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Chabros J, Placek MM, Chu KH, Beqiri E, Hutchinson PJ, Czosnyka Z, Czosnyka M, Joannides A, Smielewski P. Embracing uncertainty in cerebrospinal fluid dynamics: A Bayesian approach to analysing infusion studies. BRAIN & SPINE 2024; 4:102837. [PMID: 38868599 PMCID: PMC11166691 DOI: 10.1016/j.bas.2024.102837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/14/2024]
Abstract
Introduction Cerebrospinal fluid (CSF) infusion test analysis allows recognizing and appropriately evaluating CSF dynamics in the context of normal pressure hydrocephalus (NPH), which is crucial for effective diagnosis and treatment. However, existing methodology possesses drawbacks that may compromise the precision and interpretation of CSF dynamics parameters. Research question This study aims to circumvent these constraints by introducing an innovative analysis method grounded in Bayesian inference. Material and methods A single-centre retrospective cohort study was conducted on 858 patients who underwent a computerized CSF infusion test between 2004 and 2020. We developed a Bayesian framework-based method for parameter estimation and compared the results to the current, gradient descent-based approach. We evaluated the accuracy and reliability of both methods by analysing erroneous prediction rates and curve fitting errors. Results The Bayesian method surpasses the gradient descent approach, reflected in reduced inaccurate prediction rates and an improved goodness of model fit. On whole cohort level both techniques produced comparable results. However, the Bayesian method holds an added advantage by providing uncertainty intervals for each parameter. Sensitivity analysis revealed significance of the CSF production rate parameter and its interplay with other variables. The resistance to CSF outflow demonstrated excellent robustness. Discussion and conclusion The proposed Bayesian approach offers a promising solution for improving robustness of CSF dynamics assessment in NPH, based on CSF infusion tests. Additional provision of the uncertainty measure for each diagnostic metric may perhaps help to explain occasional poor diagnostic performance of the test, offering a robust framework for improved understanding and management of NPH.
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Affiliation(s)
- Jeremi Chabros
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
| | - Michal M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, CB2 0QQ, Cambridge, UK
| | - Ka Hing Chu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
| | - Peter J. Hutchinson
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, CB2 0QQ, Cambridge, UK
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, CB2 0QQ, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, CB2 0QQ, Cambridge, UK
| | - Alexis Joannides
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, CB2 0QQ, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, CB2 0SP, Cambridge, UK
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Zipfel J, Kohlmann-Dell’Acqua C, Noell S, Trakolis L. 17 years of experience with shunt systems in normal pressure hydrocephalus - From differential pressure to gravitational valves. World Neurosurg X 2024; 22:100293. [PMID: 38450246 PMCID: PMC10914590 DOI: 10.1016/j.wnsx.2024.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
Objective Complication rate of shunting for normal pressure hydrocephalus (NPH) has significantly improved over the last decades. Especially the use of overdrainage protection has reduced the incidence of subdural hematoma and collections. However, gravitational valves were associated with other complications of shunt dysfunction. We present our 17 years of experience with patients with normal pressure hydrocephalus who changed from a differential pressure valve to a gravitational valve system. Methods We retrospectively identified all patients with the diagnosis of normal pressure hydrocephalus, in whom primary shunt implantation was performed between 2004 and 2020. Shunt implantation was performed as per our internal standard. Review of imaging, charts and patient reports was performed. Results In total, 409 patients were included in the analysis. Mean age was 73.0 ± 7.1years. Between 2004 and 2010, predominantly Hakim valves (n = 100, 24.4%) were implanted, whilst from 2009 until 2020, proGAV valves (n = 296, 72.4%) were used. Mean follow-up was 8.9 ± 4.5 years. Initial subjective improvement of symptoms was reported in 69.9%, whilst this number decreased at the last follow-up to 29.8%. No significant differences were observed between the valves in the frequency of surgery for subdural hematoma. Shunt assistant implantation was performed in 17% of patients with Hakim valve, in 9.5% of patients with proGAV, a shunt assistant was added. Shunt obstruction was significantly higher in proGAV valves (p < 0.001). Conclusions Our findings confirm the observation of frequent overdrainage in shunts without anti-siphon/gravitational component. Gravitational valves on the other hand may be associated with more obstruction.
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Affiliation(s)
- Julian Zipfel
- Department of Neurosurgery, University Hospital Tuebingen, Germany
- Centre for Clinical Studies, Neuropsychiatric Study Centre, University Hospital Tuebingen, Germany
| | - Cristina Kohlmann-Dell’Acqua
- Department of Neurosurgery, University Hospital Tuebingen, Germany
- Centre for Clinical Studies, Neuropsychiatric Study Centre, University Hospital Tuebingen, Germany
| | - Susan Noell
- Department of Neurosurgery, University Hospital Tuebingen, Germany
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Rostgaard N, Olsen MH, Lolansen SD, Nørager NH, Plomgaard P, MacAulay N, Juhler M. Ventricular CSF proteomic profiles and predictors of surgical treatment outcome in chronic hydrocephalus. Acta Neurochir (Wien) 2023; 165:4059-4070. [PMID: 37857909 PMCID: PMC10739511 DOI: 10.1007/s00701-023-05832-y] [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: 07/07/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND By applying an unbiased proteomic approach, we aimed to search for cerebrospinal fluid (CSF) protein biomarkers distinguishing between obstructive and communicating hydrocephalus in order to improve appropriate surgical selection for endoscopic third ventriculostomy vs. shunt implants. Our second study purpose was to look for potential CSF biomarkers distinguishing between patients with adult chronic hydrocephalus benefitting from surgery (responders) vs. those who did not (non-responders). METHODS Ventricular CSF samples were collected from 62 patients with communicating hydrocephalus and 28 patients with obstructive hydrocephalus. CSF was collected in relation to the patients' surgical treatment. As a control group, CSF was collected from ten patients with unruptured aneurysm undergoing preventive surgery (vascular clipping). RESULTS Mass spectrometry-based proteomic analysis of the samples identified 1251 unique proteins. No proteins differed significantly between the communicating hydrocephalus group and the obstructive hydrocephalus group. Four proteins were found to be significantly less abundant in CSF from communicating hydrocephalus patients compared to control subjects. A PCA plot revealed similar proteomic CSF profiles of obstructive and communicating hydrocephalus and control samples. For obstructive hydrocephalus, ten proteins were found to predict responders from non-responders. CONCLUSION Here, we show that the proteomic profile of ventricular CSF from patients with hydrocephalus differs slightly from control subjects. Furthermore, we find ten predictors of response to surgical outcome (endoscopic third ventriculostomy or ventriculo-peritoneal shunt) in patients with obstructive hydrocephalus.
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Affiliation(s)
- Nina Rostgaard
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Sara Diana Lolansen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas Hernandez Nørager
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Plomgaard
- Department of Clinical Biochemistry, Centre of Diagnostic Investigations, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nanna MacAulay
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Wilhelmy F, Krause M, Schob S, Merkenschlager A, Wachowiak R, Härtig W, Meixensberger J, Gburek-Augustat J, Wende T. Cerebrospinal Fluid Protein Concentrations in Hydrocephalus. CHILDREN 2023; 10:children10040644. [PMID: 37189895 DOI: 10.3390/children10040644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/19/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
CSF protein levels are altered in neurological disorders, such as hydrocephalus of different etiologies. In this retrospective observational study, we analyzed cerebrospinal fluid (CSF) samples in hydrocephalic diseases such as aqueductal stenosis (AQS, n = 27), normal pressure hydrocephalus (NPH, n = 24), hydrocephalus communicans (commHC, n = 25) and idiopathic intracranial hypertension (IIH)/pseudotumor cerebri (PC, n = 7) in comparison with neurological patients without hydrocephalic configuration (control, n = 95). CSF was obtained through CSF diversion procedures and lumbar punction and analyzed for protein concentrations according to the institution’s laboratory standards. We found significantly decreased CSF protein levels in patients suffering from AQS (0.13 mg/dL [0.1–0.16 mg/dL] p = 2.28 × 10−8) and from PC (0.18 mg/dL [0.12–0.24 mg/dL] p = 0.01) compared with controls (0.34 mg/dL [0.33–0.35 mg/dL]). Protein levels were not altered in patients suffering from commHC and NPH compared with neurologically healthy individuals. We propose that a decrease in CSF protein levels is part of an active counterregulatory mechanism to lower CSF volume and, subsequently, intracranial pressure in specific diseases. Research regarding said mechanism and more specific proteomic research on a cellular level must still be performed to prove this hypothesis. Differences in protein levels between different diseases point to different etiologies and mechanisms in different hydrocephalic pathologies.
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Affiliation(s)
- Florian Wilhelmy
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Matthias Krause
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Stefan Schob
- Division of Neuroradiology, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Andreas Merkenschlager
- Department of Childrens and Adolescence Health, Division of Neuropediatrics, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Robin Wachowiak
- Department of Pediatric Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Wolfgang Härtig
- Paul-Flechsig-Insitute for Brain Research, Liebigstraße 19, 04103 Leipzig, Germany
| | - Jürgen Meixensberger
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Janina Gburek-Augustat
- Department of Childrens and Adolescence Health, Division of Neuropediatrics, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Tim Wende
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
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Kasprowicz M, Kazimierska A, Ziółkowski A, Lalou A, Czosnyka Z, Czosnyka M. Mathematical Modelling in Hydrocephalus. Neurol India 2021; 69:S275-S282. [DOI: 10.4103/0028-3886.332259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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