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Drabek-Maunder ER, Mankad K, Aquilina K, Dean JA, Nisbet A, Clark CA. Using diffusion MRI to understand white matter damage and the link between brain microstructure and cognitive deficits in paediatric medulloblastoma patients. Eur J Radiol 2024; 177:111562. [PMID: 38901074 DOI: 10.1016/j.ejrad.2024.111562] [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: 03/01/2024] [Revised: 05/09/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE Survivors of medulloblastoma face a range of challenges after treatment, involving behavioural, cognitive, language and motor skills. Post-treatment outcomes are associated with structural changes within the brain resulting from both the tumour and the treatment. Diffusion magnetic resonance imaging (MRI) has been used to investigate the microstructure of the brain. In this review, we aim to summarise the literature on diffusion MRI in patients treated for medulloblastoma and discuss future directions on how diffusion imaging can be used to improve patient quality. METHOD This review summarises the current literature on medulloblastoma in children, focusing on the impact of both the tumour and its treatment on brain microstructure. We review studies where diffusion MRI has been correlated with either treatment characteristics or cognitive outcomes. We discuss the role diffusion MRI has taken in understanding the relationship between microstructural damage and cognitive and behavioural deficits. RESULTS We identified 35 studies that analysed diffusion MRI changes in patients treated for medulloblastoma. The majority of these studies found significant group differences in measures of brain microstructure between patients and controls, and some of these studies showed associations between microstructure and neurocognitive outcomes, which could be influenced by patient characteristics (e.g. age), treatment, radiation dose and treatment type. CONCLUSIONS In future, studies would benefit from being able to separate microstructural white matter damage caused by the tumour, tumour-related complications and treatment. Additionally, advanced diffusion modelling methods can be explored to understand and describe microstructural changes to white matter.
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Affiliation(s)
- Emily R Drabek-Maunder
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Kristian Aquilina
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
| | - Jamie A Dean
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Andrew Nisbet
- UCL Dept of Medical Physics and Biomedical Engineering, Malet Place, Gower St, London WC1E 6BT, UK
| | - Chris A Clark
- UCL Great Ormond Street Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK
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Bagatto D, Piccolo D, Fabbro S, Copetti S, D'Agostini S, De Colle MC, Belgrado E, Tereshko Y, Valente M, Vindigni M, Tuniz F. Intravoxel incoherent motion magnetic resonance imaging in the assessment of brain microstructure and perfusion in idiopathic normal-pressure hydrocephalus. Neuroradiology 2024; 66:557-566. [PMID: 38273103 DOI: 10.1007/s00234-024-03291-5] [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: 09/03/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE To determine the relationship between intravoxel incoherent motion (IVIM) MRI parameters and clinical changes post-tap test (TT) in idiopathic normal-pressure hydrocephalus (iNPH) patients. METHODS Forty-four probable iNPH patients underwent 3 T MRI before and after TT. IVIM parameters were calculated from eight different bilateral regions of interest in basal ganglia, centrum semiovale, and corona radiata. Patients were categorized based on TT response into positive (group 1) and negative (group 2) groups. A Welch two-sample t-test was used to compare differences in D, D*, f, and ADC between the two groups, while a paired t-test was employed to assess the changes within each group before and after TT. These parameters were then correlated with clinical results. RESULTS In the lenticular and thalamic nuclei, D value was significantly lower in the group 1 compared to group 2 both pre- and post-TT (p = 0.002 and p = 0.007 respectively). Post-TT, the positive response group exhibited a notably reduced D* value (p = 0.012) and significantly higher f values (p = 0.028). In the corona radiata and centrum semiovale, a significant post-TT reduction in D* was observed in the positive response group (p = 0.017). Within groups, the positive response cohort showed a significant post-TT increase in ADC (p < 0.001) and a decrease in D* (p = 0.007). CONCLUSION IVIM permits the acquisition of important non-invasive information about tissue and vascularization in iNPH patients. Enhanced perfusion in the lenticular and thalamic nuclei may suggest the role of re-established microvascular and glymphatic pathways, potentially elucidating the functional improvement in motor function after TT in iNPH patients.
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Affiliation(s)
- Daniele Bagatto
- Unit of Neuroradiology, Department of Diagnostic Imaging, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Daniele Piccolo
- Unit of Neurosurgery, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy.
- Clinic of Neurosurgery, Department of Neuroscience, University of Padua, Padua, (PD), Italy.
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, (PV), Italy.
| | - Sara Fabbro
- Unit of Neurosurgery, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
- Unit of Neurosurgery, Department of Integrated Specialized Surgery, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, (TS), Italy
| | - Stefano Copetti
- Unit of Neurosurgery, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Serena D'Agostini
- Unit of Neuroradiology, Department of Diagnostic Imaging, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Maria Cristina De Colle
- Unit of Neuroradiology, Department of Diagnostic Imaging, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Enrico Belgrado
- Unit of Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Yan Tereshko
- Unit of Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Mariarosaria Valente
- Unit of Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Marco Vindigni
- Unit of Neurosurgery, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
| | - Francesco Tuniz
- Unit of Neurosurgery, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale, Udine, (UD), Italy
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Bovonsunthonchai S, Witthiwej T, Vachalathiti R, Hengsomboon P, Thong-On S, Sathornsumetee S, Ngamsombat C, Chawalparit O, Muangpaisan W, Richards J. Clinical improvements in temporospatial gait variables after a spinal tap test in individuals with idiopathic normal pressure hydrocephalus. Sci Rep 2024; 14:2053. [PMID: 38267518 PMCID: PMC10808249 DOI: 10.1038/s41598-024-52516-3] [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: 10/09/2023] [Accepted: 01/19/2024] [Indexed: 01/26/2024] Open
Abstract
Idiopathic Normal Pressure Hydrocephalus (iNPH) is a neurological condition that often presents gait disturbance in the early stages of the disease and affects other motor activities. This study investigated changes in temporospatial gait variables after cerebrospinal fluid (CSF) removal using a spinal tap test in individuals with idiopathic normal pressure hydrocephalus (iNPH), and explored if the tap test responders and non-responders could be clinically identified from temporospatial gait variables. Sixty-two individuals with iNPH were recruited from an outpatient clinic, eleven were excluded, leaving a total of 51 who were included in the analysis. Temporospatial gait variables at self-selected speed were recorded at pre- and 24-h post-tap tests which were compared using Paired t-tests, Cohen's d effect size, and percentage change. A previously defined minimal clinical important change (MCIC) for gait speed was used to determine the changes and to classify tap test responders and non-responders. A mixed model ANOVA was used to determine the within-group, between-group, and interaction effects. Comparisons of the data between pre- and post-tap tests showed significant improvements with small to medium effect sizes for left step length, right step time, stride length and time, cadence, and gait speed. Gait speed showed the largest percentage change among temporospatial gait variables. Within-group and interaction effects were found in some variables but no between-group effect was found. Tap test responders showed significant improvements in right step length and time, stride length and time, cadence, and gait speed while non-responders did not. Some individuals with iNPH showed clinically important improvements in temporospatial gait variables after the tap test, particularly in step/stride length and time, cadence, who could be classified by gait speed. However, gait-related balance variables did not change. Therefore, additional treatments should focus on improving such variables.
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Affiliation(s)
| | - Theerapol Witthiwej
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | | | | | | | - Sith Sathornsumetee
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, NANOTEC-Mahidol University Center of Excellence in Nanotechnology for Cancer Diagnosis and Treatment, Mahidol University, Bangkok, Thailand
| | - Chanon Ngamsombat
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Orasa Chawalparit
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Weerasak Muangpaisan
- Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jim Richards
- Allied Health Research Unit, University of Central Lancashire, Preston, UK
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Ragguett RM, Eagleson R, de Ribaupierre S. Association between altered white matter networks and post operative ventricle volume in shunt-treated pediatric hydrocephalus. Brain Res Bull 2024; 206:110847. [PMID: 38103800 DOI: 10.1016/j.brainresbull.2023.110847] [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: 07/07/2023] [Revised: 11/26/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE The objective of this study was to use probabilistic tractography in combination with white matter microstructure metrics to characterize differences in white matter networks between shunt-treated pediatric hydrocephalus patients relative to healthy controls. We were also able to explore the relationship between these white matter networks and postoperative ventricle volume. METHODS Network-based statistics was used in combination with whole-brain probabilistic tractography to determine dysregulated white matter networks in a sample of patients with pediatric hydrocephalus (n = 8), relative to controls (n = 36). Metrics such as streamline count (SC), as well as the mean of the fractional anisotropy along a tract, axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) were assessed. In networks that were found to be significantly different for patients with hydrocephalus, tracts were evaluated to assess their relationship with postoperative lateral ventricle volume. RESULTS Patients with pediatric hydrocephalus had various networks that were either upregulated or downregulated relative to controls across all white matter measures. Predominately, network dysregulation occurred in tracts involving structures located outside of the frontal lobe. Furthermore tracts with values suggesting decreased white matter integrity were not only found between subcortical structures, but also cortical structures. While there were various tracts with white matter metrics that were initially predicted by lateral ventricle volume, only two tracts remained significant following multiple comparisons. CONCLUSIONS This cross-sectional study in pediatric patients with hydrocephalus and healthy controls demonstrated using whole-brain probabilistic tractography that there are various networks with dysregulated white matter integrity in hydrocephalus patients relative to controls. These dysregulated networks have tracts connecting structures throughout the brain, and the regions were predominately located centrally and posteriorly. Postoperative ventricle volume did not predict the white matter integrity of many tracts. Future studies with larger sample sizes are needed to further understand these results.
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Affiliation(s)
| | - Roy Eagleson
- School of Biomedical Engineering, Western University, London, Ontario, Canada; Department of Electrical and Computer Engineering, Western University, London, Ontario, Canada; Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Sandrine de Ribaupierre
- School of Biomedical Engineering, Western University, London, Ontario, Canada; Western Institute for Neuroscience, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Schulich School of Medicine, Western University, London, Ontario, Canada.
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Petrella G, Ciarlo S, Elia S, Piaz RD, Nucera P, Pompucci A, Palmieri M, Pesce A. Idiopathic Normal Pressure Hydrocephalus: The Real Social and Economic Burden of a Possibly Enormous Underdiagnosis Problem. Tomography 2023; 9:2006-2015. [PMID: 37987343 PMCID: PMC10661316 DOI: 10.3390/tomography9060157] [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: 09/08/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
Normal Pressure Hydrocephalus (iNPH) typically affects the elderly and can cause cognitive decline, resulting in its differential diagnosis with other neurodegenerative conditions. Moreover, it is probably underdiagnosed; such under- and misdiagnosis prevents the patient from receiving the right treatment and significantly affects the quality of life and life expectancy. This investigation is an in-depth analysis of the actual incidence of iNPH in the population of the province served by our hospital (circa 580,000 individuals). The first phase of this study was conducted by visualizing a total of 1232 brain CT scans performed in the Emergency Departments of the four hospitals of our network on patients who were admitted for different complaints yet screened as suspicious for iNPH. Subsequently, corresponding Emergency Department medical records were investigated to understand the medical history of each patient in search of elements attributable to an alteration of CSF dynamics. The cohort of positive CT scans, according to the radiological and clinical inclusion criteria, included 192 patients. Among the reasons to require acute medical care, "Fall" was the most common. The cumulative incidence of CT scans suggestive of iNPH among the patients undergoing CT scans was as high as 15.58%, and the period prevalence calculated for the total amount of patients accessing the Emergency Departments was 1.084%. The real incidence of iNPH in the population may be underestimated, and the social burden linked to the assistance of patients suffering from such untreated conditions could be significantly relieved.
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Affiliation(s)
- Gianpaolo Petrella
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Silvia Ciarlo
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Stefania Elia
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Rita Dal Piaz
- Emergency Department, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy;
| | - Paolo Nucera
- Emergency Department, A.O. “Dono Svizzero” General Hospital, Via Appia Lato Napoli, 04023 Formia, Italy;
| | - Angelo Pompucci
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Mauro Palmieri
- Department of Human Neurosciences, Neurosurgery Division, Università “La Sapienza” di Roma, Viale del Policlinico 155, 00161 Roma, Italy;
| | - Alessandro Pesce
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
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Zhang Q, Yan X, Du J, Chen Z, Chang C. Diffusion Tensor Imaging as a Tool to Evaluate the Cognitive Function of Patients With Vascular Dementia: A Meta-Analysis. Neurologist 2023; 28:143-149. [PMID: 35986673 PMCID: PMC10158599 DOI: 10.1097/nrl.0000000000000461] [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] [Indexed: 10/15/2022]
Abstract
BACKGROUND Vascular dementia (VaD) is the most common type of dementia secondary to Alzheimer's disease. The pathologic mechanism of VaD is complex, and VaD still lacks a more objective diagnosis and evaluation method. Diffusion tensor imaging (DTI) can better detect the organizational structure and functional characteristics compared with any other diagnosis methods. Therefore, DTI has broad application in evaluating the severity and prognosis of VaD. This study aimed to assess the value of DTI in evaluating the cognitive function of patients with VaD. METHODS Authors searched Pubmed, Embase, and Cochrane Library, using the search terms, such as "diffusion tensor imaging," "DTI," "Vascular Dementia," "Arteriosclerotic Dementia," "Cognition," and "Cognitive." A voxel-based meta-analysis combined with quality statistics was performed, using the anisotropic effect-size version of the signed differential mapping method. RESULTS A total of 8 case-control studies were included in this meta-analysis. The sample size of patients ranged from 35 to 60, including 166 patients in the VaD group and 177 healthy individuals. The DTI imaging of the brain tissue of VaD patients was significantly different from that of healthy individuals. CONCLUSIONS DTI imaging of the brain tissue of VaD patients was clearly different from that of healthy controls. Therefore it may be feasible to use DTI imaging as a diagnostic method for VaD.
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Affiliation(s)
- Qiuchi Zhang
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Xiwu Yan
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Jun Du
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Zhaoyao Chen
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine
| | - Cheng Chang
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
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Pyrgelis ES, Velonakis G, Papageorgiou SG, Stefanis L, Kapaki E, Constantinides VC. Imaging Markers for Normal Pressure Hydrocephalus: An Overview. Biomedicines 2023; 11:biomedicines11051265. [PMID: 37238936 DOI: 10.3390/biomedicines11051265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Idiopathic bormal pressure hydrocephalus (iNPH) is a neurological syndrome that clinically presents with Hakim's triad, namely cognitive impairment, gait disturbances, and urinary incontinence. The fact that iNPH is potentially reversible makes its accurate and early diagnosis of paramount importance. Its main imaging characteristic is the dilation of the brain's ventricular system and the imaging parameters are also included in its diagnostic criteria along with clinical data. There is a variety of different modalities used and a great number of imaging markers that have been described while assessing iNPH patients. The present literature review attempts to describe the most important of these imaging markers and to shed some light on their role in diagnosis, differential diagnosis, and possibly prognosis of this potentially reversible neurological syndrome.
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Affiliation(s)
- Efstratios-Stylianos Pyrgelis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Georgios Velonakis
- Research Unit of Radiology, 2nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sokratis G Papageorgiou
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Elisabeth Kapaki
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Vasilios C Constantinides
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
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Cai H, Zou Y, Gao H, Huang K, Liu Y, Cheng Y, Liu Y, Zhou L, Zhou D, Chen Q. Radiological biomarkers of idiopathic normal pressure hydrocephalus: new approaches for detecting concomitant Alzheimer's disease and predicting prognosis. PSYCHORADIOLOGY 2022; 2:156-170. [PMID: 38665278 PMCID: PMC10917212 DOI: 10.1093/psyrad/kkac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 04/28/2024]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a clinical syndrome characterized by cognitive decline, gait disturbance, and urinary incontinence. As iNPH often occurs in elderly individuals prone to many types of comorbidity, a differential diagnosis with other neurodegenerative diseases is crucial, especially Alzheimer's disease (AD). A growing body of published work provides evidence of radiological methods, including multimodal magnetic resonance imaging and positron emission tomography, which may help noninvasively differentiate iNPH from AD or reveal concurrent AD pathology in vivo. Imaging methods detecting morphological changes, white matter microstructural changes, cerebrospinal fluid circulation, and molecular imaging have been widely applied in iNPH patients. Here, we review radiological biomarkers using different methods in evaluating iNPH pathophysiology and differentiating or detecting concomitant AD, to noninvasively predict the possible outcome postshunt and select candidates for shunt surgery.
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Affiliation(s)
- Hanlin Cai
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Yinxi Zou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Hui Gao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Keru Huang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Yu Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Yuting Cheng
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Qin Chen
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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Chen LJ, Tsai ST, Tseng GF. Rodent models of senile normal-pressure hydrocephalus. Tzu Chi Med J 2022; 35:18-23. [PMID: 36866352 PMCID: PMC9972929 DOI: 10.4103/tcmj.tcmj_120_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/04/2022] Open
Abstract
Cerebrospinal fluid (CSF) and its drainage are crucial in clearing metabolic waste and maintaining the microenvironment of the central nervous system for proper functioning. Normal-pressure hydrocephalus (NPH) is a serious neurological disorder of the elderly with obstruction of CSF flow outside the cerebral ventricles, causing ventriculomegaly. The stasis of CSF in NPH compromises brain functioning. Although treatable, often with shunt implantation for drainage, the outcome depends highly on early diagnosis, which, however, is challenging. The initial symptoms of NPH are hard to be aware of and the complete symptoms overlap with those of other neurological diseases. Ventriculomegaly is not specific to NPH as well. The lack of knowledge on the initial stages in its development and throughout its progression further deters early diagnosis. Thus, we are in dire need for an appropriate animal model for researches into a more thorough understanding of its development and pathophysiology so that we can enhance the diagnosis and therapeutic strategies to improve the prognosis of NPH following treatment. With this, we review the few currently available experimental rodent NPH models for these animals are smaller in sizes, easier in maintenance, and having a rapid life cycle. Among these, a parietal convexity subarachnoid space kaolin injection adult rat model appears promising as it shows a slow onset of ventriculomegaly in association with cognitive and motor disabilities resembling the elderly NPH in humans.
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Affiliation(s)
- Li-Jin Chen
- Department of Anatomy, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Sheng-Tzung Tsai
- Departments of Neurosurgery, School of Medicine, Tzu Chi University, Hualien, Taiwan,Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Guo-Fang Tseng
- Department of Anatomy, College of Medicine, Tzu Chi University, Hualien, Taiwan,Address for correspondence: Prof. Guo-Fang Tseng, Department of Anatomy, Tzu Chi University, 701, Zhongyang Road, Section 3, Hualien, Taiwan. E-mail:
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10
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Sohn G, Bae MJ, Park J, Kim SE. Semi-quantitative analysis of periventricular gray-white matter ratio on CT in patients with idiopathic normal pressure hydrocephalus. J Clin Neurosci 2022; 101:16-20. [DOI: 10.1016/j.jocn.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
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Huang W, Fang X, Li S, Mao R, Ye C, Liu W, Lin G. Preliminary Exploration of the Sequence of Nerve Fiber Bundles Involvement for Idiopathic Normal Pressure Hydrocephalus: A Correlation Analysis Using Diffusion Tensor Imaging. Front Neurosci 2022; 15:794046. [PMID: 34975390 PMCID: PMC8718542 DOI: 10.3389/fnins.2021.794046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/24/2021] [Indexed: 12/21/2022] Open
Abstract
The study preliminarily explored the sequence and difference of involvement in different neuroanatomical structures in idiopathic normal pressure hydrocephalus (INPH). We retrospectively analyzed the differences in diffusion tensor imaging (DTI) parameters in 15 ROIs [including the bilateral centrum semiovale (CS), corpus callosum (CC) (body, genu, and splenium), head of the caudate nucleus (CN), internal capsule (IC) (anterior and posterior limb), thalamus (TH), and the bilateral frontal horn white matter hyperintensity (FHWMH)] between 27 INPH patients and 11 healthy controls and the correlation between DTI indices and clinical symptoms, as evaluated by the INPH grading scale (INPHGS), the Mini-Mental State Examination (MMSE), and the timed up and go test (TUG-t), before and 1 month after shunt surgery. Significant differences were observed in DTI parameters from the CS (pFA1 = 0.004, pADC1 = 0.005) and the genu (pFA2 = 0.022; pADC2 = 0.001) and body (pFA3 = 0.003; pADC3 = 0.002) of the CC between the groups. The DTI parameters from the CS were strongly correlated with the MMSE score both pre-operatively and post-operatively. There was association between apparent diffusion coefficient (ADC) values of anterior and posterior limbs of the IC and MMSE. The DTI parameters of the head of the CN were correlated with motion, and the ADC value was significantly associated with the MMSE score. The FA value from TH correlated with an improvement in urination after shunt surgery. We considered that different neuroanatomical structures are affected differently by disease due to their positions in neural pathways and characteristics, which is further reflected in clinical symptoms and the prognosis of shunt surgery.
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Affiliation(s)
- Wenjun Huang
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xuhao Fang
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Shihong Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Renling Mao
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Chuntao Ye
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Wei Liu
- 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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12
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Kuroda T, Honma M, Mori Y, Futamura A, Sugimoto A, Kasai H, Yano S, Hieda S, Kasuga K, Ikeuchi T, Ono K. White Matter Lesions May Aid in Differentiating Idiopathic Normal Pressure Hydrocephalus and Alzheimer's Disease. J Alzheimers Dis 2021; 85:851-862. [PMID: 34864676 DOI: 10.3233/jad-215187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) is often misdiagnosed as Alzheimer's disease (AD) due to overlapping pathophysiology and similar imaging characteristics, including ventricular enlargement and increased white matter lesions (WMLs). OBJECTIVE To compare the extent and distribution of WMLs directly between iNPH and AD and examine the association with underlying pathophysiology. METHODS Twelve patients with iNPH (mean age: 78.08 years; 5 females), 20 with AD (mean age: 75.40 years; 13 females), and 10 normal cognition (NC) participants (mean age: 76.60 years; 7 females) were recruited. The extent and distribution of WMLs and the lateral ventricular volume (LV-V) were evaluated on MRI using voxel-based morphometry analysis. Concentrations of cerebrospinal fluid biomarkers, such as amyloid-β protein (Aβ)42, Aβ 40, Aβ 38, and tau species, were also measured. Risk factors for small vessel disease (SVD) were assessed by blood examination and medical records. RESULTS The periventricular WML volume (PWML-V) and deep WML volume (DWML-V) were significantly larger in iNPH than in AD and NC. The DWML-V was dominant in iNPH, while the PWML-V was dominant in AD and NC. GM-V was significantly smaller in AD than in iNPH and NC. The LV-V positively correlated with WML-V in all participants. There was a significant negative correlation between LV-V and Aβ 38 in iNPH. Furthermore, there was no significant difference in SVD risk factors between the groups. CONCLUSION The differences in the extent and distribution of WMLs between iNPH and AD, especially predominance of DWML-V over PWML-V in iNPH, may reflect decreased fluid and Aβ clearance.
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Affiliation(s)
- Takeshi Kuroda
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Motoyasu Honma
- Department of Physiology, Showa University School of Medicine, Tokyo, Japan
| | - Yukiko Mori
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akinori Futamura
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Azusa Sugimoto
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hideyo Kasai
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Yano
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Sotaro Hieda
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kensaku Kasuga
- Department of Molecular Genetics, Brain Research Institute, Niigata University, Chuo-ku, Niigata, Japan
| | - Takeshi Ikeuchi
- Department of Molecular Genetics, Brain Research Institute, Niigata University, Chuo-ku, Niigata, Japan
| | - Kenjiro Ono
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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13
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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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14
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Grazzini I, Venezia D, Cuneo GL. The role of diffusion tensor imaging in idiopathic normal pressure hydrocephalus: A literature review. Neuroradiol J 2021; 34:55-69. [PMID: 33263494 PMCID: PMC8041402 DOI: 10.1177/1971400920975153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a syndrome that comprises a triad of gait disturbance, dementia and urinary incontinence, associated with ventriculomegaly in the absence of elevated intraventricular cerebrospinal fluid (CSF) pressure. It is important to identify patients with iNPH because some of its clinical features may be reversed by the insertion of a CSF shunt. The diagnosis is based on clinical history, physical examination and brain imaging, especially magnetic resonance imaging (MRI). Recently, some papers have investigated the role of diffusion tensor imaging (DTI) in evaluating white matter alterations in patients with iNPH. DTI analysis in specific anatomical regions seems to be a promising MR biomarker of iNPH and could also be used in the differential diagnosis from other dementias. However, there is a substantial lack of structured reviews on this topic. Thus, we performed a literature search and analyzed the most recent and pivotal articles that investigated the role of DTI in iNPH in order to provide an up-to-date overview of the application of DTI in this setting. We reviewed studies published between January 2000 and June 2020. Thirty-eight studies and four reviews were included. Despite heterogeneity in analysis approaches, the majority of studies reported significant correlations between DTI and clinical symptoms in iNPH patients, as well as different DTI patterns in patients with iNPH compared to those with Alzheimer or Parkinson diseases. It remains to be determined whether DTI could predict the success after CSF shunting.
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Affiliation(s)
- Irene Grazzini
- Department of Radiology, Section of Neuroradiology, San Donato Hospital, Arezzo, Italy
| | - Duccio Venezia
- Department of Radiology, Section of Neuroradiology, San Donato Hospital, Arezzo, Italy
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15
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NAKAJIMA M, YAMADA S, MIYAJIMA M, ISHII K, KURIYAMA N, KAZUI H, KANEMOTO H, SUEHIRO T, YOSHIYAMA K, KAMEDA M, KAJIMOTO Y, MASE M, MURAI H, KITA D, KIMURA T, SAMEJIMA N, TOKUDA T, KAIJIMA M, AKIBA C, KAWAMURA K, ATSUCHI M, HIRATA Y, MATSUMAE M, SASAKI M, YAMASHITA F, AOKI S, IRIE R, MIYAKE H, KATO T, MORI E, ISHIKAWA M, DATE I, ARAI H. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir (Tokyo) 2021; 61:63-97. [PMID: 33455998 PMCID: PMC7905302 DOI: 10.2176/nmc.st.2020-0292] [Citation(s) in RCA: 190] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/13/2020] [Indexed: 01/18/2023] Open
Abstract
Among the various disorders that manifest with gait disturbance, cognitive impairment, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. The first edition of these guidelines for management of iNPH was published in 2004, and the second edition in 2012, to provide a series of timely, evidence-based recommendations related to iNPH. Since the last edition, clinical awareness of iNPH has risen dramatically, and clinical and basic research efforts on iNPH have increased significantly. This third edition of the guidelines was made to share these ideas with the international community and to promote international research on iNPH. The revision of the guidelines was undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project. This revision proposes a new classification for NPH. The category of iNPH is clearly distinguished from NPH with congenital/developmental and acquired etiologies. Additionally, the essential role of disproportionately enlarged subarachnoid-space hydrocephalus (DESH) in the imaging diagnosis and decision for further management of iNPH is discussed in this edition. We created an algorithm for diagnosis and decision for shunt management. Diagnosis by biomarkers that distinguish prognosis has been also initiated. Therefore, diagnosis and treatment of iNPH have entered a new phase. We hope that this third edition of the guidelines will help patients, their families, and healthcare professionals involved in treating iNPH.
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Affiliation(s)
- Madoka NAKAJIMA
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shigeki YAMADA
- Department of Neurosurgery, Shiga University of Medical Science, Ohtsu, Shiga, Japan
| | - Masakazu MIYAJIMA
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kazunari ISHII
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Nagato KURIYAMA
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Kyoto, Japan
| | - Hiroaki KAZUI
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Hideki KANEMOTO
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi SUEHIRO
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kenji YOSHIYAMA
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiro KAMEDA
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoshinaga KAJIMOTO
- Department of Neurosurgery, Division of Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Mitsuhito MASE
- Department of Neurosurgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hisayuki MURAI
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Daisuke KITA
- Department of Neurosurgery, Noto General Hospital, Nanao, Ishikawa, Japan
| | - Teruo KIMURA
- Department of Neurosurgery, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
| | - Naoyuki SAMEJIMA
- Department of Neurosurgery, Tokyo Kyosai Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Takahiko TOKUDA
- Department of Functional Brain Imaging Research, National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Chiba, Japan
| | - Mitsunobu KAIJIMA
- Department of Neurosurgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan
| | - Chihiro AKIBA
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kaito KAWAMURA
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masamichi ATSUCHI
- Normal Pressure Hydrocephalus Center, Jifukai Atsuchi Neurosurgical Hospital, Kagoshima, Kagoshima, Japan
| | - Yoshihumi HIRATA
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Kumamoto, Japan
| | - Mitsunori MATSUMAE
- Department of Neurosurgery at Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Makoto SASAKI
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Fumio YAMASHITA
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
| | - Shigeki AOKI
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryusuke IRIE
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroji MIYAKE
- Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Hyogo, Japan
| | - Takeo KATO
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine, Yamagata, Yamagata, Japan
| | - Etsuro MORI
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
| | - Masatsune ISHIKAWA
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Kyoto, Japan
| | - Isao DATE
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Hajime ARAI
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - The research committee of idiopathic normal pressure hydrocephalus
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
- Department of Neurosurgery, Shiga University of Medical Science, Ohtsu, Shiga, Japan
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Kyoto, Japan
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
- Department of Neurosurgery, Division of Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
- Department of Neurosurgery, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Aichi, Japan
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
- Department of Neurosurgery, Noto General Hospital, Nanao, Ishikawa, Japan
- Department of Neurosurgery, Kitami Red Cross Hospital, Kitami, Hokkaido, Japan
- Department of Neurosurgery, Tokyo Kyosai Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
- Department of Functional Brain Imaging Research, National Institute of Radiological Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Chiba, Japan
- Department of Neurosurgery, Hokushinkai Megumino Hospital, Eniwa, Hokkaido, Japan
- Normal Pressure Hydrocephalus Center, Jifukai Atsuchi Neurosurgical Hospital, Kagoshima, Kagoshima, Japan
- Department of Neurosurgery, Kumamoto Takumadai Hospital, Kumamoto, Kumamoto, Japan
- Department of Neurosurgery at Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Iwate, Japan
- Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
- Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Hyogo, Japan
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University School of Medicine, Yamagata, Yamagata, Japan
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Osaka, Japan
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Kyoto, Japan
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16
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Griffa A, Bommarito G, Assal F, Herrmann FR, Van De Ville D, Allali G. Dynamic functional networks in idiopathic normal pressure hydrocephalus: Alterations and reversibility by CSF tap test. Hum Brain Mapp 2020; 42:1485-1502. [PMID: 33296129 PMCID: PMC7927299 DOI: 10.1002/hbm.25308] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/02/2020] [Accepted: 11/26/2020] [Indexed: 12/19/2022] Open
Abstract
Idiopathic Normal Pressure Hydrocephalus (iNPH)—the leading cause of reversible dementia in aging—is characterized by ventriculomegaly and gait, cognitive and urinary impairments. Despite its high prevalence estimated at 6% among the elderlies, iNPH remains underdiagnosed and undertreated due to the lack of iNPH‐specific diagnostic markers and limited understanding of pathophysiological mechanisms. INPH diagnosis is also complicated by the frequent occurrence of comorbidities, the most common one being Alzheimer's disease (AD). Here we investigate the resting‐state functional magnetic resonance imaging dynamics of 26 iNPH patients before and after a CSF tap test, and of 48 normal older adults. Alzheimer's pathology was evaluated by CSF biomarkers. We show that the interactions between the default mode, and the executive‐control, salience and attention networks are impaired in iNPH, explain gait and executive disturbances in patients, and are not driven by AD‐pathology. In particular, AD molecular biomarkers are associated with functional changes distinct from iNPH functional alterations. Finally, we demonstrate a partial normalization of brain dynamics 24 hr after a CSF tap test, indicating functional plasticity mechanisms. We conclude that functional changes involving the default mode cross‐network interactions reflect iNPH pathophysiological mechanisms and track treatment response, possibly contributing to iNPH differential diagnosis and better clinical management.
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Affiliation(s)
- Alessandra Griffa
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Bioengineering, Center of Neuroprosthetics, École Polytechnique Fédérale De Lausanne (EPFL), Geneva, Switzerland
| | - Giulia Bommarito
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Institute of Bioengineering, Center of Neuroprosthetics, École Polytechnique Fédérale De Lausanne (EPFL), Geneva, Switzerland
| | - Frédéric Assal
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - François R Herrmann
- Department of Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Dimitri Van De Ville
- Institute of Bioengineering, Center of Neuroprosthetics, École Polytechnique Fédérale De Lausanne (EPFL), Geneva, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | - Gilles Allali
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Neurology, Division of Cognitive & Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York, USA
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17
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Wang Z, Zhang Y, Hu F, Ding J, Wang X. Pathogenesis and pathophysiology of idiopathic normal pressure hydrocephalus. CNS Neurosci Ther 2020; 26:1230-1240. [PMID: 33242372 PMCID: PMC7702234 DOI: 10.1111/cns.13526] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 12/11/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH), the most common type of adult-onset hydrocephalus, is a potentially reversible neuropsychiatric entity characterized by dilated ventricles, cognitive deficit, gait apraxia, and urinary incontinence. Despite its relatively typical imaging features and clinical symptoms, the pathogenesis and pathophysiology of iNPH remain unclear. In this review, we summarize current pathogenetic conceptions of iNPH and its pathophysiological features that lead to neurological deficits. The common consensus is that ventriculomegaly resulting from cerebrospinal fluid (CSF) dynamics could initiate a vicious cycle of neurological damages in iNPH. Pathophysiological factors including hypoperfusion, glymphatic impairment, disturbance of metabolism, astrogliosis, neuroinflammation, and blood-brain barrier disruption jointly cause white matter and gray matter lesions, and eventually lead to various iNPH symptoms. Also, we review the current treatment options and discuss the prospective treatment strategies for iNPH. CSF diversion with ventriculoperitoneal or lumboperitonealshunts remains as the standard therapy, while its complications prompt attempts to refine shunt insertion and develop new therapeutic procedures. Recent progress on advanced biomaterials and improved understanding of pathogenesis offers new avenues to treat iNPH.
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Affiliation(s)
- Zhangyang Wang
- Department of NeurologyZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Yiying Zhang
- Department of NeurologyZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Fan Hu
- Department of NeurosugeryZhongshan Hospital, Shanghai Medical College, Fudan UniversityShanghaiChina
| | - Jing Ding
- Department of NeurologyZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Xin Wang
- Department of NeurologyZhongshan Hospital, Fudan UniversityShanghaiChina
- Department of The State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain ScienceFudan UniversityShanghaiChina
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18
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Huo J, Qi Z, Chen S, Wang Q, Wu X, Zang D, Hiromi T, Tan J, Zhang L, Tang W, Shen D. Neuroimage-Based Consciousness Evaluation of Patients with Secondary Doubtful Hydrocephalus Before and After Lumbar Drainage. Neurosci Bull 2020; 36:985-996. [PMID: 32607740 DOI: 10.1007/s12264-020-00542-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 03/10/2020] [Indexed: 01/25/2023] Open
Abstract
Hydrocephalus is often treated with a cerebrospinal fluid shunt (CFS) for excessive amounts of cerebrospinal fluid in the brain. However, it is very difficult to distinguish whether the ventricular enlargement is due to hydrocephalus or other causes, such as brain atrophy after brain damage and surgery. The non-trivial evaluation of the consciousness level, along with a continuous drainage test of the lumbar cistern is thus clinically important before the decision for CFS is made. We studied 32 secondary mild hydrocephalus patients with different consciousness levels, who received T1 and diffusion tensor imaging magnetic resonance scans before and after lumbar cerebrospinal fluid drainage. We applied a novel machine-learning method to find the most discriminative features from the multi-modal neuroimages. Then, we built a regression model to regress the JFK Coma Recovery Scale-Revised (CRS-R) scores to quantify the level of consciousness. The experimental results showed that our method not only approximated the CRS-R scores but also tracked the temporal changes in individual patients. The regression model has high potential for the evaluation of consciousness in clinical practice.
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Affiliation(s)
- Jiayu Huo
- Institute for Medical Imaging Technology, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Zengxin Qi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200030, China.,Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200030, China.,State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200030, China
| | - Sen Chen
- Institute for Medical Imaging Technology, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Qian Wang
- Institute for Medical Imaging Technology, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Xuehai Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200030, China.,Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200030, China.,State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200030, China
| | - Di Zang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200030, China.,Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200030, China.,State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200030, China
| | - Tanikawa Hiromi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200030, China.,Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200030, China.,State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200030, China
| | - Jiaxing Tan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200030, China.,Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200030, China.,State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, 200030, China
| | - Lichi Zhang
- Institute for Medical Imaging Technology, Shanghai Jiao Tong University, Shanghai, 200030, China.
| | - Weijun Tang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, 200030, China.
| | - Dinggang Shen
- Department of Radiology and Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.,Department of Brain and Cognitive Engineering, Korea University, Seoul, 02841, Republic of Korea
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19
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Indication of Thalamo-Cortical Circuit Dysfunction in Idiopathic Normal Pressure Hydrocephalus: A Tensor Imaging Study. Sci Rep 2020; 10:6148. [PMID: 32273554 PMCID: PMC7145806 DOI: 10.1038/s41598-020-63238-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/19/2020] [Indexed: 11/29/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a disorder with unclear pathophysiology. The diagnosis of iNPH is challenging due to its radiological similarity with other neurodegenerative diseases and ischemic subcortical white matter changes. By using Diffusion Tensor Imaging (DTI) we explored differences in apparent diffusion coefficient (ADC) and fractional anisotropy (FA) in iNPH patients (before and after a shunt surgery) and healthy individuals (HI) and we correlated the clinical results with DTI parameters. Thirteen consecutive iNPH-patients underwent a pre- and post-operative clinical work-up: 10 m walk time (w10mt) steps (w10ms), TUG-time (TUGt) and steps (TUGs); for cognitive function MMSE. Nine HI were included. DTI was performed before and 3 months after surgery, HI underwent DTI once. DTI differences analyzed by manually placing 12 regions-of-interest. In patients motor and balance function improved significantly after surgery (p = 0.01, p = 0.025). Higher nearly significant FA values found in the patients vs HI pre-operatively in the thalamus (p = 0.07) accompanied by an almost significant lower ADC (p = 0.08). Significantly FA and ADC-values were found between patients and HI in FWM (p = 0.02, p = 0.001) and almost significant (p = 0.057) pre- vs postoperatively. Postoperatively we found a trend towards the HIs FA values and a strong significant negative correlation between FA changes vs. gait results in the FWM (r = −0.7, p = 0.008). Our study gives a clear indication of an ongoing pathological process in the periventricular white matter, especially in the thalamus and in the frontal white matter supporting the hypothesis of a shunt reversible thalamo-cortical circuit dysfunction in iNPH.
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20
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Reeves BC, Karimy JK, Kundishora AJ, Mestre H, Cerci HM, Matouk C, Alper SL, Lundgaard I, Nedergaard M, Kahle KT. Glymphatic System Impairment in Alzheimer's Disease and Idiopathic Normal Pressure Hydrocephalus. Trends Mol Med 2020; 26:285-295. [PMID: 31959516 PMCID: PMC7489754 DOI: 10.1016/j.molmed.2019.11.008] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/11/2019] [Accepted: 11/20/2019] [Indexed: 12/31/2022]
Abstract
Approximately 10% of dementia patients have idiopathic normal pressure hydrocephalus (iNPH), an expansion of the cerebrospinal fluid (CSF)-filled brain ventricles. iNPH and Alzheimer's disease (AD) both exhibit sleep disturbances, build-up of brain metabolic wastes and amyloid-β (Aβ) plaques, perivascular reactive astrogliosis, and mislocalization of astrocyte aquaporin-4 (AQP4). The glia-lymphatic (glymphatic) system facilitates brain fluid clearance and waste removal during sleep via glia-supported perivascular channels. Human studies have implicated impaired glymphatic function in both AD and iNPH. Continued investigation into the role of glymphatic system biology in AD and iNPH models could lead to new strategies to improve brain health by restoring homeostatic brain metabolism and CSF dynamics.
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Affiliation(s)
- Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - Jason K Karimy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - Humberto Mestre
- Center for Translational Neuromedicine, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - H Mert Cerci
- Istanbul Universty-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul 34096, Turkey
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center and Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Iben Lundgaard
- Department of Experimental Medical Science, Lund University, 221 84 Lund, Sweden; Wallenberg Center for Molecular Medicine, Lund University, 221 84 Lund, Sweden
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, University of Rochester Medical Center, Rochester, NY 14642, USA; Center for Translational Neuromedicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristopher T Kahle
- Departments of Neurosurgery, Pediatrics, and Cellular and Molecular Physiology; and Yale-Rockefeller National Institutes of Health (NIH) Centers for Mendelian Genomics, Yale School of Medicine, New Haven, CT 06510, USA.
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21
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Vlasák A, Skalický P, Mládek A, Vrána J, Beneš V, Bradáč O. Structural volumetry in NPH diagnostics and treatment-future or dead end? Neurosurg Rev 2020; 44:503-514. [PMID: 31980974 DOI: 10.1007/s10143-020-01245-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 12/18/2022]
Abstract
To assess automated volumetric analysis as a potential presurgical diagnostic tool or as a method to potentially shed light on normal pressure hydrocephalus (NPH) pathophysiology. MRI imaging according to our protocol was performed in 29 NPH patients, 45 non-NPH (but suspected) patients and 15 controls. Twenty patients underwent a second MRI 3 months after ventriculoperitoneal (VP) shunt surgery. All structures relevant to NPH diagnosis were automatically segmented using commercial software. The results were subsequently tested using ANOVA analysis. Significant differences in the volumes of the corpus callosum, left hippocampus, internal globus pallidus, grey and white matter and ventricular volumes were observed between NPH group and healthy controls. However, the differences between NPH and non-NPH groups were non-significant. Three months after, VP shunt insertion decreased ventricular volume was the only clearly significant result (p value 0.0001). Even though a detailed volumetric study shows several significant differences, volumetric analysis as a standalone method does not provide a simple diagnostic biomarker, nor does it shed a light on an unknown NPH aetiology.
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Affiliation(s)
- Aleš Vlasák
- Department of Neurosurgery and Neurooncology, Military University Hospital and Charles University, First Medical Faculty, U Vojenské nemocnice 1200/1, 162 00, Prague 6, Czech Republic
| | - Petr Skalický
- Department of Neurosurgery and Neurooncology, Military University Hospital and Charles University, First Medical Faculty, U Vojenské nemocnice 1200/1, 162 00, Prague 6, Czech Republic
| | - Arnošt Mládek
- Department of Neurosurgery and Neurooncology, Military University Hospital and Charles University, First Medical Faculty, U Vojenské nemocnice 1200/1, 162 00, Prague 6, Czech Republic.,Department of Cognitive Systems and Neurosciences, Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University, Prague, Czech Republic
| | - Jiří Vrána
- Department of Radiology, Military University Hospital, Prague, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, Military University Hospital and Charles University, First Medical Faculty, U Vojenské nemocnice 1200/1, 162 00, Prague 6, Czech Republic
| | - Ondřej Bradáč
- Department of Neurosurgery and Neurooncology, Military University Hospital and Charles University, First Medical Faculty, U Vojenské nemocnice 1200/1, 162 00, Prague 6, Czech Republic.
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22
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Normal Pressure Hydrocephalus: Clinical Symptoms, Cerebrospinal Fluid Flow Metrics and White Matter Changes. J Comput Assist Tomogr 2020; 44:59-64. [PMID: 31939883 DOI: 10.1097/rct.0000000000000959] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to investigate correlations between clinical symptoms, cerebrospinal fluid flow metrics, hydrocephalus index, small-vessel disease, and white matter (WM) changes in normal pressure hydrocephalus (NPH). METHODS Aquaductal stroke volumes (ASVs), Z Evans index, Fazekas grading (FG), and diffusion tensor imaging measurements from WM bundles of 37 patients with NPH were retrospectively evaluated. Mann-Whitney U test between clinical symptoms and other variables and Spearman ρ correlations for relationships between variables and Kruskal-Wallis to correlate FG with nonclinical variables were used. RESULTS Patients with NPH had increased ASV (median 53 μL). No correlation was found between Z Evans index and ASV. Three groups of patients with dementia or ataxia or incontinence had increased ASV values than their counterparts without symptoms (55 vs 48.5 μL, 75 vs 47 μL, 64 vs 49.5 μL, respectively). Patients having 2 common symptoms of dementia and ataxia and patients having all 3 symptoms of dementia, ataxia, and incontinence were compared with ASV values of 63.5 versus 78 μL, respectively. Patients with FG 1 had median ASV values of 45 μL; FG 2, 82.5 μL; and FG 3, 59 μL. Patients with dementia had significantly higher apparent diffusion coefficient (ADC) values of corona radiata (CR) on both sides. There were no significant WM changes in patients with ataxia and incontinence. The Z Evans index was positively correlated with ADC values of CR on both sides and genu of corpus callosum. Fazekas grading was found positively correlated with ADC and negatively correlated with FA values of CR. CONCLUSIONS Patients with NPH, regardless of stages of the diseases, have increased ASV values and could benefit from shunting. Decreasing ASV values of patients with FG 3 comparing with those with FG 2 support the hypothesis of decreasing compliance of brain with aging and increasing severity of small-vessel disease.
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23
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Skalický P, Mládek A, Vlasák A, De Lacy P, Beneš V, Bradáč O. Normal pressure hydrocephalus—an overview of pathophysiological mechanisms and diagnostic procedures. Neurosurg Rev 2019; 43:1451-1464. [DOI: 10.1007/s10143-019-01201-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/27/2019] [Accepted: 10/25/2019] [Indexed: 01/25/2023]
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24
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Quantitative Gait Analysis and Cerebrospinal Fluid Tap Test for Idiopathic Normal-pressure Hydrocephalus. Sci Rep 2019; 9:16255. [PMID: 31700018 PMCID: PMC6838166 DOI: 10.1038/s41598-019-52448-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/14/2019] [Indexed: 11/08/2022] Open
Abstract
We investigated gait performance utilizing a quantitative gait analysis for 2 groups: (1) idiopathic normal-pressure hydrocephalus (INPH) patients who had a positive response to the cerebrospinal fluid tap test (CSFTT) and (2) healthy controls. The aims of the study were (1) to analyze the characteristics of gait features, (2) to characterize changes in gait parameters before and after the CSFTT, and (3) to determine whether there was any relationship between stride time and stride length variability and Frontal Assessment Battery (FAB) scores in INPH patients. Twenty-three INPH patients and 17 healthy controls were included in this study. Compared with healthy controls, the gait of INPH patients was characterized by lower velocity, shorter stride length, and more broad-based gait. Patients with INPH had a longer stance phase with increased double-limb support. Variability in stride time and stride length was increased in INPH patients. Stride time and stride length variability were correlated with FAB score. After the CSFTT, gait velocity, stride length, and step width significantly improved. There were significant decreases in stride time and stride length variability. These results suggest that the CSFTT for INPH patients might improve the so-called balance-related gait parameter (ie, step width) as well. Stride time and stride length variability also responded to the CSFTT. Association between FAB scores and both stride time and stride length variability suggests involvement of similar circuits producing gait variability and frontal lobe functions in INPH patients.
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25
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Ishii K. Diagnostic imaging of dementia with Lewy bodies, frontotemporal lobar degeneration, and normal pressure hydrocephalus. Jpn J Radiol 2019; 38:64-76. [DOI: 10.1007/s11604-019-00881-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
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26
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Tan K, Meiri A, Mowrey WB, Abbott R, Goodrich JT, Sandler AL, Suri AK, Lipton ML, Wagshul ME. Diffusion tensor imaging and ventricle volume quantification in patients with chronic shunt-treated hydrocephalus: a matched case-control study. J Neurosurg 2018; 129:1611-1622. [PMID: 29350598 DOI: 10.3171/2017.6.jns162784] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 06/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe object of this study was to use diffusion tensor imaging (DTI) and tract-based spatial statistics (TBSS) to characterize the long-term effects of hydrocephalus and shunting on white matter integrity and to investigate the relationship of ventricular size and alterations in white matter integrity with headache and quality-of-life outcome measures.METHODSPatients with shunt-treated hydrocephalus and age- and sex-matched healthy controls were recruited into the study and underwent anatomical and DTI imaging on a 3-T MRI scanner. All patients were clinically stable, had undergone CSF shunt placement before 2 years of age, and had a documented history of complaints of headaches. Outcome was scored based on the Headache Disability Inventory and the Hydrocephalus Outcome Questionnaire. Fractional anisotropy (FA) and other DTI-based measures (axial, radial, and mean diffusivity; AD, RD, and MD, respectively) were extracted in the corpus callosum and internal capsule with manual region-of-interest delineation and in other regions with TBSS. Paired t-tests, corrected with a 5% false discovery rate, were used to identify regions with significant differences between patients and controls. Within the patient group, linear regression models were used to investigate the relationship between FA or ventricular volume and outcome, as well as the effect of shunt-related covariates.RESULTSTwenty-one hydrocephalus patients and 21 matched controls completed the study, and their data were used in the final analysis. The authors found significantly lower FA for patients than for controls in 20 of the 48 regions, mostly posterior white matter structures, in periventricular as well as more distal tracts. Of these 20 regions, 17 demonstrated increased RD, while only 5 showed increased MD and 3 showed decreased AD. No areas of increased FA were observed. Higher FA in specific periventricular white matter tracts, tending toward FA in controls, was associated with increased ventricular size, as well as improved clinical outcome.CONCLUSIONSThe study shows that TBSS-based DTI is a sensitive technique for elucidating changes in white matter structures due to hydrocephalus and chronic CSF shunting and provides preliminary evidence that DTI may be a valuable tool for tailoring shunt procedures to monitor ventricular size following shunting and achieve optimal outcome, as well as for guiding the development of alternate therapies for hydrocephalus.
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Affiliation(s)
- Kristy Tan
- 1Department of Radiology, Gruss Magnetic Resonance Research Center, and
| | - Avital Meiri
- 1Department of Radiology, Gruss Magnetic Resonance Research Center, and
| | | | - Rick Abbott
- 3Department of Neurological Surgery, Children's Hospital at Montefiore; and
| | - James T Goodrich
- 3Department of Neurological Surgery, Children's Hospital at Montefiore; and
| | - Adam L Sandler
- 3Department of Neurological Surgery, Children's Hospital at Montefiore; and
| | - Asif K Suri
- 1Department of Radiology, Gruss Magnetic Resonance Research Center, and
- 5Department of Radiology, Montefiore Medical Center, Bronx, New York
| | - Michael L Lipton
- 1Department of Radiology, Gruss Magnetic Resonance Research Center, and
- 4Neuroscience
- 5Department of Radiology, Montefiore Medical Center, Bronx, New York
- 6Psychiatry and Behavioral Sciences, and
| | - Mark E Wagshul
- 1Department of Radiology, Gruss Magnetic Resonance Research Center, and
- 7Physiology and Biophysics, Albert Einstein College of Medicine
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27
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Mansour TR, Alnemari A, Ashour O, Entezami P, Buehler M, Gaudin D. Efficacy of difusion tensor imaging in the perioperative evaluation of corticospinal tracts and gait improvement in normal pressure hydrocephalus. J Neurosurg Sci 2018; 63:744-746. [PMID: 29480685 DOI: 10.23736/s0390-5616.18.04300-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Tarek R Mansour
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Ahmed Alnemari
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Omar Ashour
- Department of Radiology, University of Toledo Medical Center, Toledo, OH, USA
| | - Pouya Entezami
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Mark Buehler
- Department of Radiology, University of Toledo Medical Center, Toledo, OH, USA
| | - Daniel Gaudin
- Division of Neurological Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA -
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28
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Allali G, Laidet M, Armand S, Assal F. Brain comorbidities in normal pressure hydrocephalus. Eur J Neurol 2018; 25:542-548. [PMID: 29222955 DOI: 10.1111/ene.13543] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/01/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE This cross-sectional study aims to compare gait changes after the cerebrospinal fluid (CSF) tap test between normal pressure hydrocephalus patients with and without brain comorbidities (NPH+ and NPH- respectively) and then to identify significant contributors to a poor CSF tap test amongst individuals with NPH+. METHODS Gait changes (during the single task and the dual task of backward counting) were quantified before and 24 h after the CSF tap test with an optoelectronic system in 52 NPH patients (77.4 ± 6.0 years; 34.6% women). Changes after the CSF tap test in stride time variability (STV, %) were our main outcome. CSF Alzheimer's disease biomarkers, cerebrovascular white matter changes assessed with brain imaging and neurodegenerative diseases with parkinsonian syndrome represented the three individual brain comorbidities. RESULTS Brain comorbidities were frequently identified, NPH+ patients representing 40 patients of our sample (76.9%). NPH- patients improved their STV better in the single task (delta of STV = -58.6% ± 54.3% vs. -14.1% ± 62.0%; P = 0.031) and in the dual task (delta of STV =-32.2% ± 33.7% vs. 6.3% ± 58.4%; P = 0.028) after the CSF tap test than NPH+ patients. Amongst NPH+ individuals, only comorbid Alzheimer's disease was associated with STV increase (i.e. deterioration of gait) in the dual task [β 38.4; 95% confidence interval (5.64; 71.24); P = 0.023] after the CSF tap test, whilst it was borderline in the single task [β 35.0; 95% confidence interval (-1.97; 71.90); P = 0.063]. CONCLUSIONS Brain comorbidities affect gait improvement after the CSF tap test in NPH patients; this influence is driven by Alzheimer's disease-related pathology.
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Affiliation(s)
- G Allali
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Neurology, Division of Cognitive and Motor Aging, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - M Laidet
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - S Armand
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - F Assal
- Department of Clinical Neurosciences, Division of Neurology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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29
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Staffaroni AM, Elahi FM, McDermott D, Marton K, Karageorgiou E, Sacco S, Paoletti M, Caverzasi E, Hess CP, Rosen HJ, Geschwind MD. Neuroimaging in Dementia. Semin Neurol 2017; 37:510-537. [PMID: 29207412 PMCID: PMC5823524 DOI: 10.1055/s-0037-1608808] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Although the diagnosis of dementia still is primarily based on clinical criteria, neuroimaging is playing an increasingly important role. This is in large part due to advances in techniques that can assist with discriminating between different syndromes. Magnetic resonance imaging remains at the core of differential diagnosis, with specific patterns of cortical and subcortical changes having diagnostic significance. Recent developments in molecular PET imaging techniques have opened the door for not only antemortem but early, even preclinical, diagnosis of underlying pathology. This is vital, as treatment trials are underway for pharmacological agents with specific molecular targets, and numerous failed trials suggest that earlier treatment is needed. This article provides an overview of classic neuroimaging findings as well as new and cutting-edge research techniques that assist with clinical diagnosis of a range of dementia syndromes, with an emphasis on studies using pathologically proven cases.
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Affiliation(s)
- Adam M. Staffaroni
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
| | - Fanny M. Elahi
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
| | - Dana McDermott
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
| | - Kacey Marton
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
| | - Elissaios Karageorgiou
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
- Neurological Institute of Athens, Athens, Greece
| | - Simone Sacco
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
- Institute of Radiology, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Matteo Paoletti
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
- Institute of Radiology, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Eduardo Caverzasi
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Christopher P. Hess
- Division of Neuroradiology, Department of Radiology, University of California, San Francisco (UCSF), California
| | - Howard J. Rosen
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
| | - Michael D. Geschwind
- Department of Neurology, Memory and Aging Center, University of California, San Francisco (UCSF), San Francisco, California
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30
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Goujon A, Mejdoubi M, Purcell Y, Banydeen R, Colombani S, Arrigo A. Can MRI water apparent diffusion coefficient (ADC) value discriminate between idiopathic normal pressure hydrocephalus, Alzheimer's disease and subcortical vascular dementia? J Neuroradiol 2017; 45:15-22. [PMID: 28923529 DOI: 10.1016/j.neurad.2017.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/02/2017] [Accepted: 08/15/2017] [Indexed: 10/18/2022]
Abstract
Numerous similarities in MRI and clinical symptoms exist between Alzheimer's disease (AD), subcortical vascular dementia (sVD) and possible idiopathic normal pressure hydrocephalus (iHPN). The aim of this study is to explore mean apparent coefficient diffusion (ADC) difference between theses diseases in different periventricular and deep white matter areas, as compared to healthy controls. This retrospective study analyzed mean ADC values of 120 patients in normal appearing deep white matter and lenticular nuclei, frontal, caudate nuclei corpus and parietal periventricular and deep white matter areas INPH group showed significantly lower ADC than sVD group in frontal periventricular region (1567.10-6mm2/s vs 1755.10-6mm2/s; P=0.0009) and in parietal deep region (1087.10-6mm2/s vs 1271.10-6mm2/s; P=0.0052), but showed significantly higher ADC in lenticular nuclei ROI (834.10-6mm2/s vs 753.10-6mm2/s; P=0.002). The comparison between iNPH and sVD showed a cut-off value of 1676.10-6mm2/s (sensitivity 0.70, specificity 0.77) in periventricular frontal area. INPH group, in comparison with NA group, showed significantly higher ADC in all ROIs. The iNPH group also showed significantly higher ADC than AD group in all ROIs. AD group showed significantly lower ADC than sVD group in all regions, except in normal appearing lenticular nuclei and caudate nuclei corpus deep ROI. SVD group showed significantly higher ADC than NA in all ROIs, except in normal appearing lenticular nucleus ROI. Different patterns of ADC values can differentiate between AD, sVD and iNPH, even when other MRI sequences appear morphologically similar.
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Affiliation(s)
- Adrien Goujon
- Department of Neuroradiology, University Hospital of Martinique, 97200 Fort-de-France, Martinique.
| | - Mehdi Mejdoubi
- Department of Neuroradiology, University Hospital of Martinique, 97200 Fort-de-France, Martinique
| | - Yvonne Purcell
- Department of Radiology, Beaujon hospital, University Paris Diderot, 92110 Clichy, France
| | - Rishika Banydeen
- Clinical Research Department, University Hospital of Martinique, 97200 Fort-de-France, Martinique
| | - Sylvie Colombani
- Department of Neuroradiology, University Hospital of Martinique, 97200 Fort-de-France, Martinique
| | - Alessandro Arrigo
- Department of Neuroradiology, University Hospital of Martinique, 97200 Fort-de-France, Martinique
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31
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Martín Noguerol T, Martínez Barbero J. Advanced diffusion MRI and biomarkers in the central nervous system: A new approach. RADIOLOGIA 2017. [DOI: 10.1016/j.rxeng.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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32
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Martín Noguerol T, Martínez Barbero JP. Advanced diffusion MRI and biomarkers in the central nervous system: a new approach. RADIOLOGIA 2017; 59:273-285. [PMID: 28552216 DOI: 10.1016/j.rx.2017.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/13/2017] [Accepted: 04/16/2017] [Indexed: 01/08/2023]
Abstract
The introduction of diffusion-weighted sequences has revolutionized the detection and characterization of central nervous system (CNS) disease. Nevertheless, the assessment of diffusion studies of the CNS is often limited to qualitative estimation. Moreover, the pathophysiological complexity of the different entities that affect the CNS cannot always be correctly explained through classical models. The development of new models for the analysis of diffusion sequences provides numerous parameters that enable a quantitative approach to both diagnosis and prognosis as well as to monitoring the response to treatment; these parameters can be considered potential biomarkers of health and disease. In this update, we review the physical bases underlying diffusion studies and diffusion tensor imaging, advanced models for their analysis (intravoxel coherent motion and kurtosis), and the biological significance of the parameters derived.
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Affiliation(s)
- T Martín Noguerol
- Sección de Neurorradiología. Clínica las Nieves. SERCOSA. Grupo HealthTime, Jaén, España.
| | - J P Martínez Barbero
- Sección de Neurorradiología. Clínica las Nieves. SERCOSA. Grupo HealthTime, Jaén, España
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Kamiya K, Hori M, Irie R, Miyajima M, Nakajima M, Kamagata K, Tsuruta K, Saito A, Nakazawa M, Suzuki Y, Mori H, Kunimatsu A, Arai H, Aoki S, Abe O. Diffusion imaging of reversible and irreversible microstructural changes within the corticospinal tract in idiopathic normal pressure hydrocephalus. NEUROIMAGE-CLINICAL 2017; 14:663-671. [PMID: 28348958 PMCID: PMC5358533 DOI: 10.1016/j.nicl.2017.03.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 03/05/2017] [Accepted: 03/10/2017] [Indexed: 11/05/2022]
Abstract
The symptoms of idiopathic normal pressure hydrocephalus (iNPH) can be improved by shunt surgery, but prediction of treatment outcome is not established. We investigated changes of the corticospinal tract (CST) in iNPH before and after shunt surgery by using diffusion microstructural imaging, which infers more specific tissue properties than conventional diffusion tensor imaging. Two biophysical models were used: neurite orientation dispersion and density imaging (NODDI) and white matter tract integrity (WMTI). In both methods, the orientational coherence within the CSTs was higher in patients than in controls, and some normalization occurred after the surgery in patients, indicating axon stretching and recovery. The estimated axon density was lower in patients than in controls but remained unchanged after the surgery, suggesting its potential as a marker for irreversible neuronal damage. In a Monte-Carlo simulation that represented model axons as undulating cylinders, both NODDI and WMTI separated the effects of axon density and undulation. Thus, diffusion MRI may distinguish between reversible and irreversible microstructural changes in iNPH. Our findings constitute a step towards a quantitative image biomarker that reflects pathological process and treatment outcomes of iNPH. NODDI and WMTI provide markers of reversible and irreversible changes in iNPH. Measures of axon orientation indicated recovery from stretching after surgery. Axon density remained low after surgery, suggesting chronic neuronal damage. Axon stretching in simulations differentially affected diffusion metrics.
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Key Words
- AD, axial diffusivity
- AWF, axonal water fraction
- Axon density
- Axon undulation
- CSF, cerebrospinal fluid
- CST, corticospinal tract
- DTI, diffusion tensor imaging
- Diffusion MRI
- FA, fractional anisotropy
- Idiopathic normal pressure hydrocephalus
- MD, mean diffusivity
- NODDI, neurite orientation dispersion and density imaging
- ODI, orientation dispersion index
- RD, radial diffusivity
- ROI, region of interest
- VF, volume fraction
- VOI, volume of interest
- WMTI, white matter tract integrity
- iNPH, idiopathic normal pressure hydrocephalus
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Affiliation(s)
- Kouhei Kamiya
- Department of Radiology, The University of Tokyo, Bunkyo, Tokyo, Japan; Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Masaaki Hori
- Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Ryusuke Irie
- Department of Radiology, The University of Tokyo, Bunkyo, Tokyo, Japan; Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Koji Kamagata
- Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Kouhei Tsuruta
- Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Asami Saito
- Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Misaki Nakazawa
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa, Tokyo, Japan
| | - Yuichi Suzuki
- Department of Radiology, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Harushi Mori
- Department of Radiology, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Akira Kunimatsu
- Department of Radiology, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University School of Medicine, Bunkyo, Tokyo, Japan
| | - Osamu Abe
- Department of Radiology, The University of Tokyo, Bunkyo, Tokyo, Japan
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Siasios I, Kapsalaki EZ, Fountas KN, Fotiadou A, Dorsch A, Vakharia K, Pollina J, Dimopoulos V. The role of diffusion tensor imaging and fractional anisotropy in the evaluation of patients with idiopathic normal pressure hydrocephalus: a literature review. Neurosurg Focus 2017; 41:E12. [PMID: 27581308 DOI: 10.3171/2016.6.focus16192] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Diffusion tensor imaging (DTI) for the assessment of fractional anisotropy (FA) and involving measurements of mean diffusivity (MD) and apparent diffusion coefficient (ADC) represents a novel, MRI-based, noninvasive technique that may delineate microstructural changes in cerebral white matter (WM). For example, DTI may be used for the diagnosis and differentiation of idiopathic normal pressure hydrocephalus (iNPH) from other neurodegenerative diseases with similar imaging findings and clinical symptoms and signs. The goal of the current study was to identify and analyze recently published series on the use of DTI as a diagnostic tool. Moreover, the authors also explored the utility of DTI in identifying patients with iNPH who could be managed by surgical intervention. METHODS The authors performed a literature search of the PubMed database by using any possible combinations of the following terms: "Alzheimer's disease," "brain," "cerebrospinal fluid," "CSF," "diffusion tensor imaging," "DTI," "hydrocephalus," "idiopathic," "magnetic resonance imaging," "normal pressure," "Parkinson's disease," and "shunting." Moreover, all reference lists from the retrieved articles were reviewed to identify any additional pertinent articles. RESULTS The literature search retrieved 19 studies in which DTI was used for the identification and differentiation of iNPH from other neurodegenerative diseases. The DTI protocols involved different approaches, such as region of interest (ROI) methods, tract-based spatial statistics, voxel-based analysis, and delta-ADC analysis. The most studied anatomical regions were the periventricular WM areas, such as the internal capsule (IC), the corticospinal tract (CST), and the corpus callosum (CC). Patients with iNPH had significantly higher MD in the periventricular WM areas of the CST and the CC than had healthy controls. In addition, FA and ADCs were significantly higher in the CST of iNPH patients than in any other patients with other neurodegenerative diseases. Gait abnormalities of iNPH patients were statistically significantly and negatively correlated with FA in the CST and the minor forceps. Fractional anisotropy had a sensitivity of 94% and a specificity of 80% for diagnosing iNPH. Furthermore, FA and MD values in the CST, the IC, the anterior thalamic region, the fornix, and the hippocampus regions could help differentiate iNPH from Alzheimer or Parkinson disease. Interestingly, CSF drainage or ventriculoperitoneal shunting significantly modified FA and ADCs in iNPH patients whose condition clinically responded to these maneuvers. CONCLUSIONS Measurements of FA and MD significantly contribute to the detection of axonal loss and gliosis in the periventricular WM areas in patients with iNPH. Diffusion tensor imaging may also represent a valuable noninvasive method for differentiating iNPH from other neurodegenerative diseases. Moreover, DTI can detect dynamic changes in the WM tracts after lumbar drainage or shunting procedures and could help identify iNPH patients who may benefit from surgical intervention.
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Affiliation(s)
- Ioannis Siasios
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;,Department of Neurosurgery, Kaleida Health, Buffalo, New York; and
| | | | | | | | - Alexander Dorsch
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;,Department of Neurosurgery, Kaleida Health, Buffalo, New York; and
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;,Department of Neurosurgery, Kaleida Health, Buffalo, New York; and
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;,Department of Neurosurgery, Kaleida Health, Buffalo, New York; and
| | - Vassilios Dimopoulos
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;,Department of Neurosurgery, Kaleida Health, Buffalo, New York; and
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Kanno S, Saito M, Kashinoura T, Nishio Y, Iizuka O, Kikuchi H, Takagi M, Iwasaki M, Takahashi S, Mori E. A change in brain white matter after shunt surgery in idiopathic normal pressure hydrocephalus: a tract-based spatial statistics study. Fluids Barriers CNS 2017; 14:1. [PMID: 28132644 PMCID: PMC5278569 DOI: 10.1186/s12987-016-0048-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2016] [Indexed: 11/24/2022] Open
Abstract
Background The aim of this study was to elucidate changes in cerebral white matter after shunt surgery in idiopathic normal pressure hydrocephalus (INPH) using diffusion tensor imaging (DTI). Methods Twenty-eight consecutive INPH patients whose symptoms were followed for 1 year after shunt placement and 10 healthy control (HC) subjects were enrolled. Twenty of the initial 28 INPH patients were shunt-responsive (SR) and the other 8 patients were non-responsive (SNR). The cerebral white matter integrity was detected by assessing fractional anisotropy (FA) and mean diffusivity (MD). The mean hemispheric DTI indices and the ventricular sizes were calculated, and a map of these DTI indices was created for each subject. The DTI maps were analysed to compare preshunt INPH with HC and preshunt INPH with 1 year after shunt placement in each INPH group, using tract-based spatial statistics. We restricted analyses to the left hemisphere because of shunt valve artefacts. Results The ventricles became significantly smaller after shunt placement both in the SR and SNR groups. In addition, there was a significant interaction between clinical improvement after shunt and decrease in ventricular size. Although the hemispheric DTI indices were not significantly changed after shunt placement, there was a significant interaction between clinical improvement and increase in hemispheric MD. Compared with the HC group, FA in the corpus callosum and in the subcortical white matter of the convexity and the occipital cortex was significantly lower in SR at baseline, whereas MD in the periventricular and peri-Sylvian white matter was significantly higher in the SR group. Compared with the pre-operative images, the post-operative FA was only decreased in the corona radiata and only in the SR group. There were no significant regions in which DTI indices were altered after shunt placement in the SNR group. Conclusions Brain white matter regions in which FA was decreased after shunt placement were in the corona radiata between the lateral ventricles and the Sylvian fissures. This finding was observed only in shunt-responsive INPH patients and might reflect the plasticity of the brain for mechanical pressure changes from the cerebrospinal fluid system. Electronic supplementary material The online version of this article (doi:10.1186/s12987-016-0048-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shigenori Kanno
- Department of Neurology, Southmiyagi Medical Center, 38-1, Aza-nishi, Shibata, Miyagi, 989-1253, Japan. .,Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Makoto Saito
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohito Kashinoura
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Nishio
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Osamu Iizuka
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hirokazu Kikuchi
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masahito Takagi
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shoki Takahashi
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Etsuro Mori
- Department of Behavioural Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
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Garcia-Armengol R, Domenech S, Botella-Campos C, Goncalves FJ, Menéndez B, Teixidor P, Muñoz-Narbona L, Rimbau J. Comparison of elevated intracranial pressure pulse amplitude and disproportionately enlarged subarachnoid space (DESH) for prediction of surgical results in suspected idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2016; 158:2207-2213. [PMID: 27349896 DOI: 10.1007/s00701-016-2858-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/24/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND To compare the prognostic value of pulse amplitude on intracranial pressure (ICP) monitoring and disproportionately enlarged subarachnoid space hydrocephalus (DESH) on magnetic resonance imaging (MRI) for predicting surgical benefit after shunt placement in idiopathic normal pressure hydrocephalus (iNPH). METHOD Patients with suspected iNPH were prospectively recruited from a single centre. All patients received preoperative MRI and ICP monitoring. Patients were classified as shunt responders if they had an improvement of one point or more on the NPH score at 1 year post-surgery. The sensitivity, specificity, Youden index, and positive and negative predictive values of the two diagnostic methods were calculated. RESULTS Sixty-four of 89 patients clinically improved at 1 year post-surgery and were classed as shunt responders. Positive DESH findings had a sensitivity of 79.4 % and specificity of 80.8 % for predicting shunt responders. Fifty-five of 89 patients had positive DESH findings: 50 of these responded to VP shunt, giving a positive and negative predictive value of 90.9 % and 61.8 %, respectively. Fifty-seven of 89 patients had high ICP pulse amplitude. High ICP pulse amplitude had a sensitivity of 84.4 %, specificity of 88 %, positive predictive value of 94.7 % and negative predictive value of 61.8 % for predicting shunt responders. CONCLUSIONS Both positive DESH findings and high ICP pulse amplitude support the diagnosis of iNPH and provide additional diagnostic value for predicting shunt-responsive patients; however, high ICP amplitude was more accurate than positive DESH findings, although it is an invasive test.
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Affiliation(s)
- Roser Garcia-Armengol
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain.
| | - Sira Domenech
- Institut de Diagnòstic per la Imatge (IDI), University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Carlos Botella-Campos
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Francisco Javier Goncalves
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Belén Menéndez
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Pilar Teixidor
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Lucia Muñoz-Narbona
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
| | - Jordi Rimbau
- Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain
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Irie R, Tsuruta K, Hori M, Suzuki M, Kamagata K, Nakanishi A, Kamiya K, Nakajima M, Miyajima M, Arai H, Aoki S. Neurite orientation dispersion and density imaging for evaluation of corticospinal tract in idiopathic normal pressure hydrocephalus. Jpn J Radiol 2016; 35:25-30. [PMID: 27787666 DOI: 10.1007/s11604-016-0594-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/20/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE To evaluate diffusional changes of the corticospinal tract (CST) in patients with idiopathic normal pressure hydrocephalus (iNPH) by neurite orientation dispersion and density imaging (NODDI). MATERIALS AND METHODS Nineteen patients with iNPH and 12 healthy controls were included. Diffusion MRI data for NODDI were acquired with a 3-T system, using 32 motion-probing gradient directions with six b-values (from 0 to 2500 s/mm2). The orientation dispersion index (ODI), intra-cellular volume fraction (Vic), and isotropic volume fraction (Viso) of the CST were calculated by tract-specific analysis in patients and controls. We also measured the fractional anisotropy (FA) and apparent diffusion coefficient (ADC). RESULTS The ODI of the CST (0.087 ± 0.024 vs. 0.183 ± 0.051, P < 0.01, Mann-Whitney U test) and Vic of the CST (0.551 ± 0.061 vs. 0.628 ± 0.038, P < 0.01, Mann-Whitney U test) were significantly lower in iNPH patients than in healthy controls. In receiver-operating characteristic analysis, the area under the curve (AUC) of the ODI and FA were not significantly different (Fig. 4a, 0.987 vs. 0.904, P = 0.061), and the AUC of the Vic and ADC also showed no significant difference (Fig. 4b, 0.864 vs. 0.912, P = 0.194). CONCLUSION The NODDI can effectively evaluate the condition of neurites in the CST of iNPH patients, and the ODI could be clinically useful in the diagnosis of iNPH.
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Affiliation(s)
- Ryusuke Irie
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Kohei Tsuruta
- Department of Radiological Sciences, Tokyo Metropolitan University Graduate School of Human Health Sciences, Tokyo, Japan
| | - Masaaki Hori
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Michimasa Suzuki
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Koji Kamagata
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsushi Nakanishi
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kouhei Kamiya
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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Chankaew E, Srirabheebhat P, Manochiopinig S, Witthiwej T, Benjamin I. Bulbar dysfunction in normal pressure hydrocephalus: a prospective study. Neurosurg Focus 2016; 41:E15. [PMID: 27581311 DOI: 10.3171/2016.6.focus16183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Normal pressure hydrocephalus (NPH) is clinically characterized by gait disturbance, cognitive impairment, and urinary incontinence, as well as enlargement of the ventricles. To the best of the authors' knowledge, there have been no previous publications regarding the correlation between bulbar dysfunction and NPH. The primary objective of this study was to compare preoperative and postoperative prevalence of bulbar dysfunction in patients with NPH. Secondary objectives included assessing the results of surgery for swallowing, speech, gait, cognition, and urination, and evaluating the correlation between bulbar dysfunction and triad symptoms. METHODS Fifty-three patients with NPH who underwent shunt placement surgery at Siriraj Hospital were included in the study. Patients were evaluated for gait, cognition, urination, swallowing, and speech before and 6 months after shunt placement. Triad symptoms were assessed using standard methods. Bulbar dysfunctions were assessed using the Swallowing Problem Questionnaire, Thai Articulation Test, Resonation Screening Test (RST), and Thai Nasality Test. The Thai Speech Assessment Program and nasometer were used for objective speech measurement. RESULTS Preoperatively, 86% (43/50) of patients had swallowing problems and 75% (37/49) had speech problems, as measured by the RST. Postoperatively, there was significant improvement in swallowing (p < 0.001), speech problems by RST (p = 0.008), and voice volume (p = 0.009), but no significant change in the nasometer test. All triad symptoms were improved. There were significant correlations between swallowing impairment and gait disturbance (r = 0.358, p = 0.009), and RST and cognitive impairment (r = -0.502, p < 0.001). CONCLUSIONS This is the first study of bulbar dysfunction in patients with NPH. The results showed that the prevalence of bulbar dysfunction is very high. The correlation between bulbar dysfunction and the classic NPH triad has been documented and published. These bulbar symptoms also significantly improved after surgery. As such, bulbar dysfunction should be regarded as a core symptom that should be considered along with the classic triad in the clinical diagnosis and management of NPH.
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Affiliation(s)
| | | | - Sriwimon Manochiopinig
- Division of Speech-Language Therapy, Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Fractional anisotropy in patients with disproportionately enlarged subarachnoid space hydrocephalus. Acta Neurochir (Wien) 2016; 158:1495-500. [PMID: 27272943 DOI: 10.1007/s00701-016-2861-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Disproportionately enlarged subarachnoid space hydrocephalus (DESH) findings on MRI were described as a prognostic factor for responsiveness to the treatment of idiopathic normal pressure hydrocephalus (iNPH). Our premise is that DESH could be associated with compression of the cerebral white matter. Microstructural changes can be identified using diffusion tensor imaging (DTI), specifically fractional anisotropy (FA). The aim of this study is to compare FA in iNPH patients with and without DESH and healthy controls. METHODS We analysed 1.5-T MRI scans of patients fulfilling the criteria of probable or possible iNPH and positive supplementary tests before and after surgery (ventriculo-peritoneal shunt). FA was measured in the anterior and posterior limb of the internal capsule (PLIC) and in the corpus callosum. Patients were divided into the DESH and non-DESH group. These data were also compared to FA values in the control group. RESULTS Twenty-seven patients and 24 healthy controls were enrolled. DESH was present in 15 patients and lacking in 12. Twenty-three iNPH patients were shunt responders (85.2 %), and 4 were non-responders (14.8 %). All patients in the DESH group were shunt responders. In the non-DESH group, eight patients were responders (66.7 %). A significant difference between the DESH and non-DESH group was found in the FA of the PLIC. The mean value of FA in the PLIC was 0.72 in the DESH group and 0.66 in the non-DESH group. After the surgery FA decreased in both groups. In the DESH iNPH group FA PLIC decreased to 0.65 and in the non-DESH iNPH group to 0.60. In the healthy controls, the mean FA in the PLIC was 0.58. CONCLUSION DESH on MRI scans is related to a higher FA in the PLIC with a decrease after the surgery. It reflects a more severe compression of the white matter than in non-DESH patients or healthy volunteers. DESH patients had better outcome than non-DESH patients. This study confirmed the importance of DESH as a supportive sign for iNPH.
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Kang K, Jeon JS, Kim T, Choi D, Ko PW, Hwang SK, Lee HW. Asymmetric and Upper Body Parkinsonism in Patients with Idiopathic Normal-Pressure Hydrocephalus. J Clin Neurol 2016; 12:452-459. [PMID: 27486933 PMCID: PMC5063872 DOI: 10.3988/jcn.2016.12.4.452] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 01/28/2023] Open
Abstract
Background and Purpose Our aims were to analyze the characteristics of parkinsonian features and to characterize changes in parkinsonian motor symptoms before and after the cerebrospinal fluid tap test (CSFTT) in idiopathic normal-pressure hydrocephalus (INPH) patients. Methods INPH subjects were selected in consecutive order from a prospectively enrolled INPH registry. Fifty-five INPH patients (37 males) having a positive response to the CSFTT constituted the final sample for analysis. The mean age was 73.7±4.7 years. The pre-tap mean Unified Parkinson's Disease Rating Scale motor (UPDRS-III) score was 24.5±10.2. Results There was no significant difference between the upper and lower body UPDRS-III scores (p=0.174). The parkinsonian signs were asymmetrical in 32 of 55 patients (58.2%). At baseline, the Timed Up and Go Test and 10-meter walking test scores were positively correlated with the total motor score, global bradykinesia score, global rigidity score, upper body score, lower body score, and postural instability/gait difficulties score of UPDRS-III. After the CSFTT, the total motor score, global bradykinesia score, upper body score, and lower body score of UPDRS-III significantly improved (p<0.01). There was a significant decrease in the number of patients with asymmetric parkinsonism (p<0.05). Conclusions In the differential diagnosis of elderly patients presenting with asymmetric and upper body parkinsonism, we need to consider a diagnosis of INPH. The association between gait function and parkinsonism severity suggests the involvement of similar circuits producing gait and parkinsonian symptoms in INPH.
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Affiliation(s)
- Kyunghun Kang
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, Korea.,Brain Science & Engineering Institute, Kyungpook National University, Daegu, Korea
| | - Ji Su Jeon
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Taegyeong Kim
- Kyungpook National University School of Medicine, Daegu, Korea
| | - Dongho Choi
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Pan Woo Ko
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, Korea.,Brain Science & Engineering Institute, Kyungpook National University, Daegu, Korea
| | - Sung Kyoo Hwang
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ho Won Lee
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, Korea.,Brain Science & Engineering Institute, Kyungpook National University, Daegu, Korea.
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Lee H, Jang SH. Change of cingulum following shunt operation for hydrocephalus in a patient with a haemorrhagic stroke. Clin Neurol Neurosurg 2016; 148:49-51. [PMID: 27391976 DOI: 10.1016/j.clineuro.2016.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/01/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Affiliation(s)
- HanDo Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Republic of Korea
| | - Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Republic of Korea.
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Güngör A, Baydin S, Middlebrooks EH, Tanriover N, Isler C, Rhoton AL. The white matter tracts of the cerebrum in ventricular surgery and hydrocephalus. J Neurosurg 2016; 126:945-971. [PMID: 27257832 DOI: 10.3171/2016.1.jns152082] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The relationship of the white matter tracts to the lateral ventricles is important when planning surgical approaches to the ventricles and in understanding the symptoms of hydrocephalus. The authors' aim was to explore the relationship of the white matter tracts of the cerebrum to the lateral ventricles using fiber dissection technique and MR tractography and to discuss these findings in relation to approaches to ventricular lesions. METHODS Forty adult human formalin-fixed cadaveric hemispheres (20 brains) and 3 whole heads were examined using fiber dissection technique. The dissections were performed from lateral to medial, medial to lateral, superior to inferior, and inferior to superior. MR tractography showing the lateral ventricles aided in the understanding of the 3D relationships of the white matter tracts with the lateral ventricles. RESULTS The relationship between the lateral ventricles and the superior longitudinal I, II, and III, arcuate, vertical occipital, middle longitudinal, inferior longitudinal, inferior frontooccipital, uncinate, sledge runner, and lingular amygdaloidal fasciculi; and the anterior commissure fibers, optic radiations, internal capsule, corona radiata, thalamic radiations, cingulum, corpus callosum, fornix, caudate nucleus, thalamus, stria terminalis, and stria medullaris thalami were defined anatomically and radiologically. These fibers and structures have a consistent relationship to the lateral ventricles. CONCLUSIONS Knowledge of the relationship of the white matter tracts of the cerebrum to the lateral ventricles should aid in planning more accurate surgery for lesions within the lateral ventricles.
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Affiliation(s)
| | | | - Erik H Middlebrooks
- Radiology, and the.,K. Scott and E. R. Andrew Advanced Neuroimaging Lab, College of Medicine, University of Florida, Gainesville, Florida; and
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Cihan Isler
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Chen YC, Chiang SW, Chi CH, Liou M, Kuo DP, Kao HW, Chung HW, Ma HI, Peng GS, Wu YT, Chen CY. Early Idiopathic Normal Pressure Hydrocephalus Patients With Neuropsychological Impairment Are Associated With Increased Fractional Anisotropy in the Anterior Thalamic Nucleus. Medicine (Baltimore) 2016; 95:e3636. [PMID: 27175677 PMCID: PMC4902519 DOI: 10.1097/md.0000000000003636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In this study, we aimed to investigate the reactive changes in diffusion tensor imaging (DTI)-derived diffusion metrics of the anterior thalamic nucleus (AN), a relaying center for the Papez circuit, in early idiopathic normal pressure hydrocephalus (iNPH) patients with memory impairment, as well as its correlation with the patients' neuropsychological performances. In total, 28 probable iNPH patients with symptom onset within 1 year and 17 control subjects were prospectively recruited between 2010 and 2013 for this institutional review board-approved study. Imaging studies including DTI and a neuropsychological assessment battery were performed in all subjects. Diffusion metrics were measured from the region of the AN using tract-deterministic seeding method by reconstructing the mammillo-thalamo-cingulate connections within the Papez circuit. Differences in diffusion metrics and memory assessment scores between the patient and control group were examined via the Mann-Whitney U test. Spearman correlation analyses were performed to examine associations between diffusion metrics of AN and neuropsychological tests within the patient group. We discovered that early iNPH patients exhibited marked elevations in fractional anisotropy, pure diffusion anisotropy, and axial diffusivity (all P < 0.01), as well as lower neuropsychological test scores including verbal and nonverbal memory (all P < 0.05) compared with normal control. Spearman rank correlation analyses did not disclose significant correlations between AN diffusion metrics and neuropsychological test scores in the patient group, whereas ranked scatter plots clearly demonstrated a dichotic sample distribution between patient and control samples. In summary, our study highlighted the potential compensatory role of the AN by increasing thalamocortical connectivity within the Papez circuit because memory function declines in early iNPH when early shunt treatment may potentially reverse the memory deficits.
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Affiliation(s)
- Yung-Chieh Chen
- From the Department of Biomedical Imaging and Radiological Sciences (Y-CC, Y-TW), National Yang-Ming University; Department of Radiology (S-WC, H-WK, C-YC), Tri-Service General Hospital and National Defense Medical Center; Graduate Institute of Biomedical Electrics and Bioinformatics (S-WC, H-WC), National Taiwan University; Department of Psychiatry (C-HC), Tri-Service General Hospital; Institute of Statistical Science (ML), Academia Sinica, Taipei; Department of Radiology (D-PK), Taoyuan Armed Forces General Hospital, Taoyuan; Department of Neurosurgery (HIM); Department of Neurology (G-SP), Tri-Service General Hospital; Department of Medical Imaging and Imaging Research Center (C-YC), Taipei Medical University Hospital; and Department of Radiology (C-YC), College of Medicine, Taipei Medical University, Taipei, Taiwan
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Hořínek D, Štěpán-Buksakowska I, Szabó N, Erickson BJ, Tóth E, Šulc V, Beneš V, Vrána J, Hort J, Nimsky C, Mohapl M, Roček M, Vécsei L, Kincses ZT. Difference in white matter microstructure in differential diagnosis of normal pressure hydrocephalus and Alzheimer's disease. Clin Neurol Neurosurg 2015; 140:52-9. [PMID: 26646649 DOI: 10.1016/j.clineuro.2015.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 11/07/2015] [Accepted: 11/14/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Alzheimer's disease (AD) and normal pressure hydrocephalus (NPH) are both associated with cognitive decline and ventriculomegaly. While promising approach in differentiating between the two diseases, only a few diffusion tensor imaging (DTI) studies compared directly NPH and AD patients. The current study compares global whitematter (WM) alterations in AD and NPH addressing some of the methodological issues of previous studies. PATIENTS AND METHODS Diffusion tensor images were obtained from 17 patients with NPH, 14 with AD, and 17 healthy controls. White matter integrity was quantified by fractional anisotropy (FA), mean (MD), axial (λ1) and radial diffusivity (RD). The diffusion parameters were compared between the groups in 'skeletonised' tracts representing the core of the fibre bundles. RESULTS Reduced FA was found in NPH patients throughout the corpus callosum, particularly in the splenium, along with increased RD. On the other hand, FA, MD and RD were higher in NPH in the cortico-fugal fibres arising from the frontal and parietal cortex. While no FA changes were detected in AD patients compared to controls, widespread increased RD was observed. When comparing NPH and AD patients, higher FA, MD and RD was observed in the corona radiata in the periventricular fibres arising from the frontal and parietal cortex in NPH patients. The ventricular volumes were correlated with diffusivity parameters in the tracts next to the ventricles in AD and NPH patients. CONCLUSION Our analysis identified a pattern of WM diffusion alterations that can differentiate NPH patients from controls and AD patients.
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Affiliation(s)
- Daniel Hořínek
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic; Department of Neurosurgery, 1st Faculty of Medicine, Charles University and University Central Military Hospital, Prague, Czech Republic.
| | - Irena Štěpán-Buksakowska
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic; Department of Radiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Nikoletta Szabó
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic; Department of Neurology, Faculty of General Medicine, University of Szeged, Szeged, Hungary
| | | | - Eszter Tóth
- Department of Neurology, Faculty of General Medicine, University of Szeged, Szeged, Hungary
| | - Vlastimil Šulc
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Vladimir Beneš
- Department of Neurosurgery, 1st Faculty of Medicine, Charles University and University Central Military Hospital, Prague, Czech Republic
| | - Jiří Vrána
- Department of Radiodiagnostics, University Central Military Hospital, Prague, Czech Republic
| | - Jakub Hort
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic; Memory Disorders Clinic, Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic
| | | | - Milan Mohapl
- Department of Neurosurgery, 1st Faculty of Medicine, Charles University and University Central Military Hospital, Prague, Czech Republic
| | - Miloslav Roček
- Department of Radiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - László Vécsei
- Department of Neurology, Faculty of General Medicine, University of Szeged, Szeged, Hungary
| | - Zsigmond Tamás Kincses
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic; Department of Neurology, Faculty of General Medicine, University of Szeged, Szeged, Hungary
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Ivkovic M, Reiss-Zimmermann M, Katzen H, Preuss M, Kovanlikaya I, Heier L, Alperin N, Hoffmann KT, Relkin N. MRI assessment of the effects of acetazolamide and external lumbar drainage in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2015; 12:9. [PMID: 25928394 PMCID: PMC4432506 DOI: 10.1186/s12987-015-0004-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/25/2015] [Indexed: 12/14/2022] Open
Abstract
Background The objective was to identify changes in quantitative MRI measures in patients with idiopathic normal pressure hydrocephalus (iNPH) occurring in common after oral acetazolamide (ACZ) and external lumbar drainage (ELD) interventions. Methods A total of 25 iNPH patients from two clinical sites underwent serial MRIs and clinical assessments. Eight received ACZ (125-375 mg/day) over 3 months and 12 underwent ELD for up to 72 hours. Five clinically-stable iNPH patients who were scanned serially without interventions served as controls for the MRI component of the study. Subjects were divided into responders and non-responders to the intervention based on gait and cognition assessments made by clinicians blinded to MRI results. The MRI modalities analyzed included T1-weighted images, diffusion tensor Imaging (DTI) and arterial spin labelling (ASL) perfusion studies. Automated threshold techniques were used to define regions of T1 hypo-intensities. Results Decreased volume of T1-hypointensities and decreased mean diffusivity (MD) within remaining hypointensities was observed after ACZ and ELD but not in controls. Patients responding positively to these interventions had more extensive decreases in T1-hypointensites than non-responders: ACZ-responders (4,651 ± 2,909 mm3), ELD responders (2,338 ± 1,140 mm3), ELD non-responders (44 ± 1,188 mm3). Changes in DTI MD within T1-hypointensities were greater in ACZ-responders (7.9% ± 2%) and ELD-responders (8.2% ± 3.1%) compared to ELD non-responders (2.1% ± 3%). All the acetazolamide-responders showed increases in whole-brain-average cerebral blood flow (wbCBF) estimated by ASL (18.8% ± 8.7%). The only observed decrease in wbCBF (9.6%) occurred in an acetazolamide-non-responder. A possible association between cerebral atrophy and response was observed, with subjects having the least cortical atrophy (as indicated by a positive z-score on cortical thickness measurements) showing greater clinical improvement after ACZ and ELD. Conclusions T1-hypointensity volume and DTI MD measures decreased in the brains of iNPH patients following oral ACZ and ELD. The magnitude of the decrease was greater in treatment responders than non-responders. Despite having different mechanisms of action, both ELD and ACZ may decrease interstitial brain water and increase cerebral blood flow in patients with iNPH. Quantitative MRI measurements appear useful for objectively monitoring response to acetazolamide, ELD and potentially other therapeutic interventions in patients with iNPH.
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Affiliation(s)
| | | | | | | | | | - Linda Heier
- Weill Cornell Medical College, New York, NY, USA.
| | - Noam Alperin
- University of Miami School of Medicine, Miami, FL, USA.
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Hoza D, Vlasák A, Hořínek D, Sameš M, Alfieri A. DTI-MRI biomarkers in the search for normal pressure hydrocephalus aetiology: a review. Neurosurg Rev 2014; 38:239-44; discussion 244. [DOI: 10.1007/s10143-014-0584-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 08/16/2014] [Accepted: 08/31/2014] [Indexed: 11/28/2022]
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Eskandari R, Abdullah O, Mason C, Lloyd KE, Oeschle AN, McAllister JP. Differential vulnerability of white matter structures to experimental infantile hydrocephalus detected by diffusion tensor imaging. Childs Nerv Syst 2014; 30:1651-61. [PMID: 25070594 DOI: 10.1007/s00381-014-2500-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/14/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE The differential vulnerability of white matter (WM) to acute and chronic infantile hydrocephalus and the related effects of early and late reservoir treatment are unknown, but diffusion tensor imaging (DTI) could provide this information. Thus, we characterized WM integrity using DTI in a clinically relevant model. METHODS Obstructive hydrocephalus was induced in 2-week-old felines by intracisternal kaolin injection. Ventricular reservoirs were placed 1 (early) or 2 (late) weeks post-kaolin and tapped frequently based solely on neurological deficit. Hydrocephalic and age-matched control animals were sacrificed 12 weeks postreservoir. WM integrity was evaluated in the optic system, corpus callosum, and internal capsule prereservoir and every 3 weeks using DTI. Analyses were grouped as acute (<6 weeks) or chronic (≥6 weeks). RESULTS In the corpus callosum during acute stages, fractional anisotropy (FA) decreased significantly with early and late reservoir placement (p = 0.0008 and 0.0008, respectively), and diffusivity increased significantly in early (axial, radial, and mean diffusivity, p = 0.0026, 0.0012, and 0.0002, respectively) and late (radial and mean diffusivity, p = 0.01 and 0.0038, respectively) groups. Chronically, the corpus callosum was thinned and not detectable by DTI. FA was significantly lower in the optic chiasm and tracts (p = 0.0496 and 0.0052, respectively) with late but not early reservoir placement. In the internal capsule, FA in both reservoir groups increased significantly with age (p < 0.05) but diffusivity remained unchanged. CONCLUSIONS All hydrocephalic animals treated with intermittent ventricular reservoir tapping demonstrated progressive ventriculomegaly. Both reservoir groups demonstrated WM integrity loss, with the CC the most vulnerable and the optic system the most resilient.
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Affiliation(s)
- Ramin Eskandari
- Stanford Children's Health, Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA, USA,
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Kamiya K, Hori M, Miyajima M, Nakajima M, Suzuki Y, Kamagata K, Suzuki M, Arai H, Ohtomo K, Aoki S. Axon diameter and intra-axonal volume fraction of the corticospinal tract in idiopathic normal pressure hydrocephalus measured by q-space imaging. PLoS One 2014; 9:e103842. [PMID: 25093733 PMCID: PMC4122461 DOI: 10.1371/journal.pone.0103842] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 07/02/2014] [Indexed: 11/26/2022] Open
Abstract
Purpose Previous studies suggest that compression and stretching of the corticospinal tract (CST) potentially cause treatable gait disturbance in patients with idiopathic normal pressure hydrocephalus (iNPH). Measurement of axon diameter with diffusion MRI has recently been used to investigate microstructural alterations in neurological diseases. In this study, we investigated alterations in the axon diameter and intra-axonal fraction of the CST in iNPH by q-space imaging (QSI) analysis. Methods Nineteen patients with iNPH and 10 age-matched controls were recruited. QSI data were obtained with a 3-T system by using a single-shot echo planar imaging sequence with the diffusion gradient applied parallel to the antero-posterior axis. By using a two-component low-q fit model, the root mean square displacements of intra-axonal space ( = axon diameter) and intra-axonal volume fraction of the CST were calculated at the levels of the internal capsule and body of the lateral ventricle, respectively. Results Wilcoxon's rank-sum test revealed a significant increase in CST intra-axonal volume fraction at the paraventricular level in patients (p<0.001), whereas no significant difference was observed in the axon diameter. At the level of the internal capsule, neither axon diameter nor intra-axonal volume fraction differed significantly between the two groups. Conclusion Our results suggest that in patients with iNPH, the CST does not undergo irreversible axonal damage but is rather compressed and/or stretched owing to pressure from the enlarged ventricle. These analyses of axon diameter and intra-axonal fraction yield insights into microstructural alterations of the CST in iNPH.
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Affiliation(s)
- Kouhei Kamiya
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Radiology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- * E-mail:
| | - Masaaki Hori
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuriko Suzuki
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Philips Electronics Japan, Ltd., Tokyo, Japan
| | - Koji Kamagata
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Michimasa Suzuki
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kuni Ohtomo
- Department of Radiology, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Serulle Y, Rusinek H, Kirov II, Milch H, Fieremans E, Baxter AB, McMenamy J, Jain R, Wisoff J, Golomb J, Gonen O, George AE. Differentiating shunt-responsive normal pressure hydrocephalus from Alzheimer disease and normal aging: pilot study using automated MRI brain tissue segmentation. J Neurol 2014; 261:1994-2002. [PMID: 25082631 DOI: 10.1007/s00415-014-7454-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/23/2014] [Accepted: 07/24/2014] [Indexed: 11/26/2022]
Abstract
Evidence suggests that normal pressure hydrocephalus (NPH) is underdiagnosed in day to day radiologic practice, and differentiating NPH from cerebral atrophy due to other neurodegenerative diseases and normal aging remains a challenge. To better characterize NPH, we test the hypothesis that a prediction model based on automated MRI brain tissue segmentation can help differentiate shunt-responsive NPH patients from cerebral atrophy due to Alzheimer disease (AD) and normal aging. Brain segmentation into gray and white matter (GM, WM), and intracranial cerebrospinal fluid was derived from pre-shunt T1-weighted MRI of 15 shunt-responsive NPH patients (9 men, 72.6 ± 8.0 years-old), 17 AD patients (10 men, 72.1 ± 11.0 years-old) chosen as a representative of cerebral atrophy in this age group; and 18 matched healthy elderly controls (HC, 7 men, 69.7 ± 7.0 years old). A multinomial prediction model was generated based on brain tissue volume distributions. GM decrease of 33% relative to HC characterized AD (P < 0.005). High preoperative ventricular and near normal GM volumes characterized NPH. A multinomial regression model based on gender, GM and ventricular volume had 96.3% accuracy differentiating NPH from AD and HC. In conclusion, automated MRI brain tissue segmentation differentiates shunt-responsive NPH with high accuracy from atrophy due to AD and normal aging. This method may improve diagnosis of NPH and improve our ability to distinguish normal from pathologic aging.
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Affiliation(s)
- Yafell Serulle
- Center for Biomedical Imaging, Department of Radiology, New York University School of Medicine, 660 First Avenue, New York, NY, 10016, USA,
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Koyama T, Marumoto K, Domen K, Miyake H. White matter characteristics of idiopathic normal pressure hydrocephalus: a diffusion tensor tract-based spatial statistic study. Neurol Med Chir (Tokyo) 2014; 53:601-8. [PMID: 24067771 PMCID: PMC4508678 DOI: 10.2176/nmc.oa2012-0307] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Using magnetic resonance-diffusion tensor imaging (DTI), we examined white matter changes within the brains of patients diagnosed with idiopathic normal pressure hydrocephalus (INPH). We analyzed data for 24 INPH patients who were presented with typical clinical symptoms (gait disturbance, dementia, and/ or urinary incontinence) and Evans index > 0.3, and compared these with the control data from 21 elderly persons (≥ 60 years). DTI brain images were obtained with a 3T scanner. Fractional anisotropy (FA) brain maps were generated using a computer-automated method, and tract-based spatial statistics (TBSS) were then applied to compare the FA brain maps of the INPH and control groups in standard space. The TBSS data were further investigated using region-of-interest (ROI) analyses. ROIs were set within the corpus callosum, the posterior limb of the internal capsule (PLIC), and the cerebral peduncle in reference to a standard brain template. Compared with the control group, FA values in the INPH group were significantly lower in the corpus callosum and just significantly higher in the PLIC, but no significant differences were evident in the cerebral peduncle. The much lower FA values in the corpus callosum, but not the slightly higher FA values in the PLIC, were associated with more severe clinical symptoms such as gait disturbance. The lower FA values in the corpus callosum may offer a clue to solve the pathophysiology of INPH.
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Affiliation(s)
- Tetsuo Koyama
- Department of Rehabilitation Medicine, Nishinomiya Kyoritsu Neurosurgical Hospital
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