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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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Tang Y, Yuan X, Duan J, Zhang X, Chen J, Zhou Y, Song F, Zhou D. White Matter Characteristics of Cognitive Impairment in Tap-Test Positive Idiopathic Normal Pressure Hydrocephalus: A Diffusion Tensor Tract-Based Spatial Study. Front Neurosci 2021; 15:774638. [PMID: 34924943 PMCID: PMC8678068 DOI: 10.3389/fnins.2021.774638] [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: 09/12/2021] [Accepted: 11/16/2021] [Indexed: 02/05/2023] Open
Abstract
The present study was designed to systemically evaluate changes in the diffusion tensor imaging (DTI)-derived parameters of iNPH (idiopathic normal pressure hydrocephalus) patients with different responses to the tap test (TT), and to correlate cognitive impairment with white matter (WM) degeneration. This study included 22 iNPH patients and 14 healthy controls with structural magnetic resonance imaging (MRI) and DTI scanning. DTI was used to explore the differences in fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) for all participants. DTI parameters were evaluated using an ROI (region of interest)-based and tract-based spatial statistics (TBSS) approach. Neuropsychological assessments and the idiopathic normal pressure hydrocephalus grading scoring scale (iNPHGS) were performed. Compared to the TT non-responders, the TT responders group had significantly lower FA values in the corpus callosum, cingulum cingulate gyrus, superior longitudinal fasciculus, and lower AD values in the right cingulum cingulate gyrus and the left posterior thalamic radiation. Besides, the MD values were significantly increased in the corpus callosum, left anterior corona radiata, and the RD values in the corpus callosum and cingulum cingulate gyrus. In addition, the cognitive improvement was negatively correlated with FA of the corpus callosum, cingulum cingulate gyrus, and MD values of the genu of corpus callosum. While, the cognitive improvement was positively related to the AD of the cingulum cingulate gyrus, superior longitudinal, and RD values of the corpus callosum, cingulum cingulate gyrus and uncinate fasciculus. The ROI specific WM lesions in iNPH patients are the underlying basis for cognitive impairment.
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Affiliation(s)
- Yufeng Tang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Xiaoqin Yuan
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Jinfeng Duan
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Xianwen Zhang
- Department of Neurology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Jiao Chen
- Department of Radiology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Ying Zhou
- Department of Radiology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Fangzhou Song
- Basic Medicine College, Chongqing Medical University, Chongqing, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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Diffusion and Flow MR Imaging to Investigate Hydrocephalus Patients Before and After Endoscopic Third Ventriculostomy. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839862 DOI: 10.1007/978-3-030-59436-7_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
INTRODUCTION In patients with noncommunicating hydrocephalus, dilation of the ventricles stresses white matter fibers and alters the cerebral blood flow (CBF) and cerebrospinal fluid (CSF) dynamics. The purpose of this work was to investigate, non-invasively, how endoscopic third ventriculostomy (ETV) impacts white matter, CSF oscillations, and CBF. METHODS Eleven patients presenting with chronic headaches and noncommunicating hydrocephalus due to aqueductal stenosis were treated by ETV. Phase Contrast-MRI (PCMRI) and Diffusion Tensor Imaging (DTI) were performed before and after surgery to evaluate CSF and CBF as well as white matter stresses in the Corpus Callosum (CC) and Corona Radiata (CR). ETV success was confirmed by quantification of the CSF oscillations through the aperture in the third ventricle. RESULTS All patients improved after surgery. CSF stroke volume was five times greater than normal ventricular stroke volume. Decrease in cervical CSF oscillations and increase in CBF were observed after ETV. In CR, fiber anisotropy decreased, while water diffusion increased. In CC, anisotropy did not vary, while water diffusion also increased. CONCLUSION Even if static ICP typically do not increase, CSF and blood flow are impacted. PCMRI and DTI can provide useful information to help neurosurgeons select patients with good chance to improve after ETV.
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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: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [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
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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 2020; 34:55-69. [PMID: 33263494 DOI: 10.1177/1971400920975153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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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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Vivas-Buitrago T, Lokossou A, Jusué-Torres I, Pinilla-Monsalve G, Blitz AM, Herzka DA, Robison J, Xu J, Guerrero-Cazares H, Mori S, Quiñones-Hinojosa A, Baledént O, Rigamonti D. Aqueductal Cerebrospinal Fluid Stroke Volume Flow in a Rodent Model of Chronic Communicating Hydrocephalus: Establishing a Homogeneous Study Population for Cerebrospinal Fluid Dynamics Exploration. World Neurosurg 2019; 128:e1118-e1125. [PMID: 31121363 DOI: 10.1016/j.wneu.2019.05.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) is a cause of dementia that can be reversed when treated timely with cerebrospinal fluid (CSF) diversion. Understanding CSF dynamics throughout the development of hydrocephalus is crucial to identify prognostic markers to estimate benefit/risk to shunts. OBJECTIVE To explore the cerebral aqueduct CSF flow dynamics with phase-contrast magnetic resonance imaging (MRI) in a novel rodent model of adult chronic communicating hydrocephalus. METHODS Kaolin was injected into the subarachnoid space at the convexities in Sprague-Dawley adult rats. 11.7-T Bruker MRI was used to acquire T2-weighted images for anatomic identification and phase-contrast MRI at the cerebral aqueduct. Aqueductal stroke volume (ASV) results were compared with the ventricular volume (VV) at 15, 60, 90, and 120 days. RESULTS Significant ventricular enlargement was found in kaolin-injected animals at all times (P < 0.001). ASV differed between cases and controls/shams at every time point (P = 0.004, 0.001, 0.001, and <0.001 at 15, 60, 90, and 120 days, respectively). After correlation between the ASV and the VV, there was a significant correlation at 15 (P = 0.015), 60 (P = 0.001), 90 (P < 0.001), and 120 days. Moreover, there was a significant positive correlation between the VV expansion and the aqueductal CSF stroke between 15 and 60 days. CONCLUSIONS An initial active phase of rapid ventricular enlargement shows a strong correlation between the expansion of the VV and the increment in the ASV during the first 60 days, followed by a second phase with less ventricular enlargement and heterogeneous behavior in the ASV. Further correlation with complementary data from intracranial pressure and histologic/microstructural brain parenchyma assessments are needed to better understand the ASV variations after 60 days.
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Affiliation(s)
- Tito Vivas-Buitrago
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA; School of Medicine, Faculty of Health Sciences, Universidad de Santander UDES, Bucaramanga, Colombia
| | - Armelle Lokossou
- Chimère EA, Research Team for Head & Neck, University of Picardie Jules Verne, Amiens, France
| | - Ignacio Jusué-Torres
- Department of Neurosurgery, Loyola University School of Medicine, Maywood, Illinois, USA
| | | | - Ari M Blitz
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel A Herzka
- Department of Biomedical Engineering, Johns Hopkins School of Engineering, Baltimore, Maryland, USA
| | - Jamie Robison
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jiadi Xu
- Department of Neurosurgery, Kennedy Krieger Institute, Kirby Research Center for Functional Brain Imaging, Baltimore, Maryland, USA
| | | | - Susumu Mori
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Kennedy Krieger Institute, Kirby Research Center for Functional Brain Imaging, Baltimore, Maryland, USA
| | | | - Olivier Baledént
- Chimère EA, Research Team for Head & Neck, University of Picardie Jules Verne, Amiens, France; Department of Image Processing, Jules Verne University Hospital, Amiens, France
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia.
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Saito A, Kamagata K, Ueda R, Nakazawa M, Andica C, Irie R, Nakajima M, Miyajima M, Hori M, Tanaka F, Arai H, Aoki S. Ventricular volumetry and free-water corrected diffusion tensor imaging of the anterior thalamic radiation in idiopathic normal pressure hydrocephalus. J Neuroradiol 2019; 47:312-317. [PMID: 31034894 DOI: 10.1016/j.neurad.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 03/06/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE The pathophysiology of idiopathic normal pressure hydrocephalus (iNPH) has not been completely clarified. We investigated the brain structure in iNPH using automatic ventricular volumetry, single-tensor diffusion tensor imaging (DTI) and bi-tensor free-water (FW) imaging analyses while focusing on cognitive impairments before and after lumboperitoneal shunt surgery. MATERIALS AND METHODS This retrospective study included 12 iNPH patients with structural magnetic resonance imaging (MRI) and diffusion MRI (dMRI) on a 3T-MRI scanner who underwent neuropsychological assessments before and after shunting and 8 healthy controls. Ventricular volumetry was conducted on structural MRI datasets using FreeSurfer. Ventricular volume was compared pre- and postoperatively. Correlation analyses were performed between ventricular volume or volume change and neuropsychological scores or score change. Tract-based spatial statistics were performed using dMRI datasets for group analyses between iNPH and controls and between pre- and post-surgery iNPH patients and for correlation analyses using neuropsychological scores. Tract-specific analyses were performed in the anterior thalamic radiation (ATR), followed by comparison and correlation analyses. RESULTS The third ventricular volume was significantly decreased after shunting; its volume reduction negatively correlated with a neuropsychological improvement. Compared with controls, iNPH patients had lower fractional anisotropy and higher axial, radial, and mean diffusivities, and FW in the periventricular white matter including ATR, resulting in no difference in FW-corrected indices. Single-tensor DTI indices partially correlated with neuropsychological improvements, while FW-corrected indices had no correlations. CONCLUSION Third ventricle enlargement is possibly linked to cognitive impairment and FW imaging possibly provides better white matter characterization in iNPH.
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Affiliation(s)
- Asami Saito
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; 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
| | - Ryo Ueda
- Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10, Higashiogu, Arakawa-ku, Tokyo 116-8551, Japan
| | - Misaki Nakazawa
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Christina Andica
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Ryusuke Irie
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Masaaki Hori
- Department of Radiology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, 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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Bräutigam K, Vakis A, Tsitsipanis C. Pathogenesis of idiopathic Normal Pressure Hydrocephalus: A review of knowledge. J Clin Neurosci 2019; 61:10-13. [DOI: 10.1016/j.jocn.2018.10.147] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/29/2018] [Indexed: 11/16/2022]
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Matsumae M, Kuroda K, Yatsushiro S, Hirayama A, Hayashi N, Takizawa K, Atsumi H, Sorimachi T. Changing the Currently Held Concept of Cerebrospinal Fluid Dynamics Based on Shared Findings of Cerebrospinal Fluid Motion in the Cranial Cavity Using Various Types of Magnetic Resonance Imaging Techniques. Neurol Med Chir (Tokyo) 2019; 59:133-146. [PMID: 30814424 PMCID: PMC6465527 DOI: 10.2176/nmc.ra.2018-0272] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The “cerebrospinal fluid (CSF) circulation theory” of CSF flowing unidirectionally and circulating through the ventricles and subarachnoid space in a downward or upward fashion has been widely recognized. In this review, observations of CSF motion using different magnetic resonance imaging (MRI) techniques are described, findings that are shared among these techniques are extracted, and CSF motion, as we currently understand it based on the results from the quantitative analysis of CSF motion, is discussed, along with a discussion of slower water molecule motion in the perivascular, paravascular, and brain parenchyma. Today, a shared consensus regarding CSF motion is being formed, as follows: CSF motion is not a circulatory flow, but a combination of various directions of flow in the ventricles and subarachnoid space, and the acceleration of CSF motion differs depending on the CSF space. It is now necessary to revise the currently held concept that CSF flows unidirectionally. Currently, water molecule motion in the order of centimeters per second can be detected with various MRI techniques. Thus, we need new MRI techniques with high-velocity sensitivity, such as in the order of 10 μm/s, to determine water molecule movement in the vessel wall, paravascular space, and brain parenchyma. In this paper, the authors review the previous and current concepts of CSF motion in the central nervous system using various MRI techniques.
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Affiliation(s)
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University
| | - Satoshi Yatsushiro
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University.,BioView Inc., Tokyo, Japan
| | | | - Naokazu Hayashi
- Department of Neurosurgery, Tokai University School of Medicine
| | - Ken Takizawa
- Department of Ophthalmology, Tokai University School of Medicine
| | - Hideki Atsumi
- Department of Neurosurgery, Tokai University School of Medicine
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11
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Sarica A, Curcio M, Rapisarda L, Cerasa A, Quattrone A, Bono F. Periventricular white matter changes in idiopathic intracranial hypertension. Ann Clin Transl Neurol 2019; 6:233-242. [PMID: 30847356 PMCID: PMC6389746 DOI: 10.1002/acn3.685] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/25/2018] [Accepted: 10/05/2018] [Indexed: 12/12/2022] Open
Abstract
Objective To evaluate whether increased cerebrospinal fluid (CSF) pressure causes alteration of periventricular white matter (WM) microstructure in patients with idiopathic intracranial hypertension (IIH). Methods In a prospective study, patients with refractory chronic headache with and without IIH performed a neuroimaging study including 3T MRI, 3D Phase Contrast MR venography, and diffusion tensor imaging (DTI) of the brain. Whole‐brain voxel‐wise comparisons of DTI abnormalities of WM were performed using tract‐based spatial statistics. A correlation analysis between DTI indices and CSF opening pressure, highest peak, and mean pressure was also performed in patients with IIH. Results We enrolled 62 consecutive patients with refractory chronic headaches. Thirty‐five patients with IIH, and 27 patients without increased intracranial pressure. DTI analysis revealed no fractional anisotropy changes, but decreased mean, axial, and radial diffusivity in body (IIHMD = 0.80 ± 0.04, non‐IIHMD = 0.84 ± 0.4, IIHAD = 1.67 ± 0.07, non‐IIHAD = 1.74 ± 0.05, IIHRD = 0.38 ± 0.04, non‐IIHRD = 0.42 ± 0.05 [mm2/sec × 10−3]) of corpus callosum, and in right superior corona radiata (IIHMD = 0.75 ± 0.04, non‐IIHMD = 0.79 ± 0.05, IIHAD = 1.19 ± 0.07, non‐IIHAD = 1.28 ± 0.09, IIHRD = 0.59 ± 0.03, non‐IIHRD = 0.53 ± 0.03 [mm2/sec × 10−3]) of 35 patients with IIH compared with 27 patients without increased intracranial pressure. DTI indices were negatively correlated with high CSF pressures (P < 0.05). After medical treatment, eight patients showed incremented MD in anterior corona radiata left and right and superior corona radiata right. Conclusions There is significant DTI alteration in periventricular WM microstructure of patients with IIH suggesting tissue compaction correlated with high CSF pressure. This periventricular WM change may be partially reversible after medical treatment.
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Affiliation(s)
- Alessia Sarica
- Department of Medical and Surgical Sciences Neuroscience Centre Magna Græcia University of Catanzaro Catanzaro Italy
| | - Maria Curcio
- Department of Medical and Surgical Sciences Center for Headache and Intracranial Pressure Disorders Institute of Neurology Magna Græcia University of Catanzaro Catanzaro Italy
| | - Laura Rapisarda
- Department of Medical and Surgical Sciences Center for Headache and Intracranial Pressure Disorders Institute of Neurology Magna Græcia University of Catanzaro Catanzaro Italy
| | - Antonio Cerasa
- Neuroimaging Research Unit Institute of Bioimaging and Molecular Physiology National Research Council Catanzaro Italy.,S. Anna Institute and Research in Advanced Neurorehabilitation Crotone Italy
| | - Aldo Quattrone
- Department of Medical and Surgical Sciences Neuroscience Centre Magna Græcia University of Catanzaro Catanzaro Italy.,Neuroimaging Research Unit Institute of Bioimaging and Molecular Physiology National Research Council Catanzaro Italy
| | - Francesco Bono
- Department of Medical and Surgical Sciences Center for Headache and Intracranial Pressure Disorders Institute of Neurology Magna Græcia University of Catanzaro Catanzaro Italy
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12
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Takizawa K, Matsumae M, Hayashi N, Hirayama A, Yatsushiro S, Kuroda K. Hyperdynamic CSF motion profiles found in idiopathic normal pressure hydrocephalus and Alzheimer's disease assessed by fluid mechanics derived from magnetic resonance images. Fluids Barriers CNS 2017; 14:29. [PMID: 29047355 PMCID: PMC5648475 DOI: 10.1186/s12987-017-0077-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 10/13/2017] [Indexed: 11/29/2022] Open
Abstract
Background Magnetic resonance imaging (MRI) does not only ascertain morphological features, but also measures physiological properties such as fluid velocity or pressure gradient. The purpose of this study was to investigate cerebrospinal fluid (CSF) dynamics in patients with morphological abnormalities such as enlarged brain ventricles and subarachnoid spaces. We used a time-resolved three dimensional phase contrast (3D-PC) MRI technique to quantitatively evaluate CSF dynamics in the Sylvian aqueduct of healthy elderly individuals and patients with either idiopathic normal pressure hydrocephalus (iNPH) or Alzheimer’s disease (AD) presenting with ventricular enlargement. Methods Nineteen healthy elderly individuals, ten iNPH patients, and seven AD patients (all subjects ≥ 60 years old) were retrospectively evaluated 3D-PC MRI. The CSF velocity, pressure gradient, and rotation in the Sylvian aqueduct were quantified and compared between the three groups using Kolmogorov–Smirnov and Mann–Whitney U tests. Results There was no statistically significant difference in velocity among the three groups. The pressure gradient was not significantly different between the iNPH and AD groups, but was significantly different between the iNPH group and the healthy controls (p < 0.001), and similarly, between the AD group and the healthy controls (p < 0.001). Rotation was not significantly different between the iNPH and AD groups, but was significantly different between the iNPH group and healthy controls (p < 0.001), and similarly, between the AD group and the healthy controls (p < 0.001). Conclusions Quantitative analysis of CSF dynamics with time resolved 3D-PC MRI revealed differences and similarities in the Sylvian aqueduct between healthy elderly individuals, iNPH patients, and AD patients. The results showed that CSF motion is in a hyperdynamic state in both iNPH and AD patient groups compared to healthy elderly individuals, and that iNPH patients and AD patients display similar CSF motion profiles.
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Affiliation(s)
- Ken Takizawa
- Department of Neurosurgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 2591193, Japan
| | - Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 2591193, Japan.
| | - Naokazu Hayashi
- Department of Neurosurgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 2591193, Japan
| | - Akihiro Hirayama
- Department of Neurosurgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 2591193, Japan
| | - Satoshi Yatsushiro
- Course of Science and Technology, Graduate School of Science and Technology, Tokai University, 4-1-1 Kitakaname, Hiratsuka, Kanagawa, 2591292, Japan.,Department of Biological Engineering, Tokai University, School of Biological Engineering, 4-1-1 Kitakaname, Hiratsuka, Kanagawa, 2591292, Japan
| | - Kagayaki Kuroda
- Course of Science and Technology, Graduate School of Science and Technology, Tokai University, 4-1-1 Kitakaname, Hiratsuka, Kanagawa, 2591292, Japan.,Department of Biological Engineering, Tokai University, School of Biological Engineering, 4-1-1 Kitakaname, Hiratsuka, Kanagawa, 2591292, Japan
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13
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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: 5] [Impact Index Per Article: 0.7] [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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14
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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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15
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Beggs CB, Magnano C, Shepherd SJ, Belov P, Ramasamy DP, Hagemeier J, Zivadinov R. Dirty-Appearing White Matter in the Brain is Associated with Altered Cerebrospinal Fluid Pulsatility and Hypertension in Individuals without Neurologic Disease. J Neuroimaging 2015; 26:136-43. [DOI: 10.1111/jon.12249] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 03/04/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Clive B. Beggs
- Centre for Infection Control and Biophysics; University of Bradford; Bradford UK
- Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Christopher Magnano
- Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
- MRI Clinical Translational Research Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Simon J. Shepherd
- Centre for Infection Control and Biophysics; University of Bradford; Bradford UK
| | - Pavel Belov
- Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Deepa P. Ramasamy
- Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
- MRI Clinical Translational Research Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Jesper Hagemeier
- Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Robert Zivadinov
- Department of Neurology, Buffalo Neuroimaging Analysis Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
- MRI Clinical Translational Research Center, School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
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