Development of a nomogram for fetal Evans Index

PURPOSE

This study aims to investigate the fetal Evans Index and establish a nomogram for fetuses without any additional fetal anomalies detected during the prenatal period.

METHODS

We conducted our research at Ankara City Hospital, including 894 patients who were admitted and evaluated between gestational weeks 16-40. These patients had no fetal anomalies detected in subsequent gestational weeks. Descriptive data, such as age, gravidity, parity, and body mass index (BMI), were recorded. Gestational week and Evans Index (mean, median, standard deviation, minimum, maximum, and percentile) were also documented. The Evans index was calculated as the ratio between the maximal width of the frontal horns and the maximal width of the inner diameter of the cranium.

RESULTS

We evaluated 894 fetuses in pregnant women had no fetal anomalies detected throughout the pregnancy. The evaluation took place at different gestational weeks, and a nomogram for the Evans Index was created.

CONCLUSIONS

It is relevant for clinicians and researchers to be aware of the range of fetal Evans Index values across different gestational weeks as a prognostic criterion.

MRI markers of idiopathic normal pressure hydrocephalus in a population study with 791 participants: Exploring reference values and associations

PURPOSE

Epidemiological studies on idiopathic normal pressure hydrocephalus (iNPH) imaging markers and their normal values are scarce. This population-based study aimed to analyze several morphologic and volumetric iNPH-related imaging markers in a large sample, determining their distribution, diagnostic accuracy, suggested cut-offs, and associations with iNPH symptoms.

METHODS

This cross-sectional study included 791 70 year olds, 40 with radiologically probable iNPH (iNPHRadiol) and 751 without iNPH features (reference). MRI measures included Evans index (EI), z-EI, brain per ventricle ratio at anterior (BVRAC) and posterior commissures (BVRPC), sulcal compression, Sylvian fissure enlargement, callosal angle, diameter of temporal horns, 3rd and 4th ventricles, midbrain, and pons. Volumes of ventricles, corpus callosum, and brainstem were computed using automated segmentation. ROC analysis determined imaging markers' cut-offs. Symptoms were evaluated clinically and through self-report.

RESULTS

In the reference group, median values (95% CI) for imaging markers were as follows: EI: 0.27 (0.26-0.27), z-EI: 0.28 (0.26-0.31), BVRAC: 1.69 (1.48-1.90), and BVRPC: 2.66 (2.24-3.27). Most imaging markers differed significantly between iNPHRadiol and the reference. Lateral ventricle volumes correlated better with z-EI and BVR than EI (Rs > 0.81 vs 0.68). Optimal cut-off values for z-EI, and BVRAC and BVRPC for distinguishing iNPHRadiol were 0.32, 1.36, and 1.83, respectively. Clinical symptoms correlated moderately with imaging markers (Rs < 0.49 for iNPHRadiol, p < .01).

CONCLUSIONS

We report population-based reference values and propose cut-offs for iNPH-related imaging markers and volumetric measurements. Z-EI and BVR are likely superior markers for assessing ventricular enlargement in iNPH. Imaging markers of iNPH correlate moderately with iNPH symptoms.

Efficacy of Ventriculoperitoneal Shunt for Postoperative Central Nervous System Infection Complicated with Hydrocephalus

Objective  Our aim was to assess the efficacy of ventriculoperitoneal shunt (VPS) for treating postoperative central nervous system infection (PCNSI) complicated with hydrocephalus and to identify factors associated with treatment failure. Materials and Methods  We conducted a retrospective analysis of PCNSI patients with hydrocephalus treated by VPS at the Department of Neurosurgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, between December 2012 and January 2020. Functional recovery was evaluated during follow-up using the Glasgow Outcome Scale. Results  A total of 29 patients (21 males, 8 females) were enrolled in the study (mean age: 56.4 ± 12.0 years, range: 18.0-77.0 years). Seventeen patients were treated successfully by VPS (58.6%). Among the 11 patients with shunt complications (37.9%), 8 (27.6%) presented with fever, 3 (10.3%) with shunt infection, and 3 (10.3%) with shunt obstruction. Univariate analysis identified low Glasgow Coma Scale (GCS) score (3-8) at the time of VPS and post-treatment fever as predictive of shunt failure. Conclusion  VPS was effective for treating PCNSI complicated with hydrocephalus. However, patients with low GCS score at the time of VPS or fever post-treatment were at greater risk of shunt failure and poor outcome.

Shunting for idiopathic normal pressure hydrocephalus

BACKGROUND

Normal pressure hydrocephalus (NPH) occurs when the brain ventricles expand, causing a triad of gait, cognitive, and urinary impairment. It can occur after a clear brain injury such as trauma, but can also occur without a clear cause (termed idiopathic, or iNPH). Non-randomised studies have shown a benefit from surgically diverting ventricular fluid to an area of lower pressure by cerebrospinal fluid (CSF)-shunting in iNPH, but historically there have been limited randomised controlled trial (RCT) data to confirm this.

OBJECTIVES

To determine the effect of CSF-shunting versus no CSF-shunting in people with iNPH and the frequency of adverse effects of CSF-shunting in iNPH.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 15 February 2023.

SELECTION CRITERIA

We included only RCTs of people who had symptoms of gait, cognitive, or urinary impairment with communicating hydrocephalus (Evans index of > 0.3) and normal CSF pressure. Control groups included those with no CSF shunts or those with CSF shunts that were in 'inactive' mode.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Where necessary, we contacted study authors requesting data not provided in the papers. We assessed the overall certainty of the evidence using GRADE.

MAIN RESULTS

We included four RCTs, of which three were combined in a meta-analysis. The four RCTs included 140 participants (73 with immediate CSF-shunting and 67 controls who had delayed CSF-shunting) with an average age of 75 years. Risk of bias was low in all parallel-group outcomes evaluated apart from gait speed, cognitive function (general cognition and Symbol Digit Test) (some concerns) and adverse events, which were not blind-assessed. CSF-shunting probably improves gait speed at less than six months post-surgery (standardised mean difference (SMD) 0.62, 95% confidence interval (CI) 0.24 to 0.99; 3 studies, 116 participants; moderate-certainty evidence). CSF-shunting may improve qualitative gait function at less than six months post-surgery by an uncertain amount (1 study, 88 participants; low-certainty evidence). CSF-shunting probably results in a large reduction of disability at less than six months post-surgery (risk ratio 2.08, 95% CI 1.31 to 3.31; 3 studies, 118 participants; moderate-certainty evidence). The evidence is very uncertain about the effect of CSF-shunting on cognitive function at less than six months post-CSF-shunt surgery (SMD 0.35, 95% CI -0.04 to 0.74; 2 studies, 104 participants; very low-certainty evidence). The evidence is also very uncertain about the effect of CSF-shunt surgery on adverse events (1 study, 88 participants; very low-certainty evidence). There were no data regarding the effect of CSF-shunting on quality of life.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that CSF-shunting likely improves gait speed and disability in iNPH in the relative short term. The evidence is very uncertain regarding cognition and adverse events. There were no longer-term RCT data for any of our prespecified outcomes. More studies are required to improve the certainty of these findings. In addition, more information is required regarding patient ethnicity and the effect of CSF-shunting on quality of life.

Prognostic Role of Ventricular Size and Its Dynamics in Patients With Leptomeningeal Metastasis From Solid Tumors

BACKGROUND AND OBJECTIVES

Hydrocephalus is a common radiologic sign in patients with leptomeningeal metastasis (LM) from solid tumors which can be assessed using the Evans index (EI). Here, we explored the prognostic value of ventricular size in LM.

METHODS

We identified patients with LM from solid tumors by chart review at 3 academic hospitals to explore the prognostic associations of the EI at diagnosis, first follow-up, and progression.

RESULTS

We included 113 patients. The median age was 58.3 years (interquartile range [IQR] 46.1-65.8), 41 patients (36%) were male, and 72 patients (64%) were female. The most frequent cancers were lung cancer (n = 39), breast cancer (n = 36), and melanoma (n = 23). The median EI at baseline was 0.28 (IQR 0.26-0.31); the EI value was 0.27 or more in 67 patients (59%) and 0.30 or more in 37 patients (33%). Among patients with MRI follow-up, the EI increased by 0.01 or more in 16 of 31 patients (52%), including 8 of 30 patients (30%) without and 10 of 17 patients (59%) with LM progression at first follow-up. At LM progression, an increase of EI of 0.01 or more was noted in 18 of 34 patients (53%). The median survival was 2.9 months (IQR 1-7.2). Patients with a baseline EI below 0.27 had a longer survival than those with an EI of 0.27 or more (5.3 months, IQR 2.4-10.8, vs 1.3 months, IQR 0.6-4.1) (HR 1.70, 95% CI 1.135-2.534, p = 0.0099). The median survival was 3.7 months (IQR 1.4-8.3) with an EI below 0.30 vs 1.8 months (IQR 0.8-4.1) with an EI of 0.30 or more (HR 1.40, 95% CI 0.935-1.243, p = 0.1113). Among patients with follow-up scans available, the overall survival was 9.4 months (IQR 5.6-21.0) for patients with stable or decreased EI at first follow-up as opposed to 5.6 months (IQR 2.5-10.5) for those with an increase in the EI (HR 1.08, 95% CI 0.937-1.243; p = 0.300).

DISCUSSION

The EI at baseline is prognostic in LM. An increase of EI during follow-up may be associated with inferior LM progression-free survival. Independent validation cohorts with larger sample size and evaluation of confounding factors will help to better define the clinical utility of EI assessments in LM.

Ratios of head circumference to ventricular size vary over time and predict eventual need for CSF diversion in intraventricular hemorrhage of prematurity

PURPOSE

Intraventricular hemorrhage (IVH) of prematurity can lead to hydrocephalus, sometimes necessitating permanent cerebrospinal fluid (CSF) diversion. We sought to characterize the relationship between head circumference (HC) and ventricular size in IVH over time to evaluate the clinical utility of serial HC measurements as a metric in determining the need for CSF diversion.

METHODS

We included preterm infants with IVH born between January 2000 and May 2020. Three measures of ventricular size were obtained: ventricular index (VI), Evan's ratio (ER), and frontal occipital head ratio (FOHR). The Pearson correlations (r) between the initial (at birth) paired measurements of HC and ventricular size were reported. Multivariable longitudinal regression models were fit to examine the HC:ventricle size ratio, adjusting for the age of the infant, IVH grade (I/II vs. III/IV), need for CSF diversion, and sex.

RESULTS

A total of 639 patients with an average gestational age of 27.5 weeks were included. IVH grade I/II and grade III/IV patients had a positive correlation between initial HC and VI (r = 0.47, p < 0.001 and r = 0.48, p < 0.001, respectively). In our longitudinal models, patients with a low-grade IVH (I/II) had an HC:VI ratio 0.52 higher than those with a high-grade IVH (p-value < 0.001). Patients with low-grade IVH had an HC:ER ratio 12.94 higher than those with high-grade IVH (p-value < 0.001). Patients with low-grade IVH had a HC:FOHR ratio 12.91 higher than those with high-grade IVH (p-value < 0.001). Infants who did not require CSF diversion had an HC:VI ratio 0.47 higher than those who eventually did (p < 0.001). Infants without CSF diversion had an HC:ER ratio 16.53 higher than those who received CSF diversion (p < 0.001). Infants without CSF diversion had an HC:FOHR ratio 15.45 higher than those who received CSF diversion (95% CI (11.34, 19.56), p < 0.001).

CONCLUSIONS

There is a significant difference in the ratio of HC:VI, HC:ER, and HC:FOHR size between patients with high-grade IVH and low-grade IVH. Likewise, there is a significant difference in HC:VI, HC:ER, and HC:FOHR between those who did and did not have CSF diversion. The routine assessments of both head circumference and ventricle size by ultrasound are important clinical tools in infants with IVH of prematurity.

Voxel-based dysconnectomic brain morphometry with computed tomography in Down syndrome

OBJECTIVE

Alzheimer's disease (AD) is a major health concern for aging adults with Down syndrome (DS), but conventional diagnostic techniques are less reliable in those with severe baseline disability. Likewise, acquisition of magnetic resonance imaging to evaluate cerebral atrophy is not straightforward, as prolonged scanning times are less tolerated in this population. Computed tomography (CT) scans can be obtained faster, but poor contrast resolution limits its function for morphometric analysis. We implemented an automated analysis of CT scans to characterize differences across dementia stages in a cross-sectional study of an adult DS cohort.

METHODS

CT scans of 98 individuals were analyzed using an automatic algorithm. Voxel-based correlations with clinical dementia stages and AD plasma biomarkers (phosphorylated tau-181 and neurofilament light chain) were identified, and their dysconnectomic patterns delineated.

RESULTS

Dementia severity was negatively correlated with gray (GM) and white matter (WM) volumes in temporal lobe regions, including parahippocampal gyri. Dysconnectome analysis revealed an association between WM loss and temporal lobe GM volume reduction. AD biomarkers were negatively associated with GM volume in hippocampal and cingulate gyri.

INTERPRETATION

Our automated algorithm and novel dysconnectomic analysis of CT scans successfully described brain morphometric differences related to AD in adults with DS, providing a new avenue for neuroimaging analysis in populations for whom magnetic resonance imaging is difficult to obtain.

Prevalence of idiopathic normal pressure hydrocephalus in patients with vertebral compression fractures

Background

Patients with idiopathic normal pressure hydrocephalus (iNPH) may be more prone to all fracture types due to falls. Vertebral compression fractures (VCFs) are a global burden that temporarily or permanently affects millions of elderly people. This study aimed to investigate the prevalence of iNPH in patients with VCFs.

Methods

We retrospectively reviewed 128 patients aged 60-102 years who underwent balloon kyphoplasty (BKP) for VCFs between November 1, 2017, and March 31, 2020. We also assessed the presence of the iNPH triad (i.e., gait disturbance, cognitive impairment, and urinary incontinence). Patients with Evans' index (EI) >0.3 and the iNPH triad were defined as having possible iNPH, those with clinical improvement after a cerebrospinal fluid tap test were defined as having probable iNPH, and those with clinical improvement after a shunt surgery were defined as having definite iNPH.

Results

Of the 128 patients, seven were excluded due to a history of intracranial disease that could cause ventricular enlargement or gait disturbance. Another 70 patients who did not undergo head computed tomography or magnetic resonance imaging one year before or after BKP were excluded from the study. Finally, 51 patients with a mean age of 78.9 years were enrolled. The mean EI value of these 51 patients was 0.28, with 18 patients showing EI >0.3. Moreover, 18 had possible iNPH, one had probable iNPH, and one had definite iNPH.

Conclusion

Screening for iNPH in elderly patients with VCFs can allow early diagnosis of iNPH and benefit them more from surgical treatment.

Idiopathic normal pressure hydrocephalus possibly affects the occurrence of proximal femoral fracture

AIMS

The clinical triad of idiopathic normal pressure hydrocephalus (iNPH) includes gait disturbance, dementia, and urinary incontinence. These symptoms are also frequently observed in patients with proximal femoral fracture (PFF). The aim of this study was to investigate the relationship between PFF and iNPH retrospectively.

PATIENTS AND METHODS

Of the130 patients over 80-years-old with PFF included in this study, 48 were assigned to the PFF group. Forty-eight patients with peripheral vertigo matched with the PFF group for age and sex were included in the control group. We compared the Evans' index (EI), which is a head computed tomography finding of iNPH, and the percentages of patients with EI>0.3 between the two groups. The PFF group was further divided into two subgroups depending on whether EI was higher or lower than 0.3 (the higher or lower subgroup, respectively). We compared the patient's gait abilities before PFF, causes of PFF, cognitive functions, and occurrence of urinary incontinence between both groups.

RESULTS

The mean value of EI in the PFF group was significantly higher than that in the control group (PFF group, 0.301; control group, 0.284; p=0.008). The percentages of patients with EI>0.3 in the PFF and control groups were 62.5% and 35.4%, respectively (p=0.014). In subgroup analyses, the gait ability before injury was worse in the higher subgroup than that in the lower subgroup and was prominent among individuals who could walk only with human assistance (p=0.018). There were no significant differences in other parameters.

CONCLUSION

Elderly patients with PFF may have underlying idiopathic normal pressure hydrocephalus.

LEVEL OF EVIDENCE

III; case-control comparative study.

Prediction of Permanent Shunt Dependency in Patients with Intraventricular Hemorrhage: Outcomes of Early External Ventricular Drainage Weaning Protocol

BACKGROUND

Hydrocephalus remains a common sequela of intraventricular hemorrhage (IVH) despite adequate drainage of the hematoma, including endoscopic surgery, intraventricular fibrinolysis, and external ventricular drainage (EVD). Moreover, the appropriate timing for conversion from EVD to ventriculoperitoneal shunt (VPS) is uncertain. This study aimed to evaluate the predictors of shunt dependency in patients with IVH based on the early EVD weaning protocol in our institution.

METHODS

We retrospectively reviewed medical records of patients who were diagnosed with primary IVH and secondary IVH from spontaneous intracerebral hemorrhage during the period 2018-2021. Predictors associated with shunt dependency were identified using a logistic regression model. The cutoff point of each variable was selected by receiver operating characteristic curve analysis. Furthermore, shunt complications were reported as a safety measure of our early EVD weaning protocol.

RESULTS

The analysis included 106 patients. After IVH treatment, 15 (14%) patients required ventriculoperitoneal shunt, whereas 91 (86%) patients were shunt-free. The diameter of posttreatment temporal horn and the degree of IVH reduction were the significant predictors of shunt dependency. Moreover, patients with IVH reduction of >45% and temporal horn diameter of <9 mm had a lower probability of shunt dependency. Shunt failure was found in 2 (13.3%) patients.

CONCLUSIONS

This study showed that a large temporal horn diameter and a lower degree of IVH removal were predictors of shunt dependency in patients with IVH. In addition, early conversion from EVD to ventriculoperitoneal shunt is safe and feasible.

Contribution of tumor characteristics and surgery-related factors to symptomatic hydrocephalus after posterior fossa tumor resection: a single-institution experience

OBJECTIVE

Pediatric patients are at risk of persistent hydrocephalus after posterior fossa tumor resection. The relationship between surgery-related factors and postoperative symptomatic hydrocephalus has not been elucidated. The objective of this study was to analyze features influencing postoperative hydrocephalus in Chinese children.

METHODS

The authors retrospectively evaluated 197 patients younger than 15 years of age who underwent posterior fossa tumor resection at their institution from January 2015 to June 2021. The outcome was whether children underwent CSF diversion within 6 months of resection. Preoperative characteristics, surgery-related factors, and postoperative features were included to identify independent prognosticators. A new logistic model containing independent prognosticators was developed and compared with the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH).

RESULTS

In this study, 30 patients (15.2%) underwent CSF diversion within 6 months after tumor resection. Tumor location and consistency, intracranial or spinal tumor metastasis determined by perioperative cerebral and spinal MRI, intraoperative blood loss, ventricular blood as determined on postoperative CT, and pathology were statistically significant variables in the univariate analysis. The only two independent predictors of postoperative symptomatic hydrocephalus were tumor metastasis (OR 3.463, 95% CI 1.137-10.549; p = 0.029) and postoperative ventricular blood (OR 4.212, 95% CI 1.595-11.122; p = 0.004). The final logistic model comprising tumor metastasis and postoperative ventricular blood was found to have better discrimination than the mCPPRH.

CONCLUSIONS

Tumor characteristics and surgery-related features were associated with postoperative symptomatic hydrocephalus. Tumor metastasis and postoperative ventricular blood were found to be important prognosticators of persistent hydrocephalus.

Idiopathic normal pressure hydrocephalus: historical context and a contemporary guide

Idiopathic normal pressure hydrocephalus (NPH) was described in 1965 as a syndrome in which hydrocephalus develops but with a normal cerebrospinal fluid (CSF) pressure, causing shunt-responsive gait apraxia, cognitive impairment and urinary incontinence. Not all patients respond to shunting despite having the clinical syndrome with appropriate radiological features. This has led to considerable debate over subsequent decades regarding idiopathic NPH. It is now understood that asymptomatic communicating hydrocephalus can develop in many healthy older people, and that over time this can develop into a symptomatic state that sometimes responds to CSF shunting, but to a variable extent. This review looks at the historical background of NPH, the use of predictive tests, the current state of clinical evidence for the diagnosis and treatment of idiopathic NPH and the possible underlying causes, to provide a contemporary practical guide for assessing patients with the radiological features of idiopathic NPH.

Radiological biomarkers of idiopathic normal pressure hydrocephalus: new approaches for detecting concomitant Alzheimer's disease and predicting prognosis

Idiopathic normal pressure hydrocephalus (iNPH) is a clinical syndrome characterized by cognitive decline, gait disturbance, and urinary incontinence. As iNPH often occurs in elderly individuals prone to many types of comorbidity, a differential diagnosis with other neurodegenerative diseases is crucial, especially Alzheimer's disease (AD). A growing body of published work provides evidence of radiological methods, including multimodal magnetic resonance imaging and positron emission tomography, which may help noninvasively differentiate iNPH from AD or reveal concurrent AD pathology in vivo. Imaging methods detecting morphological changes, white matter microstructural changes, cerebrospinal fluid circulation, and molecular imaging have been widely applied in iNPH patients. Here, we review radiological biomarkers using different methods in evaluating iNPH pathophysiology and differentiating or detecting concomitant AD, to noninvasively predict the possible outcome postshunt and select candidates for shunt surgery.

Brain ventricles, CSF and cognition: a narrative review

The brain ventricles are structures that have been related to cognition since antiquity. They are essential components in the development and maintenance of brain functions. The aging process runs with the enlargement of ventricles and is related to a less selective blood-cerebrospinal fluid barrier and then a more toxic cerebrospinal fluid environment. The study of brain ventricles as a biological marker of aging is promissing because they are structures easily identified in neuroimaging studies, present good inter-rater reliability, and measures of them can identify brain atrophy earlier than cortical structures. The ventricular system also plays roles in the development of dementia, since dysfunction in the clearance of beta-amyloid protein is a key mechanism in sporadic Alzheimer's disease. The morphometric and volumetric studies of the brain ventricles can help to distinguish between healthy elderly and persons with mild cognitive impairment (MCI) and dementia. Brain ventricle data may contribute to the appropriate allocation of individuals in groups at higher risk for MCI-dementia progression in clinical trials and to measuring therapeutic responses in these studies, as well as providing differential diagnosis, such as normal pressure hydrocephalus. Here, we reviewed the pathophysiology of healthy aging and cognitive decline, focusing on the role of the choroid plexus and brain ventricles in this process.

Single-Center Retrospective Analysis of Risk Factors for Hydrocephalus After Lateral Ventricular Tumor Resection

Objective

There is no general consensus on the placement of preoperative and intraoperative external ventricular drainage (EVD) in patients with lateral ventricular tumors (LVTs). The aim of this study was to identify the predictors of postoperative acute and persistent hydrocephalus need for postoperative cerebrospinal fluid (CSF) drainage and guide the management of postoperative EVD in patients with LVTs.

Methods

We performed a single-institution, retrospective analysis of patients who underwent resection of LVTs in our Department between January 2011 and March 2021. Patients were divided between one group that required CSF drainage and another group without the need for CSF drainage. We analyzed the two groups by univariate and multivariate analyses to identify the predictors of the requirement for postoperative CSF drainage due to symptomatic intracranial hypertension caused by hydrocephalus.

Results

A total of 97 patients met the inclusion criteria, of which 31 patients received preoperative or intraoperative EVD. Ten patients without prophylactic EVD received postoperative EVD for postoperative acute hydrocephalus. Eleven patients received postoperative ventriculoperitoneal(VP) shunt subsequently. Logistic regression analysis showed that tumor invasion of the anterior ventricle (OR = 7.66), transependymal edema (OR = 8.76), and a large volume of postoperative intraventricular hemorrhage (IVH) (OR = 6.51) were independent risk factors for postoperative acute hydrocephalus. Perilesional edema (OR = 33.95) was an independent risk factor for postoperative VP shunt due to persistent hydrocephalus.

Conclusion

Postoperative hydrocephalus is a common complication in patients with LVTs. These findings might help to determine whether to conduct earlier interventions.

Management of Posterior Fossa Tumors in Adults Based on the Predictors of Postoperative Hydrocephalus

Objective

This study aims to identify the predictors of postoperative hydrocephalus in patients with posterior fossa tumors (PFTs) and guide the management of perioperative hydrocephalus.

Methods

We performed a single-institution, retrospective analysis of patients who underwent resection of PFTs in our department over a 10-year period (2011–2021). A total of 682 adult patients met the inclusion criteria and were divided into either a prophylactic external ventricular drainage (EVD) group or a nonprophylactic-EVD group. We analyzed data for the nonprophylactic-EVD group by univariate and multivariate analyses to identify predictors of postoperative acute hydrocephalus. We also analyzed all cases by univariate and multivariate analyses to determine the predictors of postoperative ventriculoperitoneal (VP) shunt placement.

Results

Tumor infiltrating the midbrain aqueduct [P = 0.001; odds ratio (OR) = 9.8], postoperative hemorrhage (P &lt; 0.001; OR = 66.7), and subtotal resection (P = 0.006; OR = 9.3) were independent risk factors for postoperative EVD. Tumor infiltrating the ventricular system (P &lt; 0.001; OR = 58.5) and postoperative hemorrhage (P &lt; 0.001; OR = 28.1) were independent risk factors for postoperative VP shunt placement.

Conclusions

These findings may help promote more aggressive monitoring and earlier interventions for postoperative hydrocephalus in patients with PFTs.

Examining for Cavum Septum Pellucidum and Ventricular Enlargement in Retired Elite-Level Rugby League Players

Objective

A cavum septum pellucidum (CSP) has been reported as a visible brain anomaly in normal individuals as well in some former combat and collision sport athletes. The appearance of CSP with fenestrations and ventricular enlargement are considered associated features of the neuropathological diagnosis of chronic traumatic encephalopathy. The current study examined CSP anatomic features and lateral ventricle size in retired elite rugby league players and controls.

Methods

Forty-one retired rugby league players and 41 healthy community controls, similar in age and education, underwent structural MRI scans. CSP grade, CSP length, corpus callosum septal length, and Evans' ratio (for lateral ventricle size) were rated by two of the current study authors. All participants also self-reported concussion exposure histories, depressive symptoms, daytime sleepiness, and impulsivity. They completed a neuropsychological test battery assessing premorbid intellectual functioning, attention, processing speed, language, visuospatial skills, memory, and aspects of executive functioning.

Results

The two raters had high agreement for CSP grade (Cohen's κ = 0.80), CSP length [intraclass correlation (ICC) = 0.99], corpus callosum septal length (ICC = 0.73), the CSP/septal ratio (ICC = 0.99), and the Evans' ratio (ICC = 0.75). Twenty-five retired players (61.0%) had an abnormal CSP compared to 17 controls [41.5%; χ(1, 82)2 = 3.12, p = 0.08, odds ratio = 2.21]. The CSP/septal ratio was larger for retired players than for the controls. The Evans' ratio did not differ between the two groups. In the retired rugby league players (n = 41), those with normal (n = 16) and abnormal (n = 25) CSP grades did not differ across age, age of first exposure to collision sport, years of sport exposure, concussion history, or 23 clinical and cognitive variables.

Conclusion

This study revealed a difference in the size of the CSP between retired professional rugby league players and controls. There was no significant difference in the size of the ventricles between the two groups. There were no significant differences between those with vs. without an abnormal CSP on age of first exposure to rugby league, years of exposure to repetitive neurotrauma, number of lifetime concussions, depression, impulsivity, perceived cognitive decline, or on any neuropsychological test.

Shunting for idiopathic normal pressure hydrocephalus

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To determine the effect of cerebrospinal fluid (CSF) shunting versus no CSF shunting in people with idiopathic normal pressure hydrocephalus (iNPH).

To determine the frequency of adverse effects of CSF shunting in iNPH

Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures

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.

Application of Evans Index in Normal Pressure Hydrocephalus Patients: A Mini Review

With an ever-growing aging population, the prevalence of normal pressure hydrocephalus (NPH) is increasing. Clinical symptoms of NPH include cognitive impairment, gait disturbance, and urinary incontinence. Surgery can improve symptoms, which leads to the disease's alternative name: treatable dementia. The Evans index (EI), defined as the ratio of the maximal width of the frontal horns to the maximum inner skull diameter, is the most commonly used index to indirectly assess the condition of the ventricles in NPH patients. EI measurement is simple, fast, and does not require any special software; in clinical practice, an EI >0.3 is the criterion for ventricular enlargement. However, EI's measurement methods, threshold setting, correlation with ventricle volume, and even its clinical value has been questioned. Based on the EI, the z-EI and anteroposterior diameter of the lateral ventricle index were derived and are discussed in this review.

Idiopathic normal pressure hydrocephalus; treatment and outcome in the Region of Southern Denmark

OBJECTIVE

Idiopathic normal pressure hydrocephalus (iNPH) is a prevalent and cost-effective disease to treat. However, no gold standard exists to confidently select patients for shunt surgery. The aim of this study was to investigate how patients with suspected iNPH at our center responded to shunt surgery and to compare pre-surgical variables between shunt responders and non-responders.

METHODS

Preoperative baseline characteristics, MRI and/or CT scans were retrospectively obtained in 55 shunt-operated iNPH patients. Evan's index, third ventricle diameter, dilation of Sylvian fissures, tight high convexity, focal sulci, callosal angle, Rout value, MMSE score, CSF phosphorylated tau, CSF tau, and a combination of radiologic findings (DESH score) were compared according to whether or not patients expressed satisfactory response to shunt treatment at 1-month follow-up.

RESULTS

Multiple logistic regression controlling for age and gender (α = 0.05) showed that tight high convexity, dilated Sylvian fissures, focal sulci, CSF tau, CSF phosphorylated tau, and DESH score correlated significantly with subjective shunt response at 1-month follow-up.

CONCLUSION

In line with current literature, Shunt responders had lower levels of CSF tau and CSF phosphorylated tau compared to non-responders. While commonly used radiologic markers are of value, they can be aggregated into a score for better selection of shunt candidates.

The association of disproportionately enlarged subarachnoid space hydrocephalus with cognitive deficit in a general population: the Ohasama study

Disproportionately enlarged subarachnoid space hydrocephalus (DESH) is the characteristic feature of idiopathic normal pressure hydrocephalus. We aimed to characterize the prevalence, development, and association of DESH to cognitive deficit in a large population. We reviewed the data of 1384 subjects eligible for the present study among 1590 participants who underwent magnetic resonance imaging (MRI) in the Ohasama Study, a population-based study in Ohasama, Japan. The participants with Mini-Mental State Examination (MMSE) score <  = 25 were assumed to have cognitive deficit and DESH was evaluated by reviewing the MRIs. We assessed the association between DESH, Evans index (EI), and cognitive deficit using multivariate logistic regression models adjusted for relevant confounders. Furthermore, we evaluated the new development of DESH and the deterioration of cognitive function in the participants with DESH. There were nine participants with DESH (0.65%), seven of whom showed cognitive deficit. DESH was significantly associated with cognitive deficit in multivariate regression analyses (odds ratio; 8.50 [95% confidence interval: 1.61–44.88]). In the 669 participants who underwent follow-up MRI, we found four participants newly presenting with DESH; the development of DESH was observed before/after the presence of EI > 0.3. We also found two participants with existing DESH showing no remarkable worsening in MMSE and EI. The present study demonstrated a positive association between the presence of DESH and cognitive deficit. DESH can develop independently of EI > 0.3, and ventricular enlargement in combination with DESH may be an important factor in the worsening of cognitive deficit.

Evans index among adult Ghanaians on normal head computerized tomography scan

Introduction

Normal-Pressure Hydrocephalus (NPH) is a neurological condition which is made up of a clinical triad of gait disturbance, dementia and urinary incontinence and can be reversed by ventricular shunting. Currently, some guidelines suggest the use of Evans' index (EI) for diagnosis of hydrocephalus radiologically. Most of the studies are based on the Western population data. None of these studies have been performed in the Ghanaian population setting yet. The aim of this study was to quantitatively establish normal borderline value for Evans Index in the Ghanaian adult population with respect to age and sex.

Methods

This study was retrospectively conducted on normal enhanced head CT scan images of 266 males and 241 females. EI was calculated as the linear ratio of Maximum Anterior Horn Width (MAHW) of the frontal horns of the lateral ventricles at the level of foramina of Monroe and the Maximum Intracranial Diameter (MICD) of the inner skull. Student T-test, ANOVA and Pearson's correlation were used to analyze the data. A test for a relationship was performed with a scatter plot and a linear regression was performed based on age, sex and different EI of ventricular size.

Results

The mean and median value of EI was 0.24 ± 0.02. There was no statistically significant difference in the EI values between males and females, (p-value = 0.61). A steady increase in EI with age was observed. There was a strong correlation coefficient r = 0.89 of EI and age, which suggested a strong linear relationship between EI and Age. The overall linear relationship model was EI = 0.1879 + 0.0011∗Age.

Conclusions

The mean EI of 0.24 ± 0.02 in our study agrees with adapted international guidelines cut-off value for normal adult patients of (<0.30) and can be a useful tool in determining ventricular enlargement particularly in resource limited settings.

Screening for idiopathic normal pressure hydrocephalus in the elderly after falls

OBJECTIVE

Many patients with idiopathic normal pressure hydrocephalus (iNPH) have reportedly fallen prior to diagnosis. However, there are no previous reports on the iNPH prevalence among the elderly with history of falls. This study investigated the effectiveness of screening for iNPH in elderly patients presenting after a fall.

METHODS

We retrospectively assessed the Evans' index (EI) of 235 consecutive patients aged 60-89 who presented after falls between May and October 2020. We also assessed the presence of the iNPH triad (gait disturbance, cognitive impairment, and urinary incontinence). Patients with EI > 0.3 and with all 3 triad were defined as having possible iNPH; those with clinical improvement after a cerebrospinal fluid (CSF) tap test as having probable iNPH; and those with clinical improvement after a shunt surgery as having definite iNPH. We also examined the 235 patients' EI, and performed a case-control study of EI using sex- and age-matched control patients.

RESULTS

Among the included 235 cases presenting after falls, 44 (18.7%) were diagnosed with possible iNPH, 29 (12.3%) with probable iNPH, and 25 (10.6%) with definite iNPH. The mean EI of these 235 patients was significantly larger than that of controls (0.30 ± 0.04 vs 0.26 ± 0.02, p < 0.0001). The proportion of possible iNPH in the cases was 44 out of 235 (18.7%), significantly higher than that of the controls (0%, p < 0.0001).

CONCLUSION

Screening for iNPH in the elderly presenting after falls can possibly identify iNPH patients in the earlier stage who may benefit more from surgical treatments.

The Pathogenesis Based on the Glymphatic System, Diagnosis, and Treatment of Idiopathic Normal Pressure Hydrocephalus

Idiopathic normal pressure hydrocephalus (iNPH) is a rare neurological disorder with no clear prevalence factors and is a significant danger to the elderly. The intracranial glymphatic system is the internal environment that maintains brain survival and metabolism, and thus fluid exchange changes in the glymphatic system under various pathological conditions can provide important insights into the pathogenesis and differential diagnosis of many neurodegenerative diseases such as iNPH. iNPH can be diagnosed using a combination of clinical symptoms, imaging findings and history, and cerebrospinal fluid biomarkers due to the glymphatic system disorder. However, only few researchers have linked the two. Shunt surgery can improve the glymphatic system disorders in iNPH patients, and the surgical approach is determined using a combination of clinical diagnosis and trials. Therefore, we have composed this review to provide a future opportunity for elucidating the pathogenesis of iNPH based on the glymphatic system, and link the glymphatic system to the diagnosis and treatment of iNPH. The review will provide new insights into the medical research of iNPH.

3D Deep Neural Network Segmentation of Intracerebral Hemorrhage: Development and Validation for Clinical Trials

Intracranial hemorrhage (ICH) occurs when a blood vessel ruptures in the brain. This leads to significant morbidity and mortality, the likelihood of which is predicated on the size of the bleeding event. X-ray computed tomography (CT) scans allow clinicians and researchers to qualitatively and quantitatively diagnose hemorrhagic stroke, guide interventions and determine inclusion criteria of patients in clinical trials. There is no currently available open source, validated tool to quickly segment hemorrhage. Using an automated pipeline and 2D and 3D deep neural networks, we show that we can quickly and accurately estimate ICH volume with high agreement with time-consuming manual segmentation. The training and validation datasets include significant heterogeneity in terms of pathology, such as the presence of intraventricular (IVH) or subdural hemorrhages (SDH) as well as variable image acquisition parameters. We show that deep neural networks trained with an appropriate anatomic context in the network receptive field, can effectively perform ICH segmentation, but those without enough context will overestimate hemorrhage along the skull and around calcifications in the ventricular system. We trained with all data from a multi-center phase II study (n = 112) achieving a best mean and median Dice coefficient of 0.914 and 0.919, a volume correlation of 0.979 and an average volume difference of 1.7 ml and root mean squared error of 4.7 ml in 500 out-of-sample scans from the corresponding multi-center phase III study. 3D networks with appropriate anatomic context outperformed both 2D and random forest models. Our results suggest that deep neural network models, when carefully developed can be incorporated into the workflow of an ICH clinical trial series to quickly and accurately segment ICH, estimate total hemorrhage volume and minimize segmentation failures. The model, weights and scripts for deployment are located at https://github.com/msharrock/deepbleed . This is the first publicly available neural network model for segmentation of ICH, the only model evaluated with the presence of both IVH and SDH and the only model validated in the workflow of a series of clinical trials.

The effect of mTOR inhibition on obstructive hydrocephalus in patients with tuberous sclerosis complex (TSC) related subependymal giant cell astrocytoma (SEGA)

PURPOSE

Mammalian target of rapamycin inhibitors (mTORi) are known to effectively reduce the size of subependymal giant cell astrocytomas (SEGAs), which are benign brain lesions associated with Tuberous Sclerosis Complex (TSC) that commonly cause obstructive hydrocephalus (OH). This retrospective case series reviews an institutional experience of the effect of mTORi on OH in patients with TSC-related SEGA.

METHODS

Thirteen of 16 identified patients with TSC-related SEGA treated with mTORi from October 2007 to December 2018 were included. Serial magnetic resonance imaging (MRI) and clinical charts were reviewed to correlate symptoms and signs of increased intracranial pressure (iICP) with ventriculomegaly on MRI. A proposed ventriculomegaly scale was used: none (< 7 mm), mild (7-10 mm), moderate (11-30 mm), and severe (> 30 mm). OH was defined as moderate or severe ventriculomegaly, based on the largest measurement.

RESULTS

Patients' median age at start of mTORi was 13 (6-17) years and five (38%) patients were female. Eight patients had OH at the time of mTORi initiation, five of whom were asymptomatic. Six patients had improvement of hydrocephalus on serial MRI imaging with mTORi therapy, while seven patients had no change based on the ventriculomegaly scale used. All three patients who presented with symptoms of iICP and had OH also had papilledema. None had worsening of hydrocephalus or required shunt placement. Out of five patients with symptoms of iICP, four avoided surgery.

CONCLUSION

Most patients had asymptomatic OH at the time of diagnosis, and ventricular enlargement was not correlated with iICP symptoms. mTORi was successful for treatment of OH from TSC-related SEGA, even in the setting of acute symptoms of iICP.

Reliability and Interobserver Variability of Evans' Index and Disproportionately Enlarged Subarachnoid Space Hydrocephalus as Diagnostic Criteria for Idiopathic Normal Pressure Hydrocephalus

Background:

The image diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) is based on the ventriculomegaly, whose criterion is an Evans' Index (EI) >0.3. Recently, disproportionately enlarged subarachnoid space hydrocephalus (DESH) has been proposed as a morphological characteristic to iNPH. Several studies cast doubt on the reliability of these criteria in the diagnosis of iNPH. Furthermore, interobserver differences of these criteria have not yet been investigated. The objective of this study was to assess the diagnostic reliability and interobserver variability of EI and DESH.

Materials and Methods:

The preoperative magnetic resonance (MR) images of 84 definite iNPH patients were retrospectively evaluated by a neuroradiologist (NR) and physical therapist (PT). They independently assessed the EI and DESH. The MR images were evaluated preoperatively by a neurosurgeon (NS). The results were showed in mean (standard deviation).

Results:

The mean age was 78.4 (6.3) years (male:female = 49:35). The mean EI was 0.33 (0.04), 0.32 (0.04), and 0.31 (0.03) for NS, NR, and PT, respectively (P < 0.0001). The rate of accurate diagnosis of iNPH with EI >0.3 was 74%, 66%, and 61% for NS, NR, and PT, respectively, and there was a moderate level of agreement. By contrast, there was a substantial lower level of accuracy in assessment with DESH for all three evaluators as 50%, 44%, and 27% for NS, NR, and PT, respectively, again with a moderate level of agreement. However, the rates of patients fulfilling both EI >0.3 and DESH were remarkably lower than either of the two parameters individually at a mere 37%, 30%, and 16% for NS, NR, and PT, respectively, with a low level of agreement between the rates.

Conclusion:

This study suggests that DESH cannot be a diagnostic criterion for iNPH. If EI >0.3 and DESH were both necessary to diagnose iNPH, then more than 70% of patients would have been misdiagnosed and would have been deprived of the chance of treatment and its benefits. These results request a paradigm shift in the concepts of iNPH.

A new index for assessing cerebral ventricular volume in idiopathic normal-pressure hydrocephalus: a comparison with Evans' index

PURPOSE

To recommend a new simple and explicit index termed the anteroposterior diameter of the lateral ventricle index (ALVI) for assessing brain ventricular size in neuroimaging and to compare Evans index (EI) between idiopathic normal pressure hydrocephalus (iNPH) patients and age-matched healthy elderly subjects.

METHODS

Retrospective measurements of ventricular volume (VV), relative VV (RVV), the EI, and the ALVI were taken from thin-section CT scans for 23 pre-shunt-insertion iNPH patients and 62 age-matched healthy elderly volunteers. The area under the receiver operating characteristic (ROC) curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to assess the effectiveness of ALVI scores for predicting VV.

RESULTS

The correlations between VV or RVV and ALVI scores (VV, r = 0.957; RVV, r = 0.983) were significantly stronger than the corresponding correlations with EI scores (VV, r = 0.843; RVV, r = 0.840). The AUC for ALVI scores was significantly greater than the AUC for EI scores. Furthermore, with the inclusion of the ALVI, the NRI value was 0.14 and the IDI value was 0.14; these improvements were also statistically significant.

CONCLUSION

The ALVI is a more accurate and more explicitly defined marker of VV than the EI and assesses ventricular enlargement effectively. We suggest that ventricular enlargement of the healthy elderly be defined by ALVI > 0.50.

Current Update on Treatment Strategies for Idiopathic Normal Pressure Hydrocephalus

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.

Longitudinal morphological changes during recovery from brain deformation due to idiopathic normal pressure hydrocephalus after ventriculoperitoneal shunt surgery

The present study aimed to examine time-dependent change in cerebrospinal fluid distribution and various radiological indices for evaluating shunt effectiveness in patients with idiopathic normal pressure hydrocephalus (iNPH). This study included 54 patients with iNPH who underwent MRI before and after ventriculoperitoneal shunt surgery. The volume of the total ventricles and subarachnoid spaces decreased within 1 month after shunting. However, more than 1 year after shunting, the volume of the total ventricles decreased, whereas that of the total subarachnoid spaces increased. Although cerebrospinal fluid distribution changed considerably throughout the follow-up period, the brain parenchyma expanded only 2% from the baseline brain volume within 1 month after shunting and remained unchanged thereafter. The volume of the convexity subarachnoid space markedly increased. The changing rate of convexity subarachnoid space per ventricle ratio (CVR) was greater than that of any two-dimensional index. The brain per ventricle ratio (BVR), callosal angle and z-Evans index continued gradually changing, whereas Evans index did not change throughout the follow-up period. Both decreased ventricular volume and increased convexity subarachnoid space volume were important for evaluating shunt effectiveness. Therefore, we recommend CVR and BVR as useful indices for the diagnosis and evaluation of treatment response in patients with iNPH.