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Captain Billy's troopers : a writer's life
\"In this audacious memoir, William Cobb reveals the tumultuous creative life of a distinguished practitioner of southern and Alabama storytelling. As poignant and inspiring as his own fiction, Captain Billy's Troopers traces Cobb's early life, education, and struggles with alcohol and the debilitating condition normal pressure hydrocephalus (NPH). Like a curving river, the broad sweep of Cobb's turbulent life includes both startling cataracts and desultory eddies, leading sometimes into shadows or opening into unexpected sunlight. With unsentimental clarity, Cobb recounts coming of age in his native Demopolis in the churning middle years of the twentieth century. It's there he has his first tantalizing tastes of alcohol and begins to drink habitually. Readers then travel with Cobb to Livingston University (now the University of West Alabama) and then on to Vanderbilt University. Along the way, readers relish his first experiences of love and success as a writer, leading to a career as a professor of writing at Alabama College (now the University of Montevallo) in 1963. From there Cobb's struggles with alcohol and depression lead to elongated years of tumbling creative output and the collapse of his marriage. The summer of 1984 found Cobb in rehab, the first step in his path to recovery. His unflinching memoir narrates both the milestones and telling details of his intense therapy and years in Alcoholics Anonymous (AA). In the sober thirty years since, Cobb has published a string of critically praised novels and a prize-winning collection of short stories. The capstone of his comeback was winning the Harper Lee Award in 2007 for distinguished fiction writing. In 2000, shortly after retiring, Cobb developed NPH, which upset his sense of balance and triggered dementia symptoms and other maladies. Nine years later in 2009, brain surgery brought Cobb a dramatic recovery, which began the third act in his writing career. Vital, honest, and entertaining, Captain Billy's Troopers captures the life of an Alabama original. \"-- Provided by publisher.
Book
A236 Subarachnoid trabeculae and CSF flow: potential role in the development of communicating hydrocephalus
IntroductionCerebrospinal fluid (CSF) dynamics within the subarachnoid space are critically influenced by the fine morphology of the arachnoid trabeculae, yet their contribution to CSF flow regulation remains poorly understood.Aim of StudyTo investigate how changes in subarachnoid space porosity affect CSF flow, using a real-time anatomical model derived from in-vivo high-frequency optical coherence tomography (HF-OCT) data.MethodA canine model was used to acquire in-vivo HF-OCT imaging of the subarachnoid space (SAS) microarchitecture, particularly around major blood vessels of the posterior circulation. Imaging through the vessel wall along the vertebrobasilar axis enabled detailed visualization of the trabecular network. From this data, a 3D true anatomical model of the SAS and its trabeculae was reconstructed. Variations in trabecular thickness were applied selectively within the model. High-resolution computational fluid dynamics (CFD) simulations were then used to assess the resulting changes in CSF pressure drop.Abstract A236 Figure 13D reconstruction of a canine subarachnoid space (SAS) segment using OCT images with localized 5% increase in trabecular thickness (the thickened membranes are marked in red)[Image Omitted. See PDF.]ResultsA localized 5% increase in trabecular thickness of membranes distal to the artery resulted in a fivefold increase in pressure drop across the control volume. In contrast, a uniform 5% increase across the entire segment produced only marginal additional changes. The average initial thickness of the trabecular fibers was approximately 50 microns.These findings indicate that specific trabecular structures disproportionately affect CSF flow resistance. Smaller changes in trabecular thickness produced measurable changes in pressure drop but were not found to be significant.ConclusionOur findings suggest that the arachnoid trabeculae play a critical role in modulating CSF dynamics. Alterations in their microstructure may contribute to the pathophysiology of communicating hydrocephalus.Conflict of InterestNo
Journal Article
Prevalence of idiopathic normal pressure hydrocephalus: A prospective, population-based study
Idiopathic normal pressure hydrocephalus (iNPH) causing gait impairment, dementia and urinary incontinence among the elderly, is probably under-diagnosed and under-treated. Despite being known since the 1960s, there is still a lack of prospective, population-based studies on the prevalence of iNPH. Such studies are warranted to minimize selection bias and estimate the true prevalence of the disease.
The prevalence of iNPH was determined in a randomly selected sample of residents, aged 65 years and older, in the Swedish county of Jämtland. Out of 1,000 individuals invited to participate, 673 (67.3%) completed a questionnaire with seven questions on iNPH symptoms. A subgroup, with and without self-reported symptoms, participated in clinical and radiological evaluations and were diagnosed according to international guidelines. Measurement of cerebrospinal fluid opening pressure was not performed as it was considered too invasive.
Those who reported at least two symptoms in the questionnaire (n = 117) and 51 randomly selected individuals with 0-1 symptom participated in further examinations. Out of them, 25 individuals received the diagnosis probable iNPH according to American-European guidelines (except for the criterion of CSF opening pressure) corresponding to a prevalence of 3.7%. The prevalence of iNPH was four times higher among those aged 80 years and older (8.9%) than among those aged 65-79 years (2.1%) (p <0.001). The difference in prevalence between men (4.6%) and women (2.9%) was not significant (p = 0.24). When iNPH was diagnosed according to the Japanese guidelines the prevalence was 1.5.
In this prospective, population-based study the prevalence of iNPH was 3.7% among individuals 65 years and older, and more common in the higher age group, 80 years and above. INPH should be increasingly recognized since it is a fairly common condition and an important cause of gait impairment and dementia among the elderly that can be effectively treated by shunt surgery.
Journal Article
Comparative retrospective analysis of patients with idiopathic normal pressure hydrocephalus and aqueductal web-related aqueductal stenosis
Objectives: Aquaductal web (AW) is a special form of aqueductal stenosis with similar clinical presentation with idiopathic normal pressure hydrocephalus (iNPH). iNPH is indeed a communicating hydrocephalus syndrome whereas AW is a noncommunicating subtype. Here, we aimed to investigate the similarities and differences between these two different chronic hydrocephalus syndromes in terms of clinical signs and symptoms, response to shunt treatment and postoperative complications. Methods: Forty-one patients who underwent shunt operation with the diagnosis of iNPH or AW at our clinic between January 2010-May 2019 were retrospectively analyzed. Patients were evaluated by age, gender, clinical sign and symptoms, comorbidities, intraoperative and postoperative complications, and early and late postoperative outpatient follow-up findings. Results: Twenty-six patients were classified as iNPH group and 15 patients as AW group. Patients in the AW group were significantly younger (45.5 ± 15.6 years vs. 60.3 ± 15.4 years) than the iNPH group (p = 0.006). There was no statistical difference between the groups in terms of subdural effusion formation, need for shunt revision (p = 1.000). Chronic hydrocephalus symptoms regressed in 23 (88.5%) patients in the NPH group, and at least one of them improved. symptoms. This rate was 66.7% (n = 10) in the AW group. Both groups showed similar clinical improvement with VPS (p = 0.1169). Conclusions: The placement of ventriculoperitoenal shunt is widely used in the treatment of iNPH. As iNPH and AW has clinical similarities despite the discrepancies between underlying pathophysiological mechanisms and both clinical entities respond similarly to shunt treatment we advocate VPS surgery in the management of AW as well.
Journal Article
Safety and efficacy of gravitational shunt valves in patients with idiopathic normal pressure hydrocephalus: a pragmatic, randomised, open label, multicentre trial (SVASONA)
Objectives To investigate whether gravitational valves reduce the risk of overdrainage complications compared with programmable valves in ventriculoperitoneal (VP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). Background Patients with iNPH may benefit from VP shunting but are prone to overdrainage complications during posture changes. Gravitational valves with tantalum balls are considered to reduce the risk of overdrainage but their clinical effectiveness is unclear. Methods We conducted a pragmatic, randomised, multicentre trial comparing gravitational with non-gravitational programmable valves in patients with iNPH eligible for VP shunting. The primary endpoint was any clinical or radiological sign (headache, nausea, vomiting, subdural effusion or slit ventricle) of overdrainage 6 months after randomisation. We also assessed disease specific instruments (Black and Kiefer Scale) and Physical and Mental Component Scores of the Short Form 12 (SF-12) generic health questionnaire. Results We enrolled 145 patients (mean (SD) age 71.9 (6.9) years), 137 of whom were available for endpoint analysis. After 6 months, 29 patients in the standard and five patients in the gravitational shunt group developed overdrainage (risk difference −36%, 95% CI −49% to −23%; p<0.001). This difference exceeded predetermined stopping rules and resulted in premature discontinuation of patient recruitment. Disease specific outcome scales did not differ between the groups although there was a significant advantage of the gravitational device in the SF-12 Mental Component Scores at the 6 and 12 month visits. Conclusions Implanting a gravitational rather than another type of valve will avoid one additional overdrainage complication in about every third patient undergoing VP shunting for iNPH.
Journal Article
The European iNPH Multicentre Study on the predictive values of resistance to CSF outflow and the CSF Tap Test in patients with idiopathic normal pressure hydrocephalus
Objective The objective was to determine the sensitivity, specificity, and positive and negative predictive values of the CSF Tap Test (CSF TT) and resistance to CSF outflow (Rout) for the outcome of shunting in a sample of patients with idiopathic normal pressure hydrocephalus (iNPH). Methods 115 patients were included in this European multicentre study. Diagnosis was based on clinical symptoms and signs, and MRI changes. All patients were treated with programmable ventriculoperitoneal shunts and re-examined 12 months after surgery. Outcomes were measures with a newly developed iNPH Scale and the modified Rankin Scale (mRS). Before surgery, a CSF TT and measurement of Rout was performed, with the results blinded to all caregivers. The 12 month outcome was correlated with Rout and the result of the CSF TT. Results Rout and the results of the CSF TT showed no correlation with outcome measured by either domain, or with total iNPH score or mRS score. Only an increase in the gait task (10 m of walking at free speed) of the CSF TT correlated significantly (r=0.22, p=0.02) with improvement in iNPH score. The positive predictive value of both tests was >90% and the negative predictive value <20%. Rout >12 had an overall accuracy of 65% and the CSF TT 53%. Combining both tests did not improve their predictive power. No correlation was found between Rout and the results of the CSF TT. Conclusions Rout and the results of the CSF TT did not correlate with outcome after 12 months. Rout and CSF TT can be used for selecting patients for shunt surgery but not for excluding patients from treatment. Trial registration The study has been registered at clinicaltrials.gov, identifier NCT00874198.
Journal Article
A Randomized Trial of Shunting for Idiopathic Normal-Pressure Hydrocephalus
In patients with idiopathic normal-pressure hydrocephalus responsive to CSF drainage, shunting improved gait and balance at 3 months, but not cognition or incontinence, and was associated with some procedure-related risks.
Journal Article
Biomechanical response of the CNS is associated with frailty in NPH-suspected patients
Frailty is known to predict dementia. However, its link with neurodegenerative alterations of the central nervous system (CNS) is not well understood at present. We investigated the association between the biomechanical response of the CNS and frailty in older adults suspected of normal pressure hydrocephalus (NPH) presenting with markers of multiple co-existing pathologies. The biomechanical response of the CNS was characterized by the CNS elastance coefficient inferred from phase contrast magnetic resonance imaging and intracranial pressure monitoring during a lumbar infusion test. Frailty was assessed with an index of health deficit accumulation. We found a significant association between the CNS elastance coefficient and frailty, with an effect size comparable to that between frailty and age, the latter being the strongest known risk factor for frailty. Results were independent of CSF dynamics, showing that they are not specific to the NPH neuropathological condition. The CNS biomechanical characterization may help to understand how frailty is related to neurodegeneration and detect the shift from normal to pathological brain ageing.
Journal Article
Beyond early motor response: Longitudinal cognitive and gait assessments after extended lumbar drainage in normal pressure hydrocephalus
Background Idiopathic normal pressure hydrocephalus (iNPH) is a multifactorial progressive disease affecting cognition, gait, and urinary continence, potentially reversible, or at least improvable, by a prompt surgical intervention. Given its potential surgical improvement, it is crucial to determine who will benefit of a ventriculo‐peritoneal shunt. To date, although several procedures are considered useful to diagnose iNPH, there is no agreement concerning the best timing of the clinical assessment or the role played by formal cognitive testing. Methods Thirty participants with suspected iNPH were assessed at baseline, 2, and 15 days after 24‐h extended lumbar drainage (ELD). Timed Up and Go test (TUG), Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Frontal Assessment Battery (FAB) were administered in order to quantify motor and cognitive performances. The TUG was used to assess clinical response to ELD. Results Our sample showed significant differences between baseline assessment and follow‐ups in the majority of tests. Although some enhancements in performances appeared in the first post‐ELD assessment, both treatment responders and non‐responders showed better performances in the delayed assessment. Post hoc comparison found significant differences in each time point between the two groups. Conclusions These results emphasize the key role of performing multiple assessments post CSF drainage, as response can be more prominent in a delayed rather than an early phase.
Journal Article