was significant improvement in swallowing (p < 0.001), speech problems by RST (p = 0.008), and voice volume (p = 0.009), but no significant change in the nasometer test. All triad symptoms were improved. There were significant correlations between swallowing impairment and gait disturbance (r = 0.358, p = 0.009), and RST and cognitive impairment (r = −0.502, p < 0.001). CONCLUSIONS This is the first study of bulbar dysfunction in patients with NPH. The results showed that the prevalence of bulbar dysfunction is very high. The correlation between bulbar dysfunction and the classic NPH triad has been documented and published. These bulbar symptoms also significantly improved after surgery. As such, bulbar dysfunction should be regarded as a core symptom that should be considered along with the classic triad in the clinical diagnosis and management of NPH.

Purpose. The study aimed to examine the validity of self-reporting as an additional method to indicate gait alteration among patients with idiopathic normal pressure hydrocephalus. The score from self-reporting of gait alteration was validated with the data obtained from gait pressure measuring plate. In addition, temporo-spatial gait parameters among 3 groups classified by overall gait improvement (no change, slight, and good) were compared. Methods. This study employed a cross-sectional design and investigated 31 patients with idiopathic normal pressure hydrocephalus. Gait performance was determined by a gait pressure measuring plate before and 24 hours after a tap test. Patients rated the changed score for gait behaviours using a questionnaire once on the day after the tap test. Criterion validity of the changed scores from patients' self-reporting and data from the gait pressure measuring plate was examined. In addition, temporo-spatial gait parameters were compared among 3 groups with one-way analysis of variance and the Bonferroni posthoc test to determine pairwise difference. Results. Significant correlations were found for the temporo-spatial gait parameters between data from self-reporting and the gait pressure measuring plate. Comparisons of temporo-spatial gait parameters among groups demonstrated significant differences in all parameters. Conclusions. Gait alteration identified by self-reporting was valid with gait performance measured by the gait pressure measuring plate. To achieve timely and appropriate medical management, we recommend health care professionals to request patients and caregivers to recognize gait alterations in assisting the disease progression identification.

ABSTRACT. Action observation (AO) has been proved to be of benefit in several neurological conditions, but no study has previously been conducted in idiopathic normal pressure hydrocephalus (iNPH). Objective: This study aimed to investigate the feasibility of AO in iNPH patients. Methods: A single-group pretest-posttest design was conducted in twenty-seven iNPH patients. Gait and mobility parameters were assessed using the 2D gait measurement in the timed up and go (TUG) test for two trials before and after immediate AO training. The outcomes included step length and time, stride length and time, cadence, gait speed, sit-to-stand time, 3-m walking time, turning time and step, and TUG. In addition, early step length and time were measured. AO consisted of 7.5 min of watching gait videos demonstrated by a healthy older person. Parameters were measured twice for the baseline to determine reproducibility using the intraclass correlation coefficient (ICC3,1). Data between before and after immediately applying AO were compared using the paired t-test. Results: All outcomes showed moderate to excellent test-retest reliability (ICC3,1=0.51 0.99, p<0.05), except for the step time (ICC3,1=0.19, p=0.302), which showed poor reliability. There were significant improvements (p<0.05) in step time, early step time, gait speed, sit-to-stand time, and turning time after applying AO. Yet, the rest of the outcomes showed no significant change. Conclusions: A single session of AO is feasible to provide benefits for gait and mobility parameters. Therapists may modify this method in the training program to improve gait and mobility performances for iNPH patients.

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The clinical and imaging findings of idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer's disease (AD) patients have some overlap and are often challenging to diagnose. The fornix is an important structure in the memory function, and damage to the fornix can result in memory impairment. Our study aimed to explore any differences in the microstructural changes to the fornices of iNPH and AD patients relative to those of normal control subjects, as demonstrated by using diffusion tensor imaging (DTI). Materials and methods:Ten normal control subjects, 10 iNPH patients and 10 AD patients underwent MRI scans (3-Tesla), and the DTI data were obtained. The DTI parameters and the diffusion fiber tractography were derived using DSI studio software. The differences in the fractional anisotropy (FA), apparent diffusion coefficient (ADC), axial diffusivity, and radial diffusivity data of the three groups were compared. A receiver operating characteristic (ROC) curve analysis was also evaluated.Results: There was a statistically-significant lower mean FA for the iNPH and AD patients than the normal control subjects. The mean ADC of the iNPH patients was statistically significantly higher than that of both the normal control subjects and the AD patients. The mean ADC is probably the most helpful parameter evident from our results, given its high sensitivity and high negative predictive value for discriminating between iNPH and AD patients. Conclusion:Our study revealed different microstructural changes in the fornices of iNPH and AD patients using the DTI technique. The results are probably due to differences in the pathogenesis of the diseases. Furthermore, our study demonstrated the possibility of using the DTI parameter as a supportive tool to discriminate between iNPH and AD patients with high sensitivity and a high negative predictive value.

Objective: This research aimed to study the effects of a physical exercise program on physical mobility in cranial surgery patients.Materials and Methods: The researcher used a quasi-experimental method of surveying 58 patients who had cranial surgery at Siriraj Hospital. The research group was divided into two groups: an experimental group (28 patients) participating in a physical exercise program of patients after cranial surgery, and a control group (30 patients) receiving routine nursing care only. The evaluation of the patients’ physical mobility was performed three days after the surgery.Results: Most patients in the research group had an intracranial tumor (86.2%). One day after the surgery, the experimental group had minor pain at the wound site while the control group had moderate pain. Both groups felt discomfort (64.2%) or had muscle stiffness in the neck and shoulder areas (63.3%). Three days after the surgery, at the end of the program, the body movement function of both groups was reduced compared with the preoperative data. However, the experimental group showed better body movement function scores than the control one as the scores of the former were reduced less than those of the latter at p < 0.05.Conclusion: Nurses who provide health care services to patients after cranial surgery should apply the physical exercise program to promote the recovery of the patients’ physical mobility.

A 53-year-old woman presented with a 1-month history of severe headache and intractable vomiting. Physical examination revealed left facial palsy and generalized weakness of the extremities (grade IV/V all extremities) without other localizing signs. She had no known underlying disease and there was no significant family history. MRI of the brain disclosed multiple ill-defined high signal lesions in T2W at left lower pons, left thalamus, subcortical regions of temporal, parietal, and frontal lobes bilaterally, and periventricular white matter. Nodular enhancement was noted in the left frontal lobe lesion (Figure 1a), left thalamus (not shown) and left pons ( Figure 1b). Irregular leptomeningeal enhancement was also noted diffusely. The largest mass present at the left frontal lobe was 2 cm in largest dimension and showed marked peritumoral vasogenic edema (Figure 1a). High resolution chest CT revealed an ill-defined mass at the posterior basal segment of the right lower lobe, 3.2 cm in greatest dimension (not shown). There were also multiple small nodules involving both lungs, ranging from 0.4 to 0.5 cm. Stereotactic biopsy of the left frontal lobe lesion was performed. MICROSCOPIC PATHOLOGYSections showed papillary/perivascular structures present in variably necrotic and hypercellular backgrounds (Figure 1c). The former contained hyalinized vascular cores lined by single layers of rectangular to cuboidal cells. Some of these cells had intracytoplasmic vacuoles. These cells contained moderately pleomorphic hyperchromatic to vesicular nuclei with occasionally prominent nucleoli and frequent mitoses. The hypercellular parenchymal component contained moderately pleomorphic hyperchromatic nuclei with indistinct eosinophilic cytoplasm embedded within a fibrillar background (Figure 1d). Mitotic figure were exceptionally rare in this area. The intracytoplasmic vacuoles in the papillary structures were positive for mucicarmine (Figure 1e). Immunohistochemically, these cells strongly expressed CK7 (Figure 1f) and TTF-1 (Figure 1g), but were CK 20 negative (not shown). The interspersed parenchymal cells were positive for GFAP (not shown), p53 protein (not shown), and the R132H mutant form of IDH-1 protein (Figure 1h). The MIB-1 labeling index in this area was <1%. FISH studies for chromosome 1p and 19q status were non-informative despite multiple attempts. What is your diagnosis?