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Soon SXY, Kumar AA, Tan AJL, Lo YT, Lock C, Kumar S, Kwok J, Keong NC. The Impact of Multimorbidity Burden, Frailty Risk Scoring, and 3-Directional Morphological Indices vs. Testing for CSF Responsiveness in Normal Pressure Hydrocephalus. Front Neurosci 2021; 15:751145. [PMID: 34867163 PMCID: PMC8636813 DOI: 10.3389/fnins.2021.751145] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: Multimorbidity burden across disease cohorts and variations in clinico-radiographic presentations within normal pressure hydrocephalus (NPH) confound its diagnosis, and the assessment of its amenability to interventions. We hypothesized that novel imaging techniques such as 3-directional linear morphological indices could help in distinguishing between hydrocephalus vs. non-hydrocephalus and correlate with responsiveness to external lumbar drainage (CSF responsiveness) within NPH subtypes. Methodology: Twenty-one participants with NPH were recruited and age-matched to 21 patients with Alzheimer’s Disease (AD) and 21 healthy controls (HC) selected from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database. Patients with NPH underwent testing via the NPH programme with external lumbar drainage (ELD); pre- and post-ELD MRI scans were obtained. The modified Frailty Index (mFI-11) was used to stratify the NPH cohort, including Classic and Complex subtypes, by their comorbidity and frailty risks. The quantitative imaging network tool 3D Slicer was used to derive traditional 2-dimensional (2d) linear measures; Evans Index (EI), Bicaudate Index (BCI) and Callosal Angle (CA), along with novel 3-directional (3d) linear measures; z-Evans Index and Brain per Ventricle Ratio (BVR). 3-Dimensional (3D) ventricular volumetry was performed as an independent correlate of ventriculomegaly to CSF responsiveness. Results: Mean age for study participants was 71.14 ± 6.3 years (18, 85.7% males). The majority (15/21, 71.4%) of participants with NPH comprised the Complex subtype (overlay from vascular risk burden and AD); 12/21 (57.1%) were Non-Responders to ELD. Frailty alone was insufficient in distinguishing between NPH subtypes. By contrast, 3d linear measures distinguished NPH from both AD and HC cohorts, but also correlated to CSF responsiveness. The z-Evans Index was the most sensitive volumetric measure of CSF responsiveness (p = 0.012). Changes in 3d morphological indices across timepoints distinguished between Responders vs. Non-Responders to lumbar testing. There was a significant reduction of indices, only in Non-Responders and across multiple measures (z-Evans Index; p = 0.001, BVR at PC; p = 0.024). This was due to a significant decrease in ventricular measurement (p = 0.005) that correlated to independent 3D volumetry (p = 0.008). Conclusion. In the context of multimorbidity burden, frailty risks and overlay from neurodegenerative disease, 3d morphological indices demonstrated utility in distinguishing hydrocephalus vs. non-hydrocephalus and degree of CSF responsiveness. Further work may support the characterization of patients with Complex NPH who would best benefit from the risks of interventions.
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Affiliation(s)
- Shereen X Y Soon
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - A Aravin Kumar
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Audrey J L Tan
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Yu Tung Lo
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Christine Lock
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sumeet Kumar
- Department of Neuroradiology, National Neuroscience Institute, Singapore, Singapore
| | - Janell Kwok
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Nicole C Keong
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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Kimura T, Yamada S, Sugimura T, Seki T, Miyano M, Fukuda S, Takeuchi S, Miyata S, Tucker A, Fujita T, Hashizume A, Izumi N, Kawasaki K, Nakagaki A, Sako K. Preoperative Predictive Factors of Short-Term Outcome in Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2021; 151:e399-e406. [PMID: 33895373 DOI: 10.1016/j.wneu.2021.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for <6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients. METHODS Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome. RESULTS Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P < 0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P < 0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P < 0.0001) Preoperative DESH correlated with improvement in mRS and GD (P < 0.0001). CONCLUSIONS Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.
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Affiliation(s)
- Teruo Kimura
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan; Department of Neurosurgery, Kitami Red Cross Hospital, Hokkaidō, Japan.
| | - Shigeki Yamada
- Department of Neurosurgery, Rakuwakai Otowa, Hospital, Kyoto, Japan
| | - Toshihide Sugimura
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan
| | - Toshitaka Seki
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan
| | - Makoto Miyano
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan
| | - Shin Fukuda
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan
| | - Shiro Miyata
- Department of Neurosurgery, Dohtoh Neurosurgery Hospital, Hokkaidō, Japan
| | - Adam Tucker
- Department of Neurosurgery, Kitami Red Cross Hospital, Hokkaidō, Japan
| | - Tsutomu Fujita
- Department of Neurosurgery, Bihoro Clinic, Hokkaidō, Japan
| | - Akira Hashizume
- Department of Neurosurgery, Katsuragaoka Clinic, Hokkaidō, Japan
| | - Naoto Izumi
- Department of Neurosurgery, Abashiri Neurosurgery Rehabilitation Hospital, Hokkaidō, Japan
| | - Kazutsune Kawasaki
- Department of Neurosurgery, Abashiri Neurosurgery Rehabilitation Hospital, Hokkaidō, Japan
| | - Atsushi Nakagaki
- Department of Computer Sciences, Kitami Institute of Technology, Kitami, Japan
| | - Kazuhiro Sako
- Department of Neurosurgery, Nayoro General Hospital, Nayoro City, Japan
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Hudson M, Nowak C, Garling RJ, Harris C. Comorbidity of diabetes mellitus in idiopathic normal pressure hydrocephalus: a systematic literature review. Fluids Barriers CNS 2019; 16:5. [PMID: 30744635 PMCID: PMC6371499 DOI: 10.1186/s12987-019-0125-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/29/2019] [Indexed: 11/14/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a subtype of hydrocephalus that occurs more often in the elderly population. It is usually characterized by gait disturbance, dementia and urinary incontinence. Epidemiological studies indicate that 15.7–17.8% of iNPH patients present with type-2 diabetes mellitus (DM). A review of the primary literature shows that these occurrence rates are higher than age- and cohort-matched non-iNPH controls. This suggests that this already vulnerable patient group has an increased risk for presenting with DM compared to their non-iNPH counterparts. Postoperative outcome when treating iNPH patients is inversely related to the number of patient comorbidities and a lower comorbidity status is correlated with better outcomes. This review highlights the need for further research into the relationship between iNPH and DM and speculates on a possible mechanism for an association between the development of ventriculomegaly and the development of DM and iNPH.
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Affiliation(s)
- Miles Hudson
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA.
| | - Caden Nowak
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA
| | - Richard J Garling
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA
| | - Carolyn Harris
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA
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Meier U, Stengel D, Müller C, Fritsch MJ, Kehler U, Langer N, Kiefer M, Eymann R, Schuhmann MU, Speil A, Weber F, Remenez V, Rohde V, Ludwig HC, Lemcke J. Predictors of subsequent overdrainage and clinical outcomes after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus. Neurosurgery 2014; 73:1054-60. [PMID: 24257332 DOI: 10.1227/neu.0000000000000155] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about variables associated with overdrainage complications and neurofunctional and health-related quality of life outcomes in idiopathic normal-pressure hydrocephalus (iNPH) patients after shunt surgery. OBJECTIVE To identify candidate demographic and disease-specific predictors of overdrainage and patient-related outcomes, allowing for more personalized care of patients with iNPH. METHODS This was a secondary analysis of the dataset of the SVASONA study, a multicenter randomized trial comparing gravitational and conventional gravitational valves for treating iNPH. We evaluated the association between baseline items and the incidence of overdrainage, using different endpoint definitions. RESULTS We identified only a few variables associated with a possible increased risk of overdrainage. Apart from using conventional rather than gravitational valves, longer duration of surgery and female sex were associated with a higher risk of clinical signs and symptoms suggestive of overdrainage (hazard ratio: 1.02, 95% confidence interval: 1.01-1.04 and 1.84, 95% confidence interval: 0.81-4.16). The occurrence of clinical symptoms of overdrainage, and the need for exchanging a programmable by a gravitational valve may adversely affect disease-specific outcomes like the Kiefer score. CONCLUSION Few, if any, baseline and treatment characteristics may be helpful in estimating the individual risk of complications and clinical outcomes after shunt surgery for iNPH. Patients should be informed that longer surgery for any reason may increase the risk of later overdrainage. Also, women should be counseled about a sex-associated increased risk of the development of clinical symptoms of overdrainage, although the latter cannot be distinguished from a generally higher prevalence of headaches in the female population.
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Affiliation(s)
- Ullrich Meier
- ‡Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany; §Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Germany; ¶Julius Wolff Institute, Charité Medical University Centre, Germany; ‖Department of Neurosurgery, Ernst-Moritz-Arndt-University of Greifswald, Germany; #Department of Neurosurgery, Asklepios Hospital Altona, Hamburg, Germany; **Department of Neurosurgery, Saarland Medical University, Homburg/Saar, Germany; ‡‡Department of Neurosurgery, Eberhard-Karls-University of Tübingen, Germany; §§Department of Neurosurgery, Hospital Cologne-Merheim, Germany; ¶¶Department of Neurosurgery, Georg-August-University of Göttingen, Germany
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