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Gencer AH, Schwarm FP, Nagl J, Uhl E, Kolodziej MA. The benefits of ventriculoperitoneal shunting in normal pressure hydrocephalus patients-a follow-up of three years. Acta Neurochir (Wien) 2024; 166:372. [PMID: 39289252 PMCID: PMC11408546 DOI: 10.1007/s00701-024-06263-z] [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: 02/22/2024] [Accepted: 09/03/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE The ventriculoperitoneal shunt (VPS) is an established approach in treating normal pressure hydrocephalus (NPH). This study aims to examine the long-term effects of VPS regarding clinical and radiological outcomes, to explore interdependencies with comorbidities and medication, and to determine a suitable opening pressure of the programmable valve. METHODS 127 patients with VPS were retrospectively evaluated. The Hakim triad along with Evans index (EI) and callosal angle (CA) were examined preoperatively and postoperatively at various time points up to over thirty-six months. Preexisting comorbidities and medication were considered. Adjustments to valve settings were documented along with symptom development and complications. Wilcoxon and paired-sample t-tests were used to analyze postoperative change. Chi-square, Eta-squared, and Pearson coefficients were used in correlation analyses. RESULTS Relief from individual symptoms was most prominent within the first 6 months (p < 0.01). EI and CA significantly decreased and increased, respectively (p < 0.05). Postoperative clinical and radiological improvement was largely maintained over the follow-up period. Diabetes mellitus and apoplexy correlated with surgical outcomes (p < 0.05). The median opening pressure as a function of overall symptom management was determined to be 120 mmH2O for women and 140 mmH2O for men. CONCLUSION VPS is effective in treating NPH with respect to both clinical and radiological outcomes, although these two components are independent of each other. Improvement is most pronounced in short-term and maintained in the long-term. Comorbidities have significant influence on the course of NPH. The valve setting does not forecast change in radiological findings; consequently, priority should be placed on the patient's clinical condition.
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Affiliation(s)
- Aylin H Gencer
- Department of Neurosurgery, Justus-Liebig-University, Klinikstraße 33, 35392, Gießen, Germany.
- Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Frank P Schwarm
- Department of Neurosurgery, Justus-Liebig-University, Klinikstraße 33, 35392, Gießen, Germany
| | - Jasmin Nagl
- Department of Neurosurgery, Justus-Liebig-University, Klinikstraße 33, 35392, Gießen, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University, Klinikstraße 33, 35392, Gießen, Germany
| | - Malgorzata A Kolodziej
- Department of Neurosurgery, Justus-Liebig-University, Klinikstraße 33, 35392, Gießen, Germany
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Casimiro Reis R, Harumi Gobbato Yamashita R, Fontoura Solla DJ, Fajardo Ramin L, de Andrade Lourenção Freddi T, Jacobsen Teixeira M, Campos Gomes Pinto F. Changes in Callosal Angle and Evans Index After Shunt Surgery in Patients with Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2024:S1878-8750(24)01330-5. [PMID: 39098500 DOI: 10.1016/j.wneu.2024.07.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVE Idiopathic normal pressure hydrocephalus (iNPH) is a disease characterized by gait disturbance, cognitive impairment, and urinary incontinence. For those patients who do not respond to shunt surgery, it lacks objective radiologic findings for the diagnosis of shunt malfunction. Here we aimed to evaluate whether the Evans index and callosal angle change during a prospective long-term follow-up of patients with iNPH submitted to shunt surgery. METHODS Clinical (NPH Japanese Scale) and radiologic (Evans index and callosal angle) data were collected pre- and postoperatively (3, 6, 12 and months) in 19 patients with iNPH. Imaging tests were evaluated by the same neuroradiologist during the follow-up. RESULTS Patients had lower scores on the NPH Japanese Scale over time (P < 0.001). There was no significant difference among Evans index values during the follow-up (P = 0.24). Preoperative average callosal angle was 72 ± 15, which increased to 91 ± 18 in 6 months (P = 0.003). CONCLUSIONS In this sample, patients with iNPH submitted to a programmable valve shunt had an increase in callosal angle concomitant to neurologic improvement. The Evans index did not change during follow-up.
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Affiliation(s)
- Rodolfo Casimiro Reis
- Department of Neurosurgery, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
| | | | | | - Laís Fajardo Ramin
- Neuroradiology Section, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
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Andrén K, Wikkelsø C, Laurell K, Kollén L, Hellström P, Tullberg M. Symptoms and signs did not predict outcome after surgery: a prospective study of 143 patients with idiopathic normal pressure hydrocephalus. J Neurol 2024; 271:3215-3226. [PMID: 38438818 PMCID: PMC11136756 DOI: 10.1007/s00415-024-12248-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/14/2024] [Accepted: 02/07/2024] [Indexed: 03/06/2024]
Abstract
OBJECTIVE To determine the utility of symptoms, signs, comorbidities and background variables for the prediction of outcome of treatment in iNPH. METHODS A prospective observational study of consecutively included iNPH patients, who underwent neurological, physiotherapeutic and neuropsychological assessments before and after shunt surgery. The primary outcome measure was the total change on the iNPH scale, and patients were defined as improved postoperatively if they had improved by at least five points on that scale. RESULTS 143 iNPH patients were included, and 73% of those were improved after surgery. None of the examined symptoms or signs could predict which patients would improve after shunt surgery. A dominant subjective complaint of memory problems at baseline was predictive of non-improvement. The reported comorbidities, duration of symptoms and BMI were the same in improved and non-improved patients. Each of the symptom domains (gait, neuropsychology, balance, and continence) as well as the total iNPH scale score improved significantly (from median 53 to 69, p < 0.001). The proportions of patients with shuffling gait, broad-based gait, paratonic rigidity and retropulsion all decreased significantly. DISCUSSION This study confirms that the recorded clinical signs, symptoms, and impairments in the adopted clinical tests are characteristic findings in iNPH, based on that most of them improved after shunt surgery. However, our clinical data did not enable predictions of whether patients would respond to shunt surgery, indicating that the phenotype is unrelated to the reversibility of the iNPH state and should mainly support diagnosis. Absence of specific signs should not be used to exclude patients from treatment.
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Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Laurell
- Department of Biomedical and Clinical Sciences, Neurobiology, Linköping University, Linköping, Sweden
| | - Lena Kollén
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Rao D, Yang L, Enxi X, Siyuan L, Yu Q, Zheng L, Zhou Z, Yerong C, Bo C, Xiuhong S, Eryi S. A predictive model in patients with chronic hydrocephalus following aneurysmal subarachnoid hemorrhage: a retrospective cohort study. Front Neurol 2024; 15:1366306. [PMID: 38817542 PMCID: PMC11137279 DOI: 10.3389/fneur.2024.1366306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/07/2024] [Indexed: 06/01/2024] Open
Abstract
Objective Our aim was to develop a nomogram that integrates clinical and radiological data obtained from computed tomography (CT) scans, enabling the prediction of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH). Method A total of 318 patients diagnosed with subarachnoid hemorrhage (SAH) and admitted to the Department of Neurosurgery at the Affiliated People's Hospital of Jiangsu University between January 2020 and December 2022 were enrolled in our study. We collected clinical characteristics from the hospital's medical record system. To identify risk factors associated with chronic hydrocephalus, we conducted both univariate and LASSO regression models on these clinical characteristics and radiological features, accompanied with penalty parameter adjustments conducted through tenfold cross-validation. All features were then incorporated into multivariate logistic regression analyses. Based on these findings, we developed a clinical-radiological nomogram. To evaluate its discrimination performance, we conducted Receiver Operating Characteristic (ROC) curve analysis and calculated the Area Under the Curve (AUC). Additionally, we employed calibration curves, and utilized Brier scores as an indicator of concordance. Additionally, Decision Curve Analysis (DCA) was performed to determine the clinical utility of our models by estimating net benefits at various threshold probabilities for both training and testing groups. Results The study included 181 patients, with a determined chronic hydrocephalus prevalence of 17.7%. Univariate logistic regression analysis identified 11 potential risk factors, while LASSO regression identified 7 significant risk factors associated with chronic hydrocephalus. Multivariate logistic regression analysis revealed three independent predictors for chronic hydrocephalus following aSAH: Periventricular white matter changes, External lumbar drainage, and Modified Fisher Grade. A nomogram incorporating these factors accurately predicted the risk of chronic hydrocephalus in both the training and testing cohorts. The AUC values were calculated as 0.810 and 0.811 for each cohort respectively, indicating good discriminative ability of the nomogram model. Calibration curves along with Hosmer-Lemeshow tests demonstrated excellent agreement between predicted probabilities and observed outcomes in both cohorts. Furthermore, Brier scores (0.127 for the training and 0.09 for testing groups) further validated the predictive performance of our nomogram model. The DCA confirmed that this nomogram provides superior net benefit across various risk thresholds when predicting chronic hydrocephalus. The decision curve demonstrated that when an individual's threshold probability ranged from 5 to 62%, this model is more effective in predicting the occurrence of chronic hydrocephalus after aSAH. Conclusion A clinical-radiological nomogram was developed to combine clinical characteristics and radiological features from CT scans, aiming to enhance the accuracy of predicting chronic hydrocephalus in patients with aSAH. This innovative nomogram shows promising potential in assisting clinicians to create personalized and optimal treatment plans by providing precise predictions of chronic hydrocephalus among aSAH patients.
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Affiliation(s)
- Dai Rao
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Li Yang
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Xu Enxi
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Lu Siyuan
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Qian Yu
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Li Zheng
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhou Zhou
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chen Yerong
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chen Bo
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Shan Xiuhong
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Sun Eryi
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
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Seltzer LA, Couldwell MW, Tubbs RS, Bui CJ, Dumont AS. The Top 100 Most Cited Journal Articles on Hydrocephalus. Cureus 2024; 16:e54481. [PMID: 38510885 PMCID: PMC10954317 DOI: 10.7759/cureus.54481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
Hydrocephalus represents a significant burden of disease, with more than 383,000 new cases annually worldwide. When the magnitude of this condition is considered, a centralized archive of pertinent literature is of great clinical value. From a neurosurgical standpoint, hydrocephalus is one of the most frequently treated conditions in the field. The focus of this study was to identify the top 100 journal articles specific to hydrocephalus using bibliometric analysis. Using the Journal of Citation Report database, 10 journals were identified. The Web of Science Core Collection was then searched using each journal name and the search term "hydrocephalus." The results were ordered by "Times Cited" and searched by the number of citations. The database contained journal articles from 1976 to 2021, and the following variables were collected for analysis: journal, article type, year of publication, and the number of citations. Journal articles were excluded if they had no relation to hydrocephalus, mostly involved basic science research, or included animal studies. Ten journals were identified using the above criteria, and a catalog of the 100 most cited publications in the hydrocephalus literature was created. Articles were arranged from highest to lowest citation number, with further classification by journal, article type, and publication year. Of the 100 articles referenced, 38 were review articles, 24 were original articles, 15 were comparative studies, 11 were clinical trials, six were multi-center studies, three were cross-sectional, and three were case reports with reviews. Articles were also sorted by study type and further stratified by etiology. If the etiology was not specified, studies were instead subcategorized by treatment type. Etiologies such as aqueductal stenosis, tumors, and other obstructive causes of hydrocephalus were classified as obstructive (n=6). Communicating (n=15) included idiopathic, normal pressure hydrocephalus, and other non-obstructive etiologies. The category "other" (n=3) was assigned to studies that included etiologies, populations, and/or treatments that did not fit into the classifications previously outlined. Through our analysis of highly cited journal articles focusing on different etiologies and the surgical or medical management of hydrocephalus, we hope to elucidate important trends. By establishing the 100 most cited hydrocephalus articles, we contribute one source, stratified for efficient referencing, to facilitate clinical care and future research on hydrocephalus.
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Affiliation(s)
- Laurel A Seltzer
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, USA
| | - Mitchell W Couldwell
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, USA
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, St. George's, GRD
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, USA
- Department of Structural Biology, Tulane University School of Medicine, New Orleans, USA
| | - C J Bui
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, USA
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Hansson W, Johansson E, Birgander R, Eklund A, Malm J. Cerebral Microbleeds-Long-Term Outcome After Cerebrospinal Fluid Shunting in Idiopathic Normal Pressure Hydrocephalus. Neurosurgery 2023; 93:300-308. [PMID: 36853021 DOI: 10.1227/neu.0000000000002409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/14/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are common in idiopathic normal pressure hydrocephalus (INPH) and have been suggested as radiological markers of a brain prone to bleeding. The presence of CMBs might be relevant when selecting patients for shunt surgery. OBJECTIVE To evaluate whether CMBs increases long-term risk of hemorrhagic complications and mortality or affects outcomes after cerebrospinal fluid shunt surgery in a cohort of patients with INPH. METHODS One hundred and forty nine shunted patients with INPH (mean age, 73 years) were investigated with MRI (T2* or susceptibility-weighted imaging sequences) preoperatively. CMBs were scored with the Microbleed Anatomic Rating Scale. Patients were observed for a mean of 6.5 years (range 2 weeks to 13 years) after surgery. Hemorrhagic events and death were noted. Improvement in gait was evaluated 3 to 6 months after surgery. RESULTS At baseline, 74 patients (50%) had CMBs. During follow-up, 7 patients (5%) suffered a hemorrhagic stroke and 43 (29%) suffered a subdural hematoma/hygroma with a median time from surgery of 30.2 months (IQR 50). Overall, having CMBs was not associated with suffering a subdural hematoma/hygroma or hemorrhagic stroke during follow-up with 1 exception that an extensive degree of CMBs (≥50 CMB) was more common in patients suffering a hemorrhagic stroke ( P = .03). CMBs were associated with increased mortality ( P = .02, Kaplan-Meier, log-rank test). The presence of CMBs did not affect gait outcome ( P = .28). CONCLUSION CMBs were associated with hemorrhagic stroke and mortality. CMBs do not seem to reduce the possibility of gait improvement after shunt surgery or contribute to the risk of hemorrhagic complications regarding subdural hematoma or hygroma.
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Affiliation(s)
- William Hansson
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Elias Johansson
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | | | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Jan Malm
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
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Pyrgelis ES, Velonakis G, Papageorgiou SG, Stefanis L, Kapaki E, Constantinides VC. Imaging Markers for Normal Pressure Hydrocephalus: An Overview. Biomedicines 2023; 11:biomedicines11051265. [PMID: 37238936 DOI: 10.3390/biomedicines11051265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Idiopathic bormal pressure hydrocephalus (iNPH) is a neurological syndrome that clinically presents with Hakim's triad, namely cognitive impairment, gait disturbances, and urinary incontinence. The fact that iNPH is potentially reversible makes its accurate and early diagnosis of paramount importance. Its main imaging characteristic is the dilation of the brain's ventricular system and the imaging parameters are also included in its diagnostic criteria along with clinical data. There is a variety of different modalities used and a great number of imaging markers that have been described while assessing iNPH patients. The present literature review attempts to describe the most important of these imaging markers and to shed some light on their role in diagnosis, differential diagnosis, and possibly prognosis of this potentially reversible neurological syndrome.
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Affiliation(s)
- Efstratios-Stylianos Pyrgelis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Georgios Velonakis
- Research Unit of Radiology, 2nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sokratis G Papageorgiou
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Elisabeth Kapaki
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Vasilios C Constantinides
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
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Yang L, Yang F, Deng Y, Yan A, Wei W, Fang X. White matter hyperintensity mediating gait disorders in iNPH patients via neurofilament light chain. Front Aging Neurosci 2023; 15:1117675. [PMID: 37032824 PMCID: PMC10081026 DOI: 10.3389/fnagi.2023.1117675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/28/2023] [Indexed: 03/18/2023] Open
Abstract
PurposeThis study aimed to analyze the differences in regional white matter hyperintensities (WMH) volume and cerebrospinal fluid biomarker levels between idiopathic normal pressure hydrocephalus (iNPH) patients with or without gait disorder.MethodsForty-eight iNPH patients undergoing bypass surgery and 20 normal senile individuals were included. The LST toolkit was used to segment all MRI fluid attenuation inversion images and quantify the WMH volume in each brain region. Cerebrospinal fluid was collected from all individuals and measured for concentrations of Aβ, t-tau, p-tau, and neurofilament light chain (NfL). Patients with iNPH were followed up for 1 year and divided categorized into a gait disorder improvement group and no improvement group according to the 3 m round-trip test time parameter improvement by more than 10%.ResultsWe found that WMH in all areas of iNPH patients was higher than that in the control group. CSF levels of Aβ, t-tau, and p-tau were lower than those in the control group, while NfL levels were higher than those in the control group. The gait (+) group NfL level was higher than that in gait (−), and there were no statistical differences in Aβ, t-tau, and p-tau levels. The gait (+) group of frontal and parietal lobe WMH volume PVH above the gait (−) group. The mediating effect model analysis showed that PVH might affect the gait disorder of iNPH patients through NfL. A 1-year follow-up of the patients after the bypass surgery found that 24 of the 35 patients in the gait (+) group had improvements, while 11 had no significant improvements. The comparison of CSF marker levels between the two groups showed that the CSF NfL level in the improved group was lower than that in the non-improved group. The WMH volume and PVH in the frontal–parietal lobe of the improved group were lower than those of the non-improved group.ConclusioniNPH patients have more serious frontoparietal and periventricular white matter lesions, and WMH volume in the frontoparietal may mediate the occurrence of gait disorder in iNPH patients through the increase of NfL level.
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Affiliation(s)
- Lu Yang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Fuxia Yang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yao Deng
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Aijuan Yan
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- *Correspondence: Xuhao Fang
| | - Wenshi Wei
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- *Correspondence: Xuhao Fang
| | - Xuhao Fang
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- *Correspondence: Xuhao Fang
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Thavarajasingam SG, El-Khatib M, Vemulapalli K, Iradukunda HAS, K. SV, Borchert R, Russo S, Eide PK. Radiological predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:369-419. [PMID: 36435931 PMCID: PMC9922237 DOI: 10.1007/s00701-022-05402-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery, though the predictors of shunt response remain debated. Currently, radiological features play an important role in the diagnosis of iNPH, but it is not well established which radiological markers most precisely predict shunt responsive iNPH. OBJECTIVE To conduct a systematic review and meta-analysis to identify radiological predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most predictive radiological features. METHODS Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating radiological predictors of shunt response in iNPH patients. Included studies were assessed using the ROBINS-1 tool, and eligible studies were evaluated using a univariate meta-analysis. RESULTS Overall, 301 full-text papers were screened, of which 28 studies were included, and 26 different radiological features were identified, 5 of these met the inclusion criteria for the meta-analysis: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The meta-analysis showed that only callosal angle and periventricular white matter changes significantly differentiated iNPH shunt responders from non-responders, though both markers had a low diagnostic odds ratio (DOR) of 1.88 and 1.01 respectively. None of the other radiological markers differentiated shunt responsive from shunt non-responsive iNPH. CONCLUSION Callosal angle and periventricular changes are the only diagnostically effective radiological predictors of shunt responsive iNPH patients. However, due to the DORs approximating 1, they are insufficient as sole predictors and are advised to be used only in combination with other diagnostic tests of shunt response. Future research must evaluate the combined use of multiple radiological predictors, as it may yield beneficial additive effects that may allow for more robust radiological shunt response prediction.
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Affiliation(s)
| | | | | | | | | | - Robin Borchert
- Department of Clinical Neurosciences, Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Salvatore Russo
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Per K. Eide
- Department of Neurosurgery, Oslo University Hospital – Rikshospitalet, Oslo, Norway ,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Xiao H, Hu F, Ding J, Ye Z. Cognitive Impairment in Idiopathic Normal Pressure Hydrocephalus. Neurosci Bull 2022; 38:1085-1096. [PMID: 35569106 PMCID: PMC9468191 DOI: 10.1007/s12264-022-00873-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/25/2022] [Indexed: 01/03/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a significant cause of the severe cognitive decline in the elderly population. There is no cure for iNPH, but cognitive symptoms can be partially alleviated through cerebrospinal fluid (CSF) diversion. In the early stages of iNPH, cognitive deficits occur primarily in the executive functions and working memory supported by frontostriatal circuits. As the disease progresses, cognition declines continuously and globally, leading to poor quality of life and daily functioning. In this review, we present recent advances in understanding the neurobiological mechanisms of cognitive impairment in iNPH, focusing on (1) abnormal CSF dynamics, (2) dysfunction of frontostriatal and entorhinal-hippocampal circuits and the default mode network, (3) abnormal neuromodulation, and (4) the presence of amyloid-β and tau pathologies.
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Affiliation(s)
- Haoyun Xiao
- Institute of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Zheng Ye
- Institute of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.
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Snöbohm C, Malmberg F, Freyhult E, Kultima K, Fällmar D, Virhammar J. White matter changes should not exclude patients with idiopathic normal pressure hydrocephalus from shunt surgery. Fluids Barriers CNS 2022; 19:35. [PMID: 35599321 PMCID: PMC9125842 DOI: 10.1186/s12987-022-00338-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/09/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction White matter changes (WMC) on brain imaging can be classified as deep white matter hyperintensities (DWMH) or periventricular hyperintensities (PVH) and are frequently seen in patients with idiopathic normal pressure hydrocephalus (iNPH). Contradictory results have been reported on whether preoperative WMC are associated with outcome after shunt surgery in iNPH patients. The aim of this study was to investigate any association between DWMH and PVH and shunt outcome in patients with iNPH, using magnetic resonance volumetry. Methods A total of 253 iNPH patients operated with shunt surgery and clinically assessed before and 12 months after surgery were included. All patients were investigated preoperatively with magnetic resonance imaging of the brain. The volumes of DWMH and PVH were quantified on fluid-attenuated inversion recovery images using an in-house semi-automatic volumetric segmentation software (SmartPaint). Shunt outcome was defined as the difference in symptom score between post- and preoperative investigations, measured on the iNPH scale, and shunt response was defined as improvement with ≥ 5 points. Results One year after shunt surgery, 51% of the patients were improved on the iNPH scale. When defining improvement as ≥ 5 points on the iNPH scale, there was no significant difference in preoperative volume of WMC between shunt responders and non-responders. If outcome was determined by a continuous variable, a larger volume of PVH was negatively associated with postoperative change in the total iNPH scale (p < 0.05) and negatively associated with improvement in gait (p < 0.01) after adjusting for age, sex, waiting time for surgery, preoperative level of symptoms, Evans’ index, and disproportionately enlarged subarachnoid space hydrocephalus. The volume of DWMH was not associated with shunt outcome. Conclusions An association between outcome after shunt surgery and volume of PVH was seen, but there was no difference between shunt responders and non-responders in the volumes of DWMH and PVH. We conclude that preoperative assessment of WMC should not be used to exclude patients with iNPH from shunt surgery.
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12
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Palandri G, Carretta A, La Corte E, Giannini G, Martinoni M, Mantovani P, Albini-Riccioli L, Tonon C, Mazzatenta D, Elder BD, Conti A. Open-aqueduct LOVA, LIAS, iNPH: a comparative clinical-radiological study exploring the "grey zone" between different forms of chronic adulthood hydrocephalus. Acta Neurochir (Wien) 2022; 164:1777-1788. [PMID: 35477816 PMCID: PMC9233635 DOI: 10.1007/s00701-022-05215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/07/2022] [Indexed: 11/27/2022]
Abstract
Purpose The definition of chronic adult hydrocephalus encompasses different pathological entities with overlapping characteristics, including long-standing overt ventriculomegaly in adults (LOVA), late-onset idiopathic aqueductal stenosis (LIAS) and idiopathic normal pressure hydrocephalus (iNPH). The aim of our study was to identify preoperative clinical and radiological features peculiar of these diseases providing some pathophysiology inferences on these forms of hydrocephalus. Methods Clinical and radiological preoperative records, type of surgical treatment and clinical outcome of patients with chronic adult hydrocephalus who were surgically treated between 2013 and 2019 were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the contribution of each variable to the differential diagnosis. Results In total, 105 patients were included: 18 with LOVA, 23 with LIAS and 64 with iNPH. On multivariate analysis, an enlarged cisterna magna and a more severe ventriculomegaly were associated with the diagnosis of LOVA, while an older age and DESH with iNPH. LIAS patients tend to have an higher prevalence of raised ICP symptoms. Based on that, a clinical and radiological scoring system was developed to distinguish between iNPH and no iNPH cases. A precise cut-off value with a sensitivity of 95.1% and a specificity of 90.6% was identified. Conclusions LOVA, LIAS and iNPH are different forms of chronic adulthood hydrocephalus and present different and peculiar clinical and radiological features, with an impact on the treatment and outcome prediction. The implementation of a clinical-radiological score for differential diagnosis may help the differentiation. Further studies are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05215-9.
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Affiliation(s)
- Giorgio Palandri
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Alessandro Carretta
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy.
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | - Emanuele La Corte
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Neurology Unit (NEUROMET), IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Matteo Martinoni
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Paolo Mantovani
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Luca Albini-Riccioli
- Neuroradiology Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Programma Neurochirurgia Ipofisi - Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alfredo Conti
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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13
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Jeppsson A, Bjerke M, Hellström P, Blennow K, Zetterberg H, Kettunen P, Wikkelsø C, Wallin A, Tullberg M. Shared CSF Biomarker Profile in Idiopathic Normal Pressure Hydrocephalus and Subcortical Small Vessel Disease. Front Neurol 2022; 13:839307. [PMID: 35309577 PMCID: PMC8927666 DOI: 10.3389/fneur.2022.839307] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionIn this study, we examine similarities and differences between 52 patients with idiopathic normal pressure hydrocephalus (iNPH) and 17 patients with subcortical small vessel disease (SSVD), in comparison to 28 healthy controls (HCs) by a panel of cerebrospinal fluid (CSF) biomarkers.MethodsWe analyzed soluble amyloid precursor protein alpha (sAPPα) and beta (sAPPβ), Aβ isoforms −38, −40, and −42, neurofilament light protein (NFL), glial fibrillary acidic protein (GFAP), myelin basic protein (MBP), matrix metalloproteinases (MMP −1, −2, −3, −9, and −10), and tissue inhibitors of metalloproteinase 1 (TIMP1). Radiological signs of white matter damage were scored using the age-related white matter changes (ARWMC) scale.ResultsAll amyloid fragments were reduced in iNPH and SSVD (p < 0.05), although more in iNPH than in SSVD in comparison to HC. iNPH and SSVD showed comparable elevations of NFL, MBP, and GFAP (p < 0.05). MMPs were similar in all three groups except for MMP-10, which was increased in iNPH and SSVD. Patients with iNPH had larger ventricles and fewer WMCs than patients with SSVD.ConclusionThe results indicate that patients with iNPH and SSVD share common features of subcortical neuronal degeneration, demyelination, and astroglial response. The reduction in all APP-derived proteins characterizing iNPH patients is also present, indicating that SSVD encompasses similar pathophysiological phenomena as iNPH.
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Affiliation(s)
- Anna Jeppsson
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- *Correspondence: Anna Jeppsson
| | - Maria Bjerke
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Department of Clinical Chemistry, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Biomedical Sciences, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Per Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, Hong Kong SAR, China
| | - Petronella Kettunen
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Wallin
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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14
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Yamada S, Ishikawa M, Nakajima M, Nozaki K. Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures. Front Neurol 2022; 12:798488. [PMID: 35069426 PMCID: PMC8770742 DOI: 10.3389/fneur.2021.798488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.
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Affiliation(s)
- Shigeki Yamada
- Department of Neurosurgery, Shiga University of Medical Science, Shiga, Japan.,Interfaculty Initiative in Information Studies/Institute of Industrial Science, The University of Tokyo, Tokyo, Japan.,Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Masatsune Ishikawa
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Japan.,Rakuwa Villa Ilios, Rakuwakai Healthcare System, Kyoto, Japan
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Shiga, Japan
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15
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Popal AM, Zhu Z, Guo X, Zheng Z, Cai C, Jiang H, Zhang J, Shao A, Zhu J. Outcomes of Ventriculoperitoneal Shunt in Patients With Idiopathic Normal-Pressure Hydrocephalus 2 Years After Surgery. Front Surg 2021; 8:641561. [PMID: 34869547 PMCID: PMC8634250 DOI: 10.3389/fsurg.2021.641561] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 10/14/2021] [Indexed: 11/29/2022] Open
Abstract
Objective: To evaluate the outcomes and prognostic factors of ventriculoperitoneal shunts (VP-shunts) in patients with idiopathic normal-pressure hydrocephalus (iNPH) at 6 months and 2 years after surgery. Method: We retrospectively analyzed 68 patients admitted to our institute and diagnosed with probable iNPH from January 2017 to March 2021. All patients underwent VP-shunt surgery with a programmable valve, and their outcomes were assessed via the Krauss index and modified Rankin scale (mRS) at 6 months and 2 years post-surgery. Univariate and multivariate regression analysis was performed to identify the prognostic factors. Results: The mean age of the patients was 71.1 ± 8.4 (mean ± standard deviation) years. On the Krauss improvement index, 6-month follow-up results were available for 68 patients. Of these patients, 91.2% experienced attenuation of their preoperative symptoms, with a mean Krauss index of 0.58 ± 0.27, and 48 patients (70.6%) had a Krauss index ≥0.5. Two-year follow-up results were available for 33 patients; 90.9% of them had sustained improvement, with a Krauss index of 0.54 ± 0.31, and 21 patients (66.3%) had a Krauss index ≥0.5. Thirty-three patients (58%) were living independently after 2 years (mRS 0–2). The outcomes were worse for patients with multiple comorbidities. Neither an increased patient age nor a prolonged history of illness was statistically significant prognostic factors for adverse outcomes of VP-shunt surgery. Conclusion: Surgical treatment was well-tolerated by patients with iNPH who received VP-shunts. Most patients experienced attenuation of their preoperative symptoms. Multiple concurrent comorbidities should be considered as adverse prognostic factors before shunt insertion in patients with iNPH.
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Affiliation(s)
- Abdul Malik Popal
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhoule Zhu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xinxia Guo
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhe Zheng
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chengwei Cai
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hongjie Jiang
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Anwen Shao
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Junming Zhu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
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16
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Thavarajasingam SG, El-Khatib M, Rea M, Russo S, Lemcke J, Al-Nusair L, Vajkoczy P. Clinical predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Acta Neurochir (Wien) 2021; 163:2641-2672. [PMID: 34235589 PMCID: PMC8437907 DOI: 10.1007/s00701-021-04922-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/13/2021] [Indexed: 11/29/2022]
Abstract
Background Positive shunt response (SR) remains the gold standard for diagnosing idiopathic normal pressure hydrocephalus (iNPH). However, multiple pathologies mimic iNPH symptoms, making it difficult to select patients who will respond to shunt surgery. Although presenting features, extended lumbar drainage (ELD), infusion test (IT), intracranial pressure monitoring (ICPM), and tap test (TT) have been used to predict SR, uncertainty remains over which diagnostic test to choose. Objective To conduct a systematic review and meta-analysis to identify clinical predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most effective diagnostic tests. Methods Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating clinical predictors of SR in iNPH patients. Included studies were assessed using the QUADAS-2 tool, and eligible studies were evaluated using univariate and bivariate meta-analyses. Results Thirty-five studies were included. Nine studies discussed the diagnostic use of presenting clinical features, 8 studies ELD, 8 studies IT, 11 studies ICPM, and 6 studies TT. A meta-analysis of 21 eligible studies was conducted for TT, ELD, IT, and ICPM. ICPM yielded the highest diagnostic effectiveness, with diagnostic odds ratio (DOR) = 50.9 and area under curve (AUC) = 0.836. ELD yielded DOR = 27.70 and AUC = 0.753, IT had DOR = 5.70 and AUC = 0.729, and TT scored DOR = 3.86 and AUC = 0.711. Conclusion Intraparenchymal ICPM is statistically the most effective diagnostic test, followed by ELD, IT, and lastly TT. Due to the higher accessibility of TT and IT, they are recommended to be used first line, using a timed-up-and-go improvement ≥ 5.6 s or a Rout cut-off range between 13 and 16 mmHg, respectively. Patients who test negative should ideally be followed up with ICPM, using mean ICP wave amplitude \documentclass[12pt]{minimal}
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\begin{document}$$\ge$$\end{document}≥ 3. Future research must use standardized methodologies for each diagnostic test and uniform criteria for SR to allow better comparison.
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Affiliation(s)
| | - Mahmoud El-Khatib
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Mark Rea
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Salvatore Russo
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Lana Al-Nusair
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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17
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Trevisi G, Signorelli F, de Waure C, Stifano V, Sturdà C, Rapisarda A, Pompucci A, Mangiola A, Anile C. Intraventricular infusion test accuracy in predicting short- and long-term outcome of iNPH patients: a 10-year update of a three-decade experience at a single institution. Neurosurg Rev 2021; 44:3323-3334. [PMID: 33590367 DOI: 10.1007/s10143-021-01495-4] [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: 10/08/2020] [Revised: 12/19/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In a previous work, we found that an Intracranial Elastance Index (IEI) ≥0.3 at ventricular infusion test had a high accuracy in predicting shunt response at 6 and 12 months in idiopathic normal pressure hydrocephalus (iNPH). The aim of this study was to verify the accuracy of IEI to predict response to shunt at both short- and long-term follow-up. METHODS Retrospective evaluation of 64 patients undergoing ventriculo-peritoneal shunting for iNPH between 2006 and 2015 based on a positive ventricular infusion test (IEI≥0.3). Patients were classified according to Krauss scale and mRS preoperatively, at 1-year and at last follow-up. An improvement of at least one point at Krauss score or at mRS was considered as a good outcome; unchanged or worsened patients were grouped as poor outcome. RESULTS Mean follow-up was 6.6 years. Improvement at Krauss scale was seen in 62.5% and 64.3% of patients at 1-year and last follow-up, respectively. Patients in good functional status (mRS≤2) increased from 25 in the preoperative period to 57% at both 1-year and last follow-up. IEI was significantly associated with Krauss (p=0.041) and mRS (p=0.036) outcome at last follow-up. Patients with worse preoperative Krauss and mRS had higher chance to improve but higher overall scores after treatment. At ROC curves, IEI showed a good long-term prediction of change in mRS from first year to last follow-up. CONCLUSIONS IEI≥0.3 predicts outcomes at both short- and long-term, with more than 50% of patients being able to look after themselves after 6 years from treatment.
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Affiliation(s)
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Chiara de Waure
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Vito Stifano
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Cosimo Sturdà
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Alessandro Rapisarda
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Angelo Pompucci
- Neurosurgical Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | - Annunziato Mangiola
- Neurosurgical Unit, Ospedale Spirito Santo, Pescara, Italy.,Department of Neurosciences, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Carmelo Anile
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
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18
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NAKAJIMA M, YAMADA S, MIYAJIMA M, ISHII K, KURIYAMA N, KAZUI H, KANEMOTO H, SUEHIRO T, YOSHIYAMA K, KAMEDA M, KAJIMOTO Y, MASE M, MURAI H, KITA D, KIMURA T, SAMEJIMA N, TOKUDA T, KAIJIMA M, AKIBA C, KAWAMURA K, ATSUCHI M, HIRATA Y, MATSUMAE M, SASAKI M, YAMASHITA F, AOKI S, IRIE R, MIYAKE H, KATO T, MORI E, ISHIKAWA M, DATE I, ARAI H. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir (Tokyo) 2021; 61:63-97. [PMID: 33455998 PMCID: PMC7905302 DOI: 10.2176/nmc.st.2020-0292] [Citation(s) in RCA: 190] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/13/2020] [Indexed: 01/18/2023] Open
Abstract
Among the various disorders that manifest with gait disturbance, cognitive impairment, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. The first edition of these guidelines for management of iNPH was published in 2004, and the second edition in 2012, to provide a series of timely, evidence-based recommendations related to iNPH. Since the last edition, clinical awareness of iNPH has risen dramatically, and clinical and basic research efforts on iNPH have increased significantly. This third edition of the guidelines was made to share these ideas with the international community and to promote international research on iNPH. The revision of the guidelines was undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project. This revision proposes a new classification for NPH. The category of iNPH is clearly distinguished from NPH with congenital/developmental and acquired etiologies. Additionally, the essential role of disproportionately enlarged subarachnoid-space hydrocephalus (DESH) in the imaging diagnosis and decision for further management of iNPH is discussed in this edition. We created an algorithm for diagnosis and decision for shunt management. Diagnosis by biomarkers that distinguish prognosis has been also initiated. Therefore, diagnosis and treatment of iNPH have entered a new phase. We hope that this third edition of the guidelines will help patients, their families, and healthcare professionals involved in treating iNPH.
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Affiliation(s)
- Madoka NAKAJIMA
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shigeki YAMADA
- Department of Neurosurgery, Shiga University of Medical Science, Ohtsu, Shiga, Japan
| | - Masakazu MIYAJIMA
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kazunari ISHII
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Nagato KURIYAMA
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Kyoto, Japan
| | - Hiroaki KAZUI
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Hideki KANEMOTO
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi SUEHIRO
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kenji YOSHIYAMA
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiro KAMEDA
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoshinaga KAJIMOTO
- Department of Neurosurgery, Division of Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Mitsuhito MASE
- Department of Neurosurgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hisayuki MURAI
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Daisuke KITA
- Department of Neurosurgery, Noto General Hospital, Nanao, Ishikawa, Japan
| | - Teruo KIMURA
- Department of Neurosurgery, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
| | - Naoyuki SAMEJIMA
- Department of Neurosurgery, Tokyo Kyosai Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Takahiko TOKUDA
- Department of Functional Brain Imaging Research, National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Chiba, Japan
| | - Mitsunobu KAIJIMA
- Department of Neurosurgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan
| | - Chihiro AKIBA
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kaito KAWAMURA
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masamichi ATSUCHI
- Normal Pressure Hydrocephalus Center, Jifukai Atsuchi Neurosurgical Hospital, Kagoshima, Kagoshima, Japan
| | - Yoshihumi HIRATA
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Kumamoto, Japan
| | - Mitsunori MATSUMAE
- Department of Neurosurgery at Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Makoto SASAKI
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Fumio YAMASHITA
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Shigeki AOKI
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryusuke IRIE
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroji MIYAKE
- Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Hyogo, Japan
| | - Takeo KATO
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine, Yamagata, Yamagata, Japan
| | - Etsuro MORI
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
| | - Masatsune ISHIKAWA
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Kyoto, Japan
| | - Isao DATE
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hajime ARAI
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - The research committee of idiopathic normal pressure hydrocephalus
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
- Department of Neurosurgery, Shiga University of Medical Science, Ohtsu, Shiga, Japan
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Kyoto, Japan
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
- Department of Neurosurgery, Division of Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
- Department of Neurosurgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Aichi, Japan
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
- Department of Neurosurgery, Noto General Hospital, Nanao, Ishikawa, Japan
- Department of Neurosurgery, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
- Department of Neurosurgery, Tokyo Kyosai Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
- Department of Functional Brain Imaging Research, National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Chiba, Japan
- Department of Neurosurgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan
- Normal Pressure Hydrocephalus Center, Jifukai Atsuchi Neurosurgical Hospital, Kagoshima, Kagoshima, Japan
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Kumamoto, Japan
- Department of Neurosurgery at Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
- Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Hyogo, Japan
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine, Yamagata, Yamagata, Japan
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Kyoto, Japan
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19
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Israelsson H, Larsson J, Eklund A, Malm J. Risk factors, comorbidities, quality of life, and complications after surgery in idiopathic normal pressure hydrocephalus: review of the INPH-CRasH study. Neurosurg Focus 2020; 49:E8. [DOI: 10.3171/2020.7.focus20466] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIdiopathic normal pressure hydrocephalus (INPH) is a dementia treatable by insertion of a shunt that drains CSF. The cause of the disease is unknown, but a vascular pathway has been suggested. The INPH-CRasH (Comorbidities and Risk Factors Associated with Hydrocephalus) study was a modern epidemiological case-control study designed to prospectively assess parameters regarding comorbidities and vascular risk factors (VRFs) for INPH, quality of life (QOL), and adverse events in patients with shunted INPH. The objective of this review was to summarize the findings of the INPH-CRasH study.METHODSVRFs, comorbidities, QOL, and adverse events were analyzed in consecutive patients with INPH who underwent shunt placement between 2008 and 2010 in 5 of 6 neurosurgical centers in Sweden. Patients (n = 176, within the age span of 60–85 years and not having dementia) were compared to population-based age- and gender-matched controls (n = 368, same inclusion criteria as for the patients with INPH). Assessed parameters were as follows: hypertension; diabetes; obesity; hyperlipidemia; psychosocial factors (stress and depression); smoking status; alcohol intake; physical activity; dietary pattern; cerebrovascular, cardiovascular, or peripheral vascular disease; epilepsy; abdominal pain; headache; and clinical parameters before and after surgery. Parameters were assessed through questionnaires, clinical examinations, measurements, ECG studies, and blood samples.RESULTSFour VRFs were independently associated with INPH: hyperlipidemia, diabetes, obesity, and psychosocial factors. Physical inactivity and hypertension were also associated with INPH, although not independently from the other risk factors. The population attributable risk percent for a model containing all of the VRFs associated with INPH was 24%. Depression was overrepresented in patients with INPH treated with shunts compared to the controls (46% vs 13%, p < 0.001) and the main predictor for low QOL was a coexisting depression (p < 0.001). Shunting improved QOL on a long-term basis. Epilepsy, headache, and abdominal pain remained common for a mean follow-up time of 21 months in INPH patients who received shunts.CONCLUSIONSThe results of the INPH-CRasH study are consistent with a vascular pathophysiological component of INPH. In clinical care and research, a complete risk factor analysis as well as screening for depression and a measurement for QOL should probably be included in the workup of patients with INPH. The effect of targeted interventions against modifiable VRFs and antidepressant treatment in INPH patients should be evaluated. Seizures, headache, and abdominal pain should be inquired about at postoperative follow-up examinations.
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Affiliation(s)
- Hanna Israelsson
- 1Department of Clinical Science, Neurosciences, Umeå University, Umeå
- 2Department of Health, Medicine and Caring Sciences (HMV), Linköping University Hospital, Linköping; and
| | - Jenny Larsson
- 1Department of Clinical Science, Neurosciences, Umeå University, Umeå
| | - Anders Eklund
- 3Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Jan Malm
- 1Department of Clinical Science, Neurosciences, Umeå University, Umeå
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20
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Naylor RM, Lenartowicz KA, Graff-Radford J, Jones DT, Cutsforth-Gregory JK, Graff-Radford NR, Elder BD. High prevalence of cervical myelopathy in patients with idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg 2020; 197:106099. [PMID: 32702575 DOI: 10.1016/j.clineuro.2020.106099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Both idiopathic normal pressure hydrocephalus (iNPH) and cervical myelopathy may result in progressive gait impairment. Some patients who do not respond to shunting despite a positive tap test may have gait dysfunction from cervical myelopathy. The objective of this study was to determine the prevalence of cervical myelopathy in patients with iNPH. METHODS A consecutive series of patients undergoing shunt placement for iNPH were screened for cervical stenosis. Clinical manifestations of iNPH and cervical myelopathy, grade of cervical stenosis, cervical spine surgical intervention, timing of intervention, and outcomes were recorded. RESULTS Fifty-two patients shunted for treatment of iNPH were included for analysis. 58 % were male with a mean age of 75.2 years (SD 7.3 years). All patients presented with gait disturbances. 39/52 (75 %) had cervical stenosis, and 9/52 (17.3 %) had significant (grade 2-3) cervical stenosis with myelopathy and were subsequently treated with surgical decompression. There was an association between increasing grade of stenosis and disproportionately enlarged subarachnoid space hydrocephalus (DESH). All patients with grade 2-3 cervical stenosis and symptoms of cervical myelopathy in addition to iNPH underwent cervical decompression surgery. CONCLUSIONS Clinically significant cervical myelopathy was prevalent in patients with iNPH and was associated with increased rate of DESH, a finding that requires validation in a larger cohort. Based on these results, cervical imaging could be considered preoperatively in patients with iNPH, particularly when upper motor neuron findings are identified. Additionally, concomitant cervical stenosis should be ruled out in patients whose gait does not improve after shunt placement.
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Affiliation(s)
- Ryan M Naylor
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, United States
| | | | | | - David T Jones
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | | | | | - Benjamin D Elder
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, United States; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; Department of Biomedical Engineering, Mayo Clinic, Rochester, MN, United States.
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21
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Peng A, Yang M, Zhao H, Wu Y, Zhao Y, Zhou L. Compared with conventional procedures, an intraoperative navigation system for ventriculoperitoneal shunting via the occipital horn improves outcomes in patients with hydrocephalus. Br J Neurosurg 2020; 35:292-300. [PMID: 32667226 DOI: 10.1080/02688697.2020.1789555] [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] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ventriculoperitoneal shunting (VPS) is a common neurosurgical procedure used to treat hydrocephalus. Although the use of a navigation system in VPS achieves superior results compared with conventional surgery, the relationships among clinical symptoms, ventricular catheter placement, catheter obstruction, and the postoperative Evans index have not been clearly reported. METHODS We performed a retrospective study of 40 patients with VPS (the navigation surgery group) and 31 patients with VPS (the conventional surgery group). Clinical data, follow-up times, catheterization accuracy, postoperative outcomes, cumulative survival times, and correlations between catheter placement and obstruction, symptom grade and the postoperative Evans index were analyzed. RESULTS Thirty-seven patients experienced optimal ventricular catheter placement (grade 1), three experienced suboptimal placements (grade 2), and none experienced poor ventricular catheter placement (grade 3) in the navigation surgery group. Greater improvement in postoperative symptoms (p < 0.001), including less catheter readjustment (p < 0.001), was observed in the navigation surgery group. A Kaplan-Meier analysis showed that the cumulative catheter obstruction-free survival time was longer in the navigation surgery group (p = 0.016). Moreover, catheter placement was significantly correlated with catheter obstruction (p < 0.001). Additionally, catheter obstruction was significantly correlated with the symptom grade (p < 0.001) and postoperative Evans index (p = 0.002). CONCLUSION VPS for hydrocephalus via the occipital horn with a navigation system is superior to the conventional surgical procedure in terms of clinical outcomes, the precision of ventricular catheterization, and the occurrence of complications. Catheter obstruction-free survival times were longer in the navigation surgery group and catheter placement was significantly correlated with catheter obstruction.
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Affiliation(s)
- AiJun Peng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Yang
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Hai Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - YongKang Wu
- Department of Neurosurgery, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yi Zhao
- Department of Medical Imaging, Affiliated Hospital of Yangzhou University, Yangzhou,, China
| | - LiangXue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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22
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Irie R, Otsuka Y, Hagiwara A, Kamagata K, Kamiya K, Suzuki M, Wada A, Maekawa T, Fujita S, Kato S, Nakajima M, Miyajima M, Motoi Y, Abe O, Aoki S. A Novel Deep Learning Approach with a 3D Convolutional Ladder Network for Differential Diagnosis of Idiopathic Normal Pressure Hydrocephalus and Alzheimer's Disease. Magn Reson Med Sci 2020; 19:351-358. [PMID: 31969525 PMCID: PMC7809147 DOI: 10.2463/mrms.mp.2019-0106] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Purpose: Idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer’s disease (AD) are geriatric diseases and common causes of dementia. Recently, many studies on the segmentation, disease detection, or classification of MRI using deep learning have been conducted. The aim of this study was to differentiate iNPH and AD using a residual extraction approach in the deep learning method. Methods: Twenty-three patients with iNPH, 23 patients with AD and 23 healthy controls were included in this study. All patients and volunteers underwent brain MRI with a 3T unit, and we used only whole-brain three-dimensional (3D) T1-weighted images. We designed a fully automated, end-to-end 3D deep learning classifier to differentiate iNPH, AD and control. We evaluated the performance of our model using a leave-one-out cross-validation test. We also evaluated the validity of the result by visualizing important areas in the process of differentiating AD and iNPH on the original input image using the Gradient-weighted Class Activation Mapping (Grad-CAM) technique. Results: Twenty-one out of 23 iNPH cases, 19 out of 23 AD cases and 22 out of 23 controls were correctly diagnosed. The accuracy was 0.90. In the Grad-CAM heat map, brain parenchyma surrounding the lateral ventricle was highlighted in about half of the iNPH cases that were successfully diagnosed. The medial temporal lobe or inferior horn of the lateral ventricle was highlighted in many successfully diagnosed cases of AD. About half of the successful cases showed nonspecific heat maps. Conclusion: Residual extraction approach in a deep learning method achieved a high accuracy for the differential diagnosis of iNPH, AD, and healthy controls trained with a small number of cases.
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Affiliation(s)
- Ryusuke Irie
- Department of Radiology, Juntendo University School of Medicine.,Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | - Yujiro Otsuka
- Department of Radiology, Juntendo University School of Medicine.,Milliman, Inc
| | - Akifumi Hagiwara
- Department of Radiology, Juntendo University School of Medicine.,Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | - Koji Kamagata
- Department of Radiology, Juntendo University School of Medicine
| | - Kouhei Kamiya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | | | - Akihiko Wada
- Department of Radiology, Juntendo University School of Medicine
| | - Tomoko Maekawa
- Department of Radiology, Juntendo University School of Medicine.,Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | - Shohei Fujita
- Department of Radiology, Juntendo University School of Medicine.,Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | - Shimpei Kato
- Department of Radiology, Juntendo University School of Medicine.,Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University School of Medicine
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center
| | - Yumiko Motoi
- Department of Neurology, Juntendo University School of Medicine.,Department of Diagnosis, Prevention and Treatment of Dementia, Juntendo University Graduate School of Medicine
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo
| | - Shigeki Aoki
- Department of Radiology, Juntendo University School of Medicine
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23
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Takeuchi T, Kasahara E. Surgical Indications and Operative Results of Lumbosubarachnoid-Lumboepidural Shunting in 29 Patients with Idiopathic Normal Pressure Hydrocephalus under Local Anesthesia. Neurol Med Chir (Tokyo) 2019; 59:498-503. [PMID: 31619602 PMCID: PMC6923158 DOI: 10.2176/nmc.oa.2019-0151] [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] [Indexed: 11/20/2022] Open
Abstract
This study consisted of 29 patients with idiopathic normal pressure hydrocephalus (iNPH) who underwent lumbosubarachnoid-lumboepidural (L-L) shunting under local anesthesia in accordance with our surgical indications of L-L shunting. (1) CSF absorption within the lumbar epidural space and shunt clearance were confirmed in all patients after operation. (2) Shunt responders (R) were 25 of 29 cases (86.2%) 3 months after surgery. Among the R, symptom exacerbation was confirmed in three patients (12%) within the follow-up period (mean, 25.1 months). In each of these patients, shunt function were maintained and remained unchanged even with pressure resetting, the cause being an intracranial/extracranial disease other than iNPH. (3) The initial pressure setting for this method was 8 cmH2O, with gradual change to higher pressures, such that the setting for Patient 11 and thereafter became 20 cmH2O. (4) As postsurgical complications, subcutaneous cerebral spinal fluid collection (SCC) was confirmed in five patients (17.2%). In high-pressure resetting and follow-up observation, SCC was not observed in all patients. Epidural catheter displacement was confirmed in three patients (10.3%). No recurrence was noted after the secure fixation of the catheter at the fascia insertion portion and 2 days' postsurgical bed rest. Hence, L-L shunting is an effective shunt therapy for iNPH.
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24
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Isaacs AM, Williams MA, Hamilton MG. Current Update on Treatment Strategies for Idiopathic Normal Pressure Hydrocephalus. Curr Treat Options Neurol 2019; 21:65. [PMID: 31792620 DOI: 10.1007/s11940-019-0604-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Idiopathic normal pressure hydrocephalus (iNPH) is a surgically treatable neurological disorder of the elderly population that is characterized by abnormal ventricular enlargement due to cerebrospinal fluid (CSF) accumulation and gait disturbance, cognitive impairment, or urinary incontinence. The objective of this review is to present the current diagnostic and treatment approaches for iNPH and to discuss some of the postoperative modalities that complement positive surgical outcomes. RECENT FINDINGS Although historically reported patient outcomes following iNPH surgery were dismal and highly variable, recent advances in terms of better understanding of the iNPH disease process, better standardization of iNPH diagnostic and treatment processes arising from the adoption of clinical guidelines for diagnosis, treatment and in research methodologies, and availability of long-term follow-up data, have helped reduce the variations to a much improved 73 to 96% reported good outcomes. With careful evaluation, good patient selection, and advanced surgical techniques, iNPH can be surgically treated to return patients close to their pre-iNPH functional status. Institution of an interdisciplinary effort to rehabilitate patients following surgery may help augment their recovery.
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Affiliation(s)
- Albert M Isaacs
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO, USA.,Division of Neurosurgery, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
| | - Michael A Williams
- Adult and Transitional Hydrocephalus and CSF Disorders, Departments of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Mark G Hamilton
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada. .,Adult Hydrocephalus Program, Department of Clinical Neuroscience, University of Calgary, Foothills Medical Centre - 12th Floor, Neurosurgery, 1403 - 29 Street NW, Calgary, Alberta, T2N 2T9, Canada.
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25
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Sichtermann T, Furtmann JK, Dekeyzer S, Gilmour G, Oros-Peusquens AM, Bach JP, Wiesmann M, Shah NJ, Nikoubashman O. Increased Water Content in Periventricular Caps in Patients without Acute Hydrocephalus. AJNR Am J Neuroradiol 2019; 40:784-787. [PMID: 30975653 DOI: 10.3174/ajnr.a6033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Periventricular caps are a common finding on MR imaging and are believed to reflect focally increased interstitial water content due to dysfunctional transependymal transportation rather than ischemic-gliotic changes. We compared the quantitative water content of periventricular caps and microvascular white matter lesions, hypothesizing that periventricular caps associated with increased interstitial fluid content display higher water content than white matter lesions and are therefore differentiable from microvascular white matter lesions by measurement of the water content. MATERIALS AND METHODS In a prospective study, we compared the water content of periventricular caps and white matter lesions in 50 patients using a quantitative multiple-echo, gradient-echo MR imaging water-mapping sequence. RESULTS The water content of periventricular caps was significantly higher than that of white matter lesions (P = .002). Compared with normal white matter, the mean water content of periventricular caps was 17% ± 5% higher and the mean water content of white matter lesions was 11% ± 4% higher. Receiver operating characteristic analysis revealed that areas in which water content was 15% higher compared with normal white matter correspond to periventricular caps rather than white matter lesions, with a specificity of 93% and a sensitivity of 60% (P < .001). There was no significant correlation between the water content of periventricular caps and whole-brain volume (P = .275), white matter volume (P = .243), gray matter volume (P = .548), lateral ventricle volume (P = .800), white matter lesion volume (P = .081), periventricular cap volume (P = .081), and age (P = .224). CONCLUSIONS Quantitative MR imaging allows differentiation between periventricular caps and white matter lesions. Water content quantification of T2-hyperintense lesions may be a useful additional tool for the characterization and differentiation of T2-hyperintense diseases.
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Affiliation(s)
- T Sichtermann
- From the Departments of Diagnostic and Interventional Neuroradiology (T.S., J.K.F., S.D., G.G., M.W., O.N.)
| | - J K Furtmann
- From the Departments of Diagnostic and Interventional Neuroradiology (T.S., J.K.F., S.D., G.G., M.W., O.N.)
| | - S Dekeyzer
- From the Departments of Diagnostic and Interventional Neuroradiology (T.S., J.K.F., S.D., G.G., M.W., O.N.)
- Department of Radiology (S.D.), Antwerp University Hospital (UZA), Antwerp, Belgium
| | - G Gilmour
- From the Departments of Diagnostic and Interventional Neuroradiology (T.S., J.K.F., S.D., G.G., M.W., O.N.)
| | - A M Oros-Peusquens
- Institute of Neuroscience and Medicine (A.M.O.-P., N.J.S.), Jülich, Germany
| | - J P Bach
- Neurology (J.P.B., N.J.S.), University Hospital, RWTH Aachen University, Aachen, Germany
| | - M Wiesmann
- From the Departments of Diagnostic and Interventional Neuroradiology (T.S., J.K.F., S.D., G.G., M.W., O.N.)
| | - N J Shah
- Neurology (J.P.B., N.J.S.), University Hospital, RWTH Aachen University, Aachen, Germany
- Institute of Neuroscience and Medicine (A.M.O.-P., N.J.S.), Jülich, Germany
| | - O Nikoubashman
- From the Departments of Diagnostic and Interventional Neuroradiology (T.S., J.K.F., S.D., G.G., M.W., O.N.)
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26
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Nakajima M, Kuriyama N, Miyajima M, Ogino I, Akiba C, Kawamura K, Kurosawa M, Watanabe Y, Fukushima W, Mori E, Kato T, Sugano H, Tange Y, Karagiozov K, Arai H. Background Risk Factors Associated with Shunt Intervention for Possible Idiopathic Normal Pressure Hydrocephalus: A Nationwide Hospital-Based Survey in Japan. J Alzheimers Dis 2019; 68:735-744. [PMID: 30883349 PMCID: PMC6484254 DOI: 10.3233/jad-180955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Patients with idiopathic normal-pressure hydrocephalus (iNPH) are typically older adults with multiple comorbidities that are associated with a reduction in the efficacy of iNPH treatment via cerebrospinal fluid (CSF) shunt placement. Objective: The present study aimed to investigate the effectiveness of CSF shunt for iNPH using data from a nationwide epidemiological survey in Japan. Methods: We examined 1,423 patients (581 women) aged ≥60 years (median age [25%–75%]: 77 [73–80] years) who were diagnosed with iNPH following a hospital visit in 2012. Patients who experienced an improvement of at least one modified Rankin Scale (mRS) grade after the CSF shunt were classified as “improvement” while the remaining patients were classified as “non-improvement.” The efficacy of the shunt intervention (n = 842) was analyzed using a binomial logistic regression analysis. Results: An analysis of risk factors associated with shunt placement in patients with mRS grade 2 revealed an association between comorbid chronic ischemic lesions (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.11–4.67; p = 0.025) and cervical spondylosis (OR, 3.62; 95% CI, 1.15–11.34; p = 0.027). Patients with mRS grade 3 at study entry had an association with comorbid Alzheimer’s disease (OR, 3.02; 95% CI, 1.44–6.31; p = 0.003). Conclusions: The results presented here showed that any age-related risk is minimal and should not be cause for rejection of surgical treatment options. Clinical decisions regarding CSF shunt should be individualized to each patient, with adequate consideration of the relative risks and benefits, including maximizing a healthy life expectancy.
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Affiliation(s)
- Madoka Nakajima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nagato Kuriyama
- Department of Epidemiology for Community Health and Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Ikuko Ogino
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Chihiro Akiba
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kaito Kawamura
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Michiko Kurosawa
- Department of Epidemiology and Environmental Health, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yoshiyuki Watanabe
- Department of Public Administrative Science for Community Health, Medicine and Welfare, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Wakaba Fukushima
- Department of Public Health, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Etsuro Mori
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeo Kato
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Hidenori Sugano
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yuichi Tange
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kostadin Karagiozov
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
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Kitade I, Kitai R, Neishi H, Kikuta KI, Shimada S, Matsumine A. Relationship between gait parameters and MR imaging in idiopathic normal pressure hydrocephalus patients after shunt surgery. Gait Posture 2018; 61:163-168. [PMID: 29413784 DOI: 10.1016/j.gaitpost.2018.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/18/2017] [Accepted: 01/11/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND A few previous studies have reported a change in gait motion in idiopathic normal pressure hydrocephalus (iNPH) patients after shunt surgery compared with before shunt surgery; however, there has been no detailed quantitative investigation of gait, including kinetic and kinematic parameters. Furthermore, the relationship between gait parameters and magnetic resonance (MR) imaging has not been confirmed. RESEARCH QUESTION We investigated the gait motion in patients with iNPH, and evaluated the relationship between kinetic gait parameters and MR imaging before and after shunt surgery. METHODS The subjects were 12 patients with iNPH who could walk 10 m without aids. A three-dimensional motion analysis system was used to obtain the spatiotemporal, kinetic, and kinematic parameters before and after surgery. Relationships between each gait parameter and MR imaging were assessed. RESULTS The post-shunt walking speed and step length were increased compared with pre-shunt values. The post-shunt evaluation showed increased range of motion of the hip, knee, and ankle joints in the sagittal plane during the gait cycle. The peak flexion moment of the hip during the stance phase was greater after shunt surgery. The improvement rate of the Evans index was significantly correlated with the improvement rate of walking speed, and the total ranges of motion of the hip and ankle joints in the sagittal plane. SIGNIFICANCE The propulsive force of the hip and ankle joints was regained after shunt surgery. Normalization of the Evans index could predict improvement in propulsive force after shunt surgery in iNPH.
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Affiliation(s)
- Ippei Kitade
- Division of Rehabilitation Medicine, University of Fukui Hospital, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan.
| | - Ryuhei Kitai
- Department of Neurosurgery, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan
| | - Hiroyuki Neishi
- Department of Neurosurgery, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan
| | - Ken-Ichiro Kikuta
- Department of Neurosurgery, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan
| | - Seiichiro Shimada
- Division of Rehabilitation Medicine, University of Fukui Hospital, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan
| | - Akihiko Matsumine
- Division of Rehabilitation Medicine, University of Fukui Hospital, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan; Department of Orthopaedic Surgery, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui 910-1193, Japan
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Kockum K, Lilja‐Lund O, Larsson E, Rosell M, Söderström L, Virhammar J, Laurell K. The idiopathic normal‐pressure hydrocephalus Radscale: a radiological scale for structured evaluation. Eur J Neurol 2018; 25:569-576. [DOI: 10.1111/ene.13555] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/18/2017] [Indexed: 11/25/2022]
Affiliation(s)
- K. Kockum
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund Umeå University UmeåSweden
| | - O. Lilja‐Lund
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund Umeå University UmeåSweden
| | - E.‐M. Larsson
- Department of Surgical Sciences, Radiology Uppsala University UppsalaSweden
| | - M. Rosell
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund Umeå University UmeåSweden
| | - L. Söderström
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund Umeå University UmeåSweden
| | - J. Virhammar
- Department of Neuroscience, Neurology Uppsala University Hospital Uppsala Sweden
| | - K. Laurell
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund Umeå University UmeåSweden
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Long-term effects of complications and vascular comorbidity in idiopathic normal pressure hydrocephalus: a quality registry study. J Neurol 2017; 265:178-186. [PMID: 29188384 PMCID: PMC5760598 DOI: 10.1007/s00415-017-8680-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/13/2017] [Indexed: 02/07/2023]
Abstract
Background There is little knowledge about the factors influencing the long-term outcome after surgery for idiopathic normal pressure hydrocephalus (iNPH). Objective To evaluate the effects of reoperation due to complications and of vascular comorbidity (hypertension, diabetes, stroke and heart disease) on the outcome in iNPH patients, 2–6 years after shunt surgery. Methods We included 979 patients from the Swedish Hydrocephalus Quality Registry (SHQR), operated on for iNPH during 2004–2011. The patients were followed yearly by mailed questionnaires, including a self-assessed modified Rankin Scale (smRS) and a subjective comparison between their present and their preoperative health condition. The replies were grouped according to the length of follow-up after surgery. Data on clinical evaluations, vascular comorbidity, and reoperations were extracted from the SHQR. Results On the smRS, 40% (38–41) of the patients were improved 2–6 years after surgery and around 60% reported their general health condition to be better than preoperatively. Reoperation did not influence the outcome after 2–6 years. The presence of vascular comorbidity had no negative impact on the outcome after 2–6 years, assessed as improvement on the smRS or subjective improvement of the health condition, except after 6 years when patients with hypertension and a history of stroke showed a less favorable development on the smRS. Conclusion This registry-based study shows no negative impact of complications and only minor effects of vascular comorbidity on the long-term outcome in iNPH.
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Andersson J, Rosell M, Kockum K, Söderström L, Laurell K. Challenges in diagnosing normal pressure hydrocephalus: Evaluation of the diagnostic guidelines. eNeurologicalSci 2017; 7:27-31. [PMID: 29302622 PMCID: PMC5746061 DOI: 10.1016/j.ensci.2017.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/10/2017] [Indexed: 12/04/2022] Open
Abstract
Purpose To evaluate the present diagnostic guidelines of idiopathic normal pressure hydrocephalus (iNPH) in a sample from the general population. Methods A total of 168 individuals (93 females, 75 males), mean age 75 years (range 66–92) with and without symptoms of iNPH underwent a CT-scan of the brain, a neurological examination with assessment of the triad symptoms, i.e. gait disturbances, memory impairment and urgency incontinence. The participants were then diagnosed as “unlikely”, “possible” and “probable” iNPH according to the American-European and the Japanese guidelines, respectively. Separately, a senior consultant in neurology diagnosed each patient based on the overall clinical picture. Results Obtaining a diagnosis of “probable iNPH” was three times more likely according to the American-European guidelines (n = 35) compared to the Japanese guidelines (n = 11) or the neurologist (n = 11). The concordance was highest (Kappa = 0.69) between the Japanese guidelines and the neurologist. Conclusions Considerable discrepancies were found when diagnosing iNPH according to two international guidelines and a neurologist, respectively. The Japanese guidelines, which include a minimum of two triad symptoms, were most concordant with the neurologist. As a step towards widely accepted, standardized diagnostic criteria, we suggest a revision of the current guidelines, preferably into one common diagnostic system. Normal pressure hydrocephalus lacks common, standardized diagnostic criteria. Considerable discrepancies were found between the two current international guidelines. The highest concordance in diagnoses was between the Japanese guidelines and a neurologist. We suggest a revision of the current guidelines into one common diagnostic system.
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Affiliation(s)
- J Andersson
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund, Umeå University, Sweden
| | - M Rosell
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund, Umeå University, Sweden
| | - K Kockum
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund, Umeå University, Sweden
| | - L Söderström
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund, Umeå University, Sweden
| | - K Laurell
- Department of Pharmacology and Clinical Neuroscience, Neurology, Östersund, Umeå University, Sweden
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Shinoda N, Hirai O, Hori S, Mikami K, Bando T, Shimo D, Kuroyama T, Kuramoto Y, Matsumoto M, Ueno Y. Utility of MRI-based disproportionately enlarged subarachnoid space hydrocephalus scoring for predicting prognosis after surgery for idiopathic normal pressure hydrocephalus: clinical research. J Neurosurg 2017; 127:1436-1442. [PMID: 28156249 DOI: 10.3171/2016.9.jns161080] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The presence of disproportionately enlarged subarachnoid space hydrocephalus (DESH) on brain imaging is a recognized finding of idiopathic normal pressure hydrocephalus (iNPH), but the features of DESH can vary across patients. The aim of this study was to evaluate the utility of MRI-based DESH scoring for predicting prognosis after surgery. METHODS In this single-center, retrospective cohort study, the DESH score was determined by consensus between a group of neurosurgeons, neurologists, and a neuroradiologist based on the preoperative MRI findings of the patients with suspected iNPH. The DESH score was composed of the following 5 items, each scored from 0 to 2 (maximum score 10 points): ventriculomegaly, dilated sylvian fissures, tight high convexity, acute callosal angle, and focal sulcal dilation. The association between the DESH score and improvement of the scores on the modified Rankin Scale (mRS), iNPH Grading Scale (iNPHGS), Mini-Mental State Examination (MMSE), Trail Making Test-A (TMT-A), and Timed 3-Meter Up and Go Test (TUG-t) was examined. The primary end point was improvement in the mRS score at 1 year after surgery, and the secondary outcome measures were the iNPHGS, MMSE, TMT-A, and TUG-t scores at 1 year after surgery. Improvement was determined as improvement of 1 or more levels on mRS, ≥ 1 point on iNPHGS, ≥ 3 points on MMSE, a decrease of > 30% on TMT-A, and a decrease of > 10% on TUG-t. RESULTS The mean DESH score for the 50 patients (mean age 77.6 ± 5.9 years) reviewed in this study was 5.58 ± 2.01. The mean rate of change in the mRS score was -0.50 ± 0.93, indicating an inverse correlation between the DESH score and rate of change in the mRS score (r = -0.749). Patients who showed no improvement in mRS score tended to have a low DESH score as well as low preoperative MMSE and TMT-A scores. There were no differences in the areas of deep white matter hyperintensity and periventricular hyperintensity on the images between patients with and without an improved mRS score (15.6% vs 16.7%, respectively; p = 1.000). The DESH score did differ significantly between patients with and without improved scores on the iNPHGS (6.39 ± 1.76 vs 4.26 ± 1.69, respectively; p < 0.001), MMSE (6.63 ± 1.82 vs 5.09 ± 1.93; p = 0.010), TMT-A (6.32 ± 1.97 seconds vs 5.13 ± 1.93 seconds; p = 0.042), and TUG-t (6.48 ± 1.81 seconds vs 4.33 ± 1.59 seconds; p < 0.001). CONCLUSIONS MRI-based DESH scoring is useful for the prediction of neurological improvement and prognosis after surgery for iNPH.
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Affiliation(s)
| | - Osamu Hirai
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan
| | - Shinya Hori
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan
| | | | - Toshiaki Bando
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan
| | - Daisuke Shimo
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan
| | | | - Yoji Kuramoto
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan
| | | | - Yasushi Ueno
- Department of Neurosurgery, Shinko Hospital, Kobe, Japan
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Kojoukhova M, Vanha KI, Timonen M, Koivisto AM, Nerg O, Rummukainen J, Rauramaa T, Vanninen R, Jääskeläinen JE, Sutela A, Leinonen V. Associations of intracranial pressure with brain biopsy, radiological findings, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2017; 159:51-61. [PMID: 27878614 DOI: 10.1007/s00701-016-3025-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/09/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND It remains unclear how intracranial pressure (ICP) measures are associated with brain biopsies and radiological markers. Here, we aim to investigate associations between ICP and radiological findings, brain biopsies, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus (iNPH). METHOD In this study, we retrospectively analyzed data from 73 patients admitted with suspected iNPH to Kuopio University Hospital. Of these patients, 71% underwent shunt surgery. The NPH registry included data on clinical and radiological examinations, 24-h intraventricular pressure monitoring, and frontal cortical biopsy. RESULTS The mean ICP and mean ICP pulse wave amplitude were not associated with the shunt response. Aggregations of Alzheimer's disease (AD)-related proteins (amyloid-β, hyperphosphorylated tau) in frontal cortical biopsies were associated with a poor shunt response (P = 0.014). High mean ICP was associated with Evans' index (EI; P = 0.025), disproportional sylvian and suprasylvian subarachnoid spaces (P = 0.014), and focally dilated sulci (P = 0.047). Interestingly, a high pulse wave amplitude was associated with AD-related biopsy findings (P = 0.032), but the mean ICP was not associated with the brain biopsy. The ICP was not associated with medial temporal lobe atrophy, temporal horn widths, or white matter changes. ICP B waves were associated with less atrophy of the medial temporal lobe (P = 0.018) and more severe disproportionality between the sylvian and suprasylvian subarachnoid spaces (P = 0.001). CONCLUSIONS The EI and disproportional sylvian and suprasylvian subarachnoid spaces were associated with mean ICP. Disproportionality was also associated with ICP B waves. These associations, although rather weak, with elevated ICP in 24-h measurements, support their value in iNPH diagnostics and suggest that these radiological markers are potentially related to the pathogenesis of iNPH. Interestingly, our results suggested that elevated pulse wave amplitude might be associated with brain amyloid accumulation.
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Affiliation(s)
- Maria Kojoukhova
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, P.O. Box 100, 70029, Kuopio, Finland.
| | - Krista-Irina Vanha
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, P.O. Box 100, 70029, Kuopio, Finland
| | - Matti Timonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, P.O. Box 100, 70029, Kuopio, Finland
| | - Anne M Koivisto
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Ossi Nerg
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Jaana Rummukainen
- Department of Pathology, Kuopio University Hospital, Kuopio, Finland
| | - Tuomas Rauramaa
- Department of Pathology, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine-Pathology, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, P.O. Box 100, 70029, Kuopio, Finland
| | - Anna Sutela
- Department of Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Ville Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, P.O. Box 100, 70029, Kuopio, Finland
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Keong NCH, Pena A, Price SJ, Czosnyka M, Czosnyka Z, Pickard JD. Imaging normal pressure hydrocephalus: theories, techniques, and challenges. Neurosurg Focus 2016; 41:E11. [DOI: 10.3171/2016.7.focus16194] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The pathophysiology of NPH continues to provoke debate. Although guidelines and best-practice recommendations are well established, there remains a lack of consensus about the role of individual imaging modalities in characterizing specific features of the condition and predicting the success of CSF shunting. Variability of clinical presentation and imperfect responsiveness to shunting are obstacles to the application of novel imaging techniques. Few studies have sought to interpret imaging findings in the context of theories of NPH pathogenesis. In this paper, the authors discuss the major streams of thought for the evolution of NPH and the relevance of key imaging studies contributing to the understanding of the pathophysiology of this complex condition.
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Affiliation(s)
- Nicole C. H. Keong
- 1Department of Neurosurgery, National Neuroscience Institute and Duke-NUS Medical School, Singapore
- 2Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
| | - Alonso Pena
- 3SDA Bocconi School of Management, Milan, Italy
| | - Stephen J. Price
- 2Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
| | - Marek Czosnyka
- 2Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
| | - Zofia Czosnyka
- 2Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
| | - John D. Pickard
- 2Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
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Effect of lumbo-peritoneal shunt surgery on neuropsychiatric symptoms in patients with idiopathic normal pressure hydrocephalus. J Neurol Sci 2016; 361:206-12. [DOI: 10.1016/j.jns.2016.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/24/2015] [Accepted: 01/01/2016] [Indexed: 11/21/2022]
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Ringstad G, Emblem KE, Eide PK. Phase-contrast magnetic resonance imaging reveals net retrograde aqueductal flow in idiopathic normal pressure hydrocephalus. J Neurosurg 2015; 124:1850-7. [PMID: 26636385 DOI: 10.3171/2015.6.jns15496] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECT The objective of this study was to assess the net aqueductal stroke volume (ASV) and CSF aqueductal flow rate derived from phase-contrast MRI (PC-MRI) in patients with probable idiopathic normal pressure hydrocephalus (iNPH) before and after ventriculoperitoneal shunt surgery, and to compare observations with intracranial pressure (ICP) scores. METHODS PC-MRI at the level of the sylvian aqueduct was undertaken in patients undergoing assessment for probable iNPH. Aqueductal flow in the craniocaudal direction was defined as positive, or antegrade flow, and net ASV was calculated by subtracting retrograde from antegrade aqueductal flow. Aqueductal flow rate per minute was calculated by multiplying net ASV by heart rate. During the same hospital admission, clinical examination was performed using NPH score and overnight continuous ICP monitoring. Twelve patients were followed prospectively 12 months after shunt placement with clinical assessment and a second PC-MRI. The study also included 2 healthy controls. RESULTS Among 21 patients examined for iNPH, 17 (81%) received a shunt (shunt group), and 4 were treated conservatively (conservative group). Among the patients with shunts, a clinical improvement was observed in 16 (94%) of the 17. Net ASV was negative in 16 (76%) of 21 patients before shunt placement and in 5 (42%) of 12 patients after shunt placement, and increased from a median of -5 μl (range -175 to 27 μl) to a median of 1 μl (range -61 to 30 μl; p = 0.04). Among the 12 patients with PC-MRI after shunt placement, 11 were shunt responders, and in 9 of these 11 either a reduced magnitude of retrograde aqueductal flow, or a complete reversal from retrograde to antegrade flow, occurred. Net ASV was significantly lower in the shunt group than in the conservative group (p = 0.01). The aqueductal flow rate increased from -0.56 ml/min (range -12.78 to 0.58 ml/min) to 0.06 ml/min (range -4.51 to 1.93 ml/min; p = 0.04) after shunt placement. CONCLUSIONS In this cohort of patients with iNPH, retrograde net aqueductal flow was observed in 16 (76%) of 21 patients. It was reversed toward the antegrade direction after shunt placement either by magnitude or completely in 9 (75%) of 12 patients examined using PC-MRI both before and after shunt placement (p = 0.04); 11 of the 12 were shunt responders. The study results question previously established concepts with respect to both CSF circulation pathways and CSF formation rate.
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Affiliation(s)
| | | | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, and.,Faculty of Medicine, University of Oslo, Oslo, Norway
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Feasibility of radiological markers in idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2015; 157:1709-18; discussion 1719. [PMID: 26190755 DOI: 10.1007/s00701-015-2503-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Various radiological markers have been proposed for diagnostics in idiopathic normal pressure hydrocephalus (iNPH). We examined the usefulness of radiological markers in the diagnostics and prediction of shunt response in iNPH. METHOD In this retrospective cohort study, we evaluated brain CT or MRI scans of 390 patients with suspected iNPH. Based on a 24-h intraventricular pressure monitoring session, patients were classified into a non-NPH (n = 161) or probable iNPH (n = 229) group. Volumes of cerebrospinal fluid compartments (lateral ventricles, sylvian and suprasylvian subarachnoid spaces and basal cisterns) were visually assessed. Disproportionally enlarged subarachnoid spaces, flow void, white matter changes, medial temporal lobe atrophy and focally dilated sulci were evaluated. Moreover, we measured quantitative markers: Evans' index (EI), the modified cella media index, mean width of the temporal horns and callosal angle. RESULTS iNPH was more likely in patients with severe volumetric disproportion between the suprasylvian and sylvian subarachnoid spaces than in those without disproportion (OR 7.5, CI 95 % 4.0-14.1, P < 0.0001). Mild disproportion (OR 2.6, CI 95 % 1.4-4.6, P = 0.001) and narrow temporal horns (OR per 1 mm 0.91, CI 95 % 0.84-0.98, P = 0.014) were also associated with an iNPH diagnosis. Other radiological markers had little association with the iNPH diagnosis in the final combined multivariate model. Interestingly, EI was higher in non-NPH than iNPH patients (0.40 vs. 0.38, P = 0.039). Preoperative radiological markers were not associated with shunt response. CONCLUSIONS Visually evaluated disproportion was the most useful radiological marker in iNPH diagnostics. Narrower temporal horns also supported an iNPH diagnosis, possibly since atrophy was more pronounced in the non-NPH than iNPH group.
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Ringstad G, Emblem KE, Geier O, Alperin N, Eide PK. Aqueductal Stroke Volume: Comparisons with Intracranial Pressure Scores in Idiopathic Normal Pressure Hydrocephalus. AJNR Am J Neuroradiol 2015; 36:1623-30. [PMID: 25977480 PMCID: PMC7968750 DOI: 10.3174/ajnr.a4340] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/11/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Aqueductal stroke volume from phase-contrast MR imaging has been proposed for predicting shunt response in normal pressure hydrocephalus. However, this biomarker has remained controversial in use and has a lack of validation with invasive intracranial monitoring. We studied how aqueductal stroke volume compares with intracranial pressure scores in the presurgical work-up and clinical score, ventricular volume, and aqueduct area and assessed the patient's response to shunting. MATERIALS AND METHODS Phase-contrast MR imaging was performed in 21 patients with probable idiopathic normal pressure hydrocephalus. Patients were selected for shunting on the basis of pathologically increased intracranial pressure pulsatility. Patients with shunts were offered a second MR imaging after 12 months. Ventricular volume and transverse aqueductal area were calculated, as well as clinical symptom score. RESULTS No correlations between aqueductal stroke volume and preoperative scores of mean intracranial pressure or mean wave amplitudes were observed. Preoperative aqueductal stroke volume was not different between patients with shunts and conservatively treated patients (P = .69) but was correlated with ventricular volume (R = 0.60, P = .004) and aqueductal area (R = 0.58, P = .006) but not with the severity or duration of clinical symptoms. After shunting, aqueductal stroke volume (P = .006) and ventricular volume (P = .002) were reduced. A clinical improvement was seen in 16 of 17 patients who had shunts (94%). CONCLUSIONS Aqueductal stroke volume does not reflect intracranial pressure pulsatility or symptom score, but rather aqueduct area and ventricular volume. The results do not support the use of aqueductal stroke volume for selecting patients for shunting.
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Affiliation(s)
- G Ringstad
- From the Department of Radiology and Nuclear Medicine (G.R.)
| | - K E Emblem
- Intervention Centre (K.E.E., O.G.), Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - O Geier
- Intervention Centre (K.E.E., O.G.), Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - N Alperin
- Department of Radiology (N.A.), University of Miami Miller School of Medicine, Miami, Florida
| | - P K Eide
- Department of Neurosurgery (P.K.E.), Oslo University Hospital, Oslo, Norway Faculty of Medicine (P.K.E.), University of Oslo, Oslo, Norway
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Tudor KI, Tudor M, McCleery J, Car J. Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH). Cochrane Database Syst Rev 2015. [PMID: 26222251 PMCID: PMC9187909 DOI: 10.1002/14651858.cd010033.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) is a type of communicating hydrocephalus also known as non-obstructive hydrocephalus. This type of hydrocephalus is caused by impaired cerebrospinal fluid reabsorption without any obstruction in the ventricular system and is associated with normal cerebrospinal fluid pressure. It is characterised clinically by gait disturbance, cognitive dysfunction, and urinary incontinence (known as the Hakim-Adams triad). The exact cause of iNPH is unknown. It may be managed conservatively or treated surgically by inserting a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. However, a substantial number of patients do not respond well to surgical treatment, complication rates are high and there is often a need for further surgery. Endoscopic third ventriculostomy (ETV) is an alternative surgical intervention. It has been suggested that ETV may lead to better outcomes, including fewer complications. OBJECTIVES To determine the effectiveness of ETV for treatment of patients with iNPH compared to conservative therapy, or shunting of CSF using VP or VA shunts.To assess the perioperative and postoperative complication rates in patients with iNPH after ETV compared to conservative therapy, VP or VA shunting. SEARCH METHODS We searched for eligible studies using ALOIS: a comprehensive register of dementia studies, The Cochrane Central Register of Controlled Trials (CENTRAL) and several bibliographic databases such as MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (BIREME).We also searched the Database of Abstracts of Reviews of Effects (DARE) to identify potentially relevant reviews. The search strategy was adapted for other databases, using the most appropriate controlled vocabulary for each. We did not apply any language or time restrictions. The searches were performed in August 2014. SELECTION CRITERIA We included randomised controlled trials (RCTs) of ETV treatment of iNPH. Patients had to have at least two symptoms of the Hakim-Adams triad. Exclusion criteria were obstructive causes of hydrocephalus, other significant intracranial pathology and other confirmed causes of dementia. The eligible comparators were conservative treatment or shunting using VP and VA shunts. DATA COLLECTION AND ANALYSIS Two review authors independently screened search results, selected eligible studies, assessed risk of bias and extracted data. We contacted trial authors for additional data. MAIN RESULTS Only one study met the inclusion criteria: an RCT comparing effectiveness of ETV and non-programmable VP shunts in 42 patients with iNPH. The study was conducted in Brazil between 2009 and 2012. The overall study risk of bias was high. The primary outcome in the study was the proportion of patients with improved symptoms one year after surgery, determined as a change of at least two points on the Japanese NPH scale. Due to imprecision in the results, it was not possible to determine whether there was any difference between groups in the proportion of patients who improved 3 or 12 months after surgery (3 months: odds ration (OR) 1.12, 95% confidence interval (CI) 0.26 to 4.76, n = 42; 12 months: OR 2.5, 95% CI 0.62 to 10.11, n = 38). We were unable to estimate the effect of treatment on other efficacy outcomes (cognition, balance, function, gait and mobility) because they were inadequately reported. Of the 26 patients in the VP shunting group, 5 developed subdural hematoma postoperatively, while there were no complications among the 16 patients in the ETV group (OR 0.12, 95% CI 0.01 to 2.3, n = 42), but the estimate was too imprecise to determine whether this was likely to reflect a true difference in complication rates. This was also the case for rates of further surgical intervention (OR 1.4, 95% CI 0.31 to 6.24, n = 42). There were no deaths during the trial. We judged the quality of evidence for all outcomes to be very low because of a high risk of selection, attrition and reporting bias and serious imprecision in the results. AUTHORS' CONCLUSIONS The only randomised trial of ETV for iNPH compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH.
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Affiliation(s)
- Katarina Ivana Tudor
- University Hospital Center ZagrebDepartment of NeurologyKispaticeva 12ZagrebCroatia10000
| | - Mario Tudor
- University Clinical HospitalDepartment for NeurosurgerySplitCroatia21000
| | - Jenny McCleery
- Oxford Health NHS Foundation TrustElms CentreOxford RoadBanburyOxfordshireUKOX16 9AL
| | - Josip Car
- Imperial College & Nanyang Technological UniversityLee Kong Chian School of Medicine3 Fusionopolis Link, #03‐08Nexus@one‐northSingaporeSingapore138543
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Cagnin A, Simioni M, Tagliapietra M, Citton V, Pompanin S, Della Puppa A, Ermani M, Manara R. A Simplified Callosal Angle Measure Best Differentiates Idiopathic-Normal Pressure Hydrocephalus from Neurodegenerative Dementia. J Alzheimers Dis 2015; 46:1033-8. [DOI: 10.3233/jad-150107] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Annachiara Cagnin
- Department of Neurosciences, University of Padova, Padova, Italy
- IRCCS San Camillo Hospital Foundation, Venice, Italy
| | | | | | | | - Sara Pompanin
- Department of Neurosciences, University of Padova, Padova, Italy
| | | | - Mario Ermani
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Renzo Manara
- Neuroradiology, Section of Neurosciences, University of Salerno, Salerno, Italy
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Hiraoka K, Narita W, Kikuchi H, Baba T, Kanno S, Iizuka O, Tashiro M, Furumoto S, Okamura N, Furukawa K, Arai H, Iwata R, Mori E, Yanai K. Amyloid deposits and response to shunt surgery in idiopathic normal-pressure hydrocephalus. J Neurol Sci 2015; 356:124-8. [PMID: 26095458 DOI: 10.1016/j.jns.2015.06.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/18/2015] [Accepted: 06/13/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In previous studies, patients with idiopathic normal-pressure hydrocephalus (iNPH) occasionally showed Alzheimer's pathology in frontal lobe cortical biopsy during cerebrospinal fluid shunt surgery or intracranial pressure monitoring. In clinical practice, the differential diagnosis of iNPH from Alzheimer's disease (AD) can be problematic, particularly because some iNPH cases exhibit AD comorbidity. In this study, we evaluated amyloid deposition in the brains of patients with iNPH before shunt surgery, and investigated the association between brain amyloid deposits and clinical improvement following the surgery. MATERIALS & METHODS Amyloid imaging was performed in patients with iNPH or AD and also in healthy control subjects by using positron emission tomography (PET) and a radiolabeled pharmaceutical compound, (11)C-BF227. Using the cerebellar hemispheres as reference regions, the standard uptake value ratio (SUVR) of the neocortex was estimated and used as an index for amyloid deposition. In patients with iNPH, clinical symptoms were assessed before shunt surgery and 3 months after surgery. RESULTS Five of the 10 patients with iNPH had neocortical SUVRs that were as high as those of AD subjects, whereas the SUVRs of the 5 patients were as low as those of healthy controls. A significant inverse correlation between neocortical SUVRs and cognitive improvements after shunt surgery was observed in iNPH. CONCLUSIONS The amount of amyloid deposits ranges widely in the brains of patients with iNPH and is associated with the degree of cognitive improvement after shunt surgery.
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Affiliation(s)
- Kotaro Hiraoka
- Division of Cyclotron Nuclear Medicine, Cyclotron and Radioisotope Center, Tohoku University, 6-3, Aoba, Aramaki, Aoba-ku, Sendai 980-8578, Japan.
| | - Wataru Narita
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Hirokazu Kikuchi
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Toru Baba
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Shigenori Kanno
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Osamu Iizuka
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Manabu Tashiro
- Division of Cyclotron Nuclear Medicine, Cyclotron and Radioisotope Center, Tohoku University, 6-3, Aoba, Aramaki, Aoba-ku, Sendai 980-8578, Japan
| | - Shozo Furumoto
- Department of Pharmacology, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan; Division of Radiopharmaceutical Chemistry, Cyclotron and Radioisotope Center, Tohoku University, 6-3, Aoba, Aramaki, Aoba-ku, Sendai 980-8578, Japan
| | - Nobuyuki Okamura
- Department of Pharmacology, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Katsutoshi Furukawa
- Department of Geriatrics and Gerontology, Institute of Development, Aging and Cancer, Tohoku University, 4-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Hiroyuki Arai
- Department of Geriatrics and Gerontology, Institute of Development, Aging and Cancer, Tohoku University, 4-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Ren Iwata
- Division of Radiopharmaceutical Chemistry, Cyclotron and Radioisotope Center, Tohoku University, 6-3, Aoba, Aramaki, Aoba-ku, Sendai 980-8578, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Kazuhiko Yanai
- Division of Cyclotron Nuclear Medicine, Cyclotron and Radioisotope Center, Tohoku University, 6-3, Aoba, Aramaki, Aoba-ku, Sendai 980-8578, Japan; Department of Pharmacology, Tohoku University Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
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Vizcarra JA, Lang AE, Sethi KD, Espay AJ. Vascular Parkinsonism: deconstructing a syndrome. Mov Disord 2015; 30:886-94. [PMID: 25997420 DOI: 10.1002/mds.26263] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/27/2015] [Accepted: 04/17/2015] [Indexed: 11/07/2022] Open
Abstract
Progressive ambulatory impairment and abnormal white matter (WM) signal on neuroimaging come together under the diagnostic umbrella of vascular parkinsonism (VaP). A critical appraisal of the literature, however, suggests that (1) no abnormal structural imaging pattern is specific to VaP; (2) there is poor correlation between brain MRI hyperintensities and microangiopathic brain disease and parkinsonism from available clinicopathologic data; (3) pure parkinsonism from vascular injury ("definite" vascular parkinsonism) consistently results from ischemic or hemorrhagic strokes involving the SN and/or nigrostriatal pathway, but sparing the striatum itself, the cortex, and the intervening WM; and (4) many cases reported as VaP may represent pseudovascular parkinsonism (e.g., Parkinson's disease or another neurodegenerative parkinsonism, such as PSP with nonspecific neuroimaging signal abnormalities), vascular pseudoparkinsonism (e.g., akinetic mutism resulting from bilateral mesial frontal strokes or apathetic depression from bilateral striatal lacunar strokes), or pseudovascular pseudoparkinsonism (e.g., higher-level gait disorders, including normal-pressure hydrocephalus with transependimal exudate). These syndromic designations are preferable over VaP until pathology or validated biomarkers confirm the underlying nature and relevance of the leukoaraiosis. © 2015 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Joaquin A Vizcarra
- Facultad de Medicina "Alberto Hurtado", Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Anthony E Lang
- Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Kapil D Sethi
- Georgia Regents University, Department of Neurology, August, Georgia, USA; and Merz Pharmaceuticals, Raleigh, North Carolina, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
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McGovern RA, Kelly KM, Chan AK, Morrissey NJ, McKhann GM. Should ventriculoatrial shunting be the procedure of choice for normal-pressure hydrocephalus? J Neurosurg 2014; 120:1458-64. [DOI: 10.3171/2014.1.jns131808] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Ventriculoatrial (VA) shunting is rarely used for patients with normal-pressure hydrocephalus (NPH), likely due to surgeon technical preference and case reports indicating cardiopulmonary complications. However, these complications have typically been limited to adults in whom VA shunts had been placed when they were children. Few studies have directly compared VA shunting to ventriculoperitoneal (VP) shunting in cases of NPH.
Methods
The authors retrospectively analyzed all NPH patients treated by a single surgeon at their center from January 2002 through December 2011. Thirty patients were treated with VA shunts (14 male) and 157 with VP shunts (86 male). The patients' mean age (± SD) at surgery was 73.7 ± 9.4 years for VA shunting and 76.0 ± 8.2 years for VP shunting; the median durations of follow-up were 42.0 months (IQR 19.2–63.6 months) and 34.2 months (IQR 15.8–67.5), respectively. Statistical analysis was performed using chi-square tests and Wilcoxon rank-sum tests.
Results
Perioperative and postoperative complications for VA and VP shunting cohorts, respectively, included distal revision (2.7% vs 6.6%, p = 0.45), proximal revision (2.7% vs 2.5%, p = 0.97), and postoperative seizure (2.7% vs 1.5%, p = 0.62). Shunt drainage–related subdural hematomas/hygromas developed in 8.1%/27.0% of VA shunt–treated patients versus 6.6%/26.4% of VP shunt–treated patients (p = 0.76/0.98) and were nearly always successfully managed with programmable-valve adjustment. Symptomatic intracerebral hemorrhage (1.5%) and shunt infection (2.0%) were only observed in those who underwent VP shunting. Of note, no cardiovascular complications were observed in any patient, and there were no cases of distal occlusion of the VA shunt.
Conclusions
The authors found no significant differences in complication rates between VA and VP shunting, and VA shunting was not associated with any cardiopulmonary complications. Thus, in the authors' experience, VA shunting is at least as safe as VP shunting for treating NPH.
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Affiliation(s)
| | | | | | - Nicholas J. Morrissey
- 2Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, New York
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Takeuchi T, Fukushima S, Misaki D, Shibata S. Lumbosubarachnoid-lumboepidural shunting in patients with idiopathic normal-pressure hydrocephalus: surgical procedures and follow-up study of five cases. Neurol Med Chir (Tokyo) 2013; 53:638-43. [PMID: 24067779 PMCID: PMC4508686 DOI: 10.2176/nmc.tn2012-0366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The objective of the study is to introduce the surgical procedure of the lumbosubarachnoid–lumboepidural (L–L) shunting performed as treatment for idiopathic normal-pressure hydrocephalus (iNPH) and its follow-up. The subjects were five patients with probable iNPH (aged 78–85 years; mean age 81 years; four males and one female) who were judged to be at high risk from general or lumbar anesthesia due to their systemic complications and age. The L–L shunt operation was performed for all the patients under local anesthesia using Codman–Hakim Programmable Valve® (Codman & Shurtleff, Inc., Raynham, Massachusetts, USA). The initial pressure for all patients was set at 8 cm H2O. The evaluation of shunt efficacy and the lumbar epidural space cerebrospinal fluid (CSF) absorption test (injection of contrast media into epidural space) were performed both on the operation day and during follow-up period (9–12 months). The shunt operation was judged to be effective in four out of five patients (regarded as shunt responders), whereas no improvement in symptoms was seen in one patient (regarded as shunt nonresponder) where the shunting had no effect after the initial pressure was changed to 4 cm H2O. The lumbar epidural space CSF absorption test both on the operation day and during the follow-up period confirmed absorption in all patients. The L–L shunting is useful for patients with probable iNPH who are at high risk from general or lumbar anesthesia due to their systemic complications and age. CSF was continuously absorbed in the lumbar epidural space during postoperative follow-up period. A longer follow-up is required to establish this surgical procedure.
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Miyamoto J, Imahori Y, Mineura K. Cerebral oxygen metabolism in idiopathic-normal pressure hydrocephalus. Neurol Res 2013; 29:830-4. [PMID: 17716389 DOI: 10.1179/016164107x181851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To distinguish idiopathic-normal pressure hydrocephalus (i-NPH) from the elder with brain atrophy is difficult. This investigation was undertaken to determine the cerebral oxygen metabolism and the cerebral blood flow using positron emission tomography (PET) in patients with i-NPH. Comparison of the variables between i-NPH patients and the age-comparable control with asymptomatic ventricular dilatation were performed. METHODS Nineteen patients were studied. Nine i-NPH patients with a mean age of 74.8 +/- 1.8 years (mean +/- SD) were examined using PET. The subjects who underwent a ventriculoperitoneal shunt (VPS) had the triad of NPH and ventricular dilatation on computed tomography (CT) and/or magnetic resonance imaging (MRI). The results of the PET study were compared with those for ten age-comparable controls (74.8 +/- 5.5 years) with asymptomatic ventricular dilatation and no severe cerebrovascular disease on MRI and magnetic resonance angiography (MRA). The PET study included analyses of regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV), regional oxygen extraction fraction (rOEF) and regional cerebral metabolic rate of oxygen (rCMRO(2)). RESULTS In i-NPH, rCBF tended to decrease in the frontal lobe and the basal ganglia. rCMRO(2) in the frontal lobe of i-NPH was significantly higher than that in the controls (p<0.05 by Student's t-test), although rCMRO(2) in the basal ganglia of i-NPH was reduced. rCBV and rOEF showed no significant differences. CONCLUSION Reduction of oxygen metabolism in the basal ganglia might be one of the factors causing symptoms in i-NPH. Particular pattern of cerebral oxygen metabolism in i-NPH was not obvious in the present study.
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Affiliation(s)
- Junichi Miyamoto
- Department of Neurosurgery, Kyoto Prefectural University Graduate School of Medicine, Kyoto, Japan.
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Malm J, Graff-Radford NR, Ishikawa M, Kristensen B, Leinonen V, Mori E, Owler BK, Tullberg M, Williams MA, Relkin NR. Influence of comorbidities in idiopathic normal pressure hydrocephalus - research and clinical care. A report of the ISHCSF task force on comorbidities in INPH. Fluids Barriers CNS 2013; 10:22. [PMID: 23758953 PMCID: PMC3689166 DOI: 10.1186/2045-8118-10-22] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/28/2013] [Indexed: 01/18/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (INPH) is a syndrome of ventriculomegaly, gait impairment, cognitive decline and incontinence that occurs in an elderly population prone to many types of comorbidities. Identification of the comorbidities is thus an important part of the clinical management of INPH patients. In 2011, a task force was appointed by the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders (ISHCSF) with the objective to compile an evidence-based expert analysis of what we know and what we need to know regarding comorbidities in INPH. This article is the final report of the task force. The expert panel conducted a comprehensive review of the literature. After weighing the evidence, the various proposals were discussed and the final document was approved by all the task force members and represents a consensus of expert opinions. Recommendations regarding the following topics are given: I. Musculoskeletal conditions; II. Urinary problems; III. Vascular disease including risk factors, Binswanger disease, and white matter hyperintensities; IV. Mild cognitive impairment and Alzheimer disease including biopsies; V. Other dementias (frontotemporal dementia, Lewy body, Parkinson); VI. Psychiatric and behavioral disorders; VII. Brain imaging; VIII. How to investigate and quantify. The task force concluded that comorbidity can be an important predictor of prognosis and post-operative outcome in INPH. Reported differences in outcomes among various INPH cohorts may be partly explained by variation in the rate and types of comorbidities at different hydrocephalus centers. Identification of comorbidities should thus be a central part of the clinical management of INPH where a detailed history, physical examination, and targeted investigations are the basis for diagnosis and grading. Future INPH research should focus on the contribution of comorbidity to overall morbidity, mortality and long-term outcomes.
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Affiliation(s)
- Jan Malm
- Department of Clinical Neuroscience, Umeå University, Umeå, 901 85, Sweden.
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Regional Cerebral Metabolic Rate of Glucose Evaluation and Clinical Assessment in Patients With Idiopathic Normal-Pressure Hydrocephalus Before and After Ventricular Shunt Placement. Clin Nucl Med 2013; 38:426-31. [DOI: 10.1097/rlu.0b013e31828e949b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
CLINICAL ISSUE A correct interpretation of radiological data in cases of suspected hydrocephalus is not possible when ignoring patient age and clinical symptoms. STANDARD TREATMENT An in-depth knowledge of clinical findings is accordingly essential. INNOVATIONS New pathophysiological findings and a detailed assignment of previously unrecognized or ignored clinical symptoms to various entities of the spectrum of hydrocephalus disorders allow a coherent diagnosis drawn from clinical and radiological data. For this purpose it is necessary to know the specific symptoms of hydrocephalus in relation to age. Especially in chronic hydrocephalus, this is of utmost importance to avoid misdiagnosis. DIAGNOSTIC WORK-UP The radiological method of choice depends on the age and the specific issue to be addressed. ACHIEVEMENTS The typical clinical symptoms of different hydrocephalus entities presented here must be considered as confirmed knowledge. PRACTICAL RECOMMENDATIONS Only the synopsis of clinical and radiological findings currently allows correct interpretation of imaging. There is a threat of misdiagnosis if interpretation is restricted purely to radiological findings as the sole predictive value of modern imaging is still too limited despite all innovations.
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Affiliation(s)
- R Eymann
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg/Saar, Kirrbergerstraße, Homburg/Saar, Deutschland.
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Mattei TA, Nair K, Morris M, Cole D, Flatt M, Goulart CR, Kroeter B, Warren S, Lin JJ. Design and benchmark testing of a bicorporal pump for the treatment of normal-pressure hydrocephalus and idiopathic intracranial hypertension. J Neurosurg Pediatr 2013; 11:188-97. [PMID: 23215632 DOI: 10.3171/2012.10.peds12119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Addressing overdrainage and its associated complications is still one of the greatest challenges for future shunt designs for normal-pressure hydrocephalus and idiopathic intracranial hypertension. Nevertheless, as evidenced by tap test procedures, a small amount of CSF drainage seems to be enough to relieve patients' symptoms in most cases and, therefore, in opposition to other types of hydrocephalus, continuous CSF drainage may not be absolutely warranted. In such a clinical scenario, intermittent controlled drainage of a small amount of CSF during specific periods of the day through a 2-system pump may provide several advantages over continuous drainage of current single-system shunts. The goal in this study was to design and test an innovative concept of a bicorporal pump composed of a 2-part system. The first component was designed to be implanted in the patient and act as a pump connected to standard catheter tubing. The second component was designed to be used as an external device outside of the body and function as a power supply and control system. Ultimately, flow will only occur when the system is powered by the external device. METHODS Testing and comparisons were performed to evaluate free fluid flow and the maximal flow after pumping in the standing and supine positions. After this, the authors compared the hydrodynamic effects of 2 different housing systems (2- and 3-in systems). An attenuation test was performed to show the effects of electromagnetic forces at progressively increasing distances. Finally, a biocompatibility report of the raw material used in the pilot design was completed. RESULTS In the supine position, the effect of pumping was observed to increase the volumetric flow at a rate similar to or higher than that yielded in the free-flow tests. In relation to the attenuation test, it was observed that the volume drops off fairly quickly as the air gap distance was increased until ultimately reaching zero, with approximately 15 mm between the 2 components. In relation to the testing force, the 2-in housing model showed a considerable increase in the required electromagnetic force over the 3-in housing. CONCLUSIONS The authors successfully designed and tested a new intermittent drainage system through a bicorporal shunt, which provides several advantages over current single-system continuous drainage pumps. According to the authors' benchmark results, the 3-in housing model seems to be a better choice as it requires less force from the external electromagnet control. Moreover, attenuation tests demonstrated that, for proper functioning, the gap distance between the external and implanted devices should not be greater than 15 mm. Such initial benchmark results confirm the feasibility of such innovative design and provide support for future testing of the system in in vivo animal models and in future clinical series.
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Affiliation(s)
- Tobias A Mattei
- Department of Neurosurgery, Illinois Neurological Institute, The University of Illinois College of Medicine at Peoria, Peoria, Illinois 61637, USA.
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Hellström P, Klinge P, Tans J, Wikkelsø C. A new scale for assessment of severity and outcome in iNPH. Acta Neurol Scand 2012; 126:229-37. [PMID: 22587624 DOI: 10.1111/j.1600-0404.2012.01677.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To present a new, continuous, calibrated and norm-based scale for the grading of severity and assessment of treatment outcome in idiopathic normal pressure hydrocephalus (iNPH). PATIENTS AND METHODS A scale designed for the assessment of the four domains, gait, neuropsychology, balance and continence, using ordinal ratings and continuous measures, was developed. Data from a series of 181 consecutive iNPH patients were used to calibrate the continuous parts of the scale and to describe the distributional properties of the ordinal ratings. Data from normative studies were used to determine the limits for normal scores. RESULTS The construction of the scale made it well equipped to separate iNPH patients at baseline, and the total scores assumed a bell-shaped, approximately normal distribution. All four domain scores correlated significantly with each other, underscoring the well-known syndromatic nature of iNPH, and justifying the use of a total score to describe the patients. Reliability [Cronbach's α for the total score = 0.74, and for the domains of gait and neuropsychology, 0.86 and 0.89, respectively) and validity estimates (convergent validity evaluated by Spearman rank correlations for the scale and the modified Rankin scale (ρ = -0.61) and the mini mental state examination (ρ = 0.57)] are satisfying. CONCLUSION The iNPH scale covers the four most important symptom domains and the full range of severity of the iNPH syndrome. The scale is sensitive, reliable, valid and feasible. We recommend that it should be used in future iNPH research.
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Affiliation(s)
- P. Hellström
- Hydrocephalus Research Unit; Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg; Gothenburg; Sweden
| | - P. Klinge
- Department of Neurosurgery; Rhode Island Hospital, Brown Medical School; Providence; RI; USA
| | - J. Tans
- Department of Neurology; Medical Centre Haaglanden; The Hague; The Netherlands
| | - C. Wikkelsø
- Hydrocephalus Research Unit; Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg; Gothenburg; Sweden
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Hermann EJ, Capelle HH, Tschan CA, Krauss JK. Electromagnetic-guided neuronavigation for safe placement of intraventricular catheters in pediatric neurosurgery. J Neurosurg Pediatr 2012; 10:327-33. [PMID: 22880888 DOI: 10.3171/2012.7.peds11369] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ventricular catheter shunt malfunction is the most common reason for shunt revision. Optimal ventricular catheter placement can be exceedingly difficult in patients with small ventricles or abnormal ventricular anatomy. Particularly in children and in premature infants with small head size, satisfactory positioning of the ventricular catheter can be a challenge. Navigation with electromagnetic tracking technology is an attractive and innovative therapeutic option. In this study, the authors demonstrate the advantages of using this technology for shunt placement in children. METHODS Twenty-six children ranging in age from 4 days to 14 years (mean 3.8 years) with hydrocephalus and difficult ventricular anatomy or slit ventricles underwent electromagnetic-guided neuronavigated intraventricular catheter placement in a total of 29 procedures. RESULTS The single-coil technology allows one to use flexible instruments, in this case the ventricular catheter stylet, to be tracked at the tip. Head movement during the operative procedure is possible without loss of navigation precision. The intraoperative catheter placement documented by screenshots correlated exactly with the position on the postoperative CT scan. There was no need for repeated ventricular punctures. There were no operative complications. Postoperatively, all children had accurate shunt placement. The overall shunt failure rate in our group was 15%, including 3 shunt infections (after 1 month, 5 months, and 10 months) requiring operative revision and 1 distal shunt failure. There were no proximal shunt malfunctions during follow-up (mean 23.5 months). CONCLUSIONS The electromagnetic-guided neuronavigation system enables safe and optimal catheter placement, especially in children and premature infants, alleviating the need for repeated cannulation attempts for ventricular puncture. In contrast to stereotactic techniques and conventional neuronavigation, there is no need for sharp head fixation using a Mayfield clamp. This technique may present the possibility of reducing proximal shunt failure rates and costs for hydrocephalus treatment in this age cohort.
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Affiliation(s)
- Elvis J Hermann
- Department of Neurosurgery, Medical School Hannover, Germany.
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