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Zhong W, Li W, Li Z, Wang Q, Zhang W. [Causal relationship between sleep phenotype and idiopathic normal pressure hydrocephalus: a two-sample bidirectional Mendelian randomization study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2024; 44:1612-1619. [PMID: 39276058 PMCID: PMC11378049 DOI: 10.12122/j.issn.1673-4254.2024.08.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/16/2024]
Abstract
OBJECTIVE To explore the causal relationship between sleep phenotype and idiopathic normal pressure hydrocephalus (iNPH) using two-sample bidirectional Mendelian randomization. METHODS The exposure data including 8 sleep phenotypes used in this study were obtained from GWAS catalog, FinnGenR10 and MRCIEU GWAS. The outcome data for idiopathic normal-pressure hydrocephalus were obtained from FinnGen R10. We used the inverse-variance weighted (IVW) method to perform the principal analyses. Cochrane Q-statistics test was used to assess the heterogeneity and MR Egger‑intercept test performed to evaluate the pleiotropy for sensitivity analyses. RESULTS IVW result showed that frequent daytime nap was associated with higher odds of iNPH (OR=3.3393, 95 CI% : 1.0646-10.4742, P=0.0270). Cochrane Q-statistics test and MR Egger‑intercept test showed that the MR analysis had no pleiotropy or heterogeneity (P > 0.05). The external validation reproduced this result (OR=2.5660, 95 CI% : 1.1680-5.6373, P=0.0189; OR=4.0424, 95 CI% : 1.5709-10.4024, P=0.0038). Reverse Mendelian randomization suggested that iNPH did not have significant impact on sleep phenotype. CONCLUSION The frequency of daytime naps is causally associated with iNPH, and reducing the frequency of weekly daytime naps can reduce the risk of iNPH in the elderly population.
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Affiliation(s)
- W Zhong
- Department of Pediatric Neurosurgery, Center of Neurosurgery, Zhujiang Hospital, Southern Medical University//Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration//The National Key Clinical Specialty//The Engineering Technology Research Center of Education Ministry of China, Guangzhou 510282, China
| | - W Li
- Department of Pediatric Neurosurgery, Center of Neurosurgery, Zhujiang Hospital, Southern Medical University//Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration//The National Key Clinical Specialty//The Engineering Technology Research Center of Education Ministry of China, Guangzhou 510282, China
| | - Z Li
- Department of Pediatric Neurosurgery, Center of Neurosurgery, Zhujiang Hospital, Southern Medical University//Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration//The National Key Clinical Specialty//The Engineering Technology Research Center of Education Ministry of China, Guangzhou 510282, China
| | - Q Wang
- Department of Pediatric Neurosurgery, Center of Neurosurgery, Zhujiang Hospital, Southern Medical University//Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration//The National Key Clinical Specialty//The Engineering Technology Research Center of Education Ministry of China, Guangzhou 510282, China
| | - W Zhang
- Department of Pediatric Neurosurgery, Center of Neurosurgery, Zhujiang Hospital, Southern Medical University//Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration//The National Key Clinical Specialty//The Engineering Technology Research Center of Education Ministry of China, Guangzhou 510282, China
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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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Currà A, Gasbarrone R, Gargiulo P, Rughetti A, Peschillo S, Trompetto C, Puce L, Marinelli L, Fattapposta F, Bragazzi NL, Missori P. Frequency of brain ventricular enlargement among patients with diabetes mellitus. Diabetes Res Clin Pract 2024; 210:111644. [PMID: 38552909 DOI: 10.1016/j.diabres.2024.111644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/01/2024]
Abstract
AIMS To determine the prevalence of dilated ventricles and concomitant high blood glucose measures. METHODS We retrieved blood glucose measures from the emergency department database and selected a subgroup of individuals having both the radiological marker Evans' index (EI) values and blood glucose measures. RESULTS Out of 1221 consecutive patients submitted to axial Computed Tomography scans, a blood glucose measure was detected in 841 individuals. 176 scans (21 %) showed an EI > 0.30. According to the blood glucose categorization, diabetic patients were 104 (12 %), 25 of them (24 %) were dilated (mean EI 0.33). The age difference between dilated and not-dilated ventricles is about ten years in not-diabetic participants, whereas it is five years in diabetic participants. The age difference between dilated and not-dilated ventricles is about 10 years in diabetic men, whereas it zero in diabetic women. CONCLUSIONS Pathological ventricular enlargement is more frequent in men and in the elderly. In diabetic patients (especially women), the cerebral ventricles enlarge faster than in non-diabetic individuals. Age, sex, and diabetes may interact in determining how cerebral ventricle size changes over time, especially in diabetic women, making routine brain imaging advisable in these patients after the age of 70 years.
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Affiliation(s)
- Antonio Currà
- Academic Neurology Unit, A. Fiorini Hospital, Terracina, LT, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Italy
| | - Riccardo Gasbarrone
- Department of Chemical Engineering, Materials & Environment, Sapienza University of Rome, Rome, Italy
| | - Patrizia Gargiulo
- Department of Experimental Medicine, Endocrinology-Pituitary Disease, "Sapienza" University of Rome, Rome, Italy
| | - Aurelia Rughetti
- Department of Experimental Medicine, "Sapienza" University of Rome, Italy
| | | | - Carlo Trompetto
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Italy; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Luca Puce
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Italy
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Italy; Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Francesco Fattapposta
- Department of Human Neuroscience, Neurology, Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada
| | - Paolo Missori
- Department of Human Neuroscience, Neurosurgery, Policlinico Umberto I, "Sapienza" University of Rome, Italy.
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Eklund SA, Israelsson H, Brunström M, Forsberg K, Malm J. 10-year mortality, causes of death and cardiovascular comorbidities in idiopathic normal pressure hydrocephalus. J Neurol 2024; 271:1311-1319. [PMID: 37917232 PMCID: PMC10896765 DOI: 10.1007/s00415-023-12067-5] [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: 08/30/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE The objective was to investigate 10-year mortality, causes of death and cardiovascular comorbidity in idiopathic normal pressure hydrocephalus (iNPH) and to evaluate their mutual associations. METHODS This prospective cohort study included 176 CSF-shunted iNPH patients, and 368 age- and sex-matched controls. At inclusion, participants were medically examined, had blood analyzed and answered a questionnaire. The vascular comorbidities investigated were smoking, diabetes, body mass index, blood pressure (BP), hyperlipidemia, kidney function, atrial fibrillation and, cerebro- and cardiovascular disease. RESULTS Survival was observed for a mean period of 10.3 ± 0.84 years. Shunted iNPH patients had an increased risk of death compared to controls (hazard ratio (HR) = 2.5, 95% CI 1.86-3.36; p < 0.001). After 10 years, 50% (n = 88) of iNPH patients and 24% (n = 88) of the controls were dead (p < 0.001). The risk of dying from cardiovascular disease, falls and neurological diseases were higher in iNPH (p < 0.05). The most common cause of death in iNPH was cardiovascular diseases (14% vs 7% for controls). Seven out of nine iNPH dying from falls had subdural hematomas. Systolic BP (HR = 0.985 95% CI 0.972-0.997, p = 0.018), atrial fibrillation (HR = 2.652, 95% CI 1.506-4.872, p < 0.001) and creatinine (HR = 1.018, 95% CI 1.010-1.027, p < 0.001) were independently associated with mortality for iNPH. DISCUSSION This long-term and population-matched cohort study indicates that in spite of CSF-shunt treatment, iNPH has shorter life expectancy. It may be important to treat iNPH in supplementary ways to reduce mortality. Both cardiovascular comorbidities and lethal falls are contributing to the excess mortality in iNPH and reducing these preventable risks should be an established part of the treatment plan.
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Affiliation(s)
- Sanna A Eklund
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.
| | - Hanna Israelsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mattias Brunström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Karin Forsberg
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Jan Malm
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
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Ma L, Wang W, Zhao Y, Liu M, Ye W, Li X. Application of LRG mechanism in normal pressure hydrocephalus. Heliyon 2024; 10:e23940. [PMID: 38223707 PMCID: PMC10784321 DOI: 10.1016/j.heliyon.2023.e23940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 11/02/2023] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Normal pressure hydrocephalus (NPH) is a prevalent type of hydrocephalus, including secondary normal pressure hydrocephalus (SNPH) and idiopathic normal pressure hydrocephalus (INPH). However, its clinical diagnosis and pathological mechanism are still unclear. Leucine-rich α-2 glycoprotein (LRG) is involved in various human diseases, including cancer, diabetes, cardiovascular disease, and nervous system diseases. Now the physiological mechanism of LRG is still being explored. According to the current research results on LRG, we found that the agency of LRG has much to do with the known pathological process of NPH. This review focuses on analyzing the LRG signaling pathways and the pathological mechanism of NPH. According to the collected literature evidence, we speculated that LRG probably be involved in the pathological process of NPH. Finally, based on the mechanism of LRG and NPH, we also summarized the evidence of molecular targeted therapies for future research and clinical application.
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Affiliation(s)
| | | | - Yongqiang Zhao
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Menghao Liu
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Wei Ye
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Xianfeng Li
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
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Yang HW, Lee S, Berry BC, Yang D, Zheng S, Carroll RS, Park PJ, Johnson MD. A role for mutations in AK9 and other genes affecting ependymal cells in idiopathic normal pressure hydrocephalus. Proc Natl Acad Sci U S A 2023; 120:e2300681120. [PMID: 38100419 PMCID: PMC10743366 DOI: 10.1073/pnas.2300681120] [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: 01/12/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is an enigmatic neurological disorder that develops after age 60 and is characterized by gait difficulty, dementia, and incontinence. Recently, we reported that heterozygous CWH43 deletions may cause iNPH. Here, we identify mutations affecting nine additional genes (AK9, RXFP2, PRKD1, HAVCR1, OTOG, MYO7A, NOTCH1, SPG11, and MYH13) that are statistically enriched among iNPH patients. The encoded proteins are all highly expressed in choroid plexus and ependymal cells, and most have been associated with cilia. Damaging mutations in AK9, which encodes an adenylate kinase, were detected in 9.6% of iNPH patients. Mice homozygous for an iNPH-associated AK9 mutation displayed normal cilia structure and number, but decreased cilia motility and beat frequency, communicating hydrocephalus, and balance impairment. AK9+/- mice displayed normal brain development and behavior until early adulthood, but subsequently developed communicating hydrocephalus. Together, our findings suggest that heterozygous mutations that impair ventricular epithelial function may contribute to iNPH.
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Affiliation(s)
- Hong Wei Yang
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA01655
| | - Semin Lee
- Brigham and Women’s Hospital, Boston, MA02115
- Harvard Medical School, Boston, MA02115
| | - Bethany C. Berry
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA01655
| | - Dejun Yang
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA01655
| | - Shaokuan Zheng
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA01655
| | - Rona S. Carroll
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA01655
- Brigham and Women’s Hospital, Boston, MA02115
- Harvard Medical School, Boston, MA02115
| | - Peter J. Park
- Brigham and Women’s Hospital, Boston, MA02115
- Harvard Medical School, Boston, MA02115
| | - Mark D. Johnson
- Department of Neurological Surgery, University of Massachusetts Chan Medical School, Worcester, MA01655
- Department of Neurological Surgery, University of Massachusetts Memorial Health, Worcester, MA01655
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Cai H, Yang F, Gao H, Huang K, Qin L, Wang R, Liu Y, Zhou L, Hao Z, Zhou D, Chen Q. Vascular risk factors for idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Front Neurol 2023; 14:1220473. [PMID: 37638192 PMCID: PMC10448702 DOI: 10.3389/fneur.2023.1220473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Objective Idiopathic normal-pressure hydrocephalus (iNPH) is a treatable cause of dementia; however, its etiology and pathogenesis remain poorly understood. The objective of this study was to investigate the prevalence and impact of vascular risk factors in patients with iNPH compared to a control cohort to better understand the potential mechanisms and preventive measures. Methods We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library (from inception to December 20, 2022) for studies reporting vascular risk factors for the development of iNPH. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using random-effects models. Results After screening 1,462 articles, 11 case-control studies comprising 1,048 patients with iNPH and 79,668 cognitively unimpaired controls were included in the meta-analysis. Our data showed that hypertension (N = 991, OR = 2.30, 95% CI 1.64 to 3.23, I2= 64.0%), diabetes mellitus (DM) (N = 985, OR = 3.12, 95% CI 2.29 to 4.27, I2= 44.0%), coronary heart disease (CHD; N = 880, OR = 2.34, 95% CI 1.33 to 4.12, I2= 83.1%), and peripheral vascular disease (N = 172, OR = 2.77, 95% CI 1.50 to 5.13, I2= 0.0%) increased the risk for iNPH, while overweight was a possible factor (N = 225, OR = 2.01, 95% CI 1.34 to 3.04, I2= 0.0%) based on the sensitivity analysis. Smoking and alcohol consumption were not associated with iNPH. Conclusions Our study suggested that hypertension, DM, CHD, peripheral vascular disease, and overweight were associated with iNPH. These factors might be involved in the pathophysiological mechanisms promoting iNPH. These findings require further investigation in future studies. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022383004.
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Affiliation(s)
- Hanlin Cai
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Feng Yang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Hui Gao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Keru Huang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Linyuan Qin
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Ruihan Wang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Zilong Hao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
| | - Qin Chen
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
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Deng Z, Wang H, Huang K, Li Y, Ran Y, Chen Y, Zhou L. Association between vascular risk factors and idiopathic normal pressure hydrocephalus: a Mendelian randomization study. J Neurol 2023; 270:2724-2733. [PMID: 36773060 DOI: 10.1007/s00415-023-11604-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Patients with idiopathic normal pressure hydrocephalus (iNPH) have a higher prevalence of hypertension and diabetes. However, the causal effects of these vascular risk factors on iNPH remain unclear. This study aimed to explore the causal relationship between vascular risk factors (VRFs) and iNPH. METHODS We conducted the Mendelian randomization (MR) analysis of iNPH. We included nineteen vascular risk factors related to hypertension, diabetes, lipids, obesity, smoking, alcohol consumption, exercise, sleep, and cardiovascular events as exposure factors. We used the inverse-variance weighted method for causal effect estimation and weighted median, maximum likelihood, and MR Egger regression methods for sensitivity analyses. RESULTS We found that genetically predicting essential hypertension (OR = 1.608 (1.330-1.944), p = 0.013) and increased sleep duration (OR = 16.395 (5.624-47.799), p = 0.009) were associated with higher odds of iNPH. Type 1 diabetes (OR = 0.869 (0.828-0.913), p = 0.004) was associated with lower odds of iNPH. For the other 16 VRFs, there was no evidence that they were significantly associated with iNPH. Sensitivity analyses showed that essential hypertension and type 1 diabetes were significantly associated with iNPH. CONCLUSION In our MR study on VRFs and iNPH, we found essential hypertension to be a causal risk factor for iNPH. This suggests that hypertension may be involved in the pathophysiological mechanism of iNPH.
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Affiliation(s)
- Ziang Deng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Haoxiang Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Keru Huang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanyou Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Ran
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yaxing Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
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Eide PK. Cellular changes at the glia-neuro-vascular interface in definite idiopathic normal pressure hydrocephalus. Front Cell Neurosci 2022; 16:981399. [PMID: 36119130 PMCID: PMC9478415 DOI: 10.3389/fncel.2022.981399] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a subtype of dementia with overlap toward Alzheimer's disease. Both diseases show deposition of the toxic metabolites amyloid-β and tau in brain. A unique feature with iNPH is that a subset of patients may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery. The patients responding clinically to shunting are denoted Definite iNPH, otherwise iNPH is diagnosed as Possible iNPH or Probable iNPH, high-lightening that the clinical phenotype and underlying pathophysiology remain debated. Given the role of CSF disturbance in iNPH, the water channel aquaporin-4 (AQP4) has been suggested a crucial role in iNPH. Altered expression of AQP4 at the astrocytic endfeet facing the capillaries could affect glymphatic function, i.e., the perivascular transport of fluids and solutes, including soluble amyloid-β and tau. This present study asked how altered perivascular expression of AQP4 in subjects with definite iNPH is accompanied with cellular changes at the glia-neuro-vascular interface. For this purpose, information was retrieved from a database established by the author, including prospectively collected management data, physiological data and information from brain biopsy specimens examined with light and electron microscopy. Individuals with definite iNPH were included together with control subjects who matched the definite iNPH cohort closest in gender and age. Patients with definite iNPH presented with abnormally elevated pulsatile intracranial pressure measured overnight. Cortical brain biopsies showed reduced expression of AQP4 at astrocytic endfeet both perivascular and toward neuropil. This was accompanied with reduced expression of the anchor molecule dystrophin (Dp71) at astrocytic perivascular endfeet, evidence of altered cellular metabolic activity in astrocytic endfoot processes (reduced number of normal and increased number of pathological mitochondria), and evidence of reactive changes in astrocytes (astrogliosis). Moreover, the definite iNPH subjects demonstrated in cerebral cortex changes in capillaries (reduced thickness of the basement membrane between astrocytic endfeet and endothelial cells and pericytes, and evidence of impaired blood-brain-barrier integrity). Abnormal changes in neurons were indicated by reduced post-synaptic density length, and reduced number of normal mitochondria in pre-synaptic terminals. In summary, definite iNPH is characterized by profound cellular changes at the glia-neurovascular interface, which probably reflect the underlying pathophysiology.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Per Kristian Eide
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Bonney PA, Briggs RG, Wu K, Choi W, Khahera A, Ojogho B, Shao X, Zhao Z, Borzage M, Wang DJJ, Liu C, Lee DJ. Pathophysiological Mechanisms Underlying Idiopathic Normal Pressure Hydrocephalus: A Review of Recent Insights. Front Aging Neurosci 2022; 14:866313. [PMID: 35572128 PMCID: PMC9096647 DOI: 10.3389/fnagi.2022.866313] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/28/2022] [Indexed: 01/18/2023] Open
Abstract
The pathophysiologic mechanisms underpinning idiopathic normal pressure hydrocephalus (iNPH), a clinically diagnosed dementia-causing disorder, continue to be explored. An increasing body of evidence implicates multiple systems in the pathogenesis of this condition, though a unifying causative etiology remains elusive. Increased knowledge of the aberrations involved has shed light on the iNPH phenotype and has helped to guide prognostication for treatment with cerebrospinal fluid diversion. In this review, we highlight the central role of the cerebrovasculature in pathogenesis, from hydrocephalus formation to cerebral blood flow derangements, blood-brain barrier breakdown, and glymphatic pathway dysfunction. We offer potential avenues for increasing our understanding of how this disease occurs.
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Affiliation(s)
- Phillip A. Bonney
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Phillip A. Bonney
| | - Robert G. Briggs
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kevin Wu
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Wooseong Choi
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Anadjeet Khahera
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brandon Ojogho
- Laboratory of Functional MRI Technology, Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Xingfeng Shao
- Laboratory of Functional MRI Technology, Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Zhen Zhao
- Department of Physiology & Neuroscience and the Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Matthew Borzage
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, CA, United States
| | - Danny J. J. Wang
- Laboratory of Functional MRI Technology, Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Charles Liu
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Darrin J. Lee
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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11
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Hallqvist C, Grönstedt H, Arvidsson L. Gait, falls, cognitive function, and health-related quality of life after shunt-treated idiopathic normal pressure hydrocephalus-a single-center study. Acta Neurochir (Wien) 2022; 164:2367-2373. [PMID: 35831723 PMCID: PMC9427897 DOI: 10.1007/s00701-022-05309-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/01/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Normal pressure hydrocephalus (NPH) is a neurological disorder, characterized by gait- and balance disturbance, cognitive deterioration, and urinary incontinence, combined with ventricular enlargement. Gait ability, falls, cognitive status, and health-related quality of life pre and post surgery have not previously been studied at Karolinska University Hospital. METHODS One hundred and eighteen patients with iNPH that underwent shunt surgery at Karolinska University Hospital during the years from 2016 to 2018 were included. Results of walking tests, test for cognitive function, and self-estimated health-related quality of life, before and 3 months after surgery, were collected retrospectively as a single-center study. RESULTS Walking ability, cognitive function, and health-related quality of life significantly increased 3 months after shunt surgery. A positive significant correlation was seen between a higher self-estimated quality of life and walking ability. CONCLUSIONS Patients with suspected iNPH treated with shunt surgery at Karolinska University Hospital improved their walking ability and cognitive functioning 3 months after shunt surgery. A positive significant correlation was seen between a higher self-estimated quality of life and walking ability but not with increased cognitive function. We then concluded that the selection of patients for shunting maintained a high standard.
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Affiliation(s)
- Caroline Hallqvist
- grid.24381.3c0000 0000 9241 5705Women’s Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Grönstedt
- grid.24381.3c0000 0000 9241 5705Women’s Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Arvidsson
- grid.465198.7Department of Clinical Neuroscience, Karolinska Institutet, Solna, Stockholm Sweden ,grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Eugeniavägen 27, Karolina Tower Hotel plan 4, 171 76 Stockholm, Sweden
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12
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Hänninen JJ, Nakajima M, Vanninen A, Hytönen S, Rummukainen J, Koivisto AM, Jääskeläinen JE, Soininen H, Sutela A, Vanninen R, Hiltunen M, Leinonen V, Rauramaa T. Neuropathological findings in possible normal pressure hydro-cephalus: A post-mortem study of 29 cases with lifelines. FREE NEUROPATHOLOGY 2022; 3:3-2. [PMID: 37284164 PMCID: PMC10210004 DOI: 10.17879/freeneuropathology-2022-3331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/19/2022] [Indexed: 06/08/2023]
Abstract
Aims: There are very few detailed post-mortem studies on idiopathic normal-pressure hydrocephalus (iNPH) and there is a lack of proper neuropathological criteria for iNPH. This study aims to update the knowledge on the neuropathology of iNPH and to develop the neuropathological diagnostic criteria of iNPH. Methods: We evaluated the clinical lifelines and post-mortem findings of 29 patients with possible NPH. Pre-mortem cortical brain biopsies were taken from all patients during an intracranial pressure measurement or a cerebrospinal fluid (CSF) shunt surgery. Results: The mean age at the time of the biopsy was 70±8 SD years and 74±7 SD years at the time of death. At the time of death, 11/29 patients (38%) displayed normal cognition or mild cognitive impairment (MCI), 9/29 (31%) moderate dementia and 9/29 (31%) severe dementia. Two of the demented patients had only scarce neuropathological findings indicating a probable hydrocephalic origin for the dementia. Amyloid-β (Aβ) and hyperphosphorylated τ (HPτ) in the biopsies predicted the neurodegenerative diseases so that there were 4 Aβ positive/low Alzheimer's disease neuropathological change (ADNC) cases, 4 Aβ positive/intermediate ADNC cases, 1 Aβ positive case with both low ADNC and progressive supranuclear palsy (PSP), 1 HPτ/PSP and primary age-related tauopathy (PART) case, 1 Aβ/HPτ and low ADNC/synucleinopathy case and 1 case with Aβ/HPτ and high ADNC. The most common cause of death was due to cardiovascular diseases (10/29, 34%), followed by cerebrovascular diseases or subdural hematoma (SDH) (8/29, 28%). Three patients died of a postoperative intracerebral hematoma (ICH). Vascular lesions were common (19/29, 65%). Conclusions: We update the suggested neuropathological diagnostic criteria of iNPH, which emphasize the rigorous exclusion of all other known possible neuropathological causes of dementia. Despite the first 2 probable cases reported here, the issue of "hydrocephalic dementia" as an independent entity still requires further confirmation. Extensive sampling (with fresh frozen tissue including meninges) with age-matched neurologically healthy controls is highly encouraged.
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Affiliation(s)
- Joni J. Hänninen
- The Department of Pathology, Kuopio University Hospital and the Institute of Clinical Medicine – Pathology, University of Eastern Finland, KuopioFinland
- The Department of Neurosurgery, Kuopio University Hospital and the Institute of Clinical Medicine – Neurosurgery, University of Eastern Finland, KuopioFinland
| | - Madoka Nakajima
- The Department of Neurosurgery, Juntendo University Faculty of Medicine, TokyoJapan
| | - Aleksi Vanninen
- The Department of Pathology, Kuopio University Hospital and the Institute of Clinical Medicine – Pathology, University of Eastern Finland, KuopioFinland
- The Department of Neurosurgery, Kuopio University Hospital and the Institute of Clinical Medicine – Neurosurgery, University of Eastern Finland, KuopioFinland
| | - Santtu Hytönen
- The National Institute for Health and Welfare, Forensic Medicine, KuopioFinland
| | - Jaana Rummukainen
- The Department of Pathology, Kuopio University Hospital, KuopioFinland
| | - Anne Maria Koivisto
- The Department of Neurology, Kuopio University Hospital and the Institute of Clinical Medicine – Neurology, University of Eastern Finland, KuopioFinland
- The Department of Neurosciences, Medical Faculty, University of Helsinki, HelsinkiFinland
- The Department of Geriatrics/Rehabilitation and Internal Medicine, Helsinki University Hospital, HelsinkiFinland
| | - Juha E. Jääskeläinen
- The Department of Neurosurgery, Kuopio University Hospital and the Institute of Clinical Medicine – Neurosurgery, University of Eastern Finland, KuopioFinland
| | - Hilkka Soininen
- The Department of Neurology, Kuopio University Hospital, KuopioFinland
| | - Anna Sutela
- The Department of Radiology, Kuopio University Hospital and the Institute of Clinical Medicine – Radiology, University of Eastern Finland, KuopioFinland
| | - Ritva Vanninen
- The Department of Radiology, Kuopio University Hospital and the Institute of Clinical Medicine – Radiology, University of Eastern Finland, KuopioFinland
| | - Mikko Hiltunen
- The Institute of Biomedicine, University of Eastern Finland, KuopioFinland
| | - Ville Leinonen
- The Department of Neurosurgery, Kuopio University Hospital and the Institute of Clinical Medicine – Neurosurgery, University of Eastern Finland, KuopioFinland
| | - Tuomas Rauramaa
- The Department of Pathology, Kuopio University Hospital and the Institute of Clinical Medicine – Pathology, University of Eastern Finland, KuopioFinland
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13
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Hiraldo-González L, Trillo-Contreras JL, García-Miranda P, Pineda-Sánchez R, Ramírez-Lorca R, Rodrigo-Herrero S, Blanco MO, Oliver M, Bernal M, Franco-Macías E, Villadiego J, Echevarría M. Evaluation of aquaporins in the cerebrospinal fluid in patients with idiopathic normal pressure hydrocephalus. PLoS One 2021; 16:e0258165. [PMID: 34597351 PMCID: PMC8486078 DOI: 10.1371/journal.pone.0258165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
Brain aquaporin 1 (AQP1) and AQP4 are involved in cerebrospinal fluid (CSF) homeostasis and might participate in the origin of hydrocephalus. Studies have shown alterations of perivascular AQP4 expression in idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer's disease (AD). Due to the overlapping of clinical signs between iNPH and certain neurological conditions, mainly AD, specific biomarkers might improve the diagnostic accuracy for iNPH. The goal of the present study was to analyze and quantify the presence of AQP1 and AQP4 in the CSF of patients with iNPH and AD to determine whether these proteins can be used as biomarkers of iNPH. We examined AQP1 and AQP4 protein levels in the CSF of 179 participants (88 women) classified into 5 groups: possible iNPH (81 participants), hydrocephalus associated with other neurological disorders (13 participants), AD (41 participants), non-AD dementia (32 participants) and healthy controls (12 participants). We recorded each participant's demographic and clinical variables and indicated, when available in the clinical history, the record of cardiovascular and respiratory complications. An ELISA showed virtually no AQP content in the CSF. Information on the vascular risk factors (available for 61 patients) confirmed some type of vascular risk factor in 86% of the patients with possible iNPH and 58% of the patients with AD. In conclusion, the ELISA analysis showed insufficient sensitivity to detect the presence of AQP1 and AQP4 in CSF, ruling out the possible use of these proteins as biomarkers for diagnosing iNPH.
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Affiliation(s)
- Laura Hiraldo-González
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - José Luis Trillo-Contreras
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - Pablo García-Miranda
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - Rocío Pineda-Sánchez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
| | - Reposo Ramírez-Lorca
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Department of Physiology and Biophysics, University of Seville, Seville, Spain
| | - Silvia Rodrigo-Herrero
- Clinical Neuroscience Management Unit, Neurology Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Magdalena Olivares Blanco
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Clinical Neuroscience Management Unit, Neurosurgery Service, University Hospital Virgen del Rocío, Seville, Spain
| | - María Oliver
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Clinical Neuroscience Management Unit, Neurosurgery Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Maria Bernal
- Clinical Neuroscience Management Unit, Neurology Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Emilio Franco-Macías
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Clinical Neuroscience Management Unit, Neurology Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Javier Villadiego
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Department of Physiology and Biophysics, University of Seville, Seville, Spain
- Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED), Seville, Spain
| | - Miriam Echevarría
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital, (HUVR)/Spanish National Research Council (CSIC)/University of Seville, Seville, Spain
- Department of Physiology and Biophysics, University of Seville, Seville, Spain
- * E-mail:
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14
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Valsecchi N, Mantovani P, Piserchia VA, Giannini G, Cevoli S, Aspide R, Oppi F, Milletti D, Cortelli P, Elder BD, Palandri G. The Role of Simultaneous Medical Conditions in Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2021; 157:e29-e39. [PMID: 34562629 DOI: 10.1016/j.wneu.2021.09.071] [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: 05/28/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) is a chronic neurologic syndrome that affects the elderly population in a context of concomitant medical conditions. The aim of this study was to understand the significance of comorbidities using 4 validated and specific clinical scores: Cumulative Illness Rating Scale (CIRS), American Society of Anesthesiologists (ASA) score, Comorbidity Index (CMI), and Charlson Comorbidity Index (CCI). METHODS From 2015 until 2019, the Bologna PRO-Hydro multidisciplinary team selected 63 patients for shunt surgery. All comorbidity scores were collected during preoperative anesthesia evaluation. Positive shunt response was defined as an improvement in overall disability (assessed with modified Rankin Scale [mRS]), in risk of fall (assessed with Tinetti Permormance Orientated Mobility Assessment, Tinetti) and in INPH specific symptoms (assessed with INPH Grading Scale, INPHGS). RESULTS Patients with elevated values of CIRS had worse performance in gait and balance at Tinetti scale, both before (P = 0.039) and after surgery (P = 0.005); patients with high values of CMI had inferior values of Tinetti at baseline (P = 0.027) and higher mRS after surgery (P = 0.009); ASA 2 patients had better postoperative Tinetti scores than ASA 3 patients (P = 0.027). A positive or negative shunt response was not significantly correlated with patients' preoperative comorbidity scores. CONCLUSIONS Patients with multiple comorbidities have a worse preoperative condition compared to patients with less concomitant diseases, and the proposed comorbidity scores, CIRS in particular, are useful clinical tools for the anesthesiologist. Comorbidities, though, do not impact overall postoperative outcome.
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Affiliation(s)
- Nicola Valsecchi
- Ophthalmology Unit, DIMES, Alma Mater Studiorum University of Bologna and S. Orsola-Malpighi Teaching Hospital, Bologna, Italy.
| | - Paolo Mantovani
- UOC Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Vito Antonio Piserchia
- UOC Anestesia e rianimazione Ospedale Bellaria, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy; Clinica Neurologica Metropolitana NEUROMET, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Sabina Cevoli
- Clinica Neurologica Metropolitana NEUROMET, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Raffaele Aspide
- UOC Anestesia e rianimazione Ospedale Bellaria, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Federico Oppi
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italia
| | - David Milletti
- UOSI Medicina Riabilitativa Intensiva, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giorgio Palandri
- UOC Neurochirurgia, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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15
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Engel DC, Pirpamer L, Hofer E, Schmidt R, Brendle C. Incidental findings of typical iNPH imaging signs in asymptomatic subjects with subclinical cognitive decline. Fluids Barriers CNS 2021; 18:37. [PMID: 34391462 PMCID: PMC8364005 DOI: 10.1186/s12987-021-00268-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 07/07/2021] [Indexed: 01/15/2023] Open
Abstract
Background The etiology of idiopathic normal pressure hydrocephalus (iNPH) remains unclear. Little is known about the pre-symptomatic stage. This study aimed to investigate the association of neuropsychological data with iNPH-characteristic imaging changes compared to normal imaging and unspecific atrophy in a healthy population. Methods We extracted data from the community-dwelling Austrian Stroke Prevention Family Study (ASPS-Fam) database (2006–2010). All subjects underwent a baseline and identical follow-up examination after 3–5 years with MR imaging and an extensive neuropsychological test battery (Trail Making Test B, short physical performance balance, walking speed, memory, visuo-practical skills, composite scores of executive function and g-factor). We categorized the subjects into “iNPH”-associated, non-specific “atrophy,” and “normal” based on the rating of different radiological cerebrospinal fluid (CSF) space parameters. We noted how the categories developed over time. We assessed the association of the image categories with the neuropsychological data, different demographic, and lifestyle parameters (age, sex, education, alcohol intake, arterial hypertension, hypercholesterolemia), and the extent of white matter hyperintensities. We investigated whether neuropsychological data associated with the image categories were independent from other parameters as confounders. Results One hundred and thirteen subjects, aged 50–70 years, were examined. The imaging category “iNPH” was only present at follow-up. A third of subjects with “atrophy” at baseline changed to the category “iNPH” at follow-up. More white matter hyperintensities (WMH) were present in later “iNPH” subjects. Subjects with “iNPH” performed worse than “normal” subjects on executive function (p = 0.0118), memory (p = 0.0109), and Trail Making Test B (TMT-B. p < 0.0001). Education, alcohol intake, diabetes, arterial hypertension, and hypercholesterolemia had no effect. Age, number of females, and the extent of white matter hyperintensities were higher in “iNPH” than in “normal” subjects but did not significantly confound the neuropsychological results. Conclusions Apparent asymptomatic subjects with “iNPH” imaging characteristics presented with subclinical cognitive decline and showed worse executive function, memory, and TMT-B results than “normal” subjects. WMH seem to play a role in the etiology before ventriculomegaly. Clinical screening of individuals with incidental iNPH-characteristic imaging and conspicuous results sof these neurocognitive tests needs further validation.
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Affiliation(s)
- Doortje C Engel
- Department of Neurosurgery, University Hospital of Tuebingen, Hoppe-Seyler-Strasse 3, 72076, Tuebingen, Germany. .,Institute for diagnostic and interventional neuroradiology, University Hospital Wuerzburg, Josef-Schneider-Strasse 11, 97080, Wuerzburg,, Germany.
| | - Lukas Pirpamer
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036, Graz, Austria
| | - Edith Hofer
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036, Graz, Austria.,Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Auenbruggerplatz 2, 8036, Graz, Austria
| | - Reinhold Schmidt
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036, Graz, Austria
| | - Cornelia Brendle
- Department of Neuroradiology, University Hospital of Tuebingen, Hoppe-Seyler-Strasse 3, 72076, Tuebingen, Germany
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16
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Yang HW, Lee S, Yang D, Dai H, Zhang Y, Han L, Zhao S, Zhang S, Ma Y, Johnson MF, Rattray AK, Johnson TA, Wang G, Zheng S, Carroll RS, Park PJ, Johnson MD. Deletions in CWH43 cause idiopathic normal pressure hydrocephalus. EMBO Mol Med 2021; 13:e13249. [PMID: 33459505 PMCID: PMC7933959 DOI: 10.15252/emmm.202013249] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 11/12/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder that occurs in about 1% of individuals over age 60 and is characterized by enlarged cerebral ventricles, gait difficulty, incontinence, and cognitive decline. The cause and pathophysiology of iNPH are largely unknown. We performed whole exome sequencing of DNA obtained from 53 unrelated iNPH patients. Two recurrent heterozygous loss of function deletions in CWH43 were observed in 15% of iNPH patients and were significantly enriched 6.6‐fold and 2.7‐fold, respectively, when compared to the general population. Cwh43 modifies the lipid anchor of glycosylphosphatidylinositol‐anchored proteins. Mice heterozygous for CWH43 deletion appeared grossly normal but displayed hydrocephalus, gait and balance abnormalities, decreased numbers of ependymal cilia, and decreased localization of glycosylphosphatidylinositol‐anchored proteins to the apical surfaces of choroid plexus and ependymal cells. Our findings provide novel mechanistic insights into the origins of iNPH and demonstrate that it represents a distinct disease entity.
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Affiliation(s)
- Hong Wei Yang
- University of Massachusetts Medical School, Worcester, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Semin Lee
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Dejun Yang
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Huijun Dai
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Yan Zhang
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Lei Han
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sijun Zhao
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Shuo Zhang
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Yan Ma
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Marciana F Johnson
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Anna K Rattray
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Tatyana A Johnson
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - George Wang
- University of Massachusetts Medical School, Worcester, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Shaokuan Zheng
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Rona S Carroll
- University of Massachusetts Medical School, Worcester, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Peter J Park
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mark D Johnson
- University of Massachusetts Medical School, Worcester, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,UMass Memorial Health Care, Worcester, MA, USA
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17
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Eide PK, Pripp AH, Ringstad G. Magnetic resonance imaging biomarkers of cerebrospinal fluid tracer dynamics in idiopathic normal pressure hydrocephalus. Brain Commun 2020; 2:fcaa187. [PMID: 33381757 PMCID: PMC7753057 DOI: 10.1093/braincomms/fcaa187] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/09/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
Abstract
Disturbed clearance of toxic metabolites from the brain via cerebrospinal fluid is emerging as an important mechanism behind dementia and neurodegeneration. To this end, magnetic resonance imaging work-up of dementia diseases is largely focused on anatomical derangements of the brain. This study explores magnetic resonance imaging biomarkers of cerebrospinal fluid tracer dynamics in patients with the dementia subtype idiopathic normal pressure hydrocephalus and a cohort of reference subjects. All study participants underwent multi-phase magnetic resonance imaging up to 48 h after intrathecal administration of the contrast agent gadobutrol (0.5 ml, 1 mmol/ml), serving as cerebrospinal fluid tracer. Imaging biomarkers of cerebrospinal fluid tracer dynamics (i.e. ventricular reflux grades 0–4 and clearance) were compared with anatomical magnetic resonance imaging biomarkers of cerebrospinal fluid space anatomy (Evans’ index, callosal angle and disproportional enlargement of subarachnoid spaces hydrocephalus) and neurodegeneration (Schelten’s medial temporal atrophy scores, Fazeka’s scores and entorhinal cortex thickness). The imaging scores were also related to a pulsatile intracranial pressure score indicative of intracranial compliance. In shunt-responsive idiopathic normal pressure hydrocephalus, the imaging biomarkers demonstrated significantly altered cerebrospinal fluid tracer dynamics (ventricular reflux grades 3–4 and reduced clearance of tracer), deranged cerebrospinal fluid space anatomy and pronounced neurodegeneration. The altered MRI biomarkers were accompanied by pressure indices of impaired intracranial compliance. In conclusion, we present novel magnetic resonance imaging biomarkers characterizing idiopathic normal pressure hydrocephalus pathophysiology, namely measures of cerebrospinal fluid molecular redistribution and clearance, which add information to traditional imaging scores of cerebrospinal fluid space anatomy and neurodegeneration.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Are H Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Geir Ringstad
- Department of Radiology, Oslo University Hospital- Rikshospitalet, Oslo, Norway
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18
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Jacobsen HH, Sandell T, Jørstad ØK, Moe MC, Ringstad G, Eide PK. In Vivo Evidence for Impaired Glymphatic Function in the Visual Pathway of Patients With Normal Pressure Hydrocephalus. Invest Ophthalmol Vis Sci 2020; 61:24. [PMID: 33201186 PMCID: PMC7683855 DOI: 10.1167/iovs.61.13.24] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose Impaired ability to remove toxic metabolites from central nervous system may be an important link between cerebral and ophthalmic degenerative diseases. The aim of the present study was to compare the glymphatic function in the visual pathway in patients with idiopathic normal pressure hydrocephalus (iNPH), a neurodegenerative dementia subtype, with a reference group. Methods We compared 31 subjects with Definite iNPH (i.e., shunt-responsive) with 13 references in a prospective and observational study. After intrathecal injection of the magnetic contrast agent gadobutrol (Gadovist, 0.5 mL, 1.0 mmol/mL, Bayer Pharma AG), serving as a tracer, consecutive magnetic resonance imaging (MRI) scans were obtained (next 24-48 hours). The normalized MRI T1 signal recorded in the cerebrospinal fluid (CSF) and along the visual pathway served as a semi-quantitative measure of tracer enrichment. Gadobutrol does not penetrate the blood-brain barrier and is thus confined to the extravascular space. Overnight measurements of pulsatile intracranial pressure were used as a surrogate marker for the intracranial compliance. Results The tracer enriched the prechiasmatic cistern similarly in both groups, but clearance was delayed in the iNPH group. Moreover, both delayed enrichment and clearance of the tracer were observed in the visual pathway in the iNPH subjects. The enrichment in the visual pathway and the CSF correlated. Individuals with elevated pulsatile intracranial pressure showed reduced enrichment within the visual pathway. Conclusions There was delayed enrichment and clearance of a tracer in the visual pathway of iNPH patients, which suggests impaired glymphatic function in the visual pathway in this disease.
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Affiliation(s)
- Henrik Holvin Jacobsen
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tiril Sandell
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Department of Ophthalmology, Vestre Viken Hospital, Drammen, Norway
| | | | - Morten C Moe
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Geir Ringstad
- Division of Radiology and Nuclear Medicine, Department of Radiology, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Per Kristian Eide
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway
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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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Kaestner S, Behrends R, Roth C, Graf K, Deinsberger W. Treatment for secondary deterioration in idiopathic normal pressure hydrocephalus in the later course of the disease: a retrospective analysis. Acta Neurochir (Wien) 2020; 162:2431-2439. [PMID: 32623600 DOI: 10.1007/s00701-020-04475-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunting is a highly effective treatment for idiopathic normal pressure hydrocephalus (iNPH). However, secondary deterioration can occur at a later time. Thus, the current study aimed to evaluate the incidence rate and causes of secondary deterioration. METHODS A retrospective analysis was conducted on all patients with iNPH who were treated with implantation of a CSF shunt since 1993. A meticulous shunt workup was recommended to all patients who presented to our department with secondary deterioration during their follow-up visits. Data about the proportion of patients with such deterioration and its causes, subsequent treatment, and clinical outcome were obtained. RESULTS A total of 169 patients were included, and the mean follow-up time was 69.2 months. In total, 119 (70.4%) patients presented with a total of 153 secondary deteriorations. In 9 cases (5.9%), the deterioration was caused by delayed subdural hematoma and in 27 (22.1%) cases, by shunt dysfunction. Invasive shunt testing was commonly required to validate shunt failure. Moreover, 19 of 27 patients experienced a satisfactory improvement after revision surgery. In total, 86 deteriorations were attributed to nonsurgical causes, and the valve pressure was decreased in 79 patients, with only 16.5% presenting with a satisfactory improvement after lowering of valve pressure. CONCLUSIONS Most patients with shunted iNPH presented with deterioration in the later course of the disease. Shunt dysfunction was considered a cause of secondary deterioration. Moreover, shunt revision surgery was a highly effective treatment, and patients with deterioration should undergo screening procedures for shunt dysfunction, including invasive shunt testing.
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Affiliation(s)
- Stefanie Kaestner
- Department of Neurosurgery, Klinikum Kassel, Moencheberg Str. 41-43, 34125, Kassel, Germany.
- Kassel School of Medicine, University of Southampton, 12 University Rd, Southampton, SO17 1BJ, UK.
| | - Rhea Behrends
- Kassel School of Medicine, University of Southampton, 12 University Rd, Southampton, SO17 1BJ, UK
| | - Christian Roth
- Department of Neurology, Red Cross Clinic, Hanstein Str. 29, 34121, Kassel, Germany
| | - Katharina Graf
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstraße 29, 35392, Giessen, Germany
| | - Wolfgang Deinsberger
- Department of Neurosurgery, Klinikum Kassel, Moencheberg Str. 41-43, 34125, Kassel, Germany
- Kassel School of Medicine, University of Southampton, 12 University Rd, Southampton, SO17 1BJ, UK
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21
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Räsänen J, Huovinen J, Korhonen VE, Junkkari A, Kastinen S, Komulainen S, Oinas M, Avellan C, Frantzen J, Rinne J, Ronkainen A, Kauppinen M, Lönnrot K, Perola M, Koivisto AM, Remes AM, Soininen H, Hiltunen M, Helisalmi S, Kurki MI, Jääskeläinen JE, Leinonen V. Diabetes is associated with familial idiopathic normal pressure hydrocephalus: a case-control comparison with family members. Fluids Barriers CNS 2020; 17:57. [PMID: 32933532 PMCID: PMC7493374 DOI: 10.1186/s12987-020-00217-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The pathophysiological basis of idiopathic normal pressure hydrocephalus (iNPH) is still unclear. Previous studies have shown a familial aggregation and a potential heritability when it comes to iNPH. Our aim was to conduct a novel case-controlled comparison between familial iNPH (fNPH) patients and their elderly relatives, involving multiple different families. METHODS Questionnaires and phone interviews were used for collecting the data and categorising the iNPH patients into the familial (fNPH) and the sporadic groups. Identical questionnaires were sent to the relatives of the potential fNPH patients. Venous blood samples were collected for genetic studies. The disease histories of the probable fNPH patients (n = 60) were compared with their ≥ 60-year-old relatives with no iNPH (n = 49). A modified Charlson Comorbidity Index (CCI) was used to measure the overall disease burden. Fisher's exact test (two-tailed), the Mann-Whitney U test (two-tailed) and a multivariate binary logistic regression analysis were used to perform the statistical analyses. RESULTS Diabetes (32% vs. 14%, p = 0.043), arterial hypertension (65.0% vs. 43%, p = 0.033), cardiac insufficiency (16% vs. 2%, p = 0.020) and depressive symptoms (32% vs. 8%, p = 0.004) were overrepresented among the probable fNPH patients compared to their non-iNPH relatives. In the age-adjusted multivariate logistic regression analysis, diabetes remained independently associated with fNPH (OR = 3.8, 95% CI 1.1-12.9, p = 0.030). CONCLUSIONS Diabetes is associated with fNPH and a possible risk factor for fNPH. Diabetes could contribute to the pathogenesis of iNPH/fNPH, which motivates to further prospective and gene-environmental studies to decipher the disease modelling of iNPH/fNPH.
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Affiliation(s)
- Joel Räsänen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland. .,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland.
| | - Joel Huovinen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland.,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Ville E Korhonen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland.,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Antti Junkkari
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland.,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Sami Kastinen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland.,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Simo Komulainen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland.,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Minna Oinas
- Department of Neurosurgery, University of Helsinki, Helsinki, Finland.,Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Cecilia Avellan
- Clinical Neurosciences, Department of Neurosurgery, University of Turku, Turku, Finland.,Department of Neurosurgery, Turku University Hospital, Turku, Finland
| | - Janek Frantzen
- Department of Neurosurgery, University of Helsinki, Helsinki, Finland.,Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Jaakko Rinne
- Clinical Neurosciences, Department of Neurosurgery, University of Turku, Turku, Finland.,Department of Neurosurgery, Turku University Hospital, Turku, Finland
| | - Antti Ronkainen
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Mikko Kauppinen
- Unit of Clinical Neuroscience, Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Kimmo Lönnrot
- Department of Neurosurgery, University of Helsinki, Helsinki, Finland.,Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Markus Perola
- National Institute for Health and Welfare, Helsinki, Finland.,University of Helsinki, Helsinki, Finland
| | - Anne M Koivisto
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Anne M Remes
- Unit of Clinical Neuroscience, Neurology, University of Oulu, Oulu, Finland.,Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Hilkka Soininen
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Mikko Hiltunen
- Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - Seppo Helisalmi
- Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland
| | - Mitja I Kurki
- Analytical and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, Boston, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, USA.,Stanley Center for Psychiatric Research, Broad Institute for Harvard and MIT, Cambridge, USA
| | - Juha E Jääskeläinen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland.,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Ville Leinonen
- Department of Neurosurgery, Kuopio University Hospital, P.O.Box 100, 70029, Kuopio, KYS, Finland. .,Institute of Clinical Medicine-Neurosurgery, University of Eastern Finland, Kuopio, Finland. .,Unit of Clinical Neuroscience, Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland.
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22
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Mechanisms behind altered pulsatile intracranial pressure in idiopathic normal pressure hydrocephalus: role of vascular pulsatility and systemic hemodynamic variables. Acta Neurochir (Wien) 2020; 162:1803-1813. [PMID: 32533412 PMCID: PMC7360648 DOI: 10.1007/s00701-020-04423-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The dementia subtype idiopathic normal pressure hydrocephalus (iNPH) has unknown etiology, but one characteristic is elevated intracranial pressure (ICP) wave amplitudes in those individuals who respond with clinical improvement following cerebrospinal fluid (CSF) diversion. To explore the mechanisms behind altered ICP wave amplitudes, we correlated central aortic blood pressure (BP) and ICP waveform amplitudes (intracranial aortic amplitude correlation) and examined how this correlation relates to ICP wave amplitude levels and systemic hemodynamic parameters. METHODS The study included 29 patients with probable iNPH who underwent continuous multi-hour measurement of ICP, radial artery BP, and systemic hemodynamic parameters. The radial artery BP waveforms were used to estimate central aortic BP waveforms, and the intracranial aortic amplitude correlation was determined over consecutive 4-min periods. RESULTS The average intracranial aortic amplitude correlation was 0.28 ± 0.16 at the group level. In the majority of iNPH patients, the intracranial aortic amplitude correlation was low, while in about 1/5 patients, the correlation was rather high (average Pearson correlation coefficient > 0.4). The degree of correlation was hardly influenced by systemic hemodynamic parameters. CONCLUSIONS In about 1/5 iNPH patients of this study, the intracranial aortic amplitude correlation (IAACAORTIC) was rather high (average Pearson correlation coefficient > 0.4), suggesting that cerebrovascular factors to some extent may affect the ICP wave amplitudes in a subset of patients. However, in 14/19 (74%) iNPH patients with elevated ICP wave amplitudes, the intracranial aortic amplitude correlation was low, indicating that the ICP pulse amplitude in most iNPH patients is independent of central vascular excitation, ergo it is modulated by local cerebrospinal physiology. In support of this assumption, the intracranial aortic amplitude correlation was not related to most systemic hemodynamic variables. An exception was found for a subgroup of the patients with high systemic vascular resistance, where there was a correlation.
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23
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Frič R, Eide PK. Chiari type 1-a malformation or a syndrome? A critical review. Acta Neurochir (Wien) 2020; 162:1513-1525. [PMID: 31656982 DOI: 10.1007/s00701-019-04100-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/08/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE As the understanding of pathophysiology behind Chiari malformation still is limited, the treatment of Chiari malformation type 1 remains rather empirical. This may result in suboptimal treatment strategy and outcome in many cases. In this review, we critically address whether the condition known today as Chiari malformation type I should rather be denoted Chiari syndrome. METHODS The current knowledge of Chiari malformation type 1 is summarized from the historical, etymological, genetic, clinical, and in particular pathophysiological perspectives. RESULTS There are several lines of evidence that Chiari malformation type 1 represents a condition significantly different from types 2 to 4. Unlike the other types, the type 1 should rather be considered a syndrome, thus supporting the reasons to reappraise the traditional classification of Chiari malformations. CONCLUSION We propose that Chiari malformation type 1 should rather be denoted Chiari syndrome, while the notation malformation is maintained for types 2-4.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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24
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Ghaffari-Rafi A, Gorenflo R, Hu H, Viereck J, Liow K. Role of psychiatric, cardiovascular, socioeconomic, and demographic risk factors on idiopathic normal pressure hydrocephalus: A retrospective case-control study. Clin Neurol Neurosurg 2020; 193:105836. [PMID: 32371292 DOI: 10.1016/j.clineuro.2020.105836] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Currently, predicting and preventing idiopathic normal pressure hydrocephalus (iNPH) remains challenging, especially for patients without a history of cerebrovascular disease. By exploring the role of cardiovascular and psychiatric history, demographics, and socioeconomic status in iNPH, will provide better direction for elucidating the etiology or addressing healthcare inequalities. PATIENTS AND METHODS To investigate iNPH with respect to the selected risk factors, we conducted a retrospective case-control study from a neuroscience institute in Hawaii with a patient pool of 25,843. After excluding patients with a history of cerebrovascular disease, we identified 29 cases which meet the American-European guidelines for iNPH diagnosis. Meanwhile, 116 controls matched to age, sex, and race were also randomly selected. RESULTS Median age at diagnosis was 83 (IQR: 74-88), with cases estimated 22 years older than controls (95 % CI: 14.00-29.00; p = 0.0000001). Patients with iNPH were more likely to be White (OR 4.01, 95 % CI: 1.59-10.11; p = 0.0042) and less likely Native Hawaiian and other Pacific Islander (OR 0.010, 95 % CI: 0.00-0.78; p = 0.014). Median household income was $2874 (95 % CI: 0.000089-6905; p = 0.088) greater amongst iNPH cases. Effect size amongst cardiovascular risk factors was not found statistically significant (i.e., body mass index, hyperlipidemia, type 2 diabetes mellitus, hypertension, coronary artery disease or prior myocardial infarction history, peripheral vascular disease, smoking status, congestive heart failure, atrial fibrillation/flutter, and history of prosthetic valve replacement). However, iNPH patients were more likely to have a history of alcohol use disorder (OR 8.29, 95 % CI: 0.99-453.87; p = 0.050) and history of a psychiatric disorder (OR 2.48; 95 % CI: 1.08-5.68; p = 0.029). Odds ratio for autoimmune disorder, thyroid disorder, glaucoma, and seizures did not reach statistical significance. CONCLUSION Patient race (i.e., White; Native Hawaiian or other Pacific Islander) was found associated with iNPH development. Meanwhile, after excluding those with cerebrovascular disease, cardiovascular risk factors were not found associated with iNPH. Lastly, iNPH cases were more inclined to have a history of alcohol use disorder and prior psychiatric disorder. Overall, this data reveals that a racial disparity exists amongst iNPH, as well as highlights the role of various cardiovascular and psychiatric risk factors, which can potentially provide direction in etiology elucidation.
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Affiliation(s)
- Arash Ghaffari-Rafi
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA; University College London, Queen Square Institute of Neurology, London, England, UK.
| | - Rachel Gorenflo
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA
| | - Huanli Hu
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA
| | - Jason Viereck
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA; Hawaii Pacific Neuroscience, Honolulu, Hawai'i, USA
| | - Kore Liow
- University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA; Hawaii Pacific Neuroscience, Honolulu, Hawai'i, USA
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25
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Hasan-Olive MM, Enger R, Hansson HA, Nagelhus EA, Eide PK. Pathological mitochondria in neurons and perivascular astrocytic endfeet of idiopathic normal pressure hydrocephalus patients. Fluids Barriers CNS 2019; 16:39. [PMID: 31849332 PMCID: PMC6918585 DOI: 10.1186/s12987-019-0160-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A growing body of evidence suggests that the accumulation of amyloid-β and tau (HPτ) in the brain of patients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) is associated with delayed extravascular clearance of metabolic waste. Whether also clearance of intracellular debris is affected in these patients needs to be examined. Hypothetically, defective extra- and intra-cellular clearance of metabolites may be instrumental in the neurodegeneration and dementia characterizing iNPH. This study explores whether iNPH is associated with altered mitochondria phenotype in neurons and astrocytes. METHODS Cortical brain biopsies of 9 reference (REF) individuals and 30 iNPH patients were analyzed for subcellular distribution and morphology of mitochondria using transmission electron microscopy. In neuronal soma of REF and iNPH patients, we identified normal, pathological and clustered mitochondria, mitochondria-endoplasmic reticulum contact sites and autophagic vacuoles. We also differentiated normal and pathological mitochondria in pre- and post-synaptic nerve terminals, as well as in astrocytic endfoot processes towards vessels. RESULTS We found a high prevalence of pathological mitochondria in neuronal soma and pre- and post-synaptic terminals, as well as increased mitochondrial clustering, and altered number of mitochondria-endoplasmic reticulum contact sites in iNPH. Non-fused autophagic vacuoles were more abundant in neuronal soma of iNPH patients, suggestive of cellular clearance failure. Moreover, the length of postsynaptic densities was reduced in iNPH, potentially related to reduced synaptic activity. In astrocytic endfoot processes, we also found increased number, area and area fraction of pathological mitochondria in iNPH patients. The proportion of pathological mitochondria correlated significantly with increasing degree of astrogliosis and reduced perivascular expression of aquaporin-4 (AQP4), assessed by light microscopy immunohistochemistry. CONCLUSION Our results provide evidence of mitochondrial pathology and signs of impaired cellular clearance in iNPH patients. The results indicate that iNPH is a neurodegenerative disease with close similarity to Alzheimer's disease.
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Affiliation(s)
- Md Mahdi Hasan-Olive
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, 0027, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Rune Enger
- GliaLab and Letten Centre, Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, 0317, Oslo, Norway.,Department of Neurology, Oslo University Hospital-Rikshospitalet, 0027, Oslo, Norway
| | - Hans-Arne Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
| | - Erlend A Nagelhus
- GliaLab and Letten Centre, Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, 0317, Oslo, Norway.,Department of Neurology, Oslo University Hospital-Rikshospitalet, 0027, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, 0027, Oslo, Norway. .,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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26
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Eide PK, Ringstad G. In Vivo Imaging of Molecular Clearance From Human Entorhinal Cortex: A Possible Method for Preclinical Testing of Dementia. Gerontol Geriatr Med 2019; 5:2333721419889739. [PMID: 31819895 PMCID: PMC6883359 DOI: 10.1177/2333721419889739] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 10/22/2019] [Indexed: 01/07/2023] Open
Abstract
Accumulation in the brain of metabolic waste products such as amyloid-β and hyperphosporylated tau (tau) is a hallmark of dementia (e.g., Alzheimer's disease). One possible underlying mechanism is impaired cerebral paravascular (glymphatic) clearance of toxic solutes. Recently, we have provided evidence of glymphatic circulation being present in the human brain, utilizing repeated magnetic resonance imaging (MRI) acquisitions before/after intrathecal injection of an MRI contrast agent, serving as a cerebrospinal fluid (CSF) tracer (glymphatic MRI [gMRI]). In a recent study, we utilized the same methodology to assess glymphatic clearance function within an anatomical region that has a key role in cognitive function-the entorhinal cortex (ERC). gMRI was compared in individuals with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH; n = 30) and reference (REF; n = 8) subjects. We found delayed clearance of CSF tracer from CSF nearby ERC, the ERC itself, and the white matter adjacent to ERC, which was most evident after 24 hr. The observations were interpreted as indicative of impaired glymphatic circulation and further suggested this being a possible mechanism behind accumulation of amyloid-β and tau in ERC and instrumental for dementia in iNPH. We suggest that gMRI may serve as a tool for assessment of early dementia, or even in the preclinical stage.
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Affiliation(s)
- Per K Eide
- Oslo University Hospital, Rikshospitalet, Norway.,University of Oslo, Norway
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27
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Andrén K, Wikkelsø C, Sundström N, Israelsson H, Agerskov S, Laurell K, Hellström P, Tullberg M. Survival in treated idiopathic normal pressure hydrocephalus. J Neurol 2019; 267:640-648. [PMID: 31713102 PMCID: PMC7035239 DOI: 10.1007/s00415-019-09598-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/19/2019] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To describe survival and causes of death in 979 treated iNPH patients from the Swedish Hydrocephalus Quality Registry (SHQR), and to examine the influence of comorbidities, symptom severity and postoperative outcome. METHODS All 979 patients operated for iNPH 2004-2011 and registered in the SHQR were included. A matched control group of 4890 persons from the general population was selected by Statistics Sweden. Data from the Swedish Cause of Death Registry was obtained for patients and controls. RESULTS At a median 5.9 (IQR 4.2-8.1) year follow-up, 37% of the iNPH patients and 23% of the controls had died. Mortality was increased in iNPH patients by a hazard ratio of 1.81, 95% CI 1.61-2.04, p < 0.001. More pronounced symptoms in the preoperative ordinal gait scale and the Mini-mental State Examination were the most important independent predictors of mortality along with the prevalence of heart disease. Patients who improved in both the gait scale and in the modified Rankin Scale postoperatively (n = 144) had a similar survival as the general population (p = 0.391). Deaths due to cerebrovascular disease or dementia were more common in iNPH patients, while more controls died because of neoplasms or disorders of the circulatory system. CONCLUSIONS Mortality in operated iNPH patients is 1.8 times increased compared to the general population, a lower figure than previously reported. The survival of iNPH patients who improve in gait and functional independence is similar to that of the general population, indicating that shunt surgery for iNPH, besides improving symptoms and signs, can normalize survival.
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Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden.
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Hanna Israelsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Simon Agerskov
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Katarina Laurell
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
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28
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Eide PK, Ringstad G. Delayed clearance of cerebrospinal fluid tracer from entorhinal cortex in idiopathic normal pressure hydrocephalus: A glymphatic magnetic resonance imaging study. J Cereb Blood Flow Metab 2019; 39:1355-1368. [PMID: 29485341 PMCID: PMC6668515 DOI: 10.1177/0271678x18760974] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/12/2018] [Accepted: 02/01/2018] [Indexed: 12/19/2022]
Abstract
The glymphatic system plays a key role for clearance of waste solutes from the rodent brain. We recently found evidence of glymphatic circulation in the human brain when using magnetic resonance imaging (MRI) contrast agent as cerebrospinal fluid (CSF) tracer in conjunction with multiple MRI acquisitions (gMRI). The present study explored the hypothesis that reduced glymphatic clearance in entorhinal cortex (ERC) may be instrumental in idiopathic normal pressure hydrocephalus (iNPH) dementia. gMRI acquisitions were obtained over a 24-48 h time span in cognitively affected iNPH patients and non-cognitively affected patients with suspected CSF leaks. The CSF tracer enrichment was determined as changes in normalized MRI T1 signal units. The study included 30 patients with iNPH and 8 individuals with suspected CSF leaks (i.e. reference individuals). Compared to reference individuals, iNPH patients presented with higher medial temporal lobe atrophy score and Evan's index and inferior ERC thickness. We found delayed clearance of the intrathecal CSF tracer gadobutrol from CSF, the ERC and adjacent white matter, suggesting impaired glymphatic circulation. Reduced clearance and accumulation of toxic waste product such as amyloid-β may be a mechanism behind dementia in iNPH. Glymphatic MRI (gMRI) may become a tool for assessment of early dementia.
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Affiliation(s)
- Per K Eide
- Departmentof Neurosurgery, Oslo
University Hospital – Rikshospitalet, Oslo, Norway
- Faculty of Medicine, University of Oslo,
Oslo, Norway
| | - Geir Ringstad
- Faculty of Medicine, University of Oslo,
Oslo, Norway
- Departmentof Radiology and Nuclear
Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway
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29
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Fulop GA, Tarantini S, Yabluchanskiy A, Molnar A, Prodan CI, Kiss T, Csipo T, Lipecz A, Balasubramanian P, Farkas E, Toth P, Sorond F, Csiszar A, Ungvari Z. Role of age-related alterations of the cerebral venous circulation in the pathogenesis of vascular cognitive impairment. Am J Physiol Heart Circ Physiol 2019; 316:H1124-H1140. [PMID: 30848677 PMCID: PMC6580383 DOI: 10.1152/ajpheart.00776.2018] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/31/2019] [Accepted: 02/18/2019] [Indexed: 02/07/2023]
Abstract
There has been an increasing appreciation of the role of vascular contributions to cognitive impairment and dementia (VCID) associated with old age. Strong preclinical and translational evidence links age-related dysfunction and structural alterations of the cerebral arteries, arterioles, and capillaries to the pathogenesis of many types of dementia in the elderly, including Alzheimer's disease. The low-pressure, low-velocity, and large-volume venous circulation of the brain also plays critical roles in the maintenance of homeostasis in the central nervous system. Despite its physiological importance, the role of age-related alterations of the brain venous circulation in the pathogenesis of vascular cognitive impairment and dementia is much less understood. This overview discusses the role of cerebral veins in the pathogenesis of VCID. Pathophysiological consequences of age-related dysregulation of the cerebral venous circulation are explored, including blood-brain barrier disruption, neuroinflammation, exacerbation of neurodegeneration, development of cerebral microhemorrhages of venous origin, altered production of cerebrospinal fluid, impaired function of the glymphatics system, dysregulation of cerebral blood flow, and ischemic neuronal dysfunction and damage. Understanding the age-related functional and phenotypic alterations of the cerebral venous circulation is critical for developing new preventive, diagnostic, and therapeutic approaches to preserve brain health in older individuals.
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Affiliation(s)
- Gabor A Fulop
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Heart and Vascular Center, Semmelweis University , Budapest , Hungary
| | - Stefano Tarantini
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
| | - Andrea Molnar
- Heart and Vascular Center, Semmelweis University , Budapest , Hungary
| | - Calin I Prodan
- Veterans Affairs Medical Center , Oklahoma City, Oklahoma
- Department of Neurology, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
| | - Tamas Kiss
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Vascular Cognitive Impairment Program, Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
| | - Tamas Csipo
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
| | - Agnes Lipecz
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
| | - Priya Balasubramanian
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
| | - Eszter Farkas
- Vascular Cognitive Impairment Program, Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
| | - Peter Toth
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Cerebrovascular Laboratory, Department of Neurosurgery and Szentagothai Research Center, University of Pecs Medical School , Pecs , Hungary
| | - Farzaneh Sorond
- Department of Neurology, Northwestern University , Chicago, Illinois
| | - Anna Csiszar
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Vascular Cognitive Impairment Program, Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment and Neurodegeneration Program, Reynolds Oklahoma Center on Aging, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Translational Geroscience Laboratory, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center , Oklahoma City, Oklahoma
- Vascular Cognitive Impairment Program, Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
- Semmelweis University, Department of Pulmonology , Budapest , Hungary
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30
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Hudson M, Nowak C, Garling RJ, Harris C. Comorbidity of diabetes mellitus in idiopathic normal pressure hydrocephalus: a systematic literature review. Fluids Barriers CNS 2019; 16:5. [PMID: 30744635 PMCID: PMC6371499 DOI: 10.1186/s12987-019-0125-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/29/2019] [Indexed: 11/14/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a subtype of hydrocephalus that occurs more often in the elderly population. It is usually characterized by gait disturbance, dementia and urinary incontinence. Epidemiological studies indicate that 15.7–17.8% of iNPH patients present with type-2 diabetes mellitus (DM). A review of the primary literature shows that these occurrence rates are higher than age- and cohort-matched non-iNPH controls. This suggests that this already vulnerable patient group has an increased risk for presenting with DM compared to their non-iNPH counterparts. Postoperative outcome when treating iNPH patients is inversely related to the number of patient comorbidities and a lower comorbidity status is correlated with better outcomes. This review highlights the need for further research into the relationship between iNPH and DM and speculates on a possible mechanism for an association between the development of ventriculomegaly and the development of DM and iNPH.
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Affiliation(s)
- Miles Hudson
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA.
| | - Caden Nowak
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA
| | - Richard J Garling
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA
| | - Carolyn Harris
- Department of Neurosurgery, Wayne State University, 51 W Palmer ave, Detroit, MI, 48202, USA
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31
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Korhonen VE, Helisalmi S, Jokinen A, Jokinen I, Lehtola JM, Oinas M, Lönnrot K, Avellan C, Kotkansalo A, Frantzen J, Rinne J, Ronkainen A, Kauppinen M, Junkkari A, Hiltunen M, Soininen H, Kurki M, Jääskeläinen JE, Koivisto AM, Sato H, Kato T, Remes AM, Eide PK, Leinonen V. Copy number loss in SFMBT1 is common among Finnish and Norwegian patients with iNPH. NEUROLOGY-GENETICS 2018; 4:e291. [PMID: 30584596 PMCID: PMC6283454 DOI: 10.1212/nxg.0000000000000291] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Objective To evaluate the role of the copy number loss in SFMBT1 in a Caucasian population. Methods Five hundred sixty-seven Finnish and 377 Norwegian patients with idiopathic normal pressure hydrocephalus (iNPH) were genotyped and compared with 508 Finnish elderly, neurologically healthy controls. The copy number loss in intron 2 of SFMBT1 was determined using quantitative PCR. Results The copy number loss in intron 2 of SFMBT1 was detected in 10% of Finnish (odds ratio [OR] = 1.9, p = 0.0078) and in 21% of Norwegian (OR = 4.7, p < 0.0001) patients with iNPH compared with 5.4% in Finnish controls. No copy number gains in SFMBT1 were detected in patients with iNPH or healthy controls. The carrier status did not provide any prognostic value for the effect of shunt surgery in either population. Moreover, no difference was detected in the prevalence of hypertension or T2DM between SFMBT1 copy number loss carriers and noncarriers. Conclusions This is the largest and the first multinational study reporting the increased prevalence of the copy number loss in intron 2 of SFMBT1 among patients with iNPH, providing further evidence of its role in iNPH. The pathogenic role still remains unclear, requiring further study.
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Affiliation(s)
- Ville E Korhonen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Seppo Helisalmi
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Aleksi Jokinen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Ilari Jokinen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Juha-Matti Lehtola
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Minna Oinas
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Kimmo Lönnrot
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Cecilia Avellan
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Anna Kotkansalo
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Janek Frantzen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Jaakko Rinne
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Antti Ronkainen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Mikko Kauppinen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Antti Junkkari
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Mikko Hiltunen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Hilkka Soininen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Mitja Kurki
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Juha E Jääskeläinen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Anne M Koivisto
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Hidenori Sato
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Takeo Kato
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Anne M Remes
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
| | - Ville Leinonen
- Department of Neurosurgery (V.E.K., A. Jokinen, I.J., J.-M.L., A. Junkkari, J.E.J., V.L.), Kuopio University Hospital and University of Eastern Finland; Institute of Clinical Medicine-Neurology (S.H., M.H., H. Soininen, A.M.K.), University of Eastern Finland, Kuopio; Department of Neurosurgery (M.O., K.L.), University of Helsinki and Helsinki University Hospital; Clinical Neurosciences (C.A., A.K., J.F., J.R.), Department of Neurosurgery, University of Turku and Turku University Hospital; Department of Neurosurgery (A.R.), Tampere University Hospital; Unit of Clinical Neuroscience (M. Kauppinen, V.L.), Neurosurgery, University of Oulu and Medical Research Center, Oulu University Hospital; Institute of Biomedicine (M.H.), University of Eastern Finland, Kuopio; Analytical and Translational Genetics Unit (M. Kurki), Department of Medicine, Massachusetts General Hospital; Program in Medical and Population Genetics (M. Kurki), Broad Institute of MIT and Harvard; Stanley Center for Psychiatric Research (M. Kurki), Broad Institute for Harvard and MIT; Department of Neurology (H. Sato, T.K.), Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine, Japan; Medical Research Center (A.M.R.), Oulu University Hospital, Finland; Unit of Clinical Neuroscience (A.M.R.), Neurology, University of Oulu, Finland; Department of Neurosurgery (P.K.E.), Oslo University Hospital-Rikshospitalet; and Institute of Clinical Medicine (P.K.E.), Faculty of Medicine, University of Oslo, Norway
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Hasan-Olive MM, Enger R, Hansson HA, Nagelhus EA, Eide PK. Loss of perivascular aquaporin-4 in idiopathic normal pressure hydrocephalus. Glia 2018; 67:91-100. [DOI: 10.1002/glia.23528] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 08/10/2018] [Accepted: 08/15/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Md Mahdi Hasan-Olive
- Department of Neurosurgery; Oslo University Hospital - Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine, Faculty of Medicine; University of Oslo; Oslo Norway
| | - Rune Enger
- GliaLab and Letten Centre, Division of Physiology, Department of Molecular Medicine; Institute of Basic Medical Sciences, University of Oslo; Oslo Norway
- Department of Neurology; Oslo University Hospital - Rikshospitalet; Oslo Norway
| | | | - Erlend A. Nagelhus
- GliaLab and Letten Centre, Division of Physiology, Department of Molecular Medicine; Institute of Basic Medical Sciences, University of Oslo; Oslo Norway
- Department of Neurology; Oslo University Hospital - Rikshospitalet; Oslo Norway
| | - Per Kristian 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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Pyykkö OT, Nerg O, Niskasaari HM, Niskasaari T, Koivisto AM, Hiltunen M, Pihlajamäki J, Rauramaa T, Kojoukhova M, Alafuzoff I, Soininen H, Jääskeläinen JE, Leinonen V. Incidence, Comorbidities, and Mortality in Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2018; 112:e624-e631. [PMID: 29374607 DOI: 10.1016/j.wneu.2018.01.107] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/14/2018] [Accepted: 01/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECT To investigate the incidence, comorbidities, mortality, and causes of death in idiopathic normal pressure hydrocephalus (iNPH). METHODS A cohort of 536 patients with possible NPH from a defined population with a median follow-up time of 5.1 years, (range 0.04-19.9 years) was included in the study. Patients were evaluated by brain imaging and intraventricular pressure monitoring, with a brain biopsy specimen immunostained against amyloid-β and hyperphosphorylated τ. Hospital records were reviewed for vascular diseases and type 2 diabetes mellitus (T2DM). Death certificates and yearly population of the catchment area were obtained from national registries. RESULTS A total of 283 patients had a clinical diagnosis of iNPH, leading to a median annual incidence of 1.58 iNPH patients per 100,000 inhabitants (range, 0.8-4.5). Alzeimer disease-related brain biopsy findings were less frequent in iNPH patients than in non-iNPH patients (P < 0.05). An overrepresentation of hypertension (52% vs. 33%, P < 0.001) and T2DM (23% vs. 13%, P = 0.002) was noted in iNPH patients. Age (hazard ratio [HR] 1.04/year, 95% confidence interval [CI] 1.03-1.06, P < 0.001) and T2DM (HR 1.63, 95% CI 1.23-2.16, P < 0.001) increased the risk of death in the iNPH patients and in the total population. iNPH was associated with decreased risk of death (HR 0.63, 95% CI 0.50-0.78, P < 0.001). The most frequent causes of death were cardiovascular and cerebrovascular disease. Dementia as a cause of death was more common in non-iNPH patients (27% vs. 10%, P < 0.001). CONCLUSIONS Hypertension and T2DM are common in iNPH and the latter causes excess mortality in the affected patients.
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Affiliation(s)
- Okko T Pyykkö
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
| | - Ossi Nerg
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | | | - Timo Niskasaari
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Anne M Koivisto
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | - Mikko Hiltunen
- Institute of Biomedicine, University of Eastern Finland, Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Jussi Pihlajamäki
- Department of Clinical Nutrition, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, and Clinical Nutrition and Obesity Center, Kuopio University Hospital, Kuopio, Finland
| | - Tuomas Rauramaa
- Department of Pathology, Kuopio University Hospital, and Institute of Clinical Medicine - Pathology, University of Eastern Finland, Kuopio, Finland
| | - Maria Kojoukhova
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Irina Alafuzoff
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Hilkka Soininen
- Neurology of NeuroCenter, Kuopio University Hospital, and Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | | | - Ville Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
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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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Eidsvaag VA, Hansson HA, Heuser K, Nagelhus EA, Eide PK. Brain Capillary Ultrastructure in Idiopathic Normal Pressure Hydrocephalus: Relationship With Static and Pulsatile Intracranial Pressure. J Neuropathol Exp Neurol 2017; 76:1034-1045. [PMID: 29040647 DOI: 10.1093/jnen/nlx091] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 09/19/2017] [Indexed: 01/08/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a neurodegenerative disease of unknown cause. We investigated the morphology of capillaries in frontal cortex biopsies from iNPH patients and related the observations to overnight intracranial pressure (ICP) scores. A biopsy (0.9×10 mm) was taken from where the ICP sensor subsequently was inserted. Brain capillaries were investigated by electron microscopy of biopsies from 27 iNPH patients and 10 reference subjects, i.e. patients (not healthy individuals) without cerebrospinal fluid circulation disturbances, in whom normal brain tissue was removed as part of necessary neurosurgical treatment. Degenerating and degenerated pericyte processes were identified in 23/27 (85%) iNPH and 6/10 (60%) of reference specimens. Extensive disintegration of pericyte processes were recognized in 11/27 (41%) iNPH and 1/10 (10%) reference specimens. There were no differences in basement membrane (BM) thickness or pericyte coverage between iNPH and reference subjects. The pulsatile or static ICP scores did neither correlate with the BM thickness nor with pericyte coverage. We found increased prevalence of degenerating pericytes in iNPH while the BM thickness and pericyte coverage did not differ from the reference individuals. Observations in iNPH may to some extent be age-related since the iNPH patients were significantly older than the reference individuals.
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Affiliation(s)
- Vigdis Andersen Eidsvaag
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Faculty of Medicine; and Division of Physiology, Department of Molecular Medicine, GliaLab and Letten Centre, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden; and Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Hans-Arne Hansson
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Faculty of Medicine; and Division of Physiology, Department of Molecular Medicine, GliaLab and Letten Centre, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden; and Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Kjell Heuser
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Faculty of Medicine; and Division of Physiology, Department of Molecular Medicine, GliaLab and Letten Centre, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden; and Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Erlend A Nagelhus
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Faculty of Medicine; and Division of Physiology, Department of Molecular Medicine, GliaLab and Letten Centre, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden; and Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Per K Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway; Faculty of Medicine; and Division of Physiology, Department of Molecular Medicine, GliaLab and Letten Centre, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden; and Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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Eide PK. The pathophysiology of chronic noncommunicating hydrocephalus: lessons from continuous intracranial pressure monitoring and ventricular infusion testing. J Neurosurg 2017; 129:220-233. [PMID: 28799879 DOI: 10.3171/2017.1.jns162813] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The pathophysiology of chronic noncommunicating hydrocephalus (ncHC) is poorly understood. This present study explored whether lessons about the pathophysiology of this clinical entity might be retrieved from results of overnight monitoring of pulsatile and static intracranial pressure (ICP) and ventricular infusion testing. METHODS The study cohort included adult patients (> 20 years of age) with chronic ncHC due to aqueductal stenosis in whom symptoms had lasted a minimum of 6 months. A reference cohort consisted of age- and sex-matched patients managed for communicating HC (cHC). Information about symptoms and clinical improvement following surgery was retrieved from a quality register, and results of overnight ICP recordings and ventricular infusion testing were retrieved from the hospital ICP database. RESULTS The cohort with ncHC consisted of 61 patients of whom 6 (10%) were managed conservatively, 34 (56%) by endoscopic third ventriculostomy (ETV), and 21 (34%) using ETV and subsequent shunt surgery. In patients responding to surgery, pulsatile ICP (mean ICP wave amplitude) was significantly increased to a similar magnitude in patients with ncHC and the reference cohort (cHC). Furthermore, intracranial compliance (ICC) was reduced in clinical responders. The results of ventricular infusion testing provided evidence that patients responding to ETV have impaired ventricular CSF absorption, while those requiring shunt placement after ETV present with impaired CSF absorption both in the intraventricular and extraventricular compartments. CONCLUSIONS The study may provide some lessons about the pathophysiology of chronic ncHC. First, increased pulsatile ICP and impaired ICC characterize patients with chronic ncHC who respond clinically to CSF diversion surgery, even though static ICP is not increased. Second, in patients responding clinically to ETV, impaired ventricular CSF absorption may be a key factor. Patients requiring shunt placement for clinical response appear to have both intraventricular and extraventricular CSF absorption failure. A subgroup of patients with ncHC due to aqueductal stenosis has normal ventricular CSF absorption and normal ICC and may not be in need of surgical CSF diversion.
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Hickman TT, Shuman ME, Johnson TA, Yang F, Rice RR, Rice IM, Chung EH, Wiemann R, Tinl M, Iracheta C, Chen G, Flynn P, Mondello MB, Thompson J, Meadows ME, Carroll RS, Yang HW, Xing H, Pilgrim D, Chiocca EA, Dunn IF, Golby AJ, Johnson MD. Association between shunt-responsive idiopathic normal pressure hydrocephalus and alcohol. J Neurosurg 2017; 127:240-248. [PMID: 27689463 PMCID: PMC6625758 DOI: 10.3171/2016.6.jns16496] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Idiopathic normal pressure hydrocephalus (iNPH) is characterized by ventriculomegaly, gait difficulty, incontinence, and dementia. The symptoms can be ameliorated by CSF drainage. The object of this study was to identify factors associated with shunt-responsive iNPH. METHODS The authors reviewed the medical records of 529 patients who underwent shunt placement for iNPH at their institution between July 2001 and March 2015. Variables associated with shunt-responsive iNPH were identified using bivariate and multivariate analyses. Detailed alcohol consumption information was obtained for 328 patients and was used to examine the relationship between alcohol and shunt-responsive iNPH. A computerized patient registry from 2 academic medical centers was queried to determine the prevalence of alcohol abuse among 1665 iNPH patients. RESULTS Bivariate analysis identified associations between shunt-responsive iNPH and gait difficulty (OR 4.59, 95% CI 2.32-9.09; p < 0.0001), dementia (OR 1.79, 95% CI 1.14-2.80; p = 0.01), incontinence (OR 1.77, 95% CI 1.13-2.76; p = 0.01), and alcohol use (OR 1.98, 95% CI 1.23-3.16; p = 0.03). Borderline significance was observed for hyperlipidemia (OR 1.56, 95% CI 0.99-2.45; p = 0.054), a family history of hyperlipidemia (OR 3.09, 95% CI 0.93-10.26, p = 0.054), and diabetes (OR 1.83, 95% CI 0.96-3.51; p = 0.064). Multivariate analysis identified associations with gait difficulty (OR 3.98, 95% CI 1.81-8.77; p = 0.0006) and alcohol (OR 1.94, 95% CI 1.10-3.39; p = 0.04). Increased alcohol intake correlated with greater improvement after CSF drainage. Alcohol abuse was 2.5 times more prevalent among iNPH patients than matched controls. CONCLUSIONS Alcohol consumption is associated with the development of shunt-responsive iNPH.
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Affiliation(s)
- Thu-Trang Hickman
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Matthew E. Shuman
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Tatyana A. Johnson
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Felix Yang
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Rebecca R. Rice
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Isaac M. Rice
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Esther H. Chung
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Robert Wiemann
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Megan Tinl
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
- Department of Rehabilitation Services, Brigham and Women’s Hospital
| | - Christine Iracheta
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
- Department of Rehabilitation Services, Brigham and Women’s Hospital
| | - Grace Chen
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
- Department of Rehabilitation Services, Brigham and Women’s Hospital
| | - Patricia Flynn
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
- Department of Rehabilitation Services, Brigham and Women’s Hospital
| | - Mary Beth Mondello
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Jillian Thompson
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Mary-Ellen Meadows
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
- Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rona S. Carroll
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Hong Wei Yang
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Hongyan Xing
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - David Pilgrim
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
- Department of Neurology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - E. Antonio Chiocca
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Ian F. Dunn
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Alexandra J. Golby
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
| | - Mark D. Johnson
- Adult Hydrocephalus Program, Department of Neurosurgery, Brigham and Women’s Hospital and Harvard Medical School
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Eide PK, Hansson HA. Astrogliosis and impaired aquaporin-4 and dystrophin systems in idiopathic normal pressure hydrocephalus. Neuropathol Appl Neurobiol 2017. [PMID: 28627088 DOI: 10.1111/nan.12420] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
AIMS Idiopathic normal pressure hydrocephalus (iNPH) is one subtype of dementia that may improve following drainage of cerebrospinal fluid (CSF). This prospective observational study explored whether expression of the water channel aquaporin-4 (AQP4) and the anchoring molecule dystrophin 71 (Dp71) are altered at astrocytic perivascular endfeet and in adjacent neuropil of iNPH patient. Observations were related to measurements of pulsatile and static intracranial pressure (ICP). METHODS The study included iNPH patients undergoing overnight monitoring of the pulsatile/static ICP in whom a biopsy was taken from the frontal cerebral cortex during placement of the ICP sensor. Reference (Ref) biopsies were sampled from 13 patients who underwent brain surgery for epilepsy, tumours or cerebral aneurysms. The brain tissue specimens were examined by light microscopy, immunohistochemistry, densitometry and morphometry. RESULTS iNPH patients responding to surgery (n = 44) had elevated pulsatile ICP, indicative of impaired intracranial compliance. As compared to the Ref patients, the cortical biopsies of iNPH patients revealed prominent astrogliosis and reduced expression of AQP4 and Dp71 immunoreactivities in the astrocytic perivascular endfeet and in parts of the adjacent neuropil. There was a significant correlation between degree of astrogliosis and reduction of AQP4 and Dp71 at astrocytic perivascular endfeet. CONCLUSIONS Idiopathic normal pressure hydrocephalus patients responding to CSF diversion present with abnormal pulsatile ICP, indicative of impaired intracranial compliance. A main histopathological finding was astrogliosis and reduction of AQP4 and of Dp71 in astrocytic perivascular endfeet. We propose that the altered AQP4 and Dp71 complex contributes to the subischaemia prevalent in the brain tissue of iNPH.
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Affiliation(s)
- P K Eide
- Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - H-A Hansson
- Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
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Illán-Gala I, Pérez-Lucas J, Martín-Montes A, Máñez-Miró J, Arpa J, Ruiz-Ares G. Evolución a largo plazo de la hidrocefalia crónica del adulto idiopática tratada con válvula de derivación ventrículo-peritoneal. Neurologia 2017; 32:205-212. [DOI: 10.1016/j.nrl.2015.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 09/20/2015] [Accepted: 10/09/2015] [Indexed: 11/26/2022] Open
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Frič R, Pripp AH, Eide PK. Cardiovascular risk factors in Chiari malformation and idiopathic intracranial hypertension. Brain Behav 2017; 7:e00677. [PMID: 28523220 PMCID: PMC5434183 DOI: 10.1002/brb3.677] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/04/2017] [Accepted: 02/10/2017] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Both Chiari malformation type 1 (CMI, i.e., the idiopathic caudal ectopy of cerebellar tonsils into foramen magnum) and idiopathic intracranial hypertension (IIH) are characterized by reduced intracranial compliance (ICC) due to disturbed circulation of cerebrospinal fluid (CSF). An increasing body of evidence links cardiovascular disease to CSF circulation disturbances. The aim of this study was to explore whether the prevalence of cardiovascular risk factors in patients with CMI or IIH is higher than in the general population. MATERIALS AND METHODS Among the patients with CMI or IIH treated at our department during the period 2003-2014, we identified those with history of arterial hypertension (AH), myocardial infarction (MI), angina pectoris (AP), or diabetes mellitus (DM). For comparison with a control population, we retrieved information about the prevalence of AH, MI, AP, and DM among participants of the North-Trøndelag Health Study 3 (HUNT3). RESULTS Data from 48 CMI and 52 IIH cases were available. Compared to data from the 42,461 individuals participating in the HUNT3, we found increased prevalence of DM in male CMI as well as female IIH cases, and of AH in female IIH cases. Body mass index (BMI) was significantly increased in both female and male IIH cases. Prevalence of MI and AP in the CMI and IIH cohorts was extremely low and therefore not further studied. CONCLUSIONS This study provided evidence of an increased prevalence of DM in male CMI as well as female IIH cases and of AH in female IIH cases. Although requiring further exploration, these findings point to AH and DM as potential risk factors in the pathophysiology of CMI and IIH.
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Affiliation(s)
- Radek Frič
- Department of Neurosurgery Oslo University Hospital-Rikshospitalet Oslo Norway.,Faculty of Medicine University of Oslo Oslo Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology Oslo University Hospital Oslo Norway
| | - Per Kristian Eide
- Department of Neurosurgery Oslo University Hospital-Rikshospitalet Oslo Norway.,Faculty of Medicine University of Oslo Oslo Norway
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Illán-Gala I, Pérez-Lucas J, Martín-Montes A, Máñez-Miró J, Arpa J, Ruiz-Ares G. Long-term outcomes of adult chronic idiopathic hydrocephalus treated with a ventriculo-peritoneal shunt. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Israelsson H, Carlberg B, Wikkelsö C, Laurell K, Kahlon B, Leijon G, Eklund A, Malm J. Vascular risk factors in INPH: A prospective case-control study (the INPH-CRasH study). Neurology 2017; 88:577-585. [PMID: 28062721 DOI: 10.1212/wnl.0000000000003583] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 10/14/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To assess the complete vascular risk factor (VRF) profile of idiopathic normal pressure hydrocephalus (INPH) using a large sample of representative patients with INPH and population-based controls to determine the extent to which vascular disease influences INPH pathophysiology. METHODS All patients with INPH who underwent shunting in Sweden in 2008-2010 were compared to age- and sex-matched population-based controls. Inclusion criteria were age 60-85 years and no dementia. The 10 most important VRFs and cerebrovascular and peripheral vascular disease were prospectively assessed using blood samples, clinical examinations, and standardized questionnaires. Assessed VRFs were hypertension, hyperlipidemia, diabetes, obesity, psychosocial factors, smoking habits, diet, alcohol intake, cardiac disease, and physical activity. RESULTS In total, 176 patients with INPH and 368 controls participated. Multivariable logistic regression analysis indicated that hyperlipidemia (odds ratio [OR] 2.380; 95% confidence interval [CI] 1.434-3.950), diabetes (OR 2.169; 95% CI 1.195-3.938), obesity (OR 5.428; 95% CI 2.502-11.772), and psychosocial factors (OR 5.343; 95% CI 3.219-8.868) were independently associated with INPH. Hypertension, physical inactivity, and cerebrovascular and peripheral vascular disease were also overrepresented in INPH. Moderate alcohol intake and physical activity were overrepresented among the controls. The population-attributable risk percentage was 24%. CONCLUSIONS Our findings confirm that patients with INPH have more VRFs and lack the protective factors present in the general population. Almost 25% of cases of INPH may be explained by VRFs. This suggests that INPH may be a subtype of vascular dementia. Targeted interventions against modifiable VRFs are likely to have beneficial effects on INPH.
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Affiliation(s)
- Hanna Israelsson
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden.
| | - Bo Carlberg
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Carsten Wikkelsö
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Katarina Laurell
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Babar Kahlon
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Göran Leijon
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Anders Eklund
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
| | - Jan Malm
- From the Departments of Pharmacology and Clinical Neuroscience (H.I., K.L., J.M.), Public Health and Clinical Medicine (B.C.), and Radiation Sciences (A.E.), and Center for Biomedical Engineering and Physics (A.E.), Umeå University; Institute of Neuroscience (C.W.), Sahlgrens Academy, University of Gothenburg; Department of Neurosurgery (B.K.), Lund University; and Department of Clinical and Experimental Medicine (IKE) (G.L.), Division of Neuroscience, Linköping University, Sweden
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Multimodal analysis to predict shunt surgery outcome of 284 patients with suspected idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2016; 158:2311-2319. [PMID: 27743250 DOI: 10.1007/s00701-016-2980-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Optimal selection of idiopathic normal pressure hydrocephalus (iNPH) patients for shunt surgery is challenging. Disease State Index (DSI) is a statistical method that merges multimodal data to assist clinical decision-making. It has previously been shown to be useful in predicting progression in mild cognitive impairment and differentiating Alzheimer's disease (AD) and frontotemporal dementia. In this study, we use the DSI method to predict shunt surgery response for patients with iNPH. METHODS In this retrospective cohort study, a total of 284 patients (230 shunt responders and 54 non-responders) from the Kuopio NPH registry were analyzed with the DSI. Analysis included data from patients' memory disorder assessments, age, clinical symptoms, comorbidities, medications, frontal cortical biopsy, CT/MRI imaging (visual scoring of disproportion between Sylvian and suprasylvian subarachnoid spaces, atrophy of medial temporal lobe, superior medial subarachnoid spaces), APOE genotyping, CSF AD biomarkers, and intracranial pressure. RESULTS Our analysis showed that shunt responders cannot be differentiated from non-responders reliably even with the large dataset available (AUC = 0.58). CONCLUSIONS Prediction of the treatment response in iNPH is challenging even with our extensive dataset and refined analysis. Further research of biomarkers and indicators predicting shunt responsiveness is still needed.
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Arosio B, Casati M, Gussago C, Ferri E, Abbate C, Scortichini V, Colombo E, Rossi PD, Mari D. Adenosine Type A2A Receptor in Peripheral Cell from Patients with Alzheimer’s Disease, Vascular Dementia, and Idiopathic Normal Pressure Hydrocephalus: A New/Old Potential Target. J Alzheimers Dis 2016; 54:417-25. [DOI: 10.3233/jad-160324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Beatrice Arosio
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Fondazione Ca’ Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Casati
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Nutritional Sciences, University of Milan, Milan, Italy
| | - Cristina Gussago
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - Evelyn Ferri
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Nutritional Sciences, University of Milan, Milan, Italy
| | - Carlo Abbate
- Fondazione Ca’ Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Elena Colombo
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Daniela Mari
- Geriatric Unit, Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
- Fondazione Ca’ Granda, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
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Familial idiopathic normal pressure hydrocephalus. J Neurol Sci 2016; 368:11-8. [DOI: 10.1016/j.jns.2016.06.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/21/2016] [Accepted: 06/23/2016] [Indexed: 11/20/2022]
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Kasprowicz M, Lalou DA, Czosnyka M, Garnett M, Czosnyka Z. Intracranial pressure, its components and cerebrospinal fluid pressure-volume compensation. Acta Neurol Scand 2016; 134:168-80. [PMID: 26666840 DOI: 10.1111/ane.12541] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 11/29/2022]
Abstract
Clinical measurement of intracranial pressure (ICP) is often performed to aid diagnosis of hydrocephalus. This review discusses analysis of ICP and its components' for the investigation of cerebrospinal fluid (CSF) dynamics. The role of pulse, slow and respiratory waveforms of ICP in diagnosis, prognostication and management of hydrocephalus is presented. Two methods related to ICP measurement are listed: an overnight monitoring of ICP and a constant-rate infusion study. Due to the dynamic nature of ICP, a 'snapshot' manometric measurement of ICP is of limited use as it might lead to unreliable results. Therefore, monitoring of ICP over longer time combined with analysis of its waveforms provides more detailed information on the state of pressure-volume compensation. The infusion study implements ICP signal processing and CSF circulation model analysis in order to assess the cerebrospinal dynamics variables, such as CSF outflow resistance, compliance of CSF space, pressure amplitude, reference pressure, and CSF formation. These parameters act as an aid tool in diagnosis and prognostication of hydrocephalus and can be helpful in the assessment of a shunt malfunction.
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Affiliation(s)
- M. Kasprowicz
- Department of Biomedical Engineering; Wroclaw University of Technology; Wroclaw Poland
| | - D. A. Lalou
- National and Kapodistran University Medical School; Athens Greece
| | - M. Czosnyka
- Brain Physics Laboratory; Division of Neurosurgery; University of Cambridge Department of Clinical Neuroscience; Cambridge UK
- Institute of Electronic Systems; Warsaw University of Technology; Warsaw Poland
| | - M. Garnett
- Nerosurgery; Addenbrooke's Hospital; Cambridge UK
| | - Z. Czosnyka
- Brain Physics Laboratory; Division of Neurosurgery; University of Cambridge Department of Clinical Neuroscience; Cambridge UK
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Eide PK, Pripp AH. The prevalence of cardiovascular disease in non-communicating hydrocephalus. Clin Neurol Neurosurg 2016; 149:33-8. [PMID: 27455422 DOI: 10.1016/j.clineuro.2016.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/07/2016] [Accepted: 07/17/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hydrocephalus (HC) caused by blockade of ventricular cerebrospinal fluid (CSF) pathways is denoted non-communicating HC. One issue not previously addressed is how the prevalence of cardiovascular disease compares between patients with non-communicating HC and the general population. METHODS We examined whether the prevalence of cardiovascular disease (arterial hypertension, angina pectoris, cardiac infarction, and diabetes) differed between cases with non-communicating HC and a general control population, represented by participants of the North-Trøndelag Health 3 Survey (The HUNT3 Survey). A second control group consisted of patients with communicating hydrocephalus (idiopathic normal pressure hydrocephalus, iNPH). RESULTS The study included 50 cases with non-communicating HC (53.4+10.5years), and two control cohorts: 35,413 participants of the HUNT3 Survey (52.8+9.6years), and 176 iNPH patients (61.2+8.3years). All individuals were aged 35-70 years. Among the non-communicating HC patients, the results showed increased prevalence for arterial hypertension (males), cardiac infarction (females), and diabetes (females), as compared with the HUNT3 control group with significant odds ratio estimates. However, the prevalence of cardiovascular disease did not significantly differ between patients with non-communicating HC or iNPH. In patients with either non-communicating HC or iNPH and elevated pulsatile intracranial pressure (ICP) during overnight monitoring, the prevalence of diabetes was increased. CONCLUSION This study showed significantly increased prevalence of cardiovascular disease in non-communicating HC, indicating an association between cardiovascular disease and the development of non-communicating HC. Further, diabetes was associated with abnormal pulsatile ICP in both non-communicating HC and iNPH patients.
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Affiliation(s)
- Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
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Casati M, Arosio B, Gussago C, Ferri E, Magni L, Assolari L, Scortichini V, Nani C, Rossi PD, Mari D. Down-regulation of adenosine A1 and A2A receptors in peripheral cells from idiopathic normal-pressure hydrocephalus patients. J Neurol Sci 2016; 361:196-9. [DOI: 10.1016/j.jns.2015.12.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/21/2015] [Accepted: 12/23/2015] [Indexed: 10/22/2022]
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Jaraj D, Agerskov S, Rabiei K, Marlow T, Jensen C, Guo X, Kern S, Wikkelsø C, Skoog I. Vascular factors in suspected normal pressure hydrocephalus: A population-based study. Neurology 2016; 86:592-9. [PMID: 26773072 DOI: 10.1212/wnl.0000000000002369] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/04/2015] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE We examined clinical and imaging findings of suspected idiopathic normal pressure hydrocephalus (iNPH) in relation to vascular risk factors and white matter lesions (WMLs), using a nested case-control design in a representative, population-based sample. METHODS From a population-based sample, 1,235 persons aged 70 years or older were examined with CT of the brain between 1986 and 2000. We identified 55 persons with hydrocephalic ventricular enlargement, i.e., radiologic findings consistent with iNPH. Among these, 26 had clinical signs that fulfilled international guideline criteria for probable iNPH. These cases were labeled suspected iNPH. Each case was matched to 5 controls from the same sample, based on age, sex, and study cohort. Data on risk factors were obtained from clinical examinations and the Swedish Hospital Discharge Register. History of hypertension, diabetes mellitus (DM), smoking, overweight, history of coronary artery disease, stroke/TIA, and WMLs on CT were examined. Risk factors associated with iNPH with a p value <0.1 in χ2 tests were included in conditional logistic regression models. RESULTS In the regression analyses, suspected iNPH was related to moderate to severe WMLs (odds ratio [OR] 5.2; 95% confidence interval [CI]: 1.5-17.6), while hydrocephalic ventricular enlargement was related to hypertension (OR 2.7; 95% CI: 1.1-6.8), moderate to severe WMLs (OR 6.5; 95% CI: 2.1-20.3), and DM (OR 4.3; 95% CI: 1.1-16.3). CONCLUSIONS Hypertension, WMLs, and DM were related to clinical and imaging features of iNPH, suggesting that vascular mechanisms are involved in the pathophysiology. These findings might have implications for understanding disease mechanisms in iNPH and possibly prevention.
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Affiliation(s)
- Daniel Jaraj
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden.
| | - Simon Agerskov
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Katrin Rabiei
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Thomas Marlow
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Christer Jensen
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Xinxin Guo
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Silke Kern
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Carsten Wikkelsø
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
| | - Ingmar Skoog
- From the Institute of Neuroscience and Physiology (D.J., S.A., K.R., T.M., X.G., S.K., C.W., I.S.), Neuropsychiatric Epidemiology Research Unit (D.J., T.M., X.G., S.K., I.S.), Hydrocephalus Research Unit (D.J., S.A., K.R., C.W.), and Institute of Clinical Sciences (C.J.), University of Gothenburg, Sweden
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