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Lumbar cerebrospinal fluid-to-brain extracellular fluid surrogacy is context-specific: insights from LeiCNS-PK3.0 simulations. J Pharmacokinet Pharmacodyn 2021; 48:725-741. [PMID: 34142308 PMCID: PMC8405486 DOI: 10.1007/s10928-021-09768-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/01/2021] [Indexed: 11/01/2022]
Abstract
Predicting brain pharmacokinetics is critical for central nervous system (CNS) drug development yet difficult due to ethical restrictions of human brain sampling. CNS pharmacokinetic (PK) profiles are often altered in CNS diseases due to disease-specific pathophysiology. We previously published a comprehensive CNS physiologically-based PK (PBPK) model that predicted the PK profiles of small drugs at brain and cerebrospinal fluid compartments. Here, we improved this model with brain non-specific binding and pH effect on drug ionization and passive transport. We refer to this improved model as Leiden CNS PBPK predictor V3.0 (LeiCNS-PK3.0). LeiCNS-PK3.0 predicted the unbound drug concentrations of brain ECF and CSF compartments in rats and humans with less than two-fold error. We then applied LeiCNS-PK3.0 to study the effect of altered cerebrospinal fluid (CSF) dynamics, CSF volume and flow, on brain extracellular fluid (ECF) pharmacokinetics. The effect of altered CSF dynamics was simulated using LeiCNS-PK3.0 for six drugs and the resulting drug exposure at brain ECF and lumbar CSF were compared. Simulation results showed that altered CSF dynamics changed the CSF PK profiles, but not the brain ECF profiles, irrespective of the drug's physicochemical properties. Our analysis supports the notion that lumbar CSF drug concentration is not an accurate surrogate of brain ECF, particularly in CNS diseases. Systems approaches account for multiple levels of CNS complexity and are better suited to predict brain PK.
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Morphology of the Vascular Bodies of the Encephalon’s Ventricles of Cow (Bos Taurus Taurus). MACEDONIAN VETERINARY REVIEW 2020. [DOI: 10.2478/macvetrev-2020-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The aim of the research was to establish the morphology of the vascular bodies of the encephalon ventricles of cow (Bos taurus taurus). Methods used: thin anatomical preparation, histological method of examination, transmission electron microscopy. Given the relationship, structure and general origin of the vascular bodies, they were divided into bodies III, IV and the lateral ventricles of the encephalon. This unit has topographical nature. Functionally, vascular bodies are an indivisible organ whose main function is the secretion of the cerebrospinal fluid, which maintains the constancy of the central nervous system internal environment. Three types of capillaries, differing in their morphology, were found in the composition of the vascular bodies’ villi in Bos taurus taurus.
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Abstract
Flow compensation, a gradient pulse used for artifact reduction, often used to suppress cerebrospinal fluid (CSF) flow artifacts in spinal magnetic resonance imaging (MRI), can be switched off to make the CSF flow voids within syrinx (syringomyelia) and within aqueduct [normal pressure hydrocephalus (NPH)] more obvious (thus confirming CSF flow). It is a simple method which does not require much time or expertise.
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Affiliation(s)
- Anitha Sen
- Government Medical College, Kottayam, Kerala, India
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Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus. J Clin Neurosci 2012; 19:1107-11. [DOI: 10.1016/j.jocn.2011.11.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 11/15/2011] [Accepted: 11/16/2011] [Indexed: 11/23/2022]
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Tarnaris A, Toma AK, Kitchen ND, Watkins LD. Ongoing search for diagnostic biomarkers in idiopathic normal pressure hydrocephalus. Biomark Med 2009; 3:787-805. [DOI: 10.2217/bmm.09.37] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus is a syndrome, which typically has a clinical presentation of gait/balance disturbance, often accompanied by cognitive decline and/or urinary incontinence. Its diagnosis is based on relevant history and clinical examination, appropriate imaging findings and physiological testing. The clinical picture of idiopathic normal pressure hydrocephalus may occasionally be difficult to distinguish from that of Alzheimer’s dementia, subcortical ischemic vascular dementia and Parkinson’s disease. The aim of this article is to systematically review the literature from the last 29 years in order to identify cerebrospinal fluid (CSF) or imaging biomarkers that may aid in the diagnosis of the syndrome. The authors concluded that no CSF or imaging biomarker is currently fulfilling the criteria required to aid in the diagnosis of the condition. However, a few studies have revealed promising CSF and imaging markers that need to be verified by independent groups. The reasons that the progress in this field has been slow so far is also commented on, as well as steps required to apply the current evidence in the design of future studies within the field.
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Affiliation(s)
- Andrew Tarnaris
- Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, Box 32, Queen Square, London, WC1N 3BG, UK
| | - Ahmed K Toma
- Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, Box 32, Queen Square, London, WC1N 3BG, UK
| | - Neil D Kitchen
- Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, Box 32, Queen Square, London, WC1N 3BG, UK
| | - Laurence D Watkins
- Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, Box 32, Queen Square, London, WC1N 3BG, UK
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Tarnaris A, Kitchen ND, Watkins LD. Noninvasive biomarkers in normal pressure hydrocephalus: evidence for the role of neuroimaging. J Neurosurg 2009; 110:837-51. [DOI: 10.3171/2007.9.17572] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Object
Normal pressure hydrocephalus (NPH) represents a treatable form of dementia. Recent estimates of the incidence of this condition are in the region of 5% of patients with dementia. The symptoms of NPH can vary among individuals and may be confused with those of patients with multi-infarct dementia, dementia of the Alzheimer type, or even Parkinson disease. Traditionally the diagnosis of NPH could only be confirmed postoperatively by a favorable outcome to surgical diversion of CSF. The object of this literature review was to examine the role of structural and functional imaging in providing biomarkers of favorable surgical outcome.
Methods
A Medline search was undertaken for the years 1980–2006, using the following terms: normal pressure hydrocephalus, adult hydrocephalus, chronic hydrocephalus, imaging, neuroimaging, imaging studies, outcomes, surgical outcomes, prognosis, prognostic value, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy.
Results
The query revealed 16 studies that correlated imaging with surgical outcomes offering accuracy results. Three studies fulfilled the statistical criteria of a biomarker. A dementia Alzheimer-type pattern on SPECT in patients with idiopathic NPH, the presence of CSF flow void on MR imaging, and the N-acetylaspartate/choline ratio in patients with the secondary form are able to predict surgical outcomes with high accuracy.
Conclusions
There is at present Level A evidence for using MR spectroscopy in patients with secondary NPH, and Level B evidence for using SPECT and phase-contrast MR imaging to select patients with idiopathic NPH for shunt placement. The studies, however, need to be repeated by other groups. The current work should act as a platform to design further studies with larger sample sizes.
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Governale LS, Fein N, Logsdon J, Black PM. TECHNIQUES AND COMPLICATIONS OF EXTERNAL LUMBAR DRAINAGE FOR NORMAL PRESSURE HYDROCEPHALUS. Oper Neurosurg (Hagerstown) 2008; 63:379-84; discussion 384. [DOI: 10.1227/01.neu.0000327023.18220.88] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ishikawa M, Hashimoto M, Kuwana N, Mori E, Miyake H, Wachi A, Takeuchi T, Kazui H, Koyama H. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 2008; 48 Suppl:S1-23. [PMID: 18408356 DOI: 10.2176/nmc.48.s1] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
With the rapid aging of Japanese society, medical care of the elderly has become an important social issue. Among various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, normal pressure hydrocephalus (NPH), especially of idiopathic type (iNPH), is becoming noteworthy. The Guidelines for management of iNPH in Japan are created in compliance with the evidence-based medicine methods and published in 2004. This English version is made to show the diagnosis and treatment of iNPH with reference to the socio-medical background in Japan and to promote the international research on iNPH. They propose three diagnostic levels; possible, probable, and definite. They indicate the diagnostic importance of high convexity tightness and dilated sylvian fissure with mild to moderate ventriculomegaly on coronal magnetic resonance imaging. The cerebrospinal fluid tap test is regarded as an important diagnostic test because of its simplicity to perform and high predictability of the shunt efficacy. The use of programmable valves at shunt surgeries is recommended. Flowcharts for diagnosis, preoperative assessment, and prevention for complications of shunt surgery are made to promote a wide use of them.
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Kubo Y, Kazui H, Yoshida T, Kito Y, Kimura N, Tokunaga H, Ogino A, Miyake H, Ishikawa M, Takeda M. Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus. Dement Geriatr Cogn Disord 2008; 25:37-45. [PMID: 18025828 DOI: 10.1159/000111149] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS We developed an idiopathic normal-pressure hydrocephalus grading scale (iNPHGS) to classify a triad of disorders (cognitive impairment, gait disturbance and urinary disturbance) of iNPH with a wide range of severity. The purpose of this study was to assess the reliability and validity of this scale in 38 patients with iNPH. RESULTS The interrater reliability of this scale was high. The iNPHGS cognitive domain score significantly correlated with the cognitive test scores, including the Mini-Mental State Examination (MMSE), the gait domain score with the Up and Go Test and Gait Status Scale scores, and the urinary domain score with the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score. The MMSE, Gait Status Scale and ICIQ-SF scores significantly improved in patients whose iNPHGS scores improved after CSF tapping but not in those whose iNPHGS scores did not improve after CSF tapping. Fourteen of the 38 patients received shunt operations. In these 14 patients, changes in the iNPHGS cognitive and urinary domains after CSF tapping were significantly associated with the changes after the shunt operation.
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Affiliation(s)
- Yoshihiko Kubo
- Psychiatry and Behavioral Science, Osaka University Graduate School of Medicine, Osaka, Japan.
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Krauss JK, von Stuckrad‐Barre SF. Clinical aspects and biology of normal pressure hydrocephalus. ACTA ACUST UNITED AC 2008; 89:887-902. [DOI: 10.1016/s0072-9752(07)01278-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Abstract
Doctors find the management of normal pressure hydrocephalus (NPH) difficult because their diagnosis often is uncertain and the treatment with shunt surgery carries a significant risk. With the aim of bringing to the attention of physicians the useful, but largely anecdotal, information available regarding this problem, this article discusses the epidemiology, reasons why the diagnosis is difficult, differential diagnosis, features of the history, examination, neuropsychologic assessment, radiologic evaluation, and special tests that may help clinicians with management.
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Bateman GA, Levi CR, Schofield P, Wang Y, Lovett EC. The pathophysiology of the aqueduct stroke volume in normal pressure hydrocephalus: can co-morbidity with other forms of dementia be excluded? Neuroradiology 2005; 47:741-8. [PMID: 16021440 DOI: 10.1007/s00234-005-1418-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2004] [Accepted: 05/03/2005] [Indexed: 01/18/2023]
Abstract
Variable results are obtained from the treatment of normal pressure hydrocephalus (NPH) by shunt insertion. There is a high correlation between NPH and the pathology of Alzheimer's disease (AD) on brain biopsy. There is an overlap between AD and vascular dementia (VaD), suggesting that a correlation exists between NPH and other forms of dementia. This study seeks to (1) understand the physiological factors behind, and (2) define the ability of, the aqueduct stroke volume to exclude dementia co-morbidity. Twenty-four patients from a dementia clinic were classified as having either early AD or VaD on the basis of clinical features, Hachinski score and neuropsychological testing. They were compared with 16 subjects with classical clinical findings of NPH and 12 aged-matched non-cognitively impaired subjects. MRI flow quantification was used to measure aqueduct stroke volume and arterial pulse volume. An arterio-cerebral compliance ratio was calculated from the two volumes in each patient. The aqueduct stroke volume was elevated in all three forms of dementia, with no significant difference noted between the groups. The arterial pulse volume was elevated by 24% in VaD and reduced by 35% in NPH, compared to normal (P = 0.05 and P = 0.002, respectively), and was normal in AD. There was a spectrum of relative compliance with normal compliance in VaD and reduced compliance in AD and NPH. The aqueduct stroke volume depends on the arterial pulse volume and the relative compliance between the arterial tree and brain. The aqueduct stroke volume cannot exclude significant co-morbidity in NPH.
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Affiliation(s)
- Grant A Bateman
- Department of Medical Imaging, John Hunter Hospital, Locked Bag 1, Newcastle Region Mail Centre, Newcastle, 2310, Australia.
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Tisell M, Tullberg M, Månsson JE, Fredman P, Blennow K, Wikkelsø C. Differences in cerebrospinal fluid dynamics do not affect the levels of biochemical markers in ventricular CSF from patients with aqueductal stenosis and idiopathic normal pressure hydrocephalus. Eur J Neurol 2004; 11:17-23. [PMID: 14692883 DOI: 10.1046/j.1351-5101.2003.00698.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
To compare levels of biochemical markers in ventricular cerebrospinal fluid (vCSF) between patients with aqueductal stenosis (AS) and idiopathic normal pressure hydrocephalus (INPH) and relate these results to clinical outcome after surgery. Neurofilament light protein, tau protein, sulfatide, vasoactive intestinal peptide (VIP), neuropeptide PYY (NPY) and CSF/serum albumin ratio were measured in vCSF from 18 consecutive AS and 19 consecutive INPH patients. Clinical outcome was evaluated after surgery by standardized indices. The levels of markers were related to clinical outcome. No differences in any of the markers were found between AS and INPH patients. The concentration of sulfatide and albumin ratio correlated inversely with psychometric improvement, whilst VIP and NPY correlated inversely with improvement in alertness. The similar levels of biochemical markers in vCSF from AS and INPH patients indicate similarities in pathophysiology and turnover rate of vCSF despite differences in CSF dynamics. High albumin ratio and sulfatide concentrations in vCSF in hydrocephalus patients have negative implications for surgical outcome and might indicate concomitant cerebrovascular disorder.
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Affiliation(s)
- M Tisell
- Institute of Clinical Neuroscience, Sahlgrenska University Hospital, Göteborg University, Göteborg, Sweden.
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Tisell M, Tullberg M, Hellström P, Blomsterwall E, Wikkelsø C. Neurological symptoms and signs in adult aqueductal stenosis. Acta Neurol Scand 2003; 107:311-7. [PMID: 12713521 DOI: 10.1034/j.1600-0404.2003.00124.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To comprehensively describe and compare prospectively (pre/postoperatively) the symptomatology in aqueductal stenosis (AS) vs idiopathic normal pressure hydrocephalus (INPH). METHODS Twenty-seven patients with AS and 39 patients with INPH were consecutively included. Postural functions, gait, wakefulness, cognitive functions, urinary continence and headache were examined before and 3 months after treatment with shunt operation or endoscopic ventriculostomy. RESULTS The AS patients had better postural functions, walked faster, performed better cognitively and had a higher wakefulness than INPH patients, but these differences were explained by age differences between groups. The frequency of incontinence was similar in the two patients groups. Headache occurred more frequently in AS, but independently of the other symptoms. Most symptoms and signs improved after surgery. CONCLUSION Patients with AS had a higher frequency of headaches than INPH patients, but otherwise the symptomology of the two groups was not found to differ after correcting for age differences.
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Affiliation(s)
- M Tisell
- Institute of Clinical Neuroscience, Hydrocephalus Research Unit, Sahlgrenska University Hospital, Göteborg University, Sweden.
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Bret P, Guyotat J, Chazal J. Is normal pressure hydrocephalus a valid concept in 2002? A reappraisal in five questions and proposal for a new designation of the syndrome as "chronic hydrocephalus". J Neurol Neurosurg Psychiatry 2002; 73:9-12. [PMID: 12082037 PMCID: PMC1757288 DOI: 10.1136/jnnp.73.1.9] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The authors question the current validity of the traditional concept of normal pressure hydrocephalus (NPH) as it was described by Adams and Hakim in 1965. The classic features of the disease are addressed. It is concluded that most of the historical statements made three decades ago need to be revised. Especially, the term "normal pressure" hydrocephalus probably does not match the actual manometric profile of patients with NPH. Similarly, the terms"curable"and "reversible" dementia are inadequate to designate the mental alterations of NPH. That NPH is non-specific to the adult population is also stressed, since it may be not uncommonly encountered in paediatrics, especially in an implanted shunt malfunction. The term "chronic hydrocephalus" without reference to cerebrospinal fluid pressure and to the age of the patient is proposed instead of NPH, which seems out of step with current knowledge of the pressure profile and with the diagnosis and decision making context in patients with so called NPH.
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Affiliation(s)
- P Bret
- Service de Neurochirurgie B, Hôpital Neurologique et Neurochirurgical Pierre Wertheimer, 59 boulevard Pinel, CHU de Lyon, 69394 Lyon Cédex 3, France.
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Henry-Feugeas MC, Idy-Peretti I, Baledent O, Cornu P, Lejay H, Bittoun J, Schouman-Claeys AE. Cerebrospinal fluid flow waveforms: MR analysis in chronic adult hydrocephalus. Invest Radiol 2001; 36:146-54. [PMID: 11228578 DOI: 10.1097/00004424-200103000-00003] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Henry-Feugeas MC, Idy-Peretti I, Baledent O, et al. Cerebrospinal fluid flow waveforms: MR analysis in chronic adult hydrocephalus. Invest Radiol 2001;36:146-154. RATIONALE AND OBJECTIVES To analyze changes in cerebrospinal fluid (CSF) hydrodynamics in chronic adult hydrocephalus. METHODS Phase-contrast cine-MR acquisitions were used to explore the ventricular system and the upper ventral cervical spaces of 16 patients. The aqueductal jet was explored in 32 control subjects. RESULTS The duration of pulsatile caudal CSF flow (ie, CSF systole) was abnormally short in patients with active idiopathic and obstructive hydrocephalus. The duration of CSF cervical systole was normal in patients with stable hydrocephalus. The aqueductal stroke volume could be increased in stable communicating hydrocephalus. Patients who responded to shunting had shortened CSF systoles and hyperpulsatile ventricular patterns. Successful CSF diversion resulted in longer CSF systoles and CSF ventricular patterns that were no longer hyperpulsatile. CONCLUSIONS Magnetic resonance analysis of CSF flow can show craniospinal dissociation and limitation of CSF outflow from the ventricles in both obstructive and communicating hydrocephalus; it should help determine the response to shunting in communicating hydrocephalus.
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Affiliation(s)
- M C Henry-Feugeas
- Laboratoire d'Imagerie Médicale Paris Nord Jeune Equipe 2156, Université Paris VII-Denis Diderot-Faculté de Médecine Xavier Bichat, and Service de Radiologie, Groupe Hospitalier Bichat Claude Bernard, Paris, France
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Stolze H, Kuhtz-Buschbeck JP, Drücke H, Jöhnk K, Diercks C, Palmié S, Mehdorn HM, Illert M, Deuschl G. Gait analysis in idiopathic normal pressure hydrocephalus--which parameters respond to the CSF tap test? Clin Neurophysiol 2000; 111:1678-86. [PMID: 10964082 DOI: 10.1016/s1388-2457(00)00362-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Normal pressure hydrocephalus (NPH) is an often underestimated cause of hypokinetic gait disorders in the elderly. Diagnosing NPH is a complex problem, since many symptoms overlap with other neurological diseases. The purpose of the present study was to characterize the gait pattern in NPH quantitatively. Additionally, we analyzed the improvement of gait parameters following tapping of cerebrospinal fluid (CSF). METHODS Gait analysis was performed in 10 patients and 12 age-matched healthy controls during overground and treadmill locomotion. RESULTS Compared to healthy controls, patients with NPH walked significantly slower, with shorter and more variable strides and a somewhat lower cadence. The feet were not lifted to a normal height and the dorsal extension of the forefoot prior to heel-strike was insufficient. Balance-related gait parameters such as step width and the foot rotation angles were significantly increased in NPH, while their variability was lower. Only some gait parameters improved after tapping 30 ml CSF. Gait velocity increased by about 23% due to an increased stride length, while the cadence remained unchanged. Balance-related gait parameters and the foot-to-floor clearance during swing were not affected by the treatment. CONCLUSIONS In conclusion, we found a triad of decreased stride length, decreased foot-to-floor clearance and a broad-based gait to be the typical features of the gait abnormality in NPH. Only the stride length improved following a diagnostic spinal tap. These results may help to more reliably diagnose the condition of NPH in a routine clinical setting.
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Affiliation(s)
- H Stolze
- Department of Neurology, Christian-Albrechts-Universität zu Kiel, Niemannsweg 147, D-24105, Kiel, Germany.
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MR-tomographische Liquorflußmessungen im Aquädukt. Clin Neuroradiol 1999. [DOI: 10.1007/bf03043335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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