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Liu X, Mu J, Pang M, Fan X, Zhou Z, Guo F, Yu K, Yu H, Ming D. A Male Patient with Hydrocephalus via Multimodality Diagnostic Approaches: A Case Report. CYBORG AND BIONIC SYSTEMS 2024; 5:0135. [PMID: 39139629 PMCID: PMC11321655 DOI: 10.34133/cbsystems.0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/09/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction: Idiopathic normal pressure hydrocephalus (iNPH) is a kind of hydrocephalus that is easily to be misdiagnosed with brain atrophy due to the similarity of ventricular dilation and cognitive impairment. In this case, we present an old male patient who was diagnosed with iNPH by multimodality approaches. Outcomes: A 68-year-old male patient, with deteriorated gait, declined cognitive function for at least 3 years and urinary incontinence for 3 months. The doctors suspected him a patient with hydrocephalus or Alzheimer's disease based on his symptoms. We used multimodality diagnostic approaches including brain imaging, cerebrospinal fluid tap test, continuous intracranial pressure monitoring, and infusion study to make the final diagnosis of iNPH. He underwent ventriculoperitoneal shunt surgery and was well recovered. Conclusion: This case demonstrates the efficacy of using multimodality approaches for iNPH diagnosis, which saves patient time and clinical cost, worthy of further promotion.
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Affiliation(s)
- Xiuyun Liu
- State Key Laboratory of Advanced Medical Materials and Devices, Medical School,
Tianjin University, Tianjin 300072, China
- Haihe Laboratory of Brain Computer Interaction and Human-Machine Integration, Tianjin 300380, China
| | - Jingjing Mu
- State Key Laboratory of Advanced Medical Materials and Devices, Medical School,
Tianjin University, Tianjin 300072, China
| | - Meijun Pang
- State Key Laboratory of Advanced Medical Materials and Devices, Medical School,
Tianjin University, Tianjin 300072, China
| | - Xuehai Fan
- Department of Neurosurgery,
Tianjin Medical University General Hospital, Tianjin 300070, China
| | - Ziwei Zhou
- Department of Neurosurgery,
Tianjin Medical University General Hospital, Tianjin 300070, China
| | - Fang Guo
- Department of Neurosurgery,
Tianjin Huanhu Hospital, Tianjin 300060, China
| | - Kai Yu
- Department of Neurosurgery,
Tianjin Medical University General Hospital, Tianjin 300070, China
| | - Huijie Yu
- Department of Neurosurgery,
Tianjin Medical University General Hospital, Tianjin 300070, China
| | - Dong Ming
- State Key Laboratory of Advanced Medical Materials and Devices, Medical School,
Tianjin University, Tianjin 300072, China
- Haihe Laboratory of Brain Computer Interaction and Human-Machine Integration, Tianjin 300380, China
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Grasso G, Teresi G, Noto M, Torregrossa F. Invasive Preoperative Investigations in Idiopathic Normal Pressure Hydrocephalus: A Comprehensive Review. World Neurosurg 2024; 181:178-183. [PMID: 37939878 DOI: 10.1016/j.wneu.2023.10.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder characterized by the triad of gait disturbance, cognitive impairment, and urinary incontinence. The condition is diagnosed mainly in older adults and is associated with ventricular enlargement without an increase in cerebrospinal fluid pressure. The clinical assessment involves a detailed medical history, physical examination, and cognitive testing. Neuroimaging is an essential part of the diagnostic workup for iNPH. However, to determine the suitability of patients for shunt surgery, a range of invasive preoperative investigations are employed. This narrative review aims to provide a comprehensive analysis of the current literature on invasive preoperative investigations in iNPH, focusing primarily on the lumbar infusion test, cerebrospinal fluid drainage tests, and continuous intracranial pressure monitoring. The strengths and limitations of each method, as well as their potential impact on treatment outcomes, are discussed.
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Affiliation(s)
- Giovanni Grasso
- Department of Biomedicine, Neurosurgical Unit, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
| | - Gaia Teresi
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Manfredi Noto
- Department of Biomedicine, Neurosurgical Unit, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Fabio Torregrossa
- Department of Biomedicine, Neurosurgical Unit, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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English CJ, Taylor Z, Cramberg M, Young BA. Dynamic asymmetry in cerebrospinal fluid pressure: An indicator of regional differences in compliance. Surg Neurol Int 2023; 14:187. [PMID: 37404526 PMCID: PMC10316229 DOI: 10.25259/sni_365_2023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/05/2023] [Indexed: 07/06/2023] Open
Abstract
Background Dural compliance influences the shape and magnitude of the cerebrospinal fluid (CSF) pulsations. In humans, cranial compliance is approximately 2× greater than spinal compliance; the differential has been attributed to the associated vasculature. In alligators, the spinal cord is surrounded by a large venous sinus, which suggests that the spinal compartment may have higher compliance than is found in mammals. Methods Pressure catheters were surgically implanted into the cranial and spinal subdural spaces of eight subadult American alligators (Alligator mississippiensis). The CSF was propelled through the subdural space by orthostatic gradients and rapid changes in linear acceleration. Results CSF pressure recordings taken from the cranial compartment were consistently, and significantly, larger than those taken from the spinal compartment. After the myodural bridge of Alligator was surgically released, the asymmetry in CSF pressure was decreased. Conclusion Unlike the situation in humans, the spinal compartment of Alligator has greater compliance than the cranial compartment, presumably due to the presence of the large spinal venous sinus surrounding the dura. The change in CSF pressures after myodural surgical release supports the hypothesis that the myodural bridge functions, at least in part, to modulate dural compliance and the exchange of CSF between the cranial and spinal compartments.
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Affiliation(s)
| | | | | | - Bruce A. Young
- Corresponding author: Bruce A. Young, Department of Anatomy, Kirksville College of Osteopathic Medicine, Kirksville, Missouri, United States.
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Gholampour S, Balasundaram H, Thiyagarajan P, Droessler J. A mathematical framework for the dynamic interaction of pulsatile blood, brain, and cerebrospinal fluid. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107209. [PMID: 36796166 DOI: 10.1016/j.cmpb.2022.107209] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Shedding light on less-known aspects of intracranial fluid dynamics may be helpful to understand the hydrocephalus mechanism. The present study suggests a mathematical framework based on in vivo inputs to compare the dynamic interaction of pulsatile blood, brain, and cerebrospinal fluid (CSF) between the healthy subject and the hydrocephalus patient. METHOD The input data for the mathematical formulations was pulsatile blood velocity, which was measured using cine PC-MRI. Tube law was used to transfer the created deformation by blood pulsation in the vessel circumference to the brain domain. The pulsatile deformation of brain tissue with respect to time was calculated and considered to be inlet velocity in the CSF domain. The governing equations in all three domains were continuity, Navier-Stokes, and concentration. We used Darcy law with defined permeability and diffusivity values to define the material properties in the brain. RESULTS We validated the preciseness of the CSF velocity and pressure through the mathematical formulations with cine PC-MRI velocity, experimental ICP, and FSI simulated velocity and pressure. We used the analysis of dimensionless numbers including Reynolds, Womersley, Hartmann, and Peclet to evaluate the characteristics of the intracranial fluid flow. In the mid-systole phase of a cardiac cycle, CSF velocity had the maximum value and CSF pressure had the minimum value. The maximum and amplitude of CSF pressure, as well as CSF stroke volume, were calculated and compared between the healthy subject and the hydrocephalus patient. CONCLUSION The present in vivo-based mathematical framework has the potential to gain insight into the less-known points in the physiological function of intracranial fluid dynamics and the hydrocephalus mechanism.
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Affiliation(s)
- Seifollah Gholampour
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA
| | - Hemalatha Balasundaram
- Department of Mathematics, Vels Institute of Science, Technology and Advanced Studies, Chennai, Tamilnadu, India
| | - Padmavathi Thiyagarajan
- Department of Mathematics, Vels Institute of Science, Technology and Advanced Studies, Chennai, Tamilnadu, India
| | - Julie Droessler
- Department of Neurological Surgery, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA
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van Bilsen MWT, van den Abbeele L, Volovici V, Boogaarts HD, Bartels R, van Lindert EJ. The diagnostic value of the pulsatility curve to predict shunt responsiveness in patients with idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2022; 164:1747-1754. [PMID: 35644900 PMCID: PMC9233651 DOI: 10.1007/s00701-022-05233-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/28/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the diagnostic accuracy of the pulsatility curve to predict shunt response in patients with idiopathic normal pressure hydrocephalus (iNPH). METHODS Lumbar cerebrospinal fluid dynamics were derived from an automatic lumbar infusion test (LIT) protocol. All patients were treated with ventriculoperitoneal shunting and re-examined 6 months after shunting. Patient demographics and outcomes were gathered in a prospective, electronic database that spanned from January 2012 to January 2020. A validated iNPH scale was used to assess patients preoperatively and 6 months postoperatively. The relationship of the relative pulse pressure coefficient (RPPC), delta amplitude, successful lowering of amplitude, and the pressure-value at a hypothetical amplitude of zero (P0), resistance to outflow (Rout), and outcome, were assessed using receiver operating characteristic (ROC) curves. RESULTS We included 38 patients. The RPPC, delta amplitude, successful lowering of amplitude, and P0 parameters did not predict shunt response. Mean P0 was 0.5 (IQR 0.4-0.9) in improved patients and 0.4 (IQR 0-1.2) in non-improved patients. The delta amplitude was 0.16 kPa (IQR 0.10-0.23) in improved patients and 0.18 kPa (IQR 0.11-0.24) in non-improved patients. Furthermore, we found a technical failure rate of pulsatility curve measurements of 32%. CONCLUSION Pulsatility curve results were not suitable in predicting shunt response in our cohort. The diagnostic value of LIT in case of normal pressure hydrocephalus should be subject to more rigorous research.
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Eide PK, Lashkarivand A, Hagen-Kersten ÅA, Gjertsen Ø, Nedregaard B, Sletteberg R, Løvland G, Vatnehol SAS, Pripp AH, Valnes LM, Ringstad G. Intrathecal Contrast-Enhanced Magnetic Resonance Imaging of Cerebrospinal Fluid Dynamics and Glymphatic Enhancement in Idiopathic Normal Pressure Hydrocephalus. Front Neurol 2022; 13:857328. [PMID: 35463139 PMCID: PMC9019061 DOI: 10.3389/fneur.2022.857328] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/10/2022] [Indexed: 01/09/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a neurodegenerative disease, characterized by cerebrospinal fluid (CSF) flow disturbance. Today, the only available treatment is CSF diversion surgery (shunt surgery). While traditional imaging biomarkers typically assess CSF space anatomy, recently introduced imaging biomarkers of CSF dynamics and glymphatic enhancement, provide imaging of CSF dynamics and thereby more specifically reveal elements of the underlying pathophysiology. The biomarkers address CSF ventricular reflux grade as well as glymphatic enhancement and derive from intrathecal contrast-enhanced MRI. However, the contrast agent serving as CSF tracer is administered off-label. In medicine, the introduction of new diagnostic or therapeutic methods must consider the balance between risk and benefit. To this end, we performed a prospective observational study of 95 patients with iNPH, comparing different intrathecal doses of the MRI contrast agent gadobutrol (0.10, 0.25, and 0.50 mmol, respectively), aiming at the lowest reasonable dose needed to retrieve diagnostic information about the novel MRI biomarkers. The present observations disclosed a dose-dependent enrichment of subarachnoid CSF spaces (cisterna magna, vertex, and velum interpositum) with dose-dependent ventricular reflux of tracer in iNPH, as well as dose-dependent glymphatic tracer enrichment. The association between tracer enrichment in CSF and parenchymal compartments were as well dose-related. Intrathecal gadobutrol in a dose of 0.25 mmol, but not 0.10 mmol, was at 1.5T MRI considered sufficient for imaging altered CSF dynamics and glymphatic enhancement in iNPH, even though 3T MRI provided better sensitivity. Tracer enrichment in CSF at the vertex and within the cerebral cortex and subcortical white matter was deemed too low for maintaining diagnostic information from a dose of 0.10 mmol. We conclude that reducing the intrathecal dose of gadobutrol from 0.50 to 0.25 mmol gadobutrol improves the safety margin while maintaining the necessary diagnostic information about disturbed CSF homeostasis and glymphatic failure in iNPH.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Aslan Lashkarivand
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Øivind Gjertsen
- Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Bård Nedregaard
- Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Ruth Sletteberg
- Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Grethe Løvland
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Svein Are Sirirud Vatnehol
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Optometry Radiography and Lighting Design, Faculty of Health and Social Sciences, University of South Eastern Norway, Drammen, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Lars Magnus Valnes
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Geir Ringstad
- Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Department of Geriatrics and Internal Medicine, Sorlandet Hospital, Arendal, Norway
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Lalou AD, Czosnyka M, Placek MM, Smielewski P, Nabbanja E, Czosnyka Z. CSF Dynamics for Shunt Prognostication and Revision in Normal Pressure Hydrocephalus. J Clin Med 2021; 10:jcm10081711. [PMID: 33921142 PMCID: PMC8071572 DOI: 10.3390/jcm10081711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the quantitative information derived from testing of the CSF circulation, there is still no consensus on what the best approach could be in defining criteria for shunting and predicting response to CSF diversion in normal pressure hydrocephalus (NPH). OBJECTIVE We aimed to review the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We have focused on reporting the objective perspective of CSF dynamics testing, without further inferences to individual patient management. DISCUSSION No single parameter from the CSF infusion study has so far been able to serve as an unquestionable outcome predictor. Resistance to CSF outflow (Rout) is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. Testing of CSF dynamics provides information on hydrodynamic properties of the cerebrospinal compartment: the system which is being modified by a shunt. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the relationship between CSF circulation testing and clinical improvement. CONCLUSIONS Despite many open questions and limitations, testing of CSF dynamics provides unique perspectives for the clinician. We have found value in understanding shunt function and potentially shunt response through shunt testing in vivo. In the absence of infusion tests, further methods that provide a clear description of the pre and post-shunting CSF circulation, and potentially cerebral blood flow, should be developed and adapted to the bed-space.
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Affiliation(s)
- Afroditi Despina Lalou
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Correspondence: ; Tel.: +44-774-3567-585
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Institute of Electronic Systems, Faculty of Electronics and Information Sciences, Warsaw University of Technology, 00-661 Warsaw, Poland
| | - Michal M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Eva Nabbanja
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
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MR Elastography demonstrates reduced white matter shear stiffness in early-onset hydrocephalus. NEUROIMAGE-CLINICAL 2021; 30:102579. [PMID: 33631603 PMCID: PMC7905205 DOI: 10.1016/j.nicl.2021.102579] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/08/2020] [Accepted: 01/21/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Hydrocephalus that develops early in life is often accompanied by developmental delays, headaches and other neurological deficits, which may be associated with changes in brain shear stiffness. However, noninvasive approaches to measuring stiffness are limited. Magnetic Resonance Elastography (MRE) of the brain is a relatively new noninvasive imaging method that provides quantitative measures of brain tissue stiffness. Herein, we aimed to use MRE to assess brain stiffness in hydrocephalus patients compared to healthy controls, and to assess its associations with ventricular size, as well as demographic, shunt-related and clinical outcome measures. METHODS MRE was collected at two imaging sites in 39 hydrocephalus patients and 33 healthy controls, along with demographic, shunt-related, and clinical outcome measures including headache and quality of life indices. Brain stiffness was quantified for whole brain, global white matter (WM), and lobar WM stiffness. Group differences in brain stiffness between patients and controls were compared using two-sample t-tests and multivariable linear regression to adjust for age, sex, and ventricular volume. Among patients, multivariable linear or logistic regression was used to assess which factors (age, sex, ventricular volume, age at first shunt, number of shunt revisions) were associated with brain stiffness and whether brain stiffness predicts clinical outcomes (quality of life, headache and depression). RESULTS Brain stiffness was significantly reduced in patients compared to controls, both unadjusted (p ≤ 0.002) and adjusted (p ≤ 0.03) for covariates. Among hydrocephalic patients, lower stiffness was associated with older age in temporal and parietal WM and whole brain (WB) (beta (SE): -7.6 (2.5), p = 0.004; -9.5 (2.2), p = 0.0002; -3.7 (1.8), p = 0.046), being female in global and frontal WM and WB (beta (SE): -75.6 (25.5), p = 0.01; -66.0 (32.4), p = 0.05; -73.2 (25.3), p = 0.01), larger ventricular volume in global, and occipital WM (beta (SE): -11.5 (3.4), p = 0.002; -18.9 (5.4), p = 0.0014). Lower brain stiffness also predicted worse quality of life and a higher likelihood of depression, controlling for all other factors. CONCLUSIONS Brain stiffness is reduced in hydrocephalus patients compared to healthy controls, and is associated with clinically-relevant functional outcome measures. MRE may emerge as a clinically-relevant biomarker to assess the neuropathological effects of hydrocephalus and shunting, and may be useful in evaluating the effects of therapeutic alternatives, or as a supplement, of shunting.
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Laviv Y, Nimni M, Ben Shalom N, Eisen A, Vaknin-Assa H, Harnof S. Acute Presentation of Normal Pressure Hydrocephalus After Transcatheter Aortic Valve Implantation: A Novel Interaction Between the First and Third Circulations. World Neurosurg 2020; 146:e731-e738. [PMID: 33181380 DOI: 10.1016/j.wneu.2020.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) negatively affects gait and cognition abilities and urine continence in the elderly. It is associated with systemic hypertension, although the exact pathophysiology is still unknown. A correlation to increased intracranial pulsatility and decreased compliance was suggested. Transcatheter aortic valve implantation (TAVI) is increasingly used in the treatment of severe AS. New-onset systemic hypertension affects some patients after TAVI. OBJECTIVE To identify any association between aortic valve replacement and the development of NPH. METHODS A cohort was created retrospectively of all patients who were evaluated for NPH with cerebrospinal fluid (CSF) tap test at a single institute during 2014-2019. Patients were reviewed for a past medical history of aortic valvular disease or aortic valve replacement. RESULTS A total of 242 patients underwent evaluations for NPH. Of these patients, 133 were considered to have iNPH. Six patients underwent aortic valve replacement before the initial symptoms of NPH: 1 surgical and 5 TAVI. The time from aortic valve replacement to the initial NPH symptoms was <6 months in 3 patients (as low as 1 month in 2 of them). Two patients had functional improvement after CSF tap test and proceeded to receive a shunt, 4 and 6 months after TAVI, respectively. Two patients developed hypertension after TAVI. Pulse pressure increased by >10 mm Hg in 3 patients after TAVI. CONCLUSIONS This is the first case series of symptomatic NPH after TAVI. In this unique subgroup, NPH symptoms can develop rapidly. Post-TAVI iNPH represents a novel interaction between the blood and CSF circulations.
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Affiliation(s)
- Yosef Laviv
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel.
| | - Mor Nimni
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Nati Ben Shalom
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Alon Eisen
- Department of Cardiology, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Hana Vaknin-Assa
- Department of Cardiology, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Sagie Harnof
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
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Eide PK, Pripp AH, Ringstad G. Magnetic resonance imaging biomarkers of cerebrospinal fluid tracer dynamics in idiopathic normal pressure hydrocephalus. Brain Commun 2020; 2:fcaa187. [PMID: 33381757 PMCID: PMC7753057 DOI: 10.1093/braincomms/fcaa187] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/09/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
Abstract
Disturbed clearance of toxic metabolites from the brain via cerebrospinal fluid is emerging as an important mechanism behind dementia and neurodegeneration. To this end, magnetic resonance imaging work-up of dementia diseases is largely focused on anatomical derangements of the brain. This study explores magnetic resonance imaging biomarkers of cerebrospinal fluid tracer dynamics in patients with the dementia subtype idiopathic normal pressure hydrocephalus and a cohort of reference subjects. All study participants underwent multi-phase magnetic resonance imaging up to 48 h after intrathecal administration of the contrast agent gadobutrol (0.5 ml, 1 mmol/ml), serving as cerebrospinal fluid tracer. Imaging biomarkers of cerebrospinal fluid tracer dynamics (i.e. ventricular reflux grades 0–4 and clearance) were compared with anatomical magnetic resonance imaging biomarkers of cerebrospinal fluid space anatomy (Evans’ index, callosal angle and disproportional enlargement of subarachnoid spaces hydrocephalus) and neurodegeneration (Schelten’s medial temporal atrophy scores, Fazeka’s scores and entorhinal cortex thickness). The imaging scores were also related to a pulsatile intracranial pressure score indicative of intracranial compliance. In shunt-responsive idiopathic normal pressure hydrocephalus, the imaging biomarkers demonstrated significantly altered cerebrospinal fluid tracer dynamics (ventricular reflux grades 3–4 and reduced clearance of tracer), deranged cerebrospinal fluid space anatomy and pronounced neurodegeneration. The altered MRI biomarkers were accompanied by pressure indices of impaired intracranial compliance. In conclusion, we present novel magnetic resonance imaging biomarkers characterizing idiopathic normal pressure hydrocephalus pathophysiology, namely measures of cerebrospinal fluid molecular redistribution and clearance, which add information to traditional imaging scores of cerebrospinal fluid space anatomy and neurodegeneration.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Are H Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Geir Ringstad
- Department of Radiology, Oslo University Hospital- Rikshospitalet, Oslo, Norway
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Apura J, Tiago J, Bugalho de Moura A, Lourenço JA, Sequeira A. The effect of ventricular volume increase in the amplitude of intracranial pressure. Comput Methods Biomech Biomed Engin 2019; 22:889-900. [PMID: 30931613 DOI: 10.1080/10255842.2019.1587413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We study the impact of vascular pulse in the cerebrospinal fluid (CSF) pressure measured on the lateral cerebral ventricles, as well as its sensitivity with respect to ventricular volume change. Recent studies have addressed the importance of the compliance capacity in the brain and its relation to arterial pulse abortion in communicating hydrocephalus. Nevertheless, this mechanism is not fully understood. We propose a fluid-structure interaction (FSI) model on a 3 D idealized geometry based on realistic physiological and morphological parameters. The computational model describes the pulsatile deformation of the third ventricle due to arterial pulse and the resulting CSF dynamics inside brain pathways. The results show that when the volume of lateral ventricles increases up to 3.5 times, the amplitudes of both average and maximum pressure values, computed on the lateral ventricles surface, substantially decrease. This indicates that the lateral ventricles expansion leads to a dumping effect on the pressure exerted on the walls of the ventricles. These results strengthen the possibility that communicant hydrocephalus may, in fact, be a natural response to reduce abnormal high intracranial pressure (ICP) amplitude. This conclusion is in accordance with recent hypotheses suggesting that communicant hydrocephalus is related to a disequilibrium in brain compliance capacity.
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Affiliation(s)
- João Apura
- a Center for Computational and Stochastic Mathematics - CEMAT , Lisboa , Portugal
| | - Jorge Tiago
- a Center for Computational and Stochastic Mathematics - CEMAT , Lisboa , Portugal
| | - Alexandra Bugalho de Moura
- b Department of Mathematics and REM - CEMAPRE , ISEG - Lisbon School of Economics and Management, Universidade de Lisboa , Lisboa , Portugal
| | - José Artur Lourenço
- c Neurosurgery Department , Centro Hospitalar Universitrio do Algarve , Faro , Portugal
| | - Adélia Sequeira
- d Center for Computational and Stochastic Mathematics - CEMAT, Department of Mathematics, Instituto Superior Técnico , University of Lisbon , Lisboa , Portugal
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Sandvig A, Arnell K, Malm J, Eklund A, Koskinen LOD. Analysis of Codman microcerebrospinal fluid shunt. Brain Behav 2018; 8:e01002. [PMID: 30207083 PMCID: PMC6192409 DOI: 10.1002/brb3.1002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 03/18/2018] [Accepted: 04/15/2018] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Ventriculo-peritoneal cerebrospinal fluid (CSF) shunt is the most common method of treating pediatric hydrocephalus. The Codman microadjustable valve (CMAV) is a CSF shunt constructed for children. The objective of the study was (a) to analyze complications after insertion of a CMAV shunt in hydrocephalic children, (b) to analyze complications after replacing a CMAV by an adult-type Codman Hakim adjustable valve shunt (CHAV), and to (c) analyze the in vitro characteristics of the CMAV shunt and correlate the findings with the clinical performance of the shunt. METHODS A retrospective study analyzed a cohort of hydrocephalic children who had received a CMAV shunt and later replaced by a CHAV shunt. We report on the complications that resulted from replacing the CMAV with the CHAV. We tested six CMAV shunts with or without an antisiphon device (ASD) in which opening pressure, resistance, sensitivity to abdominal pressure, ASD position dependency, and function were determined. The test results were correlated with the clinical performance of the shunt in the retrospective study. RESULTS Thirty-seven children (19 boys, 18 girls) were identified. Within the first month after shunt placement, a total of 10 patients (27%) developed complications including infections, hygromas, and shunt dysfunction. Shunt survival varied from 1 week to 145 months. Over the 10-year follow-up period, 13 children had their shunts replaced, six of them with a CHAV without any further complications. A bench test of the CMAV was done to test whether the opening pressure was in agreement with the manufacturer's specifications. Our results were generally in agreement with specifications stated by the manufacturer. CONCLUSION Replacing a CMAV with a CHAV was well tolerated by the patients. Bench test results were generally in agreement with manufacturers specifications. Replacing a CMAV with a CHAV in pediatric hydrocephalus patients can be accomplished safely.
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Affiliation(s)
- Axel Sandvig
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University, Umeå, Sweden.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kai Arnell
- Department of Surgery, Umeå University, Umeå, Sweden
| | - Jan Malm
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Lars-Owe D Koskinen
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University, Umeå, Sweden
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Okon MD, Roberts CJ, Mahmoud AM, Springer AN, Small RH, McGregor JM, Katz SE. Characteristics of the cerebrospinal fluid pressure waveform and craniospinal compliance in idiopathic intracranial hypertension subjects. Fluids Barriers CNS 2018; 15:21. [PMID: 30064442 PMCID: PMC6069551 DOI: 10.1186/s12987-018-0106-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a condition of abnormally high intracranial pressure with an unknown etiology. The objective of this study is to characterize craniospinal compliance and measure the cerebrospinal fluid (CSF) pressure waveform as CSF is passively drained during a diagnostic and therapeutic lumbar puncture (LP) in IIH. METHODS Eighteen subjects who met the Modified Dandy Criteria, including papilledema and visual field loss, received an ultrasound guided LP where CSF pressure (CSFP) was recorded at each increment of CSF removal. Joinpoint regression models were used to calculate compliance from CSF pressure and the corresponding volume removed at each increment for each subject. Twelve subjects had their CSFP waveform recorded with an electronic transducer. Body mass index, mean CSFP, and cerebral perfusion pressure (CPP) were also calculated. T-tests were used to compare measurements, and correlations were performed between parameters. RESULTS Cerebrospinal fluid pressure, CSFP pulse amplitude (CPA), and CPP were found to be significantly different (p < 0.05) before and after the LP. CSFP and CPA decreased after the LP, while CPP increased. The craniospinal compliance significantly increased (p < 0.05) post-LP. CPA and CSFP were significantly positively correlated. CONCLUSIONS Both low craniospinal compliance (at high CSFP) and high craniospinal compliance (at low CSFP) regions were determined. The CSFP waveform morphology in IIH was characterized and CPA was found to be positively correlated to the magnitude of CSFP. Future studies will investigate how craniospinal compliance may correlate to symptoms and/or response to therapy in IIH subjects.
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Affiliation(s)
- Monica D Okon
- Department of Biomedical Engineering, The Ohio State University, 1080 Carmack Rd, Columbus, OH, 43210, USA
| | - Cynthia J Roberts
- Department of Biomedical Engineering, The Ohio State University, 1080 Carmack Rd, Columbus, OH, 43210, USA. .,Department of Ophthalmology & Visual Science, The Ohio State University, 915 Olentangy River Rd, Columbus, OH, 43212, USA.
| | - Ashraf M Mahmoud
- Department of Biomedical Engineering, The Ohio State University, 1080 Carmack Rd, Columbus, OH, 43210, USA.,Department of Ophthalmology & Visual Science, The Ohio State University, 915 Olentangy River Rd, Columbus, OH, 43212, USA
| | - Andrew N Springer
- Department of Anesthesiology, The Ohio State University, 410W. 10th Avenue, Columbus, OH, 43210, USA
| | - Robert H Small
- Department of Biomedical Engineering, The Ohio State University, 1080 Carmack Rd, Columbus, OH, 43210, USA.,Department of Anesthesiology, The Ohio State University, 410W. 10th Avenue, Columbus, OH, 43210, USA
| | - John M McGregor
- Department of Neurosurgery, The Ohio State University, 1581 Dodd Drive, Columbus, OH, 43210, USA
| | - Steven E Katz
- Ohio Neuro-Ophthalmology, Orbital Disease & Oculoplastics, 3545 Olentangy River Rd, Suite 200, Columbus, OH, 43214, USA
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Goffin C, Leonhardt S, Radermacher K. The Role of a Dynamic Craniospinal Compliance in NPH—A Review and Future Challenges. IEEE Rev Biomed Eng 2017; 10:310-322. [DOI: 10.1109/rbme.2016.2620493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Adams H, Ban VS, Leinonen V, Aoun SG, Huttunen J, Saavalainen T, Lindgren A, Frosen J, Fraunberg M, Koivisto T, Hernesniemi J, Welch BG, Jaaskelainen JE, Huttunen TJ. Risk of Shunting After Aneurysmal Subarachnoid Hemorrhage. Stroke 2016; 47:2488-96. [DOI: 10.1161/strokeaha.116.013739] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/05/2016] [Indexed: 01/30/2023]
Abstract
Background and Purpose—
Shunt dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequela that may lead to poor neurological outcome and predisposes to various interventions, admissions, and complications. We reviewed post-aSAH shunt dependency in a population-based sample and tested the feasibility of a clinical risk score to identify subgroups of aSAH patients with increasing risk of shunting for hydrocephalus.
Methods—
A total of 1533 aSAH patients from the population-based Eastern Finland Saccular Intracranial Aneurysm Database (Kuopio, Finland) were used in a recursive partitioning analysis to identify risk factors for shunting after aSAH. The risk model was built and internally validated in random split cohorts. External validation was conducted on 946 aSAH patients from the Southwestern Tertiary Aneurysm Registry (Dallas, TX) and tested using receiver-operating characteristic curves.
Results—
Of all patients alive ≥14 days, 17.7% required permanent cerebrospinal fluid diversion. The recursive partitioning analysis defined 6 groups with successively increased risk for shunting. These groups also successively risk stratified functional outcome at 12 months, shunt complications, and time-to-shunt rates. The area under the curve–receiver-operating characteristic curve for the exploratory sample and internal validation sample was 0.82 and 0.78, respectively, with an external validation of 0.68.
Conclusions—
Shunt dependency after aSAH is associated with higher morbidity and mortality, and prediction modeling of shunt dependency is feasible with clinically useful yields. It is important to identify and understand the factors that increase risk for shunting and to eliminate or mitigate the reversible factors. The aSAH-PARAS Consortium (Aneurysmal Subarachnoid Hemorrhage Patients’ Risk Assessment for Shunting) has been initiated to pool the collective insights and resources to address key questions in post-aSAH shunt dependency to inform future aSAH treatment guidelines.
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Affiliation(s)
- Hadie Adams
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Vin Shen Ban
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Ville Leinonen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Salah G. Aoun
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Jukka Huttunen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Taavi Saavalainen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Antti Lindgren
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Juhana Frosen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Mikael Fraunberg
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Timo Koivisto
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Juha Hernesniemi
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Babu G. Welch
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Juha E. Jaaskelainen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
| | - Terhi J. Huttunen
- From the Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Finland (H.A., V.L., J. Huttunen, T.S., A.L., J.F., M.F., T.K., J.E.J., T.J.H.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (V.S.B., S.G.A., B.G.W.); and Department of Neurosurgery, Helsinki University Hospital, Finland (J. Hernesniemi)
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Bradley WG. Intracranial Pressure versus Phase-Contrast MR Imaging for Normal Pressure Hydrocephalus. AJNR Am J Neuroradiol 2015; 36:1631-2. [PMID: 26251438 DOI: 10.3174/ajnr.a4507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- W G Bradley
- Department of Radiology University of California San Diego Health System San Diego, California
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