March 15, 2023

Normal Pressure Hydrocephalus Protocol Team improves lives of hard-to-diagnose patients

“The NPH Protocol exemplifies multiple disciplines working together to improve the lives of patients and their caregivers.”

The NPH Protocol Team poses for a photo on Thursday, Feb. 2, 2023 outside of the Vanderbilt Clinic at Vanderbilt University Medical Center in Nashville, Tennessee. The NPH Protocol Team was the recipient of the Elevate Team Award.

Member of the NPH Protocol Team include (from left) Christina Durrough Lugge, PT, DPT, NCS; Kassandra L. Stubblefield, MSN; Trisha Conwell, PA-C; Douglas Terry, PhD; Lealani Mae Acosta, MD, MPH; Emily Brocato, PT; and Melissa Vinea, MSN, RN-BC. In front is facility dog Norman. Photo by Erin O. Smith.

For nearly two years, a man experienced his quality of life slipping away. He became unable to walk, developed urinary incontinence, and had to quit his job. He was initially diagnosed with parkinsonism, a clinical syndrome characterized by tremor, bradykinesia (slowed movements) and instability.

Lacking a definitive diagnosis or any effective treatment for his symptoms, he came to Vanderbilt University Medical Center. He was examined by a neurologist and referred for a comprehensive assessment by a dedicated, multidisciplinary team at VUMC that runs the Normal Pressure Hydrocephalus (NPH) Protocol.

NPH is an abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles. This causes the ventricles to enlarge, putting pressure on the brain. The Hydocephalus Association estimates more than 700,000 Americans have NPH, but less than 20% receive an accurate diagnosis.

Without appropriate diagnostic testing, NPH is often misdiagnosed as Alzheimer’s disease, Parkinson’s disease, stroke or other neurodegenerative conditions. NPH is one of the few causes of dementia that can be improved through direct treatment.

After being evaluated and receiving a high-volume lumbar puncture (LP), the man’s physiological responses indicated he had NPH. A neurosurgery team placed a ventriculoperitoneal shunt to divert CSF from his brain to his abdomen where it would be safely absorbed. The man is walking again and has returned to work. He and his wife credit the NPH team for the accurate diagnosis that gave him back his life.

Because of their efforts, the NPH Protocol Team was honored with an Elevate Team Award during the February 2023 Leadership Assembly.

When the NPH Protocol began, individuals were assessed at the Clinical Research Center, utilizing inpatient consultation teams. Now patients referred for the NPH Protocol are seen at the neurology residency’s Lumbar Puncture Clinic at The Vanderbilt Clinic.

Initially, the NPH Protocol Team saw one patient per month. News of their success spread, and now the team evaluates at least two patients per week. More than 180 patients have been assessed for NPH, and neurology residents have an impressive 95.2% success rate for bedside LPs.

“Creating the NPH protocol allows us to objectively assess if a patient benefits from high-volume cerebrospinal fluid removal via lumbar puncture, with comprehensive testing including physical therapy, neuropsychology, neurology and neurosurgery,” said Lealani Mae Acosta, MD, MPH, associate professor of Neurology and one of the developers of the protocol. “Having a multidisciplinary team assess a patient enables more rigorous evaluation as to the response to a high-volume LP, to gauge potential benefit of more invasive neurosurgical intervention with placement of a ventriculoperitoneal shunt.”

Properly evaluating patients for NPH involves many specialties and lengthy pre- and post-LP assessments. This requires scheduling and coordination across practices, something the NPH protocol team has achieved with grace and total dedication to patients and their families, Acosta noted.

“This is truly a team effort,” she said. “The NPH Protocol exemplifies multiple disciplines working together to improve the lives of patients and their caregivers. This involves many dedicated people who give a lot of time and energy to make sure patients are getting the comprehensive assessments they need.”

Team leads for the NPH Protocol Team are Acosta, Trisha Conwell, PA-C; Christina Durrough, DPT; and Douglas Terry, PhD. Team members include CRC Nurse Practitioner Kassandra Stubblefield, RN, MSN, ANP-BC; Neurology Lead Financial Clearance Specialist Trywanna “Rena’” Carter; Associate Program Director of the Neurology Residency Heather Koons, MD; Neurology Residency Program Director Christopher Lee, MD, MPH; Physical Therapist Emily Sutinis, DPT; Physical Therapist Judy Booker, DPT; Melissa Vinea, RN; Clinical Research Center Nurse Manager Lana Howard, RN; Neuroscience Clinics Patient Care Programs Coordinator Kellie Gill; and Physical Therapist Cathey Norton, DPT.

If you are a VUMC employee, you can nominate a colleague for an Elevate Credo Award, Five Pillar Leader Award, or Team Award. Visit the Elevate website to fill out a nomination form. Employees demonstrate credo behaviors when: they make those they serve the highest priority; respect privacy and confidentiality; communicate effectively; conduct themselves professionally; have a sense of ownership; and are committed to their colleagues. Elevate award nominations are accepted year-round. If a nomination is received after the cut off for an award selection period, the nomination will be considered for the next period. VUMC VOICE will post stories on each of the award winners in the weeks following their announcement.