{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:46:25Z","timestamp":1790729185488,"version":"4.1.0"},"reference-count":48,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["FOC"],"published-print":{"date-parts":[[2016,9]]},"abstract":"\n OBJECTIVE<\/jats:title>\n A growing body of evidence suggests that longer durations of preoperative symptoms may correlate with worse postoperative outcomes following cerebrospinal fluid (CSF) diversion for treatment of idiopathic normal pressure hydrocephalus (iNPH). The aim of this study is to determine whether the duration of preoperative symptoms alters postoperative outcomes in patients treated for iNPH.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n The authors conducted a retrospective review of 393 cases of iNPH involving patients treated with ventriculoperitoneal (VP) shunting. The duration of symptoms prior to the operative intervention was recorded. The following outcome variables were assessed at baseline, 6 months postoperatively, and at last follow-up: gait performance, urinary continence, and cognition.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n The patients' median age at shunt placement was 74 years. Increased symptom duration was significantly associated with worse gait outcomes (relative risk (RR) 1.055 per year of symptoms, p = 0.037), and an overall absence of improvement in any of the classic triad symptomology (RR 1.053 per year of symptoms, p = 0.033) at 6 months postoperatively. Additionally, there were trends toward significance for symptom duration increasing the risk of having no 6-month postoperative improvement in urinary incontinence (RR 1.049 per year of symptoms, p = 0.069) or cognitive symptoms (RR 1.051 per year of symptoms, p = 0.069). However, no statistically significant differences were noted in these outcomes at last follow-up (median 31 months). Age stratification by decade revealed that prolonging symptom duration was significantly associated with lower Mini-Mental Status Examination scores in patients aged 60\u201370 years, and lack of cognitive improvement in patients aged 70\u201380 years.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n Patients with iNPH with longer duration of preoperative symptoms may not receive the same short-term benefits of surgical intervention as patients with shorter duration of preoperative symptoms. However, with longer follow-up, the patients generally reached the same end point. Therefore, when managing patients with iNPH, it may take longer to see the benefits of CSF shunting when patients present with a longer duration of preoperative symptoms.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2016.6.focus16146","type":"journal-article","created":{"date-parts":[[2016,9,1]],"date-time":"2016-09-01T03:39:30Z","timestamp":1472701170000},"page":"E2","source":"Crossref","is-referenced-by-count":33,"title":["Timing of surgical treatment for idiopathic normal pressure hydrocephalus: association between treatment delay and reduced short-term benefit"],"prefix":"10.3171","volume":"41","author":[{"given":"Sharif","family":"Vakili","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dane","family":"Moran","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alice","family":"Hung","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin D.","family":"Elder","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lee","family":"Jeon","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hugo","family":"Fialho","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric W.","family":"Sankey","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ignacio","family":"Jusu\u00e9-Torres","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C. Rory","family":"Goodwin","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Lu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jamie","family":"Robison","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniele","family":"Rigamonti","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-focus16146","series-title":"J Neurol Neurosurg Psychiatry","first-page":"806","article-title":"Natural course of idiopathic normal pressure hydrocephalus","volume":"85","author":"Andr\u00e9n","year":"2014"},{"key":"b2-focus16146","series-title":"Pract Neurol","first-page":"252","article-title":"Normal pressure hydrocephalus: new complications and concepts","volume":"7","author":"Conn","year":"2007"},{"key":"b3-focus16146","series-title":"Acta Neurol Scand","first-page":"414","article-title":"Impact of duration of symptoms on CSF dynamics in idiopathic normal pressure hydrocephalus","volume":"123","author":"Czosnyka","year":"2011"},{"key":"b4-focus16146","series-title":"Acta Neurochir (Wien)","first-page":"21","article-title":"Intracranial pressure parameters in idiopathic normal pressure hydrocephalus patients treated with ventriculoperitoneal shunts","volume":"148","author":"Eide","year":"2006"},{"key":"b5-focus16146","series-title":"J Neurol Sci","first-page":"307","article-title":"The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics","volume":"2","author":"Hakim","year":"1965"},{"key":"b6-focus16146","series-title":"Neurosurgery","first-page":"1166","article-title":"Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome","volume":"49","author":"Hebb","year":"2001"},{"key":"b7-focus16146","series-title":"Lancet Neurol","first-page":"585","article-title":"Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial","volume":"14","author":"Kazui","year":"2015"},{"key":"b8-focus16146","series-title":"Neurology","first-page":"1119","article-title":"Normal pressure hydrocephalus: how often does the diagnosis hold water?","volume":"77","author":"Klassen","year":"2011"},{"key":"b9-focus16146","series-title":"Acta Neurochir (Wien)","first-page":"379","article-title":"Normal pressure hydrocephalus: survey on contemporary diagnostic algorithms and therapeutic decision-making in clinical practice","volume":"146","author":"Krauss","year":"2004"},{"issue":"4","key":"b10-focus16146","series-title":"Neurosurg Focus","first-page":"E1","article-title":"Estimated incidence of normal pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities","volume":"22","author":"Marmarou","year":"2007"},{"key":"b11-focus16146","series-title":"J Neurosurg","first-page":"987","article-title":"Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients","volume":"102","author":"Marmarou","year":"2005"},{"key":"b12-focus16146","series-title":"World Neurosurg","first-page":"2002","article-title":"Epidemiology of idiopathic normal pressure hydrocephalus: a systematic review of the literature","volume":"84","author":"Mart\u00edn-L\u00e1ez","year":"2015"},{"key":"b13-focus16146","series-title":"J Neurol Sci","first-page":"13","article-title":"Clinical equipoise in idiopathic normal pressure hydrocephalus: a survey of physicians on the need for randomized controlled trials assessing the efficacy of cerebrospinal fluid diversion","volume":"333","author":"McGirr","year":"2013"},{"key":"b14-focus16146","series-title":"Neurosurgery","first-page":"699","article-title":"Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus","volume":"57","author":"McGirt","year":"2005"},{"key":"b15-focus16146","series-title":"Acta Neurochir Suppl","first-page":"358","article-title":"On the optimal opening pressure of hydrostatic valves in cases of idiopathic normal-pressure hydrocephalus: a prospective randomized study with 123 patients","volume":"96","author":"Meier","year":"2006"},{"key":"b16-focus16146","series-title":"Neurol Med Chir (Tokyo)","first-page":"775","article-title":"Guidelines for management of idiopathic normal pressure hydrocephalus: second edition","volume":"52","author":"Mori","year":"2012"},{"key":"b17-focus16146","series-title":"Scott Med J","first-page":"200","article-title":"Cerebral vascular accidents in patients over the age of 60. II. Prognosis","volume":"2","author":"Rankin","year":"1957"},{"issue":"3 Suppl","key":"b18-focus16146","series-title":"Neurosurgery","first-page":"S4","article-title":"Diagnosing idiopathic normal-pressure hydrocephalus","volume":"57","author":"Relkin","year":"2005"},{"key":"b19-focus16146","series-title":"Front Neurol","first-page":"86","article-title":"A clinical and biochemical analysis in the differential diagnosis of idiopathic normal pressure hydrocephalus.","volume":"6","author":"Schirinzi","year":"2015"},{"key":"b20-focus16146","series-title":"Curr Neurol Neurosci Rep","first-page":"371","article-title":"Normal pressure hydrocephalus: diagnosis and treatment","volume":"8","author":"Shprecher","year":"2008"},{"key":"b21-focus16146","series-title":"Neuroepidemiology","first-page":"171","article-title":"Prevalence of possible idiopathic normal-pressure hydrocephalus in Japan: the Osaki-Tajiri project","volume":"32","author":"Tanaka","year":"2009"},{"key":"b22-focus16146","series-title":"Neurosurg Rev","first-page":"433","article-title":"Natural history of idiopathic normal-pressure hydrocephalus","volume":"34","author":"Toma","year":"2011"},{"key":"b23-focus16146","series-title":"J Neurol Neurosurg Psychiatry","first-page":"562","article-title":"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","volume":"84","author":"Wikkels\u00f8","year":"2013"},{"key":"b24-focus16146","series-title":"Neurol Clin Pract","first-page":"375","article-title":"Diagnosis and management of idiopathic normal-pressure hydrocephalus","volume":"3","author":"Williams","year":"2013"},{"key":"b1-focus16146","series-title":"J Neurol Neurosurg Psychiatry","first-page":"806","article-title":"Natural course of idiopathic normal pressure hydrocephalus","volume":"85","author":"Andr\u00e9n","year":"2014"},{"key":"b2-focus16146","series-title":"Pract Neurol","first-page":"252","article-title":"Normal pressure hydrocephalus: new complications and concepts","volume":"7","author":"Conn","year":"2007"},{"key":"b3-focus16146","series-title":"Acta Neurol Scand","first-page":"414","article-title":"Impact of duration of symptoms on CSF dynamics in idiopathic normal pressure hydrocephalus","volume":"123","author":"Czosnyka","year":"2011"},{"key":"b4-focus16146","series-title":"Acta Neurochir (Wien)","first-page":"21","article-title":"Intracranial pressure parameters in idiopathic normal pressure hydrocephalus patients treated with ventriculoperitoneal shunts","volume":"148","author":"Eide","year":"2006"},{"key":"b5-focus16146","series-title":"J Neurol Sci","first-page":"307","article-title":"The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics","volume":"2","author":"Hakim","year":"1965"},{"key":"b6-focus16146","series-title":"Neurosurgery","first-page":"1166","article-title":"Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome","volume":"49","author":"Hebb","year":"2001"},{"key":"b7-focus16146","series-title":"Lancet Neurol","first-page":"585","article-title":"Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial","volume":"14","author":"Kazui","year":"2015"},{"key":"b8-focus16146","series-title":"Neurology","first-page":"1119","article-title":"Normal pressure hydrocephalus: how often does the diagnosis hold water?","volume":"77","author":"Klassen","year":"2011"},{"key":"b9-focus16146","series-title":"Acta Neurochir (Wien)","first-page":"379","article-title":"Normal pressure hydrocephalus: survey on contemporary diagnostic algorithms and therapeutic decision-making in clinical practice","volume":"146","author":"Krauss","year":"2004"},{"issue":"4","key":"b10-focus16146","series-title":"Neurosurg Focus","first-page":"E1","article-title":"Estimated incidence of normal pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities","volume":"22","author":"Marmarou","year":"2007"},{"key":"b11-focus16146","series-title":"J Neurosurg","first-page":"987","article-title":"Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients","volume":"102","author":"Marmarou","year":"2005"},{"key":"b12-focus16146","series-title":"World Neurosurg","first-page":"2002","article-title":"Epidemiology of idiopathic normal pressure hydrocephalus: a systematic review of the literature","volume":"84","author":"Mart\u00edn-L\u00e1ez","year":"2015"},{"key":"b13-focus16146","series-title":"J Neurol Sci","first-page":"13","article-title":"Clinical equipoise in idiopathic normal pressure hydrocephalus: a survey of physicians on the need for randomized controlled trials assessing the efficacy of cerebrospinal fluid diversion","volume":"333","author":"McGirr","year":"2013"},{"key":"b14-focus16146","series-title":"Neurosurgery","first-page":"699","article-title":"Diagnosis, treatment, and analysis of long-term outcomes in idiopathic normal-pressure hydrocephalus","volume":"57","author":"McGirt","year":"2005"},{"key":"b15-focus16146","series-title":"Acta Neurochir Suppl","first-page":"358","article-title":"On the optimal opening pressure of hydrostatic valves in cases of idiopathic normal-pressure hydrocephalus: a prospective randomized study with 123 patients","volume":"96","author":"Meier","year":"2006"},{"key":"b16-focus16146","series-title":"Neurol Med Chir (Tokyo)","first-page":"775","article-title":"Guidelines for management of idiopathic normal pressure hydrocephalus: second edition","volume":"52","author":"Mori","year":"2012"},{"key":"b17-focus16146","series-title":"Scott Med J","first-page":"200","article-title":"Cerebral vascular accidents in patients over the age of 60. 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