Challenges of Normal Pressure Hydrocephalus

Normal Pressure Hydrocephalus (NPH) presents a diagnostic and therapeutic challenge as no underlying cause is identified in over two-thirds of cases. In addition, secondary NPH (e.g. after meningitis or trauma) is also a difficult clinical problem that is underestimated due to a lack of robust diagnostic tools. Overall, evidence demonstrates that NPH is under-diagnosed and under-treated in both the UK and France, and the potentially avoidable financial and societal burden of these severely ill patients is substantial. Therefore, through improving the rate of diagnosis of NPH, REVERT has the potential to reverse symptoms of dementia in a large number of patients across the region.

REVERT concepts

Identification of patients with NPH who are likely to respond to surgical treatment (with a cerebrospinal fluid, CSF, shunt) is challenging, particularly in the elderly who are likely to have multiple concurrent co-morbidities. Furthermore, there are no European guidelines to date for optimal NPH management. Lumbar CSF infusion testing, developed and promoted by the University of Cambridge, forms part of the national best practice guidelines for NPH (NICE – National Institute of Clinical Excellence, UK), but remains underutilised as compared to clinical assessment in isolation. Analysis of phase contrast MRI (PCMRI) imaging of CSF and blood flows for the purspose of diagnosing hydrocephalus has been pioneered by the University of Picardie Jules Verne, Amiens. However, the predictive ability of PCMRI for selecting suitable treatment candidates is still moderate, particularly when taken in isolation, and, importantly, these imaging techniques are not readily available to the wider clinical community. Furthermore, NPH expertise is centred around tertiary neuroscience centres, with multiple barriers precluding timely referrals of potential patients with NPH from the community or secondary centres. The Orion platform developed by Obex has streamlined neurosurgical referrals across the East of England over the last 10 years, and has recently been demonstrated to reduce the time from diagnosis to specialist referral for patients with brain tumours.

What we are trying to deliver

We propose utilising the combined expertise and innovations of the REVERT partners to transform the current care pathway of NPH within the region, including timely referral, accurate diagnosis, monitoring of treatment outcomes, and supporting future research. We plan to evaluate implementation feasibility within hospitals in the programme region (North, North-West France, South and South-East UK), create a web-based hydrocephalus management platform (HMP) to allow diagnostic techniques to be rapidly disseminated and evaluated long-term but also to ensure that suspected NPH cases are rapidly referred to a tertiary centre for evaluation, and last but not least, to develop novel methods aiming to improve the accuracy and robustness of the diagnostic tests.

Through the cross-border sharing of best practice between partners, this development will establish the crucial first step in wider dissemination of advanced hydrocephalus diagnostics in the Area, the EU and internationally.