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Jóhannsdóttir AM, Pedersen CB, Munthe S, Poulsen FR, Jóhannsson B. Idiopathic normal pressure hydrocephalus: Validation of the DESH score as a prognostic tool for shunt surgery response. Clin Neurol Neurosurg 2024; 241:108295. [PMID: 38701548 DOI: 10.1016/j.clineuro.2024.108295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/01/2024] [Accepted: 04/21/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE Several radiological markers have been linked to clinical improvement after shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). However, iNPH has no pathognomonic feature, and patients are still diagnosed as probable, possible, or unlikely cases based on clinical symptoms, imaging findings, and invasive supplementary tests. The predictive value of the disproportionately enlarged subarachnoid space hydrocephalus (DESH) score is not yet conclusively determined, but it might offer a more accurate diagnostic method. The aim of the present retrospective cohort study was to validate the predictive power of the DESH score for clinical improvement after shunt surgery in iNPH patients. METHODS We retrospectively obtained presurgical MRI and/or CT scans from 71 patients with iNPH who underwent ventriculoperitoneal shunt surgery. Radiological images were evaluated for Evans index (EI), corpus callosal angle (CA), tight high convexity (THC), Sylvian fissure dilation, and focal sulci dilation. These markers were aggregated to determine the DESH score. Patient journal entries were used to subjectively determine the extent of improvement in gait function, urinary incontinence, and/or cognition as a measure of shunt surgery response. RESULTS Multiple logistic regression analysis, controlling for age and sex (α = 0.05), showed that DESH score was significantly correlated (OR 1.77) with subjective shunt-surgery response at a minimum of 1-month follow-up. Patients with higher DESH scores were more likely to have a favorable response to shunt surgery. CONCLUSION Aggregating radiological markers into the DESH score is useful for predicting shunt responders among iNPH patients and can aid the selection of patients for surgery. These findings provide further support for the DESH score as a diagnostic tool for iNPH.
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Affiliation(s)
- Anika Maí Jóhannsdóttir
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sune Munthe
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bjarni Jóhannsson
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Buscemi F, Grasso G. Usefulness of Ventricular Size in Idiopathic Normal Pressure Hydrocephalus: Is It a Reliable Marker for Good Surgical Outcome? World Neurosurg 2024; 188:20-22. [PMID: 38641245 DOI: 10.1016/j.wneu.2024.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Felice Buscemi
- Section of Neurosurgery, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Giovanni Grasso
- Section of Neurosurgery, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
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Kadaba Sridhar S, Dysterheft Robb J, Gupta R, Cheong S, Kuang R, Samadani U. Structural neuroimaging markers of normal pressure hydrocephalus versus Alzheimer's dementia and Parkinson's disease, and hydrocephalus versus atrophy in chronic TBI-a narrative review. Front Neurol 2024; 15:1347200. [PMID: 38576534 PMCID: PMC10991762 DOI: 10.3389/fneur.2024.1347200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/07/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction Normal Pressure Hydrocephalus (NPH) is a prominent type of reversible dementia that may be treated with shunt surgery, and it is crucial to differentiate it from irreversible degeneration caused by its symptomatic mimics like Alzheimer's Dementia (AD) and Parkinson's Disease (PD). Similarly, it is important to distinguish between (normal pressure) hydrocephalus and irreversible atrophy/degeneration which are among the chronic effects of Traumatic Brain Injury (cTBI), as the former may be reversed through shunt placement. The purpose of this review is to elucidate the structural imaging markers which may be foundational to the development of accurate, noninvasive, and accessible solutions to this problem. Methods By searching the PubMed database for keywords related to NPH, AD, PD, and cTBI, we reviewed studies that examined the (1) distinct neuroanatomical markers of degeneration in NPH versus AD and PD, and atrophy versus hydrocephalus in cTBI and (2) computational methods for their (semi-) automatic assessment on Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans. Results Structural markers of NPH and those that can distinguish it from AD have been well studied, but only a few studies have explored its structural distinction between PD. The structural implications of cTBI over time have been studied. But neuroanatomical markers that can predict shunt response in patients with either symptomatic idiopathic NPH or post-traumatic hydrocephalus have not been reliably established. MRI-based markers dominate this field of investigation as compared to CT, which is also reflected in the disproportionate number of MRI-based computational methods for their automatic assessment. Conclusion Along with an up-to-date literature review on the structural neurodegeneration due to NPH versus AD/PD, and hydrocephalus versus atrophy in cTBI, this article sheds light on the potential of structural imaging markers as (differential) diagnostic aids for the timely recognition of patients with reversible (normal pressure) hydrocephalus, and opportunities to develop computational tools for their objective assessment.
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Affiliation(s)
- Sharada Kadaba Sridhar
- Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, MN, United States
- Neurotrauma Research Lab, Center for Veterans Research and Education, Minneapolis, MN, United States
| | - Jen Dysterheft Robb
- Neurotrauma Research Lab, Center for Veterans Research and Education, Minneapolis, MN, United States
| | - Rishabh Gupta
- Neurotrauma Research Lab, Center for Veterans Research and Education, Minneapolis, MN, United States
- University of Minnesota Twin Cities Medical School, Minneapolis, MN, United States
| | - Scarlett Cheong
- Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, MN, United States
- Neurotrauma Research Lab, Center for Veterans Research and Education, Minneapolis, MN, United States
| | - Rui Kuang
- Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, MN, United States
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Uzma Samadani
- Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, MN, United States
- Neurotrauma Research Lab, Center for Veterans Research and Education, Minneapolis, MN, United States
- University of Minnesota Twin Cities Medical School, Minneapolis, MN, United States
- Department of Computer Science and Engineering, University of Minnesota, Minneapolis, MN, United States
- Division of Neurosurgery, Department of Surgery, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
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Yang Y, Yan M, Liu X, Li S, Lin G. Improve the diagnosis of idiopathic normal pressure hydrocephalus by combining abnormal cortical thickness and ventricular morphometry. Front Aging Neurosci 2024; 16:1338755. [PMID: 38486858 PMCID: PMC10937576 DOI: 10.3389/fnagi.2024.1338755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Background The primary imaging markers for idiopathic Normal Pressure Hydrocephalus (iNPH) emphasize morphological measurements within the ventricular system, with no attention given to alterations in brain parenchyma. This study aimed to investigate the potential effectiveness of combining ventricular morphometry and cortical structural measurements as diagnostic biomarkers for iNPH. Methods A total of 57 iNPH patients and 55 age-matched healthy controls (HC) were recruited in this study. Firstly, manual measurements of ventricular morphology, including Evans Index (EI), z-Evans Index (z-EI), Cella Media Width (CMW), Callosal Angle (CA), and Callosal Height (CH), were conducted based on MRI scans. Cortical thickness measurements were obtained, and statistical analyses were performed using surface-based morphometric analysis. Secondly, three distinct models were developed using machine learning algorithms, each based on a different input feature: a ventricular morphology model (LVM), a cortical thickness model (CT), and a fusion model (All) incorporating both features. Model performances were assessed using 10-fold cross validation and tested on an independent dataset. Model interpretation utilized Shapley Additive Interpretation (SHAP), providing a visualization of the contribution of each variable in the predictive model. Finally, Spearman correlation coefficients were calculated to evaluate the relationship between imaging biomarkers and clinical symptoms. Results iNPH patients exhibited notable differences in cortical thickness compared to HC. This included reduced thickness in the frontal, temporal, and cingulate cortices, along with increased thickness in the supracentral gyrus. The diagnostic performance of the fusion model (All) for iNPH surpassed that of the single-feature models, achieving an average accuracy of 90.43%, sensitivity of 90.00%, specificity of 90.91%, and Matthews correlation coefficient (MCC) of 81.03%. This improvement in accuracy (6.09%), sensitivity (11.67%), and MCC (11.25%) compared to the LVM strategy was significant. Shap analysis revealed the crucial role of cortical thickness in the right isthmus cingulate cortex, emerging as the most influential factor in distinguishing iNPH from HC. Additionally, significant correlations were observed between the typical triad symptoms of iNPH patients and cortical structural alterations. Conclusion This study emphasizes the significant role of cortical structure changes in the diagnosis of iNPH, providing a novel insights for assisting clinicians in improving the identification and detection of iNPH.
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Affiliation(s)
| | | | | | - Shihong Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Guangwu Lin
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
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Hasselbalch SG, Carlsen JF, Alaouie MM, Munch TN, Holst AV, Taudorf S, Rørvig-Løppentien C, Juhler M, Waldemar G. Prediction of shunt response in idiopathic normal pressure hydrocephalus by combined lumbar infusion test and preoperative imaging scoring. Eur J Neurol 2023; 30:3047-3055. [PMID: 37433569 DOI: 10.1111/ene.15981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND AND PURPOSE Idiopathic normal pressure hydrocephalus (iNPH) is a potentially treatable disorder, but prognostic tests or biomarkers are lacking. The aim was to study the predictive power of clinical, neuroimaging and lumbar infusion test parameters (resistance to outflow Rout , cardiac-related pulse amplitude PA and the PA to intracranial pressure ICP ratio). METHODS In all, 127 patients diagnosed with iNPH who had a lumbar infusion test, a subsequent ventriculo-peritoneal shunt operation and at least 2 months of postoperative follow-up were retrospectively included. Preoperative magnetic resonance images were visually scored for NPH features using the iNPH Radscale. Preoperative and postoperative assessment was performed using cognitive testing, as well as gait and incontinence scales. RESULTS At follow-up (7.4 months, range 2-20 months), an overall positive response was seen in 82% of the patients. Gait was more severely impaired at baseline in responders compared to non-responders. The iNPH Radscale score was borderline significantly higher in responders compared with non-responders, whereas no significant differences in infusion test parameters were seen between responders and non-responders. Infusion test parameters performed modestly with high positive (75%-92%) but low negative (17%-23%) predictive values. Although not significant, PA and PA/ICP seemed to perform better than Rout , and the odds ratio for shunt response seemed to increase in patients with higher PA/ICP, especially in patients with lower iNPH Radscale scores. CONCLUSION Although only indicative, lumbar infusion test results increased the likelihood of a positive shunt outcome. Pulse amplitude measures showed promising results that should be further explored in prospective studies.
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Affiliation(s)
- Steen Gregers Hasselbalch
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonathan Frederik Carlsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Radiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Mohamed Moussa Alaouie
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Tina Nørgaard Munch
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Anders Vedel Holst
- Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Sarah Taudorf
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Christina Rørvig-Løppentien
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Gunhild Waldemar
- Department of Neurology, Danish Dementia Research Centre, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Yun SY, Choi KS, Suh CH, Kim SC, Heo H, Shim WH, Jo S, Chung SJ, Lim JS, Lee JH, Kim D, Kim SO, Jung W, Kim HS, Kim SJ, Kim JH. Risk estimation for idiopathic normal-pressure hydrocephalus: development and validation of a brain morphometry-based nomogram. Eur Radiol 2023; 33:6145-6156. [PMID: 37059905 DOI: 10.1007/s00330-023-09612-1] [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: 06/06/2022] [Revised: 02/10/2023] [Accepted: 03/09/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVES To develop and validate a nomogram based on MRI features for predicting iNPH. METHODS Patients aged ≥ 60 years (clinically diagnosed with iNPH, Parkinson's disease, or Alzheimer's disease or healthy controls) who underwent MRI including three-dimensional T1-weighted volumetric MRI were retrospectively identified from two tertiary referral hospitals (one hospital for derivation set and the other for validation set). Clinical and imaging features for iNPH were assessed. Deep learning-based brain segmentation software was used for 3D volumetry. A prediction model was developed using logistic regression and transformed into a nomogram. The performance of the nomogram was assessed with respect to discrimination and calibration abilities. The nomogram was internally and externally validated. RESULTS A total of 452 patients (mean age ± SD, 73.2 ± 6.5 years; 200 men) were evaluated as the derivation set. One hundred eleven and 341 patients were categorized into the iNPH and non-iNPH groups, respectively. In multivariable analysis, high-convexity tightness (odds ratio [OR], 35.1; 95% CI: 4.5, 275.5), callosal angle < 90° (OR, 12.5; 95% CI: 3.1, 50.0), and normalized lateral ventricle volume (OR, 4.2; 95% CI: 2.7, 6.7) were associated with iNPH. The nomogram combining these three variables showed an area under the curve of 0.995 (95% CI: 0.991, 0.999) in the study sample, 0.994 (95% CI: 0.990, 0.998) in the internal validation sample, and 0.969 (95% CI: 0.940, 0.997) in the external validation sample. CONCLUSION A brain morphometry-based nomogram including high-convexity tightness, callosal angle < 90°, and normalized lateral ventricle volume can help accurately estimate the probability of iNPH. KEY POINTS • The nomogram with MRI findings (high-convexity tightness, callosal angle, and normalized lateral ventricle volume) helped in predicting the probability of idiopathic normal-pressure hydrocephalus. • The nomogram may facilitate the prediction of idiopathic normal-pressure hydrocephalus and consequently avoid unnecessary invasive procedures such as the cerebrospinal fluid tap test, drainage test, and cerebrospinal fluid shunt surgery.
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Affiliation(s)
- Su Young Yun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Kyu Sung Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Soo Chin Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hwon Heo
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Hyun Shim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sungyang Jo
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun Ju Chung
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Sung Lim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Donghyun Kim
- Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | | | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Joon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
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Sedlák V, Bubeníková A, Skalický P, Vlasák A, Whitley H, Netuka D, Beneš V, Beneš V, Bradáč O. Diffusion tensor imaging helps identify shunt-responsive normal pressure hydrocephalus patients among probable iNPH cohort. Neurosurg Rev 2023; 46:173. [PMID: 37442856 PMCID: PMC10344981 DOI: 10.1007/s10143-023-02078-1] [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: 05/21/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
The aim of this study was to investigate whether white matter changes as measured by diffusion tensor imaging (DTI) can help differentiate shunt-responsive idiopathic normal pressure hydrocephalus (iNPH) patients from patients with other causes of gait disturbances and/or cognitive decline with ventriculomegaly whose clinical symptoms do not improve significantly after cerebrospinal fluid derivation (non-iNPH). Between 2017 and 2022, 85 patients with probable iNPH underwent prospective preoperative magnetic resonance imaging (MRI) and comprehensive clinical workup. Patients with clinical symptoms of iNPH, positive result on lumbar infusion test, and gait improvement after 120-h lumbar drainage were diagnosed with iNPH and underwent shunt-placement surgery. Fractional anisotropy (FA) and mean diffusivity (MD) values for individual regions of interest were extracted from preoperative MRI, using the TBSS pipeline of FSL toolkit. These FA and MD values were then compared to results of clinical workup and established diagnosis of iNPH. An identical MRI protocol was performed on 13 age- and sex-matched healthy volunteers. Statistically significant differences in FA values of several white matter structures were found not only between iNPH patients and healthy controls but also between iNPH and non-iNPH patients. ROI that showed best diagnostic ability when differentiating iNPH among probable iNPH cohort was uncinate fasciculus, with AUC of 0.74 (p < 0.001). DTI methods of white matter analysis using standardised methods of ROI extraction can help in differentiation of iNPH patients not only from healthy patients but also from patients with other causes of gait disturbances with cognitive decline and ventriculomegaly.
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Affiliation(s)
- Vojtěch Sedlák
- Department of Radiology, Military University Hospital, Prague, Czech Republic
| | - Adéla Bubeníková
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic.
- Department of Neurosurgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
| | - Petr Skalický
- Department of Neurosurgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Aleš Vlasák
- Department of Neurosurgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Helen Whitley
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Ondřej Bradáč
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
- Department of Neurosurgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Ishida T, Murayama T, Kobayashi S. Current research of idiopathic normal pressure hydrocephalus: Pathogenesis, diagnosis and treatment. World J Clin Cases 2023; 11:3706-3713. [PMID: 37383114 PMCID: PMC10294169 DOI: 10.12998/wjcc.v11.i16.3706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/18/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is caused by impaired cerebrospinal fluid absorption in the elderly; it is a surgically treatable form of dementia. Gait disturbance, dementia, and urinary incontinence are the triad of signs for iNPH. In addition to these clinical findings, imaging studies show characteristic ventricular enlargement. High Evans Index and ‘disproportionately enlarged subarachnoid hydrocephalus’ are other well-known imaging findings of iNPH. If the tap test shows improved symptoms, shunt surgery is performed. The disease was first described by Hakim and Adams in 1965, followed by the publication of the first, second, and third editions of the guidelines in 2004, 2012, and 2020, respectively. Recent studies signal the glymphatic system and classical cerebrospinal fluid (CSF) absorption from the dural lymphatics as aetiological mechanisms of CSF retention. Research is also underway on imaging test and biomarker developments for more precise diagnosis, shunting technique options with fewer sequelae and complications, and the influence of genetics. Particularly, the newly introduced ‘suspected iNPH’ in the third edition of the guidelines may be useful for earlier diagnosis. However, less well-studied areas remain, such as pharmacotherapy in non-operative indications and neurological findings other than the triadic signs. This review briefly presents previous research on these and future issues.
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Affiliation(s)
- Tetsuro Ishida
- Department of Psychiatry, Japan Health Care College, Sapporo 062-0053, Hokkaido, Japan
| | - Tomonori Murayama
- Department of Psychiatry, Asahikawa Keisenkai Hospital, Asahikawa 078-8208, Hokkaido, Japan
| | - Seiju Kobayashi
- Department of Psychiatry, Shinyukai Nakae Hospital, Sapporo 001-0022, Hokkaido, Japan
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Carswell C. Idiopathic normal pressure hydrocephalus: historical context and a contemporary guide. Pract Neurol 2023; 23:15-22. [PMID: 36162853 DOI: 10.1136/pn-2021-003291] [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] [Accepted: 08/21/2022] [Indexed: 02/02/2023]
Abstract
Idiopathic normal pressure hydrocephalus (NPH) was described in 1965 as a syndrome in which hydrocephalus develops but with a normal cerebrospinal fluid (CSF) pressure, causing shunt-responsive gait apraxia, cognitive impairment and urinary incontinence. Not all patients respond to shunting despite having the clinical syndrome with appropriate radiological features. This has led to considerable debate over subsequent decades regarding idiopathic NPH. It is now understood that asymptomatic communicating hydrocephalus can develop in many healthy older people, and that over time this can develop into a symptomatic state that sometimes responds to CSF shunting, but to a variable extent. This review looks at the historical background of NPH, the use of predictive tests, the current state of clinical evidence for the diagnosis and treatment of idiopathic NPH and the possible underlying causes, to provide a contemporary practical guide for assessing patients with the radiological features of idiopathic NPH.
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Affiliation(s)
- Christopher Carswell
- Imperial College Healthcare NHS Trust, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
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Lilja-Lund O, Maripuu M, Kockum K, Andersson J, Lindam A, Nyberg L, Laurell K. Longitudinal neuropsychological trajectories in idiopathic normal pressure hydrocephalus: a population-based study. BMC Geriatr 2023; 23:29. [PMID: 36647004 PMCID: PMC9843855 DOI: 10.1186/s12877-023-03747-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) is a progressive syndrome affecting gait, incontinence, and cognition in a significant number of older adults. Still, prospective studies on early development of symptoms are scarce. AIM To investigate how neuropsychological functions develop before and in already diagnosed iNPH over a two-year period in a population-based material. METHOD A sample of 104 participants (median [IQR] 75 [72-80] years old) from the general population underwent CT-imaging and clinical assessment at baseline and follow-up. We used the iNPH symptom scale covering four domains (Neuropsychology, Gait, Balance, Incontinence) and additional tests of executive functions. Morphological signs were rated with the iNPH Radscale. Non-parametric statistics with Bonferroni corrections and a significance-level of p < 0.05 were used. RESULTS Median (IQR) time to follow-up was 25 (23-26) months. Effect size (ES) for individuals who developed iNPH (n = 8) showed a large (ES r = -0.55) decline in the Gait domain and on the Radscale (ES r = -0.60), with a medium deterioration in declarative memory (ES r = -0.37). Those having iNPH at baseline (n = 12) performed worse on one executive sub-function i.e., shifting (p = 0.045). CONCLUSION Besides deterioration in gait and radiology, our results suggest that a neuropsychological trajectory for those developing iNPH includes a reduction in declarative memory. Executive dysfunction was limited to those already having iNPH at baseline. These findings could suggest that memory impairments are included in the early development of iNPH.
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Affiliation(s)
- Otto Lilja-Lund
- grid.12650.300000 0001 1034 3451Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden
| | - Martin Maripuu
- grid.12650.300000 0001 1034 3451Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden
| | - Karin Kockum
- grid.12650.300000 0001 1034 3451Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden
| | - Johanna Andersson
- grid.12650.300000 0001 1034 3451Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden
| | - Anna Lindam
- grid.12650.300000 0001 1034 3451Department of Public Health and Clinical Medicine, Unit of Research, Education and Development Östersund Hospital, Umeå University, Umeå, Sweden
| | - Lars Nyberg
- grid.12650.300000 0001 1034 3451Department of Radiation Sciences, Radiology, Umeå University, Umeå, Sweden ,grid.12650.300000 0001 1034 3451Department of Integrative Medical Biology, Umeå University, Umeå, Sweden ,grid.12650.300000 0001 1034 3451Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden ,grid.5510.10000 0004 1936 8921Center for Lifespan Changes in Brain and Cognition, University of Oslo, Oslo, Norway
| | - Katarina Laurell
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
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11
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Thavarajasingam SG, El-Khatib M, Vemulapalli K, Iradukunda HAS, K. SV, Borchert R, Russo S, Eide PK. Radiological predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:369-419. [PMID: 36435931 PMCID: PMC9922237 DOI: 10.1007/s00701-022-05402-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery, though the predictors of shunt response remain debated. Currently, radiological features play an important role in the diagnosis of iNPH, but it is not well established which radiological markers most precisely predict shunt responsive iNPH. OBJECTIVE To conduct a systematic review and meta-analysis to identify radiological predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most predictive radiological features. METHODS Embase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating radiological predictors of shunt response in iNPH patients. Included studies were assessed using the ROBINS-1 tool, and eligible studies were evaluated using a univariate meta-analysis. RESULTS Overall, 301 full-text papers were screened, of which 28 studies were included, and 26 different radiological features were identified, 5 of these met the inclusion criteria for the meta-analysis: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The meta-analysis showed that only callosal angle and periventricular white matter changes significantly differentiated iNPH shunt responders from non-responders, though both markers had a low diagnostic odds ratio (DOR) of 1.88 and 1.01 respectively. None of the other radiological markers differentiated shunt responsive from shunt non-responsive iNPH. CONCLUSION Callosal angle and periventricular changes are the only diagnostically effective radiological predictors of shunt responsive iNPH patients. However, due to the DORs approximating 1, they are insufficient as sole predictors and are advised to be used only in combination with other diagnostic tests of shunt response. Future research must evaluate the combined use of multiple radiological predictors, as it may yield beneficial additive effects that may allow for more robust radiological shunt response prediction.
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Affiliation(s)
| | | | | | | | | | - Robin Borchert
- Department of Clinical Neurosciences, Cambridge University Hospital NHS Trust, Cambridge, UK
| | - Salvatore Russo
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Per K. Eide
- Department of Neurosurgery, Oslo University Hospital – Rikshospitalet, Oslo, Norway ,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Lidén S, Farahmand D, Laurell K. Ventricular volume in relation to lumbar CSF levels of amyloid-β 1–42, tau and phosphorylated tau in iNPH, is there a dilution effect? Fluids Barriers CNS 2022; 19:59. [PMID: 35843939 PMCID: PMC9288679 DOI: 10.1186/s12987-022-00353-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Levels of the biomarkers amyloid-β 1–42 (Aβ42), tau and phosphorylated tau (p-tau) are decreased in the cerebrospinal fluid (CSF) of patients with idiopathic normal pressure hydrocephalus (iNPH). The mechanism behind this is unknown, but one potential explanation is dilution by excessive CSF volumes. The aim of this study was to investigate the presence of a dilution effect, by studying the relationship between ventricular volume (VV) and the levels of the CSF biomarkers.
Methods
In this cross-sectional observational study, preoperative magnetic resonance imaging (MRI) and lumbar CSF was acquired from 136 patients with a median age of 76 years, 89 men and 47 females, selected for surgical treatment for iNPH. The CSF volume of the lateral and third ventricles was segmented on MRI and related to preoperative concentrations of Aβ42, tau and p-tau.
Results
In the total sample VV (Median 140.7 mL) correlated weakly (rs = − 0.17) with Aβ42 (Median 534 pg/mL), but not with tau (Median 216 pg/mL) nor p-tau (Median 31 pg/mL). In a subgroup analysis, the correlation between VV and Aβ42 was only present in the male group (rs = − 0.22, p = 0.038). Further, Aβ42 correlated positively with tau (rs = 0.30, p = 0.004) and p-tau (rs = 0.26, p = 0.012) in males but not in females.
Conclusions
The findings did not support a major dilution effect in iNPH, at least not in females. The only result in favor for dilution was a weak negative correlation between VV and Aβ42 but not with the other lumbar CSF biomarkers. The different results between males and females suggest that future investigations of the CSF pattern in iNPH would gain from sex-based subgroup analysis.
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13
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Gholampour S, Frim D, Yamini B. Long-term recovery behavior of brain tissue in hydrocephalus patients after shunting. Commun Biol 2022; 5:1198. [DOI: 10.1038/s42003-022-04128-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
AbstractThe unpredictable complexities in hydrocephalus shunt outcomes may be related to the recovery behavior of brain tissue after shunting. The simulated cerebrospinal fluid (CSF) velocity and intracranial pressure (ICP) over 15 months after shunting were validated by experimental data. The mean strain and creep of the brain had notable changes after shunting and their trends were monotonic. The highest stiffness of the hydrocephalic brain was in the first consolidation phase (between pre-shunting to 1 month after shunting). The viscous component overcame and damped the input load in the third consolidation phase (after the fifteenth month) and changes in brain volume were stopped. The long-intracranial elastance (long-IE) changed oscillatory after shunting and there was not a linear relationship between long-IE and ICP. We showed the long-term effect of the viscous component on brain recovery behavior of hydrocephalic brain. The results shed light on the brain recovery mechanism after shunting and the mechanisms for shunt failure.
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Lv M, Yang X, Zhou X, Chen J, Wei H, Du D, Lin H, Xia J. Gray matter volume of cerebellum associated with idiopathic normal pressure hydrocephalus: A cross-sectional analysis. Front Neurol 2022; 13:922199. [PMID: 36158963 PMCID: PMC9489844 DOI: 10.3389/fneur.2022.922199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
The cause of idiopathic normal pressure hydrocephalus's (iNPH) clinical symptoms remains unclear. The cerebral cortex is the center of the brain and provides a structural basis for complex perception and motor function. This study aimed to explore the relationship between changes in cerebral cortex volume and clinical symptoms in patients with iNPH. This study included 21 iNPH patients and 20 normal aging (NA) controls. Voxel-based morphometry statistical results showed that, compared with NA, the gray matter volumes of patients with iNPH in the bilateral temporal lobe, bilateral hippocampus, bilateral thalamus, bilateral insula, left amygdala, right lenticular nucleus, right putamen, and cerebellum decreased, while the volumes of gray matter in the bilateral paracentral lobules, precuneus, bilateral supplementary motor area, medial side of the left cerebral hemisphere, and median cingulate and paracingulate gyri increased. Correlation analysis among the volumes of white matter and gray matter in the cerebrum and cerebellum and the iNPH grading scale (iNPHGS) revealed that the volume of white matter was negatively correlated with the iNPHGS (P < 0.05), while the gray matter volumes of cerebellar area 6 and area 8 were negatively correlated with the clinical symptoms of iNPH (P < 0.05). The volume of gray matter in the cerebellar vermis was negatively correlated with gait, and the gray matter volume of cerebellar area 6 was negatively correlated with cognition. Our findings suggest that the cerebellum also plays an important role in the pathogenesis of iNPH, potentially highlighting new research avenues for iNPH.
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Affiliation(s)
- Minrui Lv
- Department of Radiology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- Department of Radiology, Southern University of Science and Technology Hospital, Shenzhen, China
| | - Xiaolin Yang
- Department of Radiology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Xi Zhou
- Department of Radiology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Jiakuan Chen
- Department of Radiology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Haihua Wei
- Department of Radiology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Duanming Du
- Department of Interventional Therapy, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Hai Lin
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Jun Xia
- Department of Radiology, Shenzhen Second People's Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- *Correspondence: Jun Xia
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15
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Lilja-Lund O, Nyberg L, Maripuu M, Laurell K. Dual-Task Performance in Older Adults With and Without Idiopathic Normal Pressure Hydrocephalus. Front Aging Neurosci 2022; 14:904194. [PMID: 35707704 PMCID: PMC9190777 DOI: 10.3389/fnagi.2022.904194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/27/2022] [Indexed: 11/18/2022] Open
Abstract
Two of the main features of idiopathic normal pressure hydrocephalus (iNPH) are disturbed gait and cognition. These features are typically investigated separately, but here we combined walking with a cognitive task to investigate if older adults with iNPH were more susceptible to dual-task interference on walking than those without iNPH. In total, 95 individuals from the general population participated in our study. Of these, 20 were classified as Possible iNPH (median [interquartile range, IQR] 80 years [75–82.5]) and 75 as Unlikely iNPH (74 years [72–78]). Conversation, 10-m walking, semantic and phonemic verbal fluency were performed either combined or independently. “Stopping walking while talking” was noted. Pairwise comparisons and multiple logistic regression analyses were used. We found that the Possible iNPH group was older, stopped walking more frequently during the conversation, and had a slower single-task pace. The dual-task pace was slower for both groups. Only single-task walking pace could predict Possible iNPH when adjusted for age. We could establish a dual-task cost on gait performance in this sample of older adults from the general population, but the cost was not exclusive for individuals with Possible iNPH. To further assess the value of dual-task testing in iNPH, including observations of stopping walking while talking, a study of a clinical iNPH material with more severe symptoms would be valuable.
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Affiliation(s)
- Otto Lilja-Lund
- Department of Clinical Sciences, Neuroscience, Umeå University, Umeå, Sweden
- *Correspondence: Otto Lilja-Lund,
| | - Lars Nyberg
- Department of Radiation Sciences, Radiology, Umeå University, Umeå, Sweden
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
- Center for Lifespan Changes in Brain and Cognition, University of Oslo, Oslo, Norway
| | - Martin Maripuu
- Department of Clinical Sciences, Psychiatry, Umeå University, Umeå, Sweden
| | - Katarina Laurell
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
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16
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Palandri G, Carretta A, La Corte E, Giannini G, Martinoni M, Mantovani P, Albini-Riccioli L, Tonon C, Mazzatenta D, Elder BD, Conti A. Open-aqueduct LOVA, LIAS, iNPH: a comparative clinical-radiological study exploring the "grey zone" between different forms of chronic adulthood hydrocephalus. Acta Neurochir (Wien) 2022; 164:1777-1788. [PMID: 35477816 PMCID: PMC9233635 DOI: 10.1007/s00701-022-05215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/07/2022] [Indexed: 11/27/2022]
Abstract
Purpose The definition of chronic adult hydrocephalus encompasses different pathological entities with overlapping characteristics, including long-standing overt ventriculomegaly in adults (LOVA), late-onset idiopathic aqueductal stenosis (LIAS) and idiopathic normal pressure hydrocephalus (iNPH). The aim of our study was to identify preoperative clinical and radiological features peculiar of these diseases providing some pathophysiology inferences on these forms of hydrocephalus. Methods Clinical and radiological preoperative records, type of surgical treatment and clinical outcome of patients with chronic adult hydrocephalus who were surgically treated between 2013 and 2019 were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the contribution of each variable to the differential diagnosis. Results In total, 105 patients were included: 18 with LOVA, 23 with LIAS and 64 with iNPH. On multivariate analysis, an enlarged cisterna magna and a more severe ventriculomegaly were associated with the diagnosis of LOVA, while an older age and DESH with iNPH. LIAS patients tend to have an higher prevalence of raised ICP symptoms. Based on that, a clinical and radiological scoring system was developed to distinguish between iNPH and no iNPH cases. A precise cut-off value with a sensitivity of 95.1% and a specificity of 90.6% was identified. Conclusions LOVA, LIAS and iNPH are different forms of chronic adulthood hydrocephalus and present different and peculiar clinical and radiological features, with an impact on the treatment and outcome prediction. The implementation of a clinical-radiological score for differential diagnosis may help the differentiation. Further studies are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05215-9.
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Affiliation(s)
- Giorgio Palandri
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Alessandro Carretta
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy.
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | - Emanuele La Corte
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Neurology Unit (NEUROMET), IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Matteo Martinoni
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Paolo Mantovani
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
| | - Luca Albini-Riccioli
- Neuroradiology Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Diego Mazzatenta
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Programma Neurochirurgia Ipofisi - Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Benjamin D Elder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alfredo Conti
- Department of Neurosurgery, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Via Altura 3, 40139, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
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17
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Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To determine the effect of cerebrospinal fluid (CSF) shunting versus no CSF shunting in people with idiopathic normal pressure hydrocephalus (iNPH). To determine the frequency of adverse effects of CSF shunting in iNPH
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18
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Carlsen JF, Backlund ADL, Mardal CA, Taudorf S, Holst AV, Munch TN, Hansen AE, Hasselbalch SG. Can Shunt Response in Patients with Idiopathic Normal Pressure Hydrocephalus Be Predicted from Preoperative Brain Imaging? A Retrospective Study of the Diagnostic Use of the Normal Pressure Hydrocephalus Radscale in 119 Patients. AJNR Am J Neuroradiol 2022; 43:223-229. [PMID: 34969666 PMCID: PMC8985670 DOI: 10.3174/ajnr.a7378] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE The Normal Pressure Hydrocephalus Radscale is a combined scoring of 7 different structural imaging markers on preoperative brain CT or MR imaging in patients with idiopathic normal pressure hydrocephalus: callosal angle, Evans Index, Sylvian fissure dilation, apical sulcal narrowing, mean temporal horn diameter, periventricular WM lesions, and focal sulcal dilation. The purpose of this retrospective study was to assess the performance of the Normal Pressure Hydrocephalus Radscale in distinguishing idiopathic normal pressure hydrocephalus shunt responders from nonresponders. MATERIALS AND METHODS The preoperative MR imaging and CT scans of 119 patients with idiopathic normal pressure hydrocephalus were scored using the Normal Pressure Hydrocephalus Radscale. A summary shunt-response score assessed within 6 months from ventriculoperitoneal shunt surgery, combining the effect on cognition, gait, and urinary incontinence, was used as a reference. The difference between the mean Normal Pressure Hydrocephalus Radscale for responders and nonresponders was tested using the Student t test. The area under the curve was calculated for the Normal Pressure Hydrocephalus Radscale to assess shunt response. To ascertain reproducibility, we assessed the interobserver agreement between the 2 independent observers as intraclass correlation coefficients for the Normal Pressure Hydrocephalus Radscale for 74 MR imaging scans and 19 CT scans. RESULTS Ninety-four (79%) of 119 patients were shunt responders. The mean Normal Pressure Hydrocephalus Radscale score for shunt responders was 8.35 (SD, 1.53), and for nonresponders, 7.48 (SD, 1.53) (P = .02). The area under the curve for the Normal Pressure Hydrocephalus Radscale was 0.66 (range, 0.54-0.78). The intraclass correlation coefficient for the Normal Pressure Hydrocephalus Radscale was 0.86 for MR imaging and 0.82 for CT. CONCLUSIONS The Normal Pressure Hydrocephalus Radscale showed moderate discrimination for shunt response but cannot, on its own, be used for selecting patients with idiopathic normal pressure hydrocephalus for shunt surgery.
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Affiliation(s)
- J F Carlsen
- From the Department of Radiology (J.F.C., C.A.M., A.E.H.)
| | - A D L Backlund
- Department of Radiology (A.D.L.B.), Hospital of North Zealand, Hillerød, Denmark
| | - C A Mardal
- From the Department of Radiology (J.F.C., C.A.M., A.E.H.)
| | - S Taudorf
- Department of Neurology (S.T., S.G.H.)
| | - A V Holst
- Danish Dementia Research Centre, and Department of Neurosurgery (A.V.H., T.N.M.), Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - T N Munch
- Danish Dementia Research Centre, and Department of Neurosurgery (A.V.H., T.N.M.), Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine (T.N.M., A.E.H.), University of Copenhagen, Copenhagen, Denmark
- Department of Epidemiology Research (T.N.M.), Statens Serum Institut, Copenhagen, Denmark
| | - A E Hansen
- From the Department of Radiology (J.F.C., C.A.M., A.E.H.)
- Department of Clinical Medicine (T.N.M., A.E.H.), University of Copenhagen, Copenhagen, Denmark
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19
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Onder H. The sustained improvement after lumbar puncture in an idiopathic normal pressure hydrocephalus subject with synucleinopathy. Neurol Sci 2021; 43:1471-1473. [PMID: 34807362 DOI: 10.1007/s10072-021-05535-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Halil Onder
- Department of Neurology, Yozgat City Hospital, Yozgat, Turkey. .,Neurology Clinic, Diskapi Yildirim Beyazit Training and Education Hospital, Ankara, Turkey.
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20
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Rau A, Reisert M, Kellner E, Hosp JA, Urbach H, Demerath T. Increased interstitial fluid in periventricular and deep white matter hyperintensities in patients with suspected idiopathic normal pressure hydrocephalus. Sci Rep 2021; 11:19552. [PMID: 34599204 PMCID: PMC8486779 DOI: 10.1038/s41598-021-98054-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/26/2021] [Indexed: 01/18/2023] Open
Abstract
Periventricular white matter changes are common in patients with idiopathic normal pressure hydrocephalus (iNPH) and considered to represent focally elevated interstitial fluid. We compared diffusion measures in periventricular hyperintensities in patients with imaging features of iNPH to patients without. The hypothesis is that periventricular hyperintensities in patients with presumed iNPH show higher water content than in patients without imaging features of iNPH. 21 patients with iNPH Radscale 7-12 ("high probability of iNPH") and 10 patients with iNPH Radscale 2-4 ("low probability of iNPH") were examined with a neurodegeneration imaging protocol including a diffusion microstructure imaging sequence. Periventricular hyperintensities and deep white matter hyperintensities were segmented and diffusion measures were compared. In patients with imaging features of iNPH, the free water content in periventricular hyperintensities was significantly higher compared to the control group (p = 0.005). This effect was also detectable in deep white matter hyperintensities (p = 0.024). Total brain volumes and total gray or white matter volumes did not differ between the groups. Periventricular cap free water fraction was highly discriminative regarding patients with presumed iNPH and controls with an ROC AUC of 0.933. Quantitative diffusion microstructure imaging shows elevated water content in periventricular hyperintensities in patients with imaging features of iNPH, which could be the imaging correlate for pathologic fluid accumulation and may be used as an imaging biomarker in the future.
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Affiliation(s)
- Alexander Rau
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Medical Physics, Department of Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elias Kellner
- Medical Physics, Department of Radiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jonas A Hosp
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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21
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Fällmar D, Andersson O, Kilander L, Löwenmark M, Nyholm D, Virhammar J. Imaging features associated with idiopathic normal pressure hydrocephalus have high specificity even when comparing with vascular dementia and atypical parkinsonism. Fluids Barriers CNS 2021; 18:35. [PMID: 34325703 PMCID: PMC8323278 DOI: 10.1186/s12987-021-00270-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/23/2021] [Indexed: 11/27/2022] Open
Abstract
Background Vascular dementia (VaD) and atypical parkinsonism often present with symptoms that can resemble idiopathic normal pressure hydrocephalus (iNPH) and enlarged cerebral ventricles, and can be challenging differential diagnoses. The aim was to investigate frequencies of imaging features usually associated with iNPH and their radiological diagnostic accuracy in a sample containing the relevant differential diagnoses VaD, progressive supranuclear palsy (PSP), multiple system atrophy parkinsonian type (MSA-P), and healthy controls. Methods Nine morphological imaging features usually associated with iNPH were retrospectively investigated in MR images of 55 patients with shunt-responsive iNPH, 32 patients with VaD, 30 patients with PSP, 27 patients with MSA-P, and 39 age-matched healthy controls. Logistic regression and receiver operating characteristic curves were used to assess diagnostic accuracy, sensitivity, and specificity for each imaging finding. Results In a logistic regression model using iNPH diagnosis as a dependent variable, the following imaging features contributed significantly to the model: callosal angle (OR = 0.95 (0.92–0.99), p = 0.012), Evans’ index * 100 (OR = 1.51 (1.23–1.86), p < 0.001), enlarged Sylvian fissures (OR = 6.01 (1.42–25.40), p = 0.015), and focally enlarged sulci (OR = 10.18 (1.89–55.02), p = 0.007). Imaging features with 95% specificity for iNPH were: callosal angle ≤ 71°, temporal horns ≥ 7 mm, Evans’ index ≥ 0.37, iNPH Radscale ≥ 9, and presence of DESH, bilateral ventricular roof bulgings or focally enlarged sulci. A simplified version of the iNPH Radscale with only four features resulted in equally high diagnostic accuracy as the original iNPH Radscale. Conclusions There is a notable overlap between some of the commonly used imaging markers regarding iNPH, VaD and atypical parkinsonism, such as PSP. However, this study shows that the specificity of imaging markers usually associated with iNPH was high even when comparing with these challenging differential diagnoses. The callosal angle was the single imaging feature with highest diagnostic accuracy to discriminate iNPH from its mimics. A simplified rating scale using only a few selected features could be used with retained specificity. Supplementary Information The online version contains supplementary material available at 10.1186/s12987-021-00270-3.
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Affiliation(s)
- David Fällmar
- Department of Surgical Sciences, Radiology, Uppsala University, Bonadsv 27, 75757, Uppsala, Sweden.
| | - Oliver Andersson
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Lena Kilander
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Malin Löwenmark
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Dag Nyholm
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Johan Virhammar
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
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Mallon DH, Malhotra P, Naik M, Edison P, Perry R, Carswell C, Win Z. The role of amyloid PET in patient selection for extra-ventricular shunt insertion for the treatment of idiopathic normal pressure hydrocephalus: A pooled analysis. J Clin Neurosci 2021; 90:325-331. [PMID: 34275571 DOI: 10.1016/j.jocn.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Idiopathic Normal Pressure Hydrocephalus (iNPH) can be effectively treated through shunt insertion. However, most shunted patients experience little or no clinical benefit, which suggests suboptimal patient selection. While contentious, multiple studies have reported poorer shunt outcomes associated with concomitant Alzheimer's disease. Prompted by this observation, multiple studies have assessed the role of amyloid PET, a specific test for Alzheimer's disease, in patient selection for shunting. METHODS A comprehensive literature search was performed to identify studies that assessed the association between amyloid PET result and the clinical response to shunting in patients with suspected iNPH. Pooled diagnostic statistics were calculated. RESULTS Across three relevant studies, a total of 38 patients with suspected iNPH underwent amyloid PET imaging and shunt insertion. Twenty-three patients had a positive clinical response to shunting. 18/28 (64.3%) of patients with a negative amyloid PET and 5/10 (50%) with a positive amyloid PET had a positive response to shunting. The pooled sensitivity, specificity and accuracy was 33.3%, 76.2% and 58.3%. None of these statistics reached statistical significance. CONCLUSION The results of this pooled analysis do not support the selection of patients with suspected iNPH for shunting on the basis of amyloid PET alone. However, due to small cohort sizes and weakness in study design, further high-quality studies are required to properly determine the role of amyloid PET in assessing this complex patient group.
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Affiliation(s)
- Dermot H Mallon
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; Imperial College London, Charing Cross Hospital, London, UK.
| | - Paresh Malhotra
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Mitesh Naik
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Paul Edison
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; Imperial College London, Charing Cross Hospital, London, UK
| | - Richard Perry
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Christopher Carswell
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; Imperial College London, Charing Cross Hospital, London, UK
| | - Zarni Win
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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Sidiropoulos C. Gaps, Controversies, and Proposed Roadmap for Research in Normal Pressure Hydrocephalus. Mov Disord 2021; 36:1043. [PMID: 33851754 DOI: 10.1002/mds.28574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Christos Sidiropoulos
- Department of Neurology and Ophthalmology, Neurology, Michigan State University, East Lansing, Michigan, USA
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Can the radiological scale "iNPH Radscale" predict tap test response in idiopathic normal pressure hydrocephalus? J Neurol Sci 2020; 420:117239. [PMID: 33278661 DOI: 10.1016/j.jns.2020.117239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/02/2020] [Accepted: 11/20/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) presents typical radiological signs that have been summarised in a semi-quantitative scale named the iNPH Radscale. However, the iNPH Radscale's predictive value for response to cerebrospinal fluid (CSF) tap test has never been studied. This study aims to investigate if the iNPH Radscale can predict locomotion improvement after CSF tap test. METHODS A total of 100 patients with iNPH (age: 76.3 ± 7.9, gender: 36% female) were included in this retrospective study. Two raters, blinded to the response of the CSF tap test, evaluated the iNPH Radscale and its seven subitems (Evan's index, callosal angle, size of temporal horns, narrow high-convexity sulci, dilated Sylvian fissures, focally dilated sulci, and periventricular hypodensities). Locomotion improvement was assessed by the Timed Up and Go (TUG) performed before, and 24 h after, the CSF tap test. RESULTS The iNPH Radscale (total score) was similar between the CSF tap test responders and non-responders (responders: 8.31 ± 1.96, non-responders: 9.18 ± 2.51, p = 0.128). However, the temporal horns score was smaller in the responders group (1.66 ± 0.57 versus 1.94 ± 0.24, p = 0.045), even after adjusting for age, gender, education level, white matter changes, and global cognition (β: -0.250, C.I. 95%: [-3.185; -0.161], p = 0.031). CONCLUSION The iNPH Radscale (total score) does not predict locomotion improvement after CSF tap test, while a smaller temporal horns score at baseline is associated with a positive tap test responder status.
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