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Duy PQ, Mehta NH, Kahle KT. Biomechanical instability of the brain-CSF interface in hydrocephalus. Brain 2024; 147:3274-3285. [PMID: 38798141 PMCID: PMC11449143 DOI: 10.1093/brain/awae155] [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: 12/11/2023] [Revised: 02/15/2024] [Accepted: 05/05/2024] [Indexed: 05/29/2024] Open
Abstract
Hydrocephalus, characterized by progressive expansion of the CSF-filled ventricles (ventriculomegaly), is the most common reason for brain surgery. 'Communicating' (i.e. non-obstructive) hydrocephalus is classically attributed to a primary derangement in CSF homeostasis, such as choroid plexus-dependent CSF hypersecretion, impaired cilia-mediated CSF flow currents, or decreased CSF reabsorption via the arachnoid granulations or other pathways. Emerging data suggest that abnormal biomechanical properties of the brain parenchyma are an under-appreciated driver of ventriculomegaly in multiple forms of communicating hydrocephalus across the lifespan. We discuss recent evidence from human and animal studies that suggests impaired neurodevelopment in congenital hydrocephalus, neurodegeneration in elderly normal pressure hydrocephalus and, in all age groups, inflammation-related neural injury in post-infectious and post-haemorrhagic hydrocephalus, can result in loss of stiffness and viscoelasticity of the brain parenchyma. Abnormal brain biomechanics create barrier alterations at the brain-CSF interface that pathologically facilitates secondary enlargement of the ventricles, even at normal or low intracranial pressures. This 'brain-centric' paradigm has implications for the diagnosis, treatment and study of hydrocephalus from womb to tomb.
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Affiliation(s)
- Phan Q Duy
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
- Department of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Neel H Mehta
- Department of Neurosurgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA 02115, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA 02115, USA
- Department of Neurosurgery, Boston Children’s Hospital, Boston, MA 02115, USA
- Division of Genetics and Genomics, Boston Children’s Hospital, Boston, MA 02114, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Developmental Brain and CSF Disorders Program, Massachusetts General Hospital, Boston, MA 02114, USA
- Program in Neuroscience, Harvard University, Cambridge, MA 02142, USA
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Bendella Z, Purrer V, Haase R, Zülow S, Kindler C, Borger V, Banat M, Dorn F, Wüllner U, Radbruch A, Schmeel FC. Brain and Ventricle Volume Alterations in Idiopathic Normal Pressure Hydrocephalus Determined by Artificial Intelligence-Based MRI Volumetry. Diagnostics (Basel) 2024; 14:1422. [PMID: 39001312 PMCID: PMC11241572 DOI: 10.3390/diagnostics14131422] [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: 05/28/2024] [Revised: 06/25/2024] [Accepted: 06/29/2024] [Indexed: 07/16/2024] Open
Abstract
The aim of this study was to employ artificial intelligence (AI)-based magnetic resonance imaging (MRI) brain volumetry to potentially distinguish between idiopathic normal pressure hydrocephalus (iNPH), Alzheimer's disease (AD), and age- and sex-matched healthy controls (CG) by evaluating cortical, subcortical, and ventricular volumes. Additionally, correlations between the measured brain and ventricle volumes and two established semi-quantitative radiologic markers for iNPH were examined. An IRB-approved retrospective analysis was conducted on 123 age- and sex-matched subjects (41 iNPH, 41 AD, and 41 controls), with all of the iNPH patients undergoing routine clinical brain MRI prior to ventriculoperitoneal shunt implantation. Automated AI-based determination of different cortical and subcortical brain and ventricular volumes in mL, as well as calculation of population-based normalized percentiles according to an embedded database, was performed; the CE-certified software mdbrain v4.4.1 or above was used with a standardized T1-weighted 3D magnetization-prepared rapid gradient echo (MPRAGE) sequence. Measured brain volumes and percentiles were analyzed for between-group differences and correlated with semi-quantitative measurements of the Evans' index and corpus callosal angle: iNPH patients exhibited ventricular enlargement and changes in gray and white matter compared to AD patients and controls, with the most significant differences observed in total ventricular volume (+67%) and the lateral (+68%), third (+38%), and fourth (+31%) ventricles compared to controls. Global ventriculomegaly and marked white matter reduction with concomitant preservation of gray matter compared to AD and CG were characteristic of iNPH, whereas global and frontoparietally accentuated gray matter reductions were characteristic of AD. Evans' index and corpus callosal angle differed significantly between the three groups and moderately correlated with the lateral ventricular volumes in iNPH patients [Evans' index (r > 0.83, p ≤ 0.001), corpus callosal angle (r < -0.74, p ≤ 0.001)]. AI-based MRI volumetry in iNPH patients revealed global ventricular enlargement and focal brain atrophy, which, in contrast to healthy controls and AD patients, primarily involved the supratentorial white matter and was marked temporomesially and in the midbrain, while largely preserving gray matter. Integrating AI volumetry in conjunction with traditional radiologic measures could enhance iNPH identification and differentiation, potentially improving patient management and therapy response assessment.
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Affiliation(s)
- Zeynep Bendella
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
| | - Veronika Purrer
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
- Department of Neurodegenerative Diseases, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Robert Haase
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
| | - Stefan Zülow
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
| | - Christine Kindler
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
- Department of Neurodegenerative Diseases, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Valerie Borger
- Department of Neurosurgery, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (V.B.); (M.B.)
| | - Mohammed Banat
- Department of Neurosurgery, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (V.B.); (M.B.)
| | - Franziska Dorn
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
| | - Ullrich Wüllner
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
- Department of Neurodegenerative Diseases, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
| | - Frederic Carsten Schmeel
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
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Bianconi A, Colonna S, Minardi M, Di Perna G, Ceroni L, Nico E, Garbossa D, Borgarello S, Cofano F. Prognostic Factors in Idiopathic Normal Pressure Hydrocephalus Patients After Ventriculo-Peritoneal Shunt: Results from a Single-Institution Observational Cohort Study with Long Term Follow-Up. World Neurosurg 2024; 187:e1089-e1096. [PMID: 38759789 DOI: 10.1016/j.wneu.2024.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE The aim of this study is to investigate long-term prognostic factors and clinical outcomes in patients with idiopathic normal pressure hydrocephalus (iNPH) treated with ventriculo-peritoneal shunt (VPS). METHODS This single-center retrospective observational study of prospectively collected data included patients with probable iNPH treated with VPS surgery. All patients underwent complete preoperative assessment, including past medical history and neurological examination, dynamic cerebrospinal fluid (CSF) flow brain magnetic resonance imaging (MRI), and preoperative CSF samplings. NPH-consistent brain MRI findings and favorable responses to CSF subtraction tests were the main factors considered for VPS surgery eligibility. All patients were subsequently followed up every six to twelve months (mean follow-up time 40 months, minimum to maximum interval 6-150 months). RESULTS A total of 238 patients with a diagnosis of probable iNPH treated with VPS were enrolled. Age, comorbidities, and response to CSF samplings were not significantly associated with a better long-term outcome after VPS surgery. The results of our retrospective analysis demonstrated a statistically significant association between the presence of preoperative aqueductal CSF flow acceleration on dynamic brain MRI and neurological outcomes at 12 and 18 months after VPS surgery. CONCLUSIONS Long-term outcomes of iNPH patients treated with VPS surgery do not appear to be directly influenced by preoperative comorbidities, age, or responses to CSF samplings. Alterations in preoperative brain MRI CSF dynamics were found to be related to long-term outcomes following VPS surgery, highlighting the role of radiological assessment as a prognostic factor in patients deemed suitable candidates for VPS surgery.
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Affiliation(s)
- Andrea Bianconi
- Departments of Neuroscience and Neurosurgery, University of Turin, Turin, Italy
| | - Stefano Colonna
- Departments of Neuroscience and Neurosurgery, University of Turin, Turin, Italy.
| | | | - Giuseppe Di Perna
- Departments of Neuroscience and Neurosurgery, University of Turin, Turin, Italy
| | - Luca Ceroni
- Department of Psychology, University of Turin, Turin, Italy
| | - Elsa Nico
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Diego Garbossa
- Departments of Neuroscience and Neurosurgery, University of Turin, Turin, Italy
| | - Silvana Borgarello
- Departments of Neuroscience and Neurosurgery, University of Turin, Turin, Italy
| | - Fabio Cofano
- Departments of Neuroscience and Neurosurgery, University of Turin, Turin, Italy
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Rohatgi S, Dua A, Avesta A, Khalid RN, Diociasi A, Buch K, Ford JN, Gupta R. Predicting Gait Speed Improvement in Idiopathic Normal Pressure Hydrocephalus Patients: The Role of Evans Index and Ventricular Volume. Cureus 2024; 16:e61799. [PMID: 38975434 PMCID: PMC11227259 DOI: 10.7759/cureus.61799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/09/2024] Open
Abstract
Objective This study aims to investigate the association between specific imaging parameters, namely, the Evans index (EI) and ventricular volume (VV), and the variation in gait speed observed in patients with idiopathic normal pressure hydrocephalus (iNPH) before and after cerebrospinal fluid (CSF) removal/lumbar drain (LD). Furthermore, it seeks to identify which imaging parameters are the most reliable predictors for significant improvements in gait speed post procedure. Methods In this retrospective analysis, the study measured the gait speed of 35 patients diagnosed with idiopathic normal pressure hydrocephalus (iNPH) before and after they underwent CSF removal. Before lumbar drain (LD), brain images were segmented to calculate the Evans index and ventricular volume. The study explored the relationship between these imaging parameters (the Evans index and ventricular volume) and the improvement in gait speed following CSF removal. Patients were divided into two categories based on the degree of improvement in gait speed, and we compared the imaging parameters between these groups. Receiver operating characteristic (ROC) curve analysis was employed to determine the optimal imaging parameter thresholds predictive of gait speed enhancement. Finally, the study assessed the predictive accuracy of these thresholds for identifying patients likely to experience improved gait speed post-LD. Results Following CSF removal/lumbar drain, the participants significantly improved in gait speed, as indicated by a paired sample t-test (p-value = 0.0017). A moderate positive correlation was observed between the imaging parameters (EI and VV) and the improvement in gait speed post-LD. Significant differences were detected between the two patient groups regarding EI, VV, and a composite score (statistical test value = 3.1, 2.8, and 2.9, respectively; p-value < 0.01). Receiver operating characteristic (ROC) curve analysis identified the optimal thresholds for the EI and VV to be 0.39 and 110.78 cm³, respectively. The classification based on these thresholds yielded significant associations between patients displaying favorable imaging parameters and those demonstrating improved gait speed post-LD, with chi-square (χ²) values of 8.5 and 7.1, respectively, and p-values < 0.01. Furthermore, these imaging parameter thresholds had a 74% accuracy rate in predicting patients who would improve post-LD. Conclusion The study demonstrates that ventricle volume and the Evans index can significantly predict gait speed improvement after lumbar drain (LD) in patients with iNPH.
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Affiliation(s)
- Saurabh Rohatgi
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Amol Dua
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Arman Avesta
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Rehab Naeem Khalid
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Andrea Diociasi
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Karen Buch
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Jeremy N Ford
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Rajiv Gupta
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Chen CH, Cheng YC, Huang CY, Chen HC, Chen WH, Chai JW. Accuracy of MRI derived cerebral aqueduct flow parameters in the diagnosis of idiopathic normal pressure hydrocephalus. J Clin Neurosci 2022; 105:9-15. [PMID: 36049363 DOI: 10.1016/j.jocn.2022.08.018] [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: 05/06/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 10/31/2022]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible cause of dementia-like symptoms among the elderly. Current diagnostic guidelines for iNPH rely on clinical manifestations and ventricular morphology, which often lack accuracy. While magnetic resonance imaging (MRI) CSF flowmetry of the cerebral aqueduct provides a noninvasive aid to differential diagnosis, previous studies suffered from small sample sizes. This study compares the accuracy of different CSF flow parameters for iNPH diagnosis in a general patient population. From 2016 to 2018, a total of 216 subjects over 60 years of age were retrospectively enrolled, including 38 patients with iNPH and 178 patients with non-iNPH neurological conditions. All participants received phase-contrast MRI (PC-MRI) CSF flowmetry, with measurements performed independently by two radiologists. Flow parameters of iNPH and non-iNPH groups were compared along with their diagnostic accuracy. Absolute stroke volume (ABSV), forward flow, backward flow, mean flux and peak velocity were significantly higher in iNPH patients (P < 0.001, P < 0.001, P < 0.001, P = 0.008, P = 0.038, respectively). Backward flow had the highest diagnostic accuracy, followed by ABSV and forward flow. Net caudocranial aqueductal flow was observed in both groups, but with greater volume in the iNPH group. PC-MRI provides a non-invasive method of CSF flowmetry across the cerebral aqueduct and may aid in iNPH diagnosis. ABSV and its component flow values may provide better accuracy in identifying iNPH than other parameters.
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Affiliation(s)
- Chia-Hsin Chen
- Department of Radiology, Taichung Veterans General Hospital, 1650 Sect. 4 Taiwan, Boulevard, Taichung 40705, Taiwan, ROC
| | - Yun-Chung Cheng
- Department of Radiology, Taichung Veterans General Hospital, 1650 Sect. 4 Taiwan, Boulevard, Taichung 40705, Taiwan, ROC; Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 407224, Taiwan, ROC.
| | - Chin-Yin Huang
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 407224, Taiwan, ROC
| | - Hung-Chieh Chen
- Department of Radiology, Taichung Veterans General Hospital, 1650 Sect. 4 Taiwan, Boulevard, Taichung 40705, Taiwan, ROC; School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan, ROC
| | - Wen-Hsien Chen
- Department of Radiology, Taichung Veterans General Hospital, 1650 Sect. 4 Taiwan, Boulevard, Taichung 40705, Taiwan, ROC
| | - Jyh-Wen Chai
- Department of Radiology, Taichung Veterans General Hospital, 1650 Sect. 4 Taiwan, Boulevard, Taichung 40705, Taiwan, ROC
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First experiences with Miethke M.blue® valve in iNPH patients. J Clin Neurosci 2022; 98:127-132. [DOI: 10.1016/j.jocn.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/05/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
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Borzage M, Saunders A, Hughes J, McComb JG, Blüml S, King KS. The First Examination of Diagnostic Performance of Automated Measurement of the Callosal Angle in 1856 Elderly Patients and Volunteers Indicates That 12.4% of Exams Met the Criteria for Possible Normal Pressure Hydrocephalus. AJNR Am J Neuroradiol 2021; 42:1942-1948. [PMID: 34620589 PMCID: PMC8583275 DOI: 10.3174/ajnr.a7294] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/03/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Many patients with dementia may have comorbid or misdiagnosed normal pressure hydrocephalus, a treatable neurologic disorder. The callosal angle is a validated biomarker for normal pressure hydrocephalus with 93% diagnostic accuracy. Our purpose was to develop and evaluate an algorithm for automatically computing callosal angles from MR images of the brain. MATERIALS AND METHODS This article reports the results of analyzing callosal angles from 1856 subjects with 5264 MR images from the Open Access Series of Imaging Studies and the Alzheimer's Disease Neuroimaging Initiative databases. Measurement variability was examined between 2 neuroradiologists (n = 50) and between manual and automatic measurements (n = 281); from differences in simulated head orientation; and from real-world changes in patients with multiple examinations (n = 906). We evaluated the effectiveness of the automatic callosal angle to differentiate normal pressure hydrocephalus from Alzheimer disease in a simulated cohort. RESULTS The algorithm identified that 12.4% of subjects from these carefully screened cohorts had callosal angles of <90°, a published threshold for possible normal pressure hydrocephalus. The intraclass correlation coefficient was 0.97 for agreement between neuroradiologists and 0.90 for agreement between manual and automatic measurement. The method was robust to different head orientations. The median coefficient of variation for repeat examinations was 4.2% (Q1 = 3.1%, Q3 = 5.8%). The simulated classification of normal pressure hydrocephalus versus Alzheimer using the automatic callosal angle had an accuracy, sensitivity, and specificity of 0.87 each. CONCLUSIONS In even the most pristine research databases, analyses of the callosal angle indicate that some patients may have normal pressure hydrocephalus. The automatic callosal angle measurement can rapidly and objectively screen for normal pressure hydrocephalus in patients who would otherwise be misdiagnosed.
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Affiliation(s)
- M Borzage
- From the Fetal and Neonatal Institute, Division of Neonatology (M.B.)
- Department of Pediatrics (M.B.)
- Rudi Schulte Research Institute (M.B., A.S., S.B., K.S.K.), Santa Barbara, California
| | - A Saunders
- Department of Radiology (A.S., S.B.)
- Rudi Schulte Research Institute (M.B., A.S., S.B., K.S.K.), Santa Barbara, California
| | - J Hughes
- Department of Neuroradiology (J.H., K.S.K.), Barrow Neurological Institute, Phoenix, Arizona
| | - J G McComb
- Division of Neurosurgery (J.G.M.), Children's Hospital Los Angeles, Los Angeles, California
- Neurological Surgery (J.G.M.), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - S Blüml
- Department of Radiology (A.S., S.B.)
- Rudi Schulte Research Institute (M.B., A.S., S.B., K.S.K.), Santa Barbara, California
| | - K S King
- Rudi Schulte Research Institute (M.B., A.S., S.B., K.S.K.), Santa Barbara, California
- Department of Neuroradiology (J.H., K.S.K.), Barrow Neurological Institute, Phoenix, Arizona
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Roblot P, Mollier O, Ollivier M, Gallice T, Planchon C, Gimbert E, Danet M, Renault S, Auzou N, Laurens B, Jecko V. Communicating chronic hydrocephalus: A review. Rev Med Interne 2021; 42:781-788. [PMID: 34144842 DOI: 10.1016/j.revmed.2021.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/30/2021] [Indexed: 11/25/2022]
Abstract
Formerly called normal pressure hydrocephalus, communicating chronic hydrocephalus (CCH) is a condition affecting 0.1 to 0.5% of patients over 60years of age. The pathophysiology of this disease is poorly understood, but a defect in cerebrospinal fluid (CSF) resorption appears to be commonly defined as the cause of the neurological disorders. The last important discovery is the description of the glymphatic system and its implication in CCH and CSF resorption. Comorbidities (Alzheimer's disease, microangiopathy, parkinsonism) are very frequent, and involve a diagnostic challenge. The clinical presentation is based on the Hakim and Adams triad, comprising gait disorders, mainly impairing walking, cognitive disorders, affecting executive functions, episodic memory, visuospatial cognition, and sphincter disorders as urinary incontinence (detrusor hyperactivity). The diagnosis is suspected through a set of arguments, combining the clinical presentation, the radiological data of the magnetic resonance imaging (MRI) showing a ventriculomegaly associated with signs of transependymomous resorption of the CSF and disappearance of the cortical sulci, and the clinical response to the depletion of CSF. In the presence of all these elements, or a strong clinical suspicion, the standard treatment will be of a permanent CSF shunt, using a ventriculoatrial or ventriculoperitoneal shunt. The effectiveness of this treatment defines the diagnosis. The clinical improvement is better when treatment occurs early after the onset of the disorders, reaching 75 to 90% of motor improvement.
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Affiliation(s)
- P Roblot
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Laboratory of anatomy, university of Bordeaux, Bordeaux, France.
| | - O Mollier
- Neurosurgery department B, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - M Ollivier
- Department of diagnostic and therapeutic neuroimaging, Pellegrin hospital, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - T Gallice
- Neurosurgery department B, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Department of critical care, Bordeaux university hospital, 33076 Bordeaux, France
| | - C Planchon
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Neurosurgery department B, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - E Gimbert
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - M Danet
- Department of geriatric medicine, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - S Renault
- Department of neurology, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France
| | - N Auzou
- Institute for neurodegenerative diseases, CNRS UMR 5293, university Bordeaux, Bordeaux, France
| | - B Laurens
- Department of neurology, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Institute for neurodegenerative diseases, CNRS UMR 5293, university Bordeaux, Bordeaux, France
| | - V Jecko
- Neurosurgery department A, university hospital of Bordeaux, place Amélie-Raba-Léon, Bordeaux, France; Université de Bordeaux, CNRS UMR 5287, INCIA, Zone nord, Bat 2, 2e étage, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France
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Hnin HH, Bovonsunthonchai S, Witthiwej T, Vachalathiti R, Ariyaudomkit R. Feasibility of action observation effect on gait and mobility in idiopathic normal pressure hydrocephalus patients. Dement Neuropsychol 2021; 15:79-87. [PMID: 33907600 PMCID: PMC8049582 DOI: 10.1590/1980-57642021dn15-010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Action observation (AO) has been proved to be of benefit in several neurological
conditions, but no study has previously been conducted in idiopathic normal
pressure hydrocephalus (iNPH).
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Affiliation(s)
- Htet Htet Hnin
- Faculty of Physical Therapy, Mahidol University - Nakhon Pathom, Thailand.,Gait and Balance Group, Faculty of Physical Therapy, Mahidol University - Nakhon Pathom, Thailand
| | - Sunee Bovonsunthonchai
- Faculty of Physical Therapy, Mahidol University - Nakhon Pathom, Thailand.,Gait and Balance Group, Faculty of Physical Therapy, Mahidol University - Nakhon Pathom, Thailand
| | - Theerapol Witthiwej
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University - Bangkok, Thailand
| | | | - Rattapha Ariyaudomkit
- Faculty of Physical Therapy, Mahidol University - Nakhon Pathom, Thailand.,Gait and Balance Group, Faculty of Physical Therapy, Mahidol University - Nakhon Pathom, Thailand
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10
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Mennecke AB, Dörfler A. Editorial for: "ΔADC Analysis of the Brain in Idiopathic Normal Pressure Hydrocephalus Before and After Cerebrospinal Fluid Drainage". J Magn Reson Imaging 2020; 53:1208-1209. [PMID: 33225537 DOI: 10.1002/jmri.27442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Arnd Dörfler
- Department of Neuroradiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Gómez-Amarillo DF, Pulido LF, Mejía I, García-Baena C, Cárdenas MF, Gómez LM, Fuentes YV, Volcinschi-Moros D, Jaramillo-Velásquez D, Ramón JF, Mejía JA, Jiménez E, Hakim F. Cerebrospinal fluid closing pressure-guided tap test for the diagnosis of idiopathic normal pressure hydrocephalus: A descriptive cross-sectional study. Surg Neurol Int 2020; 11:315. [PMID: 33093992 PMCID: PMC7568097 DOI: 10.25259/sni_380_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/03/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Tap test improves symptoms of idiopathic normal pressure hydrocephalus (iNPH); hence, it is widely used as a diagnostic procedure. However, it has a low sensitivity and there is no consensus on the parameters that should be used nor the volume to be extracted. We propose draining cerebrospinal fluid (CSF) during tap test until a closing pressure of 0 cm H2O is reached as a standard practice. We use this method with all our patients at our clinic. Methods: This is a descriptive cross-sectional study where all patients with presumptive diagnosis of iNPH from January 2014 to December 2019 were included in the study. We used a univariate descriptive analysis and stratified analysis to compare the opening pressure and the volume of CSF extracted during the lumbar puncture, between patients in whom a diagnosis of iNPH was confirmed and those in which it was discarded. Results: A total of 92 patients were included in the study. The mean age at the time of presentation was 79.4 years and 63 patients were male. The diagnosis of iNPH was confirmed in 73.9% patients. The mean opening pressure was 14.4 cm H2O mean volume of CSF extracted was 43.4 mL. Conclusion: CSF extraction guided by a closing pressure of 0 cm H2O instead of tap test with a fixed volume of CSF alone may be an effective method of optimizing iNPH symptomatic improvement and diagnosis.
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How to approach a patient with parkinsonism - red flags for atypical parkinsonism. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:1-34. [PMID: 31779810 DOI: 10.1016/bs.irn.2019.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parkinsonism is a clinical syndrome defined by bradykinesia plus rigidity or tremor. Though most commonly encountered in the setting of idiopathic Parkinson's disease, a number of neurodegenerative, structural, metabolic and toxic neurological disorders can result in parkinsonism. Accurately diagnosing the underlying cause of parkinsonism is of both therapeutic and prognostic relevance, especially as we enter the era of disease-modifying treatment trials for neurodegenerative disorders. Being aware of the wide array of potential causes of parkinsonism is of paramount importance for clinicians. In this chapter, we present a pragmatic clinical approach to patients with parkinsonism, specifically focusing on 'red flags', which should alert one to consider diagnoses other than idiopathic Parkinson's disease.
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Martinez-Tejada I, Arum A, Wilhjelm JE, Juhler M, Andresen M. B waves: a systematic review of terminology, characteristics, and analysis methods. Fluids Barriers CNS 2019; 16:33. [PMID: 31610775 PMCID: PMC6792201 DOI: 10.1186/s12987-019-0153-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/15/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although B waves were introduced as a concept in the analysis of intracranial pressure (ICP) recordings nearly 60 years ago, there is still a lack consensus on precise definitions, terminology, amplitude, frequency or origin. Several competing terms exist, addressing either their probable physiological origin or their physical characteristics. To better understand B wave characteristics and ease their detection, a literature review was carried out. Methods A systematic review protocol including search strategy and eligibility criteria was prepared in advance. A literature search was carried out using PubMed/MEDLINE, with the following search terms: B waves + review filter, slow waves + review filter, ICP B waves, slow ICP waves, slow vasogenic waves, Lundberg B waves, MOCAIP. Results In total, 19 different terms were found, B waves being the most common. These terminologies appear to be interchangeable and seem to be used indiscriminately, with some papers using more than five different terms. Definitions and etiologies are still unclear, which makes systematic and standardized detection difficult. Conclusions Two future lines of action are available for automating macro-pattern identification in ICP signals: achieving strict agreement on morphological characteristics of “traditional” B waveforms, or starting a new with a fresh computerized approach for recognition of new clinically relevant patterns.
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Affiliation(s)
- Isabel Martinez-Tejada
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. .,Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark.
| | - Alexander Arum
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens E Wilhjelm
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Marianne Juhler
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten Andresen
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Giannini G, Palandri G, Ferrari A, Oppi F, Milletti D, Albini-Riccioli L, Mantovani P, Magnoni S, Chiari L, Cortelli P, Cevoli S, Agati R, Calandra-Buonaura G, Capellari S, Parchi P, Stanzani-Maserati M, Marliani AF, Merola M, Piserchia VA, Sambati L, Sturiale C, Supino A, Nicola M, Urli T. A prospective evaluation of clinical and instrumental features before and after ventriculo-peritoneal shunt in patients with idiopathic Normal pressure hydrocephalus: The Bologna PRO-Hydro study. Parkinsonism Relat Disord 2019; 66:117-124. [DOI: 10.1016/j.parkreldis.2019.07.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
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Oliveira LM, Nitrini R, Román GC. Normal-pressure hydrocephalus: A critical review. Dement Neuropsychol 2019; 13:133-143. [PMID: 31285787 PMCID: PMC6601311 DOI: 10.1590/1980-57642018dn13-020001] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/20/2019] [Indexed: 12/13/2022] Open
Abstract
Normal-pressure hydrocephalus (NPH) is a potentially reversible syndrome characterized by enlarged cerebral ventricles (ventriculomegaly), cognitive impairment, gait apraxia and urinary incontinence. A critical review of the concept, pathophysiology, diagnosis, and treatment of both idiopathic and secondary NPH was conducted. We searched Medline and PubMed databases from January 2012 to December 2018 using the keywords "normal-pressure hydrocephalus" / "idiopathic normal-pressure hydrocephalus" / "secondary normal-pressure hydrocephalus" / "NPH" / "ventriculoperitoneal shunt". The initial search produced 341 hits. After careful selection, a total of 54 articles were chosen and additional relevant studies were included during the process of writing this article. NPH is an important cause of potentially reversible dementia, frequent falls and recurrent urinary infections in the elderly. The clinical and imaging features of NPH may be incomplete or nonspecific, posing a diagnostic challenge for medical doctors and often requiring expert assessment to minimize unsuccessful surgical treatments. Recent advances resulting from the use of non-invasive MRI methods for quantifying cerebral blood flow, in particular arterial spin-labeling (ASL), and the frequent association of NPH and obstructive sleep apnea (OSA), offer new avenues to understand and treat NPH.
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Affiliation(s)
- Louise Makarem Oliveira
- Medical Student, School of Medicine, Federal University of Amazonas
(UFAM), Manaus, AM, Brazil
| | - Ricardo Nitrini
- Professor of Neurology, Department of Neurology, University of São
Paulo Medical School, São Paulo, SP, Brazil
| | - Gustavo C. Román
- The Jack S. Blanton Distinguished Endowed Chair, Neurological
Institute Houston, Methodist Hospital, Professor of Neurology Weill Cornell Medical
College Methodist Neurological Institute, USA
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16
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Zhang L, Hussain Z, Ren Z. Recent Advances in Rational Diagnosis and Treatment of Normal Pressure Hydrocephalus: A Critical Appraisal on Novel Diagnostic, Therapy Monitoring and Treatment Modalities. Curr Drug Targets 2019; 20:1041-1057. [PMID: 30767741 DOI: 10.2174/1389450120666190214121342] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/02/2019] [Accepted: 02/06/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Normal pressure hydrocephalus (NPH) is a critical brain disorder in which excess Cerebrospinal Fluid (CSF) is accumulated in the brain's ventricles causing damage or disruption of the brain tissues. Amongst various signs and symptoms, difficulty in walking, slurred speech, impaired decision making and critical thinking, and loss of bladder and bowl control are considered the hallmark features of NPH. OBJECTIVE The current review was aimed to present a comprehensive overview and critical appraisal of majorly employed neuroimaging techniques for rational diagnosis and effective monitoring of the effectiveness of the employed therapeutic intervention for NPH. Moreover, a critical overview of recent developments and utilization of pharmacological agents for the treatment of hydrocephalus has also been appraised. RESULTS Considering the complications associated with the shunt-based surgical operations, consistent monitoring of shunting via neuroimaging techniques hold greater clinical significance. Despite having extensive applicability of MRI and CT scan, these conventional neuroimaging techniques are associated with misdiagnosis or several health risks to patients. Recent advances in MRI (i.e., Sagittal-MRI, coronal-MRI, Time-SLIP (time-spatial-labeling-inversion-pulse), PC-MRI and diffusion-tensor-imaging (DTI)) have shown promising applicability in the diagnosis of NPH. Having associated with several adverse effects with surgical interventions, non-invasive approaches (pharmacological agents) have earned greater interest of scientists, medical professional, and healthcare providers. Amongst pharmacological agents, diuretics, isosorbide, osmotic agents, carbonic anhydrase inhibitors, glucocorticoids, NSAIDs, digoxin, and gold-198 have been employed for the management of NPH and prevention of secondary sensory/intellectual complications. CONCLUSION Employment of rational diagnostic tool and therapeutic modalities avoids misleading diagnosis and sophisticated management of hydrocephalus by efficient reduction of Cerebrospinal Fluid (CSF) production, reduction of fibrotic and inflammatory cascades secondary to meningitis and hemorrhage, and protection of brain from further deterioration.
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Affiliation(s)
- Lei Zhang
- Department of Radiology, Baoji Center Hospital, Baoji, Shaanxi, China
| | - Zahid Hussain
- Department of Pharmaceutics, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM) Selangor, Puncak Alam Campus, Bandar Puncak Alam 42300, Selangor, Malaysia
| | - Zhuanqin Ren
- Department of Radiology, Baoji Center Hospital, No. 8 Jiang Tan Road, Baoji 721008, Shaanxi, China
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Damasceno BP. Normal pressure hydrocephalus and the predictive value of presurgical tests. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:285-286. [PMID: 29898073 DOI: 10.1590/0004-282x20180044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Benito P Damasceno
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Hospital das Clínicas, Departamento de Neurologia, Campinas SP, Brasil
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Shaw R, Mahant N, Jacobson E, Owler B. A Review of Clinical Outcomes for Gait and Other Variables in the Surgical Treatment of Idiopathic Normal Pressure Hydrocephalus. Mov Disord Clin Pract 2016; 3:331-341. [PMID: 30363503 PMCID: PMC6178707 DOI: 10.1002/mdc3.12335] [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: 07/13/2015] [Revised: 01/07/2016] [Accepted: 01/09/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (INPH) is a treatable cause of gait disturbance, cognitive impairment, and urinary incontinence. This clinical triad of symptoms occurs in association with ventriculomegaly and normal cerebrospinal fluid (CSF) pressure. Although the treatment outcomes after CSF shunting for INPH have improved significantly since its first description in 1965, shortcomings in our understanding still remain. Not all INPH patients exhibit clinical improvement after shunting, and it is challenging to identify patients who are more likely to benefit from shunting. METHODS The Cochrane Library, Medline, Embase, and PubMed databases were searched for English-language publications between 1965 and October 2015. Reference lists of publications were also manually searched for additional publications. RESULTS The findings of this review indicate that, despite efforts to improve patient selection, the degree of clinical improvement after shunting continues to demonstrate significant variability both within and between studies. These discrepancies in treatment outcomes are the result of controversies in 3 distinct but interrelated domains: the underlying pathophysiology of INPH, the diagnosis of INPH, and the identification of likely shunt-responders. CONCLUSIONS This review focuses on these 3 areas and their relation to surgical treatment outcomes. Despite the limitations of published outcome studies and limitations in our understanding of INPH pathophysiology, shunting is a safe and effective means of achieving meaningful clinical improvement in most patients with INPH.
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Affiliation(s)
- Richard Shaw
- Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Neil Mahant
- Department of NeurologyWestmead HospitalSydneyAustralia
- Western Clinical School: Medicine (Westmead)University of SydneySydneyAustralia
| | - Erica Jacobson
- Department of NeurosurgeryPrince of Wales HospitalSydneyAustralia
| | - Brian Owler
- Department of NeurosurgerySydney Adventist HospitalSydneyAustralia
- Department of SurgeryUniversity of SydneySydneyAustralia
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Mihalj M, Dolić K, Kolić K, Ledenko V. CSF tap test - Obsolete or appropriate test for predicting shunt responsiveness? A systemic review. J Neurol Sci 2016; 362:78-84. [PMID: 26944123 DOI: 10.1016/j.jns.2016.01.028] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES There is no accurate test for diagnosing normal pressure hydrocephalus or for screening for patients who will benefit from shunt surgery. Additional tests, such as cerebrospinal fluid tap test (CSF-TT), are often used in practice to provide further predictive value in detecting suitable patients for shunting. We performed a systematic review of the literature to evaluate the CSF-TT's effect on the outcome of main symptoms and on validity parameters in screening patients suitable for shunting. METHODS In February 2015 we searched electronic databases from their inception to the current date, using the following key words: normal pressure hydrocephalus, idiopathic normotensive hydrocephalus, shunt operation, CSF tap test, predictive value, validity. The search retrieved 8 articles explicitly addressing the topic. RESULTS There was a very high positive predictive value of CSF-TT: 92% (range from 73% to 100%) but a low negative predictive value: 37% (18%-50%). Also, the CSF-TT has high specificity: 75% (33%-100%) but average sensitivity: 58% (26%-87%). The overall accuracy of the test was 62% (45%-83%). CONCLUSIONS This systematic review did not provide unambiguous validity of the CSF-TT in the screening of patients for shunting. The validity of the CSF-TT is good for patient inclusion for shunting due to the fact that the positive response to the test is very reliable. Unfortunately, the negative response to the test does not reliably make these patients ineligible for shunting. Further studies are needed to improve and standardize the methodology in order to optimize the detection power of the test.
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Affiliation(s)
- Mario Mihalj
- Department of Neurology, University Hospital Split, Croatia.
| | - Krešimir Dolić
- Clinical Department of Interventional and Diagnostic Radiology, University Hospital Split, Croatia
| | - Krešimir Kolić
- Clinical Department of Interventional and Diagnostic Radiology, University Hospital Split, Croatia
| | - Vlatko Ledenko
- Department of Neurosurgery, University Hospital Split, Croatia
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Abstract
Normal pressure hydrocephalus (NPH) is a syndrome characterized by the triad of gait disturbance, mental deterioration and urinary incontinence, associated with ventriculomegaly and normal cerebrospinal fluid (CSF) pressure. The clinical presentation (triad) may be atypical or incomplete, or mimicked by other diseases, hence the need for supplementary tests, particularly to predict postsurgical outcome, such as CSF tap-tests and computed tomography (CT) or magnetic resonance imaging (MRI). The CSF tap-test, especially the 3 to 5 days continuous external lumbar drainage of at least 150 ml/day, is the only procedure that simulates the effect of definitive shunt surgery, with high sensitivity (50-100%) and high positive predictive value (80-100%). According to international guidelines, the following are CT or MRI signs decisive for NPH diagnosis and selection of shunt-responsive patients: ventricular enlargement disproportionate to cerebral atrophy (Evans index >0.3), and associated ballooning of frontal horns; periventricular hyperintensities; corpus callosum thinning and elevation, with callosal angle between 40º and 90º; widening of temporal horns not fully explained by hippocampal atrophy; and aqueductal or fourth ventricular flow void; enlarged Sylvian fissures and basal cistern, and narrowing of sulci and subarachnoid spaces over the high convexity and midline surface of the brain. On the other hand, other imaging methods such as radionuclide cisternography, SPECT, PET, and also DTI or resting-state functional MRI, although suitable for NPH diagnosis, do not yet provide improved accuracy for identifying shunt-responsive cases.
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Affiliation(s)
- Benito Pereira Damasceno
- MD, PhD, Department of Neurology, Medical School, University of Campinas (UNICAMP), Campinas SP, Brazil
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21
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The Role of the Craniocervical Junction in Craniospinal Hydrodynamics and Neurodegenerative Conditions. Neurol Res Int 2015; 2015:794829. [PMID: 26770824 PMCID: PMC4681798 DOI: 10.1155/2015/794829] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 02/07/2023] Open
Abstract
The craniocervical junction (CCJ) is a potential choke point for craniospinal hydrodynamics and may play a causative or contributory role in the pathogenesis and progression of neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, MS, and ALS, as well as many other neurological conditions including hydrocephalus, idiopathic intracranial hypertension, migraines, seizures, silent-strokes, affective disorders, schizophrenia, and psychosis. The purpose of this paper is to provide an overview of the critical role of the CCJ in craniospinal hydrodynamics and to stimulate further research that may lead to new approaches for the prevention and treatment of the above neurodegenerative and neurological conditions.
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Tudor KI, Tudor M, McCleery J, Car J. Endoscopic third ventriculostomy (ETV) for idiopathic normal pressure hydrocephalus (iNPH). Cochrane Database Syst Rev 2015. [PMID: 26222251 PMCID: PMC9187909 DOI: 10.1002/14651858.cd010033.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) is a type of communicating hydrocephalus also known as non-obstructive hydrocephalus. This type of hydrocephalus is caused by impaired cerebrospinal fluid reabsorption without any obstruction in the ventricular system and is associated with normal cerebrospinal fluid pressure. It is characterised clinically by gait disturbance, cognitive dysfunction, and urinary incontinence (known as the Hakim-Adams triad). The exact cause of iNPH is unknown. It may be managed conservatively or treated surgically by inserting a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt. However, a substantial number of patients do not respond well to surgical treatment, complication rates are high and there is often a need for further surgery. Endoscopic third ventriculostomy (ETV) is an alternative surgical intervention. It has been suggested that ETV may lead to better outcomes, including fewer complications. OBJECTIVES To determine the effectiveness of ETV for treatment of patients with iNPH compared to conservative therapy, or shunting of CSF using VP or VA shunts.To assess the perioperative and postoperative complication rates in patients with iNPH after ETV compared to conservative therapy, VP or VA shunting. SEARCH METHODS We searched for eligible studies using ALOIS: a comprehensive register of dementia studies, The Cochrane Central Register of Controlled Trials (CENTRAL) and several bibliographic databases such as MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost) and LILACS (BIREME).We also searched the Database of Abstracts of Reviews of Effects (DARE) to identify potentially relevant reviews. The search strategy was adapted for other databases, using the most appropriate controlled vocabulary for each. We did not apply any language or time restrictions. The searches were performed in August 2014. SELECTION CRITERIA We included randomised controlled trials (RCTs) of ETV treatment of iNPH. Patients had to have at least two symptoms of the Hakim-Adams triad. Exclusion criteria were obstructive causes of hydrocephalus, other significant intracranial pathology and other confirmed causes of dementia. The eligible comparators were conservative treatment or shunting using VP and VA shunts. DATA COLLECTION AND ANALYSIS Two review authors independently screened search results, selected eligible studies, assessed risk of bias and extracted data. We contacted trial authors for additional data. MAIN RESULTS Only one study met the inclusion criteria: an RCT comparing effectiveness of ETV and non-programmable VP shunts in 42 patients with iNPH. The study was conducted in Brazil between 2009 and 2012. The overall study risk of bias was high. The primary outcome in the study was the proportion of patients with improved symptoms one year after surgery, determined as a change of at least two points on the Japanese NPH scale. Due to imprecision in the results, it was not possible to determine whether there was any difference between groups in the proportion of patients who improved 3 or 12 months after surgery (3 months: odds ration (OR) 1.12, 95% confidence interval (CI) 0.26 to 4.76, n = 42; 12 months: OR 2.5, 95% CI 0.62 to 10.11, n = 38). We were unable to estimate the effect of treatment on other efficacy outcomes (cognition, balance, function, gait and mobility) because they were inadequately reported. Of the 26 patients in the VP shunting group, 5 developed subdural hematoma postoperatively, while there were no complications among the 16 patients in the ETV group (OR 0.12, 95% CI 0.01 to 2.3, n = 42), but the estimate was too imprecise to determine whether this was likely to reflect a true difference in complication rates. This was also the case for rates of further surgical intervention (OR 1.4, 95% CI 0.31 to 6.24, n = 42). There were no deaths during the trial. We judged the quality of evidence for all outcomes to be very low because of a high risk of selection, attrition and reporting bias and serious imprecision in the results. AUTHORS' CONCLUSIONS The only randomised trial of ETV for iNPH compares it to an intervention which is not a standard practice (VP shunting using a non-programmable valve). The evidence from this study is inconclusive and of very low quality. Clinicians should be aware of the limitations of the evidence. There is a need for more robust research on this topic to be able to determine the effectiveness of ETV in patients with iNPH.
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Affiliation(s)
- Katarina Ivana Tudor
- University Hospital Center ZagrebDepartment of NeurologyKispaticeva 12ZagrebCroatia10000
| | - Mario Tudor
- University Clinical HospitalDepartment for NeurosurgerySplitCroatia21000
| | - Jenny McCleery
- Oxford Health NHS Foundation TrustElms CentreOxford RoadBanburyOxfordshireUKOX16 9AL
| | - Josip Car
- Imperial College & Nanyang Technological UniversityLee Kong Chian School of Medicine3 Fusionopolis Link, #03‐08Nexus@one‐northSingaporeSingapore138543
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Leon-Sarmiento FE, Pradilla G, Del Rosario Zambrano M. Primary and Reversible Pisa Syndrome in Juvenile Normal Pressure Hydrocephalus. Acta Neuropsychiatr 2013; 25:57-60. [PMID: 23794788 PMCID: PMC3686565 DOI: 10.1111/j.1601-5215.2012.00657.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report a case of Pisa syndrome in a patient with idiopathic normal pressure hydrocephalus, who had never been exposed to psychotropic medications. METHODS A 26 years-old, Colombian, male patient, was referred because he had cognitive abnormalities, gait disturbances and urinary incontinence. This patient also displayed pleurothotonos. Neurofunctional evaluation of sensory and motor integration at peripheral and central nervous system levels were done. RESULTS Pisa syndrome disappeared after spinal tap drainage with further gait, balance and behavioral improvement. A brainstem-thalamocortical deregulation of the central sensory and motor programming, due to the chaotic enlargement of brain ventricles was thought to be the pathophysiological mechanism underlying this case. CONCLUSION NPH must not be longer considered as an exclusive geriatric disorder. Further, uncommon movement disorders may appear with this disorder, which should be carefully approached to avoid iatrogenic and deleterious pharmacological interventions.
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Affiliation(s)
- Fidias E Leon-Sarmiento
- Smell and Taste Center, University of Pennsylvania, PA, USA ; Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, PA, USA ; Unit of Parkinson and Movement Disorders, Mediciencias Research Group; Professor of Neurology and Neuroscience, Unit of Aerospace Medicine, Universidad Nacional, Bogota, Colombia ; Human Aerospace Laboratory, Mount Sinai School of Medicine, New York, NY, USA
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