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Nortvig MJ, Eriksen NL, Schou Andersen MC, Nielsen ET, Munthe S, Pedersen CB, Poulsen FR. Fundoscopy as a diagnostic biomarker in idiopathic normal pressure hydrocephalus: a pilot study. BMJ Neurol Open 2025; 7:e001103. [PMID: 40270621 PMCID: PMC12015714 DOI: 10.1136/bmjno-2025-001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2025] [Accepted: 04/09/2025] [Indexed: 04/25/2025] Open
Abstract
Background Idiopathic normal pressure hydrocephalus (iNPH) has a prevalence of approximately 5%. It is characterised by Hakim's triad of impaired gait, cognitive dysfunction and urinary incontinence. Despite radiological markers and liquor-dynamic tests, iNPH is difficult to diagnose due to many overlapping symptoms. The aim of this study was to evaluate funduscopy as a noninvasive method of screening patients with suspected iNPH. Methods Patients with suspected iNPH who underwent a lumbar infusion test (LIT) were included. Funduscopy was performed before the start of the LIT, and intracranial pressure (ICP) was continually measured via lumbar cannulation. Retinal images were analysed using an artificial intelligence algorithm to determine the arteriole-venule (A/V) ratio. The A/V ratio and ICP measurements were compared with the iNPH diagnosis. In addition, the mean difference in shunt response was evaluated. Results A significantly lower mean A/V ratio was found in the iNPH group compared with the non-iNPH group (p value: 0.02). Receiver operating characteristic curve analysis with an area under the curve of 0.75 showed a sensitivity of 88% and a specificity of 50% with an A/V cut-off of 0.86. Although not statistically significant, the mean A/V ratio was lower in the group with clinical shunt effect compared with those without (p value: 0.305). Conclusions This study found a statistically significant difference in baseline A/V ratios between iNPH and non-iNPH groups. This pilot study suggests the A/V ratio might be able to serve as a screening tool for iNPH. If so, this would be highly beneficial for patients and could have significant medical and socioeconomic implications.
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Affiliation(s)
- Mathias Just Nortvig
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Niclas Lynge Eriksen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Mikkel C Schou Andersen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Emma Tubæk Nielsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Sune Munthe
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Christian Bonde Pedersen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
- Clinical Institute, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
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Hamilton MG, Williams MA, Edwards S, Tullberg M. Guidelines for Diagnosis and Management of Idiopathic Normal Pressure Hydrocephalus. Neurosurg Clin N Am 2025; 36:199-205. [PMID: 40054973 DOI: 10.1016/j.nec.2024.12.006] [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: 05/13/2025]
Abstract
In 1965, Hakim and Adams described 3 patients with normal pressure hydrocephalus who responded to treatment with a ventriculoatrial shunt. Afterward the adoption of shunt treatment without clear diagnostic criteria and surgical techniques resulted in poor outcomes with significant complications. The clinical practice guidelines for the diagnosis and treatment of idiopathic normal pressure hydrocephalus were first published by the Japanese Neurosurgical Society in 2004 and the international guidelines were published in 2005. Both guidelines led to diagnosis and treatment algorithms and significantly improved outcomes, along with decreased surgical risk. These guidelines should be reevaluated and updated on a regular basis.
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Affiliation(s)
- Mark G Hamilton
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, Foothills Hospital, 1403 - 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada.
| | - Michael A Williams
- Department of Neurological Surgery, University of Washington School of Medicine, Box 359924, 325 9th Avenue, Seattle, WA 98104-2499, USA; Department of Neurological Surgery, University of Washington School of Medicine, Box 359924, 325 9th Avenue, Seattle, WA 98104-2499, USA
| | - Sara Edwards
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, Foothills Hospital, 1403 - 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska Academy, Sahlgrenska University Hospital, Neurosjukvården, Blå stråket 5, 13 vån, SE-41345, Gothenburg, Sweden
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Palermo G, Francesconi A, Bellini G, Morganti R, Migaleddu G, Di Carlo DT, Perrini P, Benedetto N, Pacchetti C, Volterrani D, Cosottini M, Fasano A, Ceravolo R. Involvement of the Nigrostriatal Pathway in Patients With Idiopathic Normal Pressure Hydrocephalus and Parkinsonism. Neurology 2025; 104:e213352. [PMID: 39928907 DOI: 10.1212/wnl.0000000000213352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 12/13/2024] [Indexed: 02/12/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Idiopathic normal pressure hydrocephalus (iNPH) is characterized by gait disturbance, cognitive decline, and urinary incontinence and may include parkinsonism. The underlying mechanism of parkinsonism in iNPH-whether neurodegenerative or mechanical-remains unclear. This study aimed to assess nigrostriatal integrity in iNPH patients with parkinsonism using dopaminergic transporter imaging (DAT-SPECT) and nigrosome MRI. METHODS This prospective study was conducted at the Movement Disorders Clinic, Santa Chiara Hospital, Pisa University, from 2021 to 2023. Inclusion criteria for the iNPH group included the following: (1) clinical diagnosis of probable iNPH per the 2021 Japanese Society Guidelines and (2) parkinsonism per United Kingdom Parkinson's Disease Society Brain Bank criteria. An equal number of patients with Parkinson disease (PD), matched for age and sex, served as a comparison group. All participants underwent DAT-SPECT and 3T MRI within 1 month. Statistical analyses included the Student t test or Fisher-Pitman permutation tests for continuous variables and χ2 tests for categorical variables. Multiple linear regression (adjusted for age and sex) compared DAT binding between groups. Pearson correlation assessed relationships between striatal DAT binding and parkinsonism in patients with iNPH evaluated using the Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III. RESULTS A total of 20 patients with iNPH (mean age 75.4 ± 5.1 years, 65% female) and 20 patients with PD (mean age 74 ± 3.7 years, 55% female) were included. Reduced striatal DAT binding was observed in 45% of patients with iNPH, with none exhibiting nigrosome loss. Conversely, all patients with PD showed both reduced DAT binding and nigrosome loss (p < 0.001). After adjusting for age and sex, patients with iNPH exhibited significantly higher putaminal and caudate DAT binding than patients with PD (right putamen: β = -0.644, p < 0.001; left putamen: β = -0.659, p < 0.001; right caudate: β = -0.429, p = 0.006; left caudate: β = -0.391, p = 0.016), with an elevated putaminal/caudate ratio (p = 0.012). In patients with iNPH, striatal DAT binding negatively correlated with motor severity (left: r = -0.626, p = 0.004; right: r = -0.425, p = 0.07). DISCUSSION Findings suggest that parkinsonism in iNPH may stem from mechanical disruption of the nigrostriatal pathway rather than neurodegeneration, as indicated by preserved nigrosome integrity despite reduced DAT binding. Limitations include the small sample size and lack of postsurgical follow-up data.
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Affiliation(s)
- Giovanni Palermo
- Center for Neurodegenerative Diseases-Parkinson's Disease and Movement Disorders, Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Alessio Francesconi
- Center for Neurodegenerative Diseases-Parkinson's Disease and Movement Disorders, Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Gabriele Bellini
- Center for Neurodegenerative Diseases-Parkinson's Disease and Movement Disorders, Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | | | - Gianmichele Migaleddu
- Neuroradiology Unit, Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Davide Tiziano Di Carlo
- Neurosurgery Unit, Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Paolo Perrini
- Neurosurgery Unit, Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Nicola Benedetto
- Neurosurgery Unit, Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Claudio Pacchetti
- Parkinson's Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Duccio Volterrani
- Nuclear Medicine Unit, Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Ontario, Canada
- Division of Neurology, University of Toronto, Ontario, Canada; and
- Krembil Brain Institute, Toronto, Ontario, Canada
| | - Roberto Ceravolo
- Center for Neurodegenerative Diseases-Parkinson's Disease and Movement Disorders, Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
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Spiegelberg A, Boraschi A, Amirah R, Wolf K, Shah M, Krismer L, Beck J, Kurtcuoglu V. B-waves in noninvasive capacitance signal correlate with B-waves in ICP. Acta Neurochir (Wien) 2025; 167:60. [PMID: 40048032 PMCID: PMC11885407 DOI: 10.1007/s00701-025-06461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 02/06/2025] [Indexed: 03/09/2025]
Abstract
BACKGROUND Analysis of B-waves in overnight intracranial pressure (ICP) recordings used to be an important element in the diagnosis of normal pressure hydrocephalus (NPH). Here, we tested the hypothesis that equivalents to B-waves can be detected and quantified in a noninvasively measured electric capacitance signal termed W. METHODS We measured ICP and W in a cohort of 15 patients with suspected diagnosis of NPH or spontaneous intracranial hypotension during infusion testing, identifying B-waves in both signals by wave-template matching in the time domain. RESULTS We found very strong correlation between the duration of B-waves in ICP and W (R2 = 0.86, p < 10-6), and weak correlation between the average B-wave amplitudes in ICP and W (R = 0.34, p = 0.02). CONCLUSIONS The concurrent presence of B-waves in the signals suggests that vasogenic activity of cerebral autoregulation is reflected in W. The weaker correlation of amplitudes may be attributed to W being an indirect measure of cranial volume composition, whereas ICP is a measure of pressure, with the two linked by the non-linear craniospinal pressure-volume relation that varies between patients. Analysis of the noninvasively acquired W signal should be evaluated as a triage tool for patients with NPH and other disorders characterized by reduced compliance.
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Affiliation(s)
- Andreas Spiegelberg
- The Interface Group, Department of Physiology, University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland
| | - Andrea Boraschi
- The Interface Group, Department of Physiology, University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland
| | - Ramy Amirah
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Katharina Wolf
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Laura Krismer
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Vartan Kurtcuoglu
- The Interface Group, Department of Physiology, University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland.
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland.
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Iseki C, Ishii K, Pozzi NG, Todisco M, Pacchetti C. Instrumental assessment of INPH: structural and functional neuroimaging. J Neurosurg Sci 2025; 69:64-78. [PMID: 40045805 DOI: 10.23736/s0390-5616.25.06411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2025]
Abstract
INTRODUCTION For the accurate diagnosis of idiopathic normal pressure hydrocephalus (iNPH) an accurate neuroimaging is essential. Disproportionately enlarged subarachnoid-space hydrocephalus (DESH) is a key neuroradiological feature and novel imaging techniques, including voxel-based morphometry and AI-assisted analyses are emerging as powerful tools to investigate iNPH pathophysiology. Converging evidence also suggests a role for dopaminergic dysfunction in iNPH. Molecular imaging of the dopamine transporter (DaT) enables the investigation of dopaminergic function and holds potential for advancing differential diagnosis and guiding treatment decisions in iNPH. EVIDENCE ACQUISITION A comprehensive literature search was conducted using MeSH key words. Studies assessing the role of structural and functional neuroimaging in iNPH. The evidence was summarized, and key results were provided. EVIDENCE SYNTHESIS DESH is crucial for accurate diagnosis and treatment planning. Advanced structural and functional imaging techniques are expanding our understanding of iNPH pathophysiology. Only few functional imaging studies have directly examined the dopaminergic dysfunction in iNPH and severe methodological limitations exist in both clinical classification and imaging processing. Nonetheless, evidence supports the presence of dopaminergic dysfunction in iNPH, which may be linked to specific clinical symptoms, aid in differential diagnosis, and be reversed with shunt surgery treatment. CONCLUSIONS This review covers the structural and functional imaging data in iNPH, providing a comprehensive outlook of the current knowledge, highlighting the limitations and possible future perspectives.
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Affiliation(s)
- Chifumi Iseki
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan -
| | - Kazunari Ishii
- Department of Radiology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Nicolò G Pozzi
- Department of Neurology, University Hospital and Julius-Maximilians-Universität Würzburg, Würzburg, Germany
| | - Massimiliano Todisco
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Claudio Pacchetti
- Parkinson's Disease and Movement Disorders Unit, IRCCS Mondino Foundation, Pavia, Italy
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Daniel Fabiyi O, Busayo Ogunlade S. A Case of Lacunar Stroke in a Patient with Possible Normal Pressure Hydrocephalus (NPH). Niger Med J 2025; 66:364-369. [PMID: 40309540 PMCID: PMC12038619 DOI: 10.71480/nmj-v66i1.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2025] Open
Abstract
Background Normal pressure hydrocephalus (NPH) is a condition seen in the elderly, characterized by gait disturbances, urinary incontinence, and cognitive impairment. However, sudden onset neurological deficits suggest a vascular event rather than NPH. Methodology We report a case of a 65-year-old male who presented with sudden onset gait difficulty and speech impairment, initially suspected to be idiopathic NPH. The diagnostic process and management strategies are discussed. Results The patient's symptoms, including insidious gait difficulties, speech impairment, and memory loss, led to a suspected diagnosis of NPH. However, the sudden improvement of neurological deficits indicated a vascular cause. Computed Tomography (CT) imaging identified supporting evidence of a lacunar stroke, leading to a revised diagnosis. Conclusion This case highlights the importance of considering vascular events in the differential diagnosis of NPH, especially when sudden neurological deficits improve rapidly. Early identification and differentiation between NPH and vascular events are crucial for appropriate management, particularly in low-resource settings.
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Brook M, Reilly J, Korutz A, Tate MC, Finley JCA, Pollner E, Yerneni K, Mosti C, Karras C, Trybula SJ, Stratton J, Martinovich Z. Neurocognitive change over the course of a multiday external lumbar drain trial in patients with suspected normal pressure hydrocephalus. Clin Neuropsychol 2024; 38:1610-1626. [PMID: 38360560 DOI: 10.1080/13854046.2024.2315737] [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: 08/11/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024]
Abstract
Objective: To characterize neurocognitive response to cerebrospinal fluid (CSF) diversion during a multiday external lumbar drainage (ELD) trial in patients with suspected normal pressure hydrocephalus (NPH). Methods: Inpatients (N = 70) undergoing an ELD trial as part of NPH evaluation participated. Cognition and balance were assessed using standardized measures before and after a three-day ELD trial. Cognitive change pre- to post-ELD trial was assessed in relation to change in balance, baseline neuroimaging findings, NPH symptoms, demographics, and other disease-relevant clinical parameters. Results: Multiday ELD resulted in significant cognitive improvement (particularly on measures of memory and language). This improvement was independent of demographics, test-retest interval, number of medical and psychiatric comorbidities, NPH symptom duration, estimated premorbid intelligence, baseline level of cognitive impairment, cerebrovascular disease burden, degree of ventriculomegaly, or other NPH-related morphological brain alterations. Balance scores evidenced a greater magnitude of improvement than cognitive scores and were weakly, but positively correlated with cognitive change scores. Conclusions: Findings suggest that cognitive improvement associated with a multiday ELD trial can be sufficiently captured with bedside neurocognitive testing. These findings support the utility of neuropsychological consultation, along with balance assessment, in informing clinical decision-making regarding responsiveness to temporary CSF diversion for patients undergoing elective NPH evaluation. Implications for the understanding of neuroanatomical and cognitive underpinnings of NPH are discussed.
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Affiliation(s)
- Michael Brook
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James Reilly
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alexander Korutz
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew C Tate
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John-Christopher A Finley
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emma Pollner
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ketan Yerneni
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Caterina Mosti
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA
| | - Constantine Karras
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Siting Joy Trybula
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Stratton
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
| | - Zoran Martinovich
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Bendella Z, Purrer V, Haase R, Zülow S, Kindler C, Borger V, Banat M, Dorn F, Wüllner U, Radbruch A, Schmeel FC. Brain and Ventricle Volume Alterations in Idiopathic Normal Pressure Hydrocephalus Determined by Artificial Intelligence-Based MRI Volumetry. Diagnostics (Basel) 2024; 14:1422. [PMID: 39001312 PMCID: PMC11241572 DOI: 10.3390/diagnostics14131422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/25/2024] [Accepted: 06/29/2024] [Indexed: 07/16/2024] Open
Abstract
The aim of this study was to employ artificial intelligence (AI)-based magnetic resonance imaging (MRI) brain volumetry to potentially distinguish between idiopathic normal pressure hydrocephalus (iNPH), Alzheimer's disease (AD), and age- and sex-matched healthy controls (CG) by evaluating cortical, subcortical, and ventricular volumes. Additionally, correlations between the measured brain and ventricle volumes and two established semi-quantitative radiologic markers for iNPH were examined. An IRB-approved retrospective analysis was conducted on 123 age- and sex-matched subjects (41 iNPH, 41 AD, and 41 controls), with all of the iNPH patients undergoing routine clinical brain MRI prior to ventriculoperitoneal shunt implantation. Automated AI-based determination of different cortical and subcortical brain and ventricular volumes in mL, as well as calculation of population-based normalized percentiles according to an embedded database, was performed; the CE-certified software mdbrain v4.4.1 or above was used with a standardized T1-weighted 3D magnetization-prepared rapid gradient echo (MPRAGE) sequence. Measured brain volumes and percentiles were analyzed for between-group differences and correlated with semi-quantitative measurements of the Evans' index and corpus callosal angle: iNPH patients exhibited ventricular enlargement and changes in gray and white matter compared to AD patients and controls, with the most significant differences observed in total ventricular volume (+67%) and the lateral (+68%), third (+38%), and fourth (+31%) ventricles compared to controls. Global ventriculomegaly and marked white matter reduction with concomitant preservation of gray matter compared to AD and CG were characteristic of iNPH, whereas global and frontoparietally accentuated gray matter reductions were characteristic of AD. Evans' index and corpus callosal angle differed significantly between the three groups and moderately correlated with the lateral ventricular volumes in iNPH patients [Evans' index (r > 0.83, p ≤ 0.001), corpus callosal angle (r < -0.74, p ≤ 0.001)]. AI-based MRI volumetry in iNPH patients revealed global ventricular enlargement and focal brain atrophy, which, in contrast to healthy controls and AD patients, primarily involved the supratentorial white matter and was marked temporomesially and in the midbrain, while largely preserving gray matter. Integrating AI volumetry in conjunction with traditional radiologic measures could enhance iNPH identification and differentiation, potentially improving patient management and therapy response assessment.
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Affiliation(s)
- Zeynep Bendella
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
| | - Veronika Purrer
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
- Department of Neurodegenerative Diseases, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Robert Haase
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
| | - Stefan Zülow
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
| | - Christine Kindler
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
- Department of Neurodegenerative Diseases, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Valerie Borger
- Department of Neurosurgery, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (V.B.); (M.B.)
| | - Mohammed Banat
- Department of Neurosurgery, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (V.B.); (M.B.)
| | - Franziska Dorn
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
| | - Ullrich Wüllner
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
- Department of Neurodegenerative Diseases, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
| | - Frederic Carsten Schmeel
- Department of Neuroradiology, Faculty of Medicine, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany; (Z.B.); (R.H.); (S.Z.); (F.D.); (A.R.)
- German Center of Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany; (V.P.); (C.K.); (U.W.)
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Valsecchi N, Roda M, Febbraro S, Trolli E, Palandri G, Giannini G, Milletti D, Schiavi C, Fontana L. In vivo assessment of the ocular biomechanical properties in patients with idiopathic normal pressure hydrocephalus. Int Ophthalmol 2024; 44:1. [PMID: 38315313 PMCID: PMC10844352 DOI: 10.1007/s10792-024-02922-3] [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: 11/09/2023] [Accepted: 12/17/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE Idiopathic normal pressure hydrocephalus (iNPH) is associated with an increased prevalence of open-angle glaucoma, attributed to variations of the pressure gradient between intraocular and intracranial compartments at the level of the lamina cribrosa (LC). As ocular biomechanics influence the behavior of the LC, and a lower corneal hysteresis (CH) has been associated to a higher risk of glaucomatous optic nerve damage, in this study we compared ocular biomechanics of iNPH patients with healthy subjects. METHODS Twenty-four eyes of 24 non-shunted iNPH patients were prospectively recruited. Ocular biomechanical properties were investigated using the ocular response analyzer (Reichert Instruments) for the calculation of the CH, corneal resistance factor (CRF), Goldmann-correlated intraocular pressure (IOPg), and corneal-compensated intraocular pressure (IOPcc). Results were compared with those of 25 eyes of 25 healthy subjects. RESULTS In iNPH eyes, the median CH value and interquartile range (IQR) were 9.7 mmHg (7.8-10) and 10.6 mmHg (9.3-11.3) in healthy controls (p = 0.015). No significant differences were found in IOPcc [18.1 mmHg (14.72-19.92) vs. 16.4 mmHg (13.05-19.6)], IOPg [15.4 mmHg (12.82-19.7) vs. 15.3 mmHg (12.55-17.35)], and CRF [9.65 mmHg (8.07-11.65) vs. 10.3 mmHg (9.3-11.5)] between iNPH patients and controls. CONCLUSIONS In iNPH patients, the CH was significantly lower compared to healthy subjects. This result suggests that ocular biomechanical properties may potentially contribute to the risk of development of glaucomatous optic nerve damage in iNPH patients.
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Affiliation(s)
- Nicola Valsecchi
- Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Matilde Roda
- Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simone Febbraro
- Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Eleonora Trolli
- Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giorgio Palandri
- Unit of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - David Milletti
- Unit of Rehabilitation Medicine, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Costantino Schiavi
- Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luigi Fontana
- Ophthalmology Unit, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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10
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Woo JE, Azariah A, Reed EA, Gut N. Medical, Neurologic, and Neuromusculoskeletal Complications. Phys Med Rehabil Clin N Am 2024; 35:127-144. [PMID: 37993183 DOI: 10.1016/j.pmr.2023.06.024] [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: 11/24/2023]
Abstract
For patients with disorders of consciousness (DoC), treating the medical, neurologic, and neuromuscular complications not only stabilizes their medical disturbances, but minimizes confounding factors that may obscure the ability to accurately identify the level of consciousness and increase the chance of patients' neurologic and functional recovery. Lack of reliable communication and low-level function of patients with DoC make it challenging to diagnose some of the complications. Skilled clinical observation will be imperative to appropriately care for the patients.
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Affiliation(s)
- Jean E Woo
- TIRR Memorial Hermann, 1333 Moursund Street, Houston, TX 77030, USA; H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
| | - Abana Azariah
- TIRR Memorial Hermann, 1333 Moursund Street, Houston, TX 77030, USA; Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, 1333 Moursund Street, Houston, TX 77030, USA
| | - Eboni A Reed
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Nicholas Gut
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center at Houston, 1333 Moursund Street, Houston, TX 77030, USA
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11
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Nikitin DV, Dolgushin MB, Dvoryanchikov AV, Rostovtseva TM, Senko IV, Tairova RT. [Possibilities of dynamic phase contrast MRI of cerebrospinal fluid for performing a tap test in a patient with idiopathic normotensive hydrocephalus]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:148-153. [PMID: 38465824 DOI: 10.17116/jnevro2024124021148] [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: 03/12/2024]
Abstract
Idiopathic normotensive hydrocephalus (iNH) is a widespread disease in elderly patients. The effectiveness of iNG treatment and the subsequent quality of patients' lives directly depends on timely and early diagnosis. The criteria for diagnosing iNG that are used in neuroimaging can also be found in patients without clinical manifestations of this disease, and the widely used tap-test is an invasive technique with a rather low sensitivity. The need for early diagnosis and initiation of treatment before the development of irreversible damage to brain structures determines the relevance of the search for an accessible, minimally invasive, accurate and safe diagnostic method. The article presents a clinical observation of the use of phase-contrast MRI of cerebrospinal fluid (CSF) in a female patient with a positive response to the tap test with a quantitative analysis of changes in CSF flow parameters and ALVI and Evans indices depending on the time after CSF evacuation. Phase-contrast MRI of CSF with a quantitative assessment of CSF flow parameters in combination with an assessment of the ALVI index has the potential to increase the accuracy of diagnosing iNH and is of scientific interest for further research.
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Affiliation(s)
- D V Nikitin
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - M B Dolgushin
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - A V Dvoryanchikov
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - T M Rostovtseva
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - I V Senko
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - R T Tairova
- Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
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12
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Pyrgelis ES, Paraskevas GP, Constantinides VC, Boufidou F, Papaioannou M, Stefanis L, Kapaki E. Alzheimer's Disease CSF Biomarkers as Possible Indicators of Tap-Test Response in Idiopathic Normal Pressure Hydrocephalus. Brain Sci 2023; 13:1593. [PMID: 38002553 PMCID: PMC10670082 DOI: 10.3390/brainsci13111593] [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: 08/30/2023] [Revised: 10/18/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
The aim of the present study is the evaluation of established Alzheimer's disease (AD) cerebrospinal fluid (CSF) biomarkers in patients with idiopathic normal-pressure hydrocephalus (iNPH), both individually and as a total profile, and the investigation of their use as potential predictors of Tap-test responsiveness. Fifty-three patients with iNPH participated in the study. Aβ42, Aβ40, total Tau and phospho-Tau proteins were measured in duplicate with double-sandwich ELISA assays. Clinical evaluation involved a 10 m timed walk test before an evacuative lumbar puncture (LP) and every 24 h for three consecutive days afterwards. Neuropsychological assessment involved a mini-mental state examination, frontal assessment battery, 5-word test and CLOX drawing test 1 and 2, which were also performed before and 48 h after LP. Response in the Tap-test was defined as a 20% improvement in gait and/or a 10% improvement in neuropsychological tests. The Aβ42/Aβ40 ratio was found to be significantly higher in Tap-test responders than non-responders. Total Tau and phospho-Tau CSF levels also differed significantly between these two groups, with Tap-test responders presenting with lower levels compared to non-responders. Regarding the AD CSF biomarker profile (decreased amyloid and increased Tau proteins levels), patients with a non-AD profile were more likely to have a positive response in the Tap-test than patients with an AD profile.
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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; (E.-S.P.); (V.C.C.); (L.S.)
- 1st Department of Neurology, Neurochemistry and Biological Markers Unit, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (G.P.P.); (F.B.); (M.P.)
| | - George P. Paraskevas
- 1st Department of Neurology, Neurochemistry and Biological Markers Unit, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (G.P.P.); (F.B.); (M.P.)
- 2nd Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University General Hospital, Rimini 1, 12462 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; (E.-S.P.); (V.C.C.); (L.S.)
- 1st Department of Neurology, Neurochemistry and Biological Markers Unit, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (G.P.P.); (F.B.); (M.P.)
| | - Fotini Boufidou
- 1st Department of Neurology, Neurochemistry and Biological Markers Unit, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (G.P.P.); (F.B.); (M.P.)
| | - Myrto Papaioannou
- 1st Department of Neurology, Neurochemistry and Biological Markers Unit, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (G.P.P.); (F.B.); (M.P.)
| | - Leonidas Stefanis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (E.-S.P.); (V.C.C.); (L.S.)
| | - Elisabeth Kapaki
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (E.-S.P.); (V.C.C.); (L.S.)
- 1st Department of Neurology, Neurochemistry and Biological Markers Unit, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece; (G.P.P.); (F.B.); (M.P.)
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13
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Passaretti M, Maranzano A, Bluett B, Rajalingam R, Fasano A. Gait Analysis in Idiopathic Normal Pressure Hydrocephalus: A Meta-Analysis. Mov Disord Clin Pract 2023; 10:1574-1584. [PMID: 38026510 PMCID: PMC10654838 DOI: 10.1002/mdc3.13816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/19/2023] [Accepted: 05/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background Gait analysis objectively quantifies gait impairment in idiopathic normal pressure hydrocephalus (iNPH), may improve diagnosis and evaluation for surgical candidacy. Objectives This meta-analysis aims to understand which objective gait parameters improve after tap-test (TT) and CSF shunt surgery (CSS), also comparing responders (R) with non-responders (NR) and to assess if gait restores within the range of healthy controls after procedures. Methods Studies enrolling iNPH with at least one instrumented gait measure were selected. Three time points of gait assessment were defined: PRE, POST-TT, and POST-CSS. Gait velocity, cadence, step length, stride length, and double limb support time were evaluated. Patients were categorized based on responsiveness to CSF diversion procedures. Results Seventeen studies including 527 patients were selected. iNPH improved significantly in almost all gait parameters POST-TT, and to a greater extent POST-CSS. Gait parameters consistently discriminated iNPH from healthy controls. Despite the aforementioned improvements, iNPH's gait did not completely normalize after CSF diversion procedures. Meta-regression analysis also revealed that TT's effect on gait velocity plateaus after 24-48 hr and returns to baseline in 90-100 hr. Conclusions Gait analysis is a reliable quantitative instrument to assess gait impairment in iNPH, demarking a net differentiation from healthy controls, according to the notion that the iNPH CSF dynamic alteration also leads to an irreversible damage. Specific gait parameters improve among TT-R, providing an opportunity to select patients that will respond to CSS. Future studies validating a standardized reporting method including criteria of responsiveness, specific gait parameters, and timeframe of assessment are needed.
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Affiliation(s)
| | - Alessio Maranzano
- Department of Neurology and Laboratory of NeuroscienceIstituto Auxologico Italiano IRCCSMilanItaly
| | - Brent Bluett
- Central California Movement DisordersPismo BeachCaliforniaUSA
| | - Rajasumi Rajalingam
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital–UHN, Division of NeurologyUniversity of TorontoTorontoOntarioCanada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital–UHN, Division of NeurologyUniversity of TorontoTorontoOntarioCanada
- Krembil Brain InstituteTorontoOntarioCanada
- Department of Parkinson's Disease and Movement Disorders RehabilitationMoriggia‐Pelascini Hospital–Gravedona ed UnitiComoItaly
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14
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Özge A, Domaç FM, Tekin N, Sünbül EA, Öksüz N, Atalar AÇ, Çallı SY, Fidan YS, Evlice A, Beştepe EE, İzci F, Küsbeci ÖY, Demirel EA, Velioğlu SK, Ungan M. One Patient, Three Providers: A Multidisciplinary Approach to Managing Common Neuropsychiatric Cases. J Clin Med 2023; 12:5754. [PMID: 37685821 PMCID: PMC10488785 DOI: 10.3390/jcm12175754] [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: 07/27/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Neuropsychiatric cases require a multidisciplinary approach for effective management. This paper presented case-based discussions on migraine, dementia, epilepsy, mood disorders, neuralgia, and psychosis from the perspectives of a family physician, neurologist, and psychiatrist. The goal was to highlight the importance of collaboration between healthcare providers in managing these complex cases. METHODS The paper was based on the proceedings of the Mediterranean Neuropsychiatry Symposium, where experts from family medicine, neurology, and psychiatry came together for comprehensive case-based discussions. The CARE framework (Case Report, Appraisal, Research, and Education) was developed to guide reporting and evaluation of case reports in clinical practice. RESULTS Six cases were presented and discussed, highlighting the importance of a multidisciplinary approach in managing neuropsychiatric cases. The cases included chronic migraine with medication overuse, memory dysfunction with language and behavioral problems, refractory epileptic seizures with subjective sensory symptoms, bipolar affective disorder with normal pressure hydrocephalus, postherpetic neuralgia in a case with bipolar affective disorder, and psychosis with recurrent attacks with the abuse of several substances. CONCLUSION A biopsychosocial multidisciplinary approach is essential for managing neuropsychiatric cases effectively on behalf of the patients and public health of the country. The CARE framework can guide the reporting and evaluation of case reports in clinical practice, ensuring that patients receive comprehensive and effective care. Healthcare providers should collaborate to provide the best possible care for patients with complex and multifaceted needs.
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Affiliation(s)
- Aynur Özge
- Department of Neurology, School of Medicine, Mersin University, Mersin 33110, Türkiye;
| | - Füsun Mayda Domaç
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye;
| | - Nil Tekin
- Department of Family Medicine, Izmir Faculty of Medicine, University of Health Sciences, İzmir 35330, Türkiye;
- Department of Family Medicine, Tepecik Education and Research Hospital, University of Health Sciences, İzmir 35330, Türkiye
| | - Esra Aydın Sünbül
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Nevra Öksüz
- Department of Neurology, School of Medicine, Mersin University, Mersin 33110, Türkiye;
| | - Arife Çimen Atalar
- Neurology Department, Kanuni Sultan Süleyman Education and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye;
| | - Sümeyye Yasemin Çallı
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Yağmur Sever Fidan
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Ahmet Evlice
- Department of Neurology, School of Medicine, Çukurova University, Adana 01330, Türkiye;
| | - Engin Emrem Beştepe
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Filiz İzci
- Department of Psychiatry, Erenköy Mental and Nervous Diseases Training and Research Hospital, University of Health Sciences, İstanbul 34668, Türkiye; (E.A.S.); (S.Y.Ç.); (Y.S.F.); (E.E.B.); (F.İ.)
| | - Özge Yılmaz Küsbeci
- Neurology Department, Medical Faculty, Izmir University of Economics, Izmir 35330, Türkiye;
| | - Esra Acıman Demirel
- Department of Neurology, Zonguldak Bulent Ecevit University of Medicine, Zonguldak 67100, Türkiye;
| | - Sibel K. Velioğlu
- Clinical Neurophysiology Unit, Neurology Department, Medical Faculty, Karadeniz Technical University, Trabzon 61080, Türkiye;
| | - Mehmet Ungan
- Department of Family Medicine, Medical Faculty, Ankara University, Ankara 06100, Türkiye;
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15
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Li H, Liu C, Tai H, Wei Y, Shen T, Yang Q, Zheng K, Xing Y. Comparison of cerebrospinal fluid space between probable normal pressure hydrocephalus and Alzheimer's disease. Front Aging Neurosci 2023; 15:1241237. [PMID: 37693646 PMCID: PMC10484096 DOI: 10.3389/fnagi.2023.1241237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction Idiopathic normal pressure hydrocephalus (INPH) is a potentially reversible syndrome characterized by complex symptoms, difficulty in diagnosis and a lack of detailed clinical description, and it is difficult to distinguish from Alzheimer's disease (AD). The objective of this study was to design a method for measuring the actual amount of hydrocephalus in patients with INPH and to evaluate INPH. Methods All subjects underwent a 3D T1-weighted MRI. Statistical parametric mapping 12 was used for preprocessing images, statistical analysis, and voxel-based morphometric gray matter (GM) volume, white matter (WM) volume, and cerebrospinal fluid (CSF) volume analysis. The demographic and clinical characteristics of the groups were compared using a t-test for continuous variables and a chi-square test for categorical variables. Pearson's correlation analysis and Bonferroni's statistic-corrected one-way ANOVA were used to determine the relationship among demographic variables. Receiver operating characteristic (ROC) curves were used to assess the accuracy of the callosal angle (CA), WM ratio, and CSF ratio in distinguishing probable INPH from AD. Results The study included 42 patients with INPH, 32 patients with AD, and 24 healthy control subjects (HCs). There were no differences among the three groups in basic characteristics except for Mini-Mental State Examination (MMSE). There was a correlation between the intracranial CSF ratio and CA. The WM ratio and CSF ratio in patients with INPH and AD were statistically different. Furthermore, the combination of CA, WM ratio, and CSF ratio had a greater differential diagnostic value between INPH and AD patients than CA alone. Conclusion INPH can be accurately assessed by measuring intracranial CSF ratio, and the addition of WM ratio and CSF ratio significantly improved the differential diagnostic value of probable INPH from AD compared to CA alone.
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Affiliation(s)
- Hongliang Li
- Department of Neurology, Aviation General Hospital, Beijing, China
| | - Chunyan Liu
- Department of Neurology, Aviation General Hospital, Beijing, China
| | - Hong Tai
- Department of Medical Imaging, Aviation General Hospital, Beijing, China
| | - Youping Wei
- Department of Rehabilitation, Aviation General Hospital, Beijing, China
| | - Taizhong Shen
- Department of Rehabilitation, Aviation General Hospital, Beijing, China
| | - Qiong Yang
- Department of Neurology, Aviation General Hospital, Beijing, China
| | - Keyang Zheng
- Department of Cardiovascular Medicine, Capital Medical University Affiliated Anzhen Hospital, Beijing, China
| | - Yan Xing
- Department of Neurology, Aviation General Hospital, Beijing, China
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16
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Funnell JP, Noor K, Khan DZ, D'Antona L, Dobson RJB, Hanrahan JG, Hepworth C, Moncur EM, Thomas BM, Thorne L, Watkins LD, Williams SC, Wong WK, Toma AK, Marcus HJ. Characterization of patients with idiopathic normal pressure hydrocephalus using natural language processing within an electronic healthcare record system. J Neurosurg 2023; 138:1731-1739. [PMID: 36401545 DOI: 10.3171/2022.9.jns221095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Idiopathic normal pressure hydrocephalus (iNPH) is an underdiagnosed, progressive, and disabling condition. Early treatment is associated with better outcomes and improved quality of life. In this paper, the authors aimed to identify features associated with patients with iNPH using natural language processing (NLP) to characterize this cohort, with the intention to later target the development of artificial intelligence-driven tools for early detection. METHODS The electronic health records of patients with shunt-responsive iNPH were retrospectively reviewed using an NLP algorithm. Participants were selected from a prospectively maintained single-center database of patients undergoing CSF diversion for probable iNPH (March 2008-July 2020). Analysis was conducted on preoperative health records including clinic letters, referrals, and radiology reports accessed through CogStack. Clinical features were extracted from these records as SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) concepts using a named entity recognition machine learning model. In the first phase, a base model was generated using unsupervised training on 1 million electronic health records and supervised training with 500 double-annotated documents. The model was fine-tuned to improve accuracy using 300 records from patients with iNPH double annotated by two blinded assessors. Thematic analysis of the concepts identified by the machine learning algorithm was performed, and the frequency and timing of terms were analyzed to describe this patient group. RESULTS In total, 293 eligible patients responsive to CSF diversion were identified. The median age at CSF diversion was 75 years, with a male predominance (69% male). The algorithm performed with a high degree of precision and recall (F1 score 0.92). Thematic analysis revealed the most frequently documented symptoms related to mobility, cognitive impairment, and falls or balance. The most frequent comorbidities were related to cardiovascular and hematological problems. CONCLUSIONS This model demonstrates accurate, automated recognition of iNPH features from medical records. Opportunities for translation include detecting patients with undiagnosed iNPH from primary care records, with the aim to ultimately improve outcomes for these patients through artificial intelligence-driven early detection of iNPH and prompt treatment.
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Affiliation(s)
- Jonathan P Funnell
- 1Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London
- 2National Hospital for Neurology and Neurosurgery, London
| | - Kawsar Noor
- 3Institute for Health Informatics, University College London
- 4NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London
| | - Danyal Z Khan
- 1Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London
- 2National Hospital for Neurology and Neurosurgery, London
| | - Linda D'Antona
- 2National Hospital for Neurology and Neurosurgery, London
- 5UCL Queen Square Institute of Neurology, University College London
| | - Richard J B Dobson
- 3Institute for Health Informatics, University College London
- 4NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London
- 6Health Data Research UK London, University College London
- 7NIHR Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London
- 8Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London
| | - John G Hanrahan
- 1Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London
- 2National Hospital for Neurology and Neurosurgery, London
| | | | - Eleanor M Moncur
- 2National Hospital for Neurology and Neurosurgery, London
- 5UCL Queen Square Institute of Neurology, University College London
| | | | - Lewis Thorne
- 2National Hospital for Neurology and Neurosurgery, London
| | | | - Simon C Williams
- 1Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London
- 2National Hospital for Neurology and Neurosurgery, London
| | - Wai Keong Wong
- 4NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London
- 6Health Data Research UK London, University College London
| | - Ahmed K Toma
- 2National Hospital for Neurology and Neurosurgery, London
- 4NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London
- 5UCL Queen Square Institute of Neurology, University College London
| | - Hani J Marcus
- 1Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London
- 2National Hospital for Neurology and Neurosurgery, London
- 4NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London
- 5UCL Queen Square Institute of Neurology, University College London
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17
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Blazer-Yost BL. Consideration of Kinase Inhibitors for the Treatment of Hydrocephalus. Int J Mol Sci 2023; 24:ijms24076673. [PMID: 37047646 PMCID: PMC10094860 DOI: 10.3390/ijms24076673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
Hydrocephalus is a devastating condition characterized by excess cerebrospinal fluid (CSF) in the brain. Currently, the only effective treatment is surgical intervention, usually involving shunt placement, a procedure prone to malfunction, blockage, and infection that requires additional, often repetitive, surgeries. There are no long-term pharmaceutical treatments for hydrocephalus. To initiate an intelligent drug design, it is necessary to understand the biochemical changes underlying the pathology of this chronic condition. One potential commonality in the various forms of hydrocephalus is an imbalance in fluid–electrolyte homeostasis. The choroid plexus, a complex tissue found in the brain ventricles, is one of the most secretory tissues in the body, producing approximately 500 mL of CSF per day in an adult human. In this manuscript, two key transport proteins of the choroid plexus epithelial cells, transient receptor potential vanilloid 4 and sodium, potassium, 2 chloride co-transporter 1, will be considered. Both appear to play key roles in CSF production, and their inhibition or genetic manipulation has been shown to affect CSF volume. As with most transporters, these proteins are regulated by kinases. Therefore, specific kinase inhibitors are also potential targets for the development of pharmaceuticals to treat hydrocephalus.
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Affiliation(s)
- Bonnie L. Blazer-Yost
- Biology Department, Indiana University—Purdue University, 723 West Michigan Street, Indianapolis, IN 46202, USA
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18
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Fang X, Deng Y, Xu X, Shu W, Tang F, Li S, Zhu T, Zhang L, Zhong P, Mao R. One-year outcome of a lumboperitoneal shunt in older adults with idiopathic normal pressure hydrocephalus. Front Surg 2022; 9:977123. [PMID: 36211266 PMCID: PMC9535338 DOI: 10.3389/fsurg.2022.977123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Lumboperitoneal shunt (LPS) is now an effective surgical modality for idiopathic normal pressure hydrocephalus (iNPH), but there is still a lack of clinical data on LPS in older adult iNPH patients in China. We aim to report the shunt effect and the complications of older adult iNPH patients treated with LPS at a single center in Shanghai, China. Methods We conducted a retrospective study among adults over 60 years old who were diagnosed as iNPH and treated with LPS from September 2016 to December 2020. The shunt effect was evaluated from two dimensions of functional and symptomatic improvement 3 months and 1 year after surgery, respectively. The potential factors related to the shunt effect one year after surgery were explored by comparing the effect between different subgroups and conducting multivariate logistic regression analysis. Result A total of 85 patients were included in this study, ranging from 60 to 93 years old, with an average age of 74.7. The function and symptoms were better both 3 months and 1 year after surgery than before (P < 0.001). At the 1-year postoperation follow-up, the functional and symptomatic improvement rates were 72.9% and 90.6%, respectively. The symptomatic improvement rates of gait, urination, and cognition were 74.1%, 72.9%, and 60.0%, respectively. Multivariate logistic regression analysis showed that improvement in function was much more possible in patients with less than 24 months from symptom onset to surgery (OR = 24.57, P < 0.001) and those with disproportionately enlarged subarachnoid-space hydrocephalus (OR = 5.88, P = 0.048); improvement in gait was also more possible in patients with less than 24 months from symptom onset to surgery (OR = 5.29, P = 0.017); improvement in urination was more possible in patients with diabetes (OR = 4.76, P = 0.019), and improvement in cognition was more possible in patients with preoperative modified Rankin scale level lower than 4 (OR = 3.51, P = 0.040). Minor operation-related complications were seen in 27 patients (31.8%) and severe complications in 6 patients (7.1%). Conclusion LPS could improve the function and symptoms of older adult iNPH patients. Early detection, diagnosis, and treatment of the disease could improve the shunt effect of the patients. Older adult iNPH patients with higher age ranges could achieve comparable shunt results compared with younger adults.
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Affiliation(s)
- Xuhao Fang
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Clinical Research Center for Geriatric Medicine, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Department of Neurosurgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Yao Deng
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xinxin Xu
- Clinical Research Center for Geriatric Medicine, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Weiquan Shu
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Feng Tang
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Shihong Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Ting Zhu
- Department of Rehabilitation Medicine, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Li Zhang
- Department of Neurology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Ping Zhong
- Department of Neurosurgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
- Correspondence: Ping Zhong Renling Mao
| | - Renling Mao
- Department of Neurosurgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Clinical Research Center for Geriatric Medicine, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Correspondence: Ping Zhong Renling Mao
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19
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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: 4] [Impact Index Per Article: 1.3] [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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20
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Xiao H, Hu F, Ding J, Ye Z. Cognitive Impairment in Idiopathic Normal Pressure Hydrocephalus. Neurosci Bull 2022; 38:1085-1096. [PMID: 35569106 PMCID: PMC9468191 DOI: 10.1007/s12264-022-00873-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/25/2022] [Indexed: 01/03/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a significant cause of the severe cognitive decline in the elderly population. There is no cure for iNPH, but cognitive symptoms can be partially alleviated through cerebrospinal fluid (CSF) diversion. In the early stages of iNPH, cognitive deficits occur primarily in the executive functions and working memory supported by frontostriatal circuits. As the disease progresses, cognition declines continuously and globally, leading to poor quality of life and daily functioning. In this review, we present recent advances in understanding the neurobiological mechanisms of cognitive impairment in iNPH, focusing on (1) abnormal CSF dynamics, (2) dysfunction of frontostriatal and entorhinal-hippocampal circuits and the default mode network, (3) abnormal neuromodulation, and (4) the presence of amyloid-β and tau pathologies.
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Affiliation(s)
- Haoyun Xiao
- Institute of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Zheng Ye
- Institute of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China.
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21
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Stöcklein S, Brandlhuber M, Lause S, Pomschar A, Jahn K, Schniepp R, Alperin N, Ertl-Wagner B. Decreased Craniocervical CSF Flow in Patients with Normal Pressure Hydrocephalus: A Pilot Study. AJNR Am J Neuroradiol 2022; 43:230-237. [PMID: 34992125 PMCID: PMC8985674 DOI: 10.3174/ajnr.a7385] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Normal pressure hydrocephalus is characterized by systolic peaks of raised intracranial pressure, possibly due to a reduced compliance of the spinal CSF spaces. This concept of a reduced spinal CSF buffer function may be reflected by a low cervical CSF outflow from the cranium. The aim of this study was to investigate craniospinal CSF flow rates by phase-contrast MR imaging in patients with normal pressure hydrocephalus. MATERIALS AND METHODS A total of 42 participants were included in this prospective study, consisting of 3 study groups: 1) 10 patients with normal pressure hydrocephalus (mean age, 74 [SD, 6] years, with proved normal pressure hydrocephalus according to current scientific criteria); 2) eighteen age-matched healthy controls (mean age, 71 [SD, 5] years); and 3) fourteen young healthy controls (mean age, 21 [SD, 2] years, for investigation of age-related effects). Axial phase-contrast MR imaging was performed, and the maximal systolic CSF and total arterial blood flow rates were measured at the level of the upper second cervical vertebra and compared among all study groups (2-sample unpaired t test). RESULTS The maximal systolic CSF flow rate was significantly decreased in patients with normal pressure hydrocephalus compared with age-matched and young healthy controls (53 [SD, 40] mL/m; 329 [SD, 175] mL/m; 472 [SD, 194] mL/m; each P < .01), whereas there were no significant differences with regard to maximal systolic arterial blood flow (1160 [SD, 404] mL/m; 1470 [SD, 381] mL/m; 1400 [SD, 254] mL/m; each P > .05). CONCLUSIONS The reduced maximal systolic craniospinal CSF flow rate in patients with normal pressure hydrocephalus may be reflective of a reduced compliance of the spinal CSF spaces and an ineffective spinal CSF buffer function. Systolic craniospinal CSF flow rates are an easily obtainable MR imaging-based measure that may support the diagnosis of normal pressure hydrocephalus.
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Affiliation(s)
| | | | - S.S. Lause
- Department of Dermatology (S.S.L.), Bethesda Hospital, Freudenberg, Germany
| | - A. Pomschar
- Radiological Office (A.P.), Centre for Radiology, Munich, Germany
| | - K. Jahn
- Neurology, and Friedrich-Baur-Institute (FBI) of the Department of Neurology (K.J.)
| | - R. Schniepp
- Neurology (R.S.), Ludwig-Maximilians-University Munich, Munich, Germany
| | - N. Alperin
- Department of Radiology (N.A.), University of Miami, Coral Gables, Florida
| | - B. Ertl-Wagner
- Department of Medical Imaging (B.E.-W.), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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22
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Yamada S, Ishikawa M, Nakajima M, Nozaki K. Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures. Front Neurol 2022; 12:798488. [PMID: 35069426 PMCID: PMC8770742 DOI: 10.3389/fneur.2021.798488] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.
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Affiliation(s)
- Shigeki Yamada
- Department of Neurosurgery, Shiga University of Medical Science, Shiga, Japan.,Interfaculty Initiative in Information Studies/Institute of Industrial Science, The University of Tokyo, Tokyo, Japan.,Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Masatsune Ishikawa
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Japan.,Rakuwa Villa Ilios, Rakuwakai Healthcare System, Kyoto, Japan
| | - Madoka Nakajima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Shiga, Japan
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23
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Kauppila LA, Ten Holter SE, van de Warrenburg B, Bloem BR. A Guide for the Differential Diagnosis of Multiple System Atrophy in Clinical Practice. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2015-2027. [PMID: 36057832 PMCID: PMC9661336 DOI: 10.3233/jpd-223392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 06/15/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic and progressive neurodegenerative disorder with a complex differential diagnosis. A range of disorders- also of nondegenerative etiology- can mimic MSA, expanding its differential diagnosis. Both misdiagnosis and diagnostic delays are relatively common in clinical practice. A correct diagnosis is vital for daily clinical practice, in order to facilitate proper counselling and to timely install therapies in treatable disorders that mimic MSA. A correct diagnosis is also essential for including properly classified individuals into research studies that aim to better understand the pathophysiology of MSA, to develop specific biomarkers or to evaluate novel symptomatic or disease-modifying therapies. Here, we offer some practical guidance to support the diagnostic process, by highlighting conditions that may be considered as MSA lookalikes, by emphasizing some key clinical aspects of these mimics, and by discussing several useful ancillary diagnostic tests.
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Affiliation(s)
- Linda Azevedo Kauppila
- CNS – Campus Neurológico, Lisbon, Portugal
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Susanne E.M. Ten Holter
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Bart van de Warrenburg
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Bastiaan R. Bloem
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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24
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Proposal for a Normal Pressure Hydrocephalus Syndrome Center of Excellence. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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25
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Carlstrom LP, Eltanahy A, Perry A, Rabinstein AA, Elder BD, Morris JM, Meyer FB, Graffeo CS, Lundgaard I, Burns TC. A clinical primer for the glymphatic system. Brain 2021; 145:843-857. [PMID: 34888633 DOI: 10.1093/brain/awab428] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 11/14/2022] Open
Abstract
The complex and dynamic system of fluid flow through the perivascular and interstitial spaces of the central nervous system has new-found implications for neurological diseases. Cerebrospinal fluid movement throughout the CNS parenchyma is more dynamic than could be explained via passive diffusion mechanisms alone. Indeed, a semi-structured glial-lymphatic (glymphatic) system of astrocyte-supported extracellular perivascular channels serves to directionally channel extracellular fluid, clearing metabolites and peptides to optimize neurologic function. Clinical studies of the glymphatic network has to date proven challenging, with most data gleaned from rodent models and post-mortem investigations. However, increasing evidence suggests that disordered glymphatic function contributes to the pathophysiology of CNS aging, neurodegenerative disease, and CNS injuries, as well as normal pressure hydrocephalus. Unlocking such pathophysiology could provide important avenues toward novel therapeutics. We here provide a multidisciplinary overview of glymphatics and critically review accumulating evidence regarding its structure, function, and hypothesized relevance to neurological disease. We highlight emerging technologies of relevance to the longitudinal evaluation of glymphatic function in health and disease. Finally, we discuss the translational opportunities and challenges of studying glymphatic science.
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Affiliation(s)
- Lucas P Carlstrom
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Ahmed Eltanahy
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Avital Perry
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | | | - Benjamin D Elder
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | | | - Fredric B Meyer
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | | | - Iben Lundgaard
- Departments of Experimental Medical Science, Lund University, Lund 228 11 Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund 228 11 Sweden
| | - Terry C Burns
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905 USA
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26
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Mallon DH, Malhotra P, Naik M, Edison P, Perry R, Carswell C, Win Z. The role of amyloid PET in patient selection for extra-ventricular shunt insertion for the treatment of idiopathic normal pressure hydrocephalus: A pooled analysis. J Clin Neurosci 2021; 90:325-331. [PMID: 34275571 DOI: 10.1016/j.jocn.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Idiopathic Normal Pressure Hydrocephalus (iNPH) can be effectively treated through shunt insertion. However, most shunted patients experience little or no clinical benefit, which suggests suboptimal patient selection. While contentious, multiple studies have reported poorer shunt outcomes associated with concomitant Alzheimer's disease. Prompted by this observation, multiple studies have assessed the role of amyloid PET, a specific test for Alzheimer's disease, in patient selection for shunting. METHODS A comprehensive literature search was performed to identify studies that assessed the association between amyloid PET result and the clinical response to shunting in patients with suspected iNPH. Pooled diagnostic statistics were calculated. RESULTS Across three relevant studies, a total of 38 patients with suspected iNPH underwent amyloid PET imaging and shunt insertion. Twenty-three patients had a positive clinical response to shunting. 18/28 (64.3%) of patients with a negative amyloid PET and 5/10 (50%) with a positive amyloid PET had a positive response to shunting. The pooled sensitivity, specificity and accuracy was 33.3%, 76.2% and 58.3%. None of these statistics reached statistical significance. CONCLUSION The results of this pooled analysis do not support the selection of patients with suspected iNPH for shunting on the basis of amyloid PET alone. However, due to small cohort sizes and weakness in study design, further high-quality studies are required to properly determine the role of amyloid PET in assessing this complex patient group.
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Affiliation(s)
- Dermot H Mallon
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; Imperial College London, Charing Cross Hospital, London, UK.
| | - Paresh Malhotra
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Mitesh Naik
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Paul Edison
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; Imperial College London, Charing Cross Hospital, London, UK
| | - Richard Perry
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Christopher Carswell
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; Imperial College London, Charing Cross Hospital, London, UK
| | - Zarni Win
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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27
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Nerg O, Junkkari A, Hallikainen I, Rauramaa T, Luikku A, Hiltunen M, Jääskeläinen JE, Leinonen V, Hänninen T, Koivisto A. The CERAD Neuropsychological Battery in Patients with Idiopathic Normal Pressure Hydrocephalus Compared with Normal Population and Patients with Mild Alzheimer's Disease. J Alzheimers Dis 2021; 81:1117-1130. [PMID: 33896842 DOI: 10.3233/jad-201363] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The usefulness of CERAD Neuropsychological Battery for describing the cognitive impairment in idiopathic normal pressure hydrocephalus (iNPH) is unknown. OBJECTIVE To compare the cognitive profile of patients with iNPH to patients with mild Alzheimer's disease (AD) and age-matched cognitively healthy individuals by using the CERAD-NB. METHODS We studied CERAD-NB subtest results, including the Mini-Mental State Examination (MMSE), between 199 patients with probable iNPH, 236 patients with mild AD, and 309 people with normal cognition, using age, education, and gender adjusted multivariate linear regression model. In addition, the effects of AD-related brain pathology detected in frontal cortical brain biopsies in iNPH patients' cognitive profiles were examined. RESULTS The iNPH patients performed worse than cognitively healthy people in all CERAD-NB subtests. Despite similar performances in the MMSE, AD patients outperformed iNPH patients in Verbal Fluency (p = 0.016) and Clock Drawing (p < 0.001) tests. However, iNPH patients outperformed AD patients in the Boston Naming Test and Word List Recall and Recognition (p < 0.001). AD-related pathology in brain biopsies did not correlate with the CERAD-NB results. CONCLUSION At the time of the iNPH diagnosis, cognitive performances differed from cognitively healthy people in all CERAD-NB subtests. When the iNPH and AD patients' results were compared, the iNPH patients performed worse in Verbal Fluency and Clock Drawing tests while the AD group had more pronounced episodic memory dysfunctions. This study demonstrates significant differences in the CERAD-NB subtests between cognitive profiles of iNPH and AD patients. These differences are not captured by the MMSE alone.
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Affiliation(s)
- Ossi Nerg
- Neurosurgery of NeuroCenter, Kuopio University Hospital and Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Antti Junkkari
- Neurosurgery of NeuroCenter, Kuopio University Hospital and Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ilona Hallikainen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tuomas Rauramaa
- Unit of Pathology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Pathology, Kuopio University Hospital, Kuopio, Finland
| | - Antti Luikku
- Neurosurgery of NeuroCenter, Kuopio University Hospital and Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mikko Hiltunen
- Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ville Leinonen
- Neurosurgery of NeuroCenter, Kuopio University Hospital and Unit of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tuomo Hänninen
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Anne Koivisto
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.,Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Unit of Neurosciences, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Geriatrics / Internal Medicine and Rehabilitation, Helsinki University Hospital, Helsinki, Finland
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28
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Chan LL, Chen R, Li H, Lee AJY, Go WY, Lee W, Lock C, Kumar S, Ng ASL, Kandiah N, Tan LCS, Tan EK, Keong NCH. The splenial angle: a novel radiological index for idiopathic normal pressure hydrocephalus. Eur Radiol 2021; 31:9086-9097. [PMID: 33991224 PMCID: PMC8589785 DOI: 10.1007/s00330-021-07871-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/08/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022]
Abstract
Objectives To evaluate the utility of the splenial angle (SA), an axial angular index of lateral ventriculomegaly measured on diffusion tensor MRI color fractional anisotropy maps, in differentiating NPH from Alzheimer’s disease (AD), Parkinson’s disease (PD), and healthy controls (HC), and post-shunt changes in NPH, compared to Evans’ index and callosal angle. Methods Evans’ index, callosal angle, and SA were measured on brain MRI of 76 subjects comprising equal numbers of age- and sex-matched subjects from each cohort of NPH, AD, PD, and HC by two raters. Receiver operating characteristics (ROC) and multivariable analysis were used to assess the screening performance of each measure in differentiating and predicting NPH from non-NPH groups respectively. Temporal changes in the measures on 1-year follow-up MRI in 11 NPH patients (with or without ventriculoperitoneal shunting) were also assessed. Results Inter-rater and intra-rater reliability were excellent for all measurements (intraclass correlation coefficients > 0.9). Pairwise comparison showed that SA was statistically different between NPH and AD/PD/HC subjects (p < 0.0001). SA performed the best in predicting NPH, with an area under the ROC curve of > 0.98, and was the only measure left in the final model of the multivariable analysis. Significant (p < 0.01) change in SA was seen at follow-up MRI of NPH patients who were shunted compared to those who were not. Conclusions The SA is readily measured on axial DTI color FA maps compared to the callosal angle and shows superior performance differentiating NPH from neurodegenerative disorders and sensitivity to ventricular changes in NPH after surgical intervention. Key Points • The splenial angle is a novel simple angular radiological index proposed for idiopathic normal pressure hydrocephalus, measured in the ubiquitous axial plane on DTI color fractional anisotropy maps. • The splenial angle quantitates the compression and stretching of the posterior callosal commissural fibers alongside the distended lateral ventricles in idiopathic normal pressure hydrocephalus (NPH) using tools readily accessible in clinical practice and shows excellent test-retest reliability. • Splenial angle outperforms Evans’ index and callosal angle in predicting NPH from healthy, Parkinson’s disease, and Alzheimer’s disease subjects on ROC analysis with an area under the curve of > 0.98 and is sensitive to morphological ventricular changes in NPH patients after ventricular shunting. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07871-4.
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Affiliation(s)
- Ling Ling Chan
- Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
| | - Robert Chen
- Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Huihua Li
- Duke-NUS Medical School, Singapore, Singapore.,Health Services Research Unit, Singapore General Hospital, Singapore, Singapore
| | - Amanda J Y Lee
- Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Wei Ying Go
- Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Weiling Lee
- Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Christine Lock
- Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sumeet Kumar
- Duke-NUS Medical School, Singapore, Singapore.,Neuroradiology, National Neuroscience Institute, Singapore, Singapore
| | - Adeline S L Ng
- Duke-NUS Medical School, Singapore, Singapore.,Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Nagaendran Kandiah
- Duke-NUS Medical School, Singapore, Singapore.,Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Louis C S Tan
- Duke-NUS Medical School, Singapore, Singapore.,Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Eng King Tan
- Duke-NUS Medical School, Singapore, Singapore.,Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Nicole C H Keong
- Duke-NUS Medical School, Singapore, Singapore.,Neurosurgery, National Neuroscience Institute, Singapore, Singapore
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Han SW, Park YH, Ryoo N, Kim K, Pyun JM, Kim S. Pearls & Oy-sters: Idiopathic Normal Pressure Hydrocephalus With Synucleinopathy: Diagnosis and Treatment. Neurology 2021; 97:196-199. [PMID: 33931530 DOI: 10.1212/wnl.0000000000012099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sang-Won Han
- From the Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Republic of Korea
| | - Young Ho Park
- From the Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Republic of Korea.
| | - Nayoung Ryoo
- From the Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Republic of Korea
| | - Kitae Kim
- From the Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Republic of Korea
| | - Jung-Min Pyun
- From the Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Republic of Korea
| | - SangYun Kim
- From the Department of Neurology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Republic of Korea
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30
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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: 12] [Impact Index Per Article: 3.0] [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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31
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Subramanian HE, Fadel SA, Matouk CC, Zohrabian VM, Mahajan A. The Utility of Imaging Parameters in Predicting Long-Term Clinical Improvement After Shunt Surgery in Patients with Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2021; 149:e1-e10. [PMID: 33662608 DOI: 10.1016/j.wneu.2021.02.108] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It is difficult to predict which patients with idiopathic normal pressure hydrocephalus (iNPH) will improve after shunt surgery. This study investigated the association between preoperative imaging parameters in patients with iNPH and long-term outcome after shunt placement. METHODS Patients with iNPH who showed a response to large-volume cerebrospinal fluid drainage and subsequently underwent ventriculoperitoneal shunt surgery were reviewed. Long-term patient-reported outcomes were obtained by telephone interview. Preoperative computed tomography and/or magnetic resonance imaging were retrospectively reviewed to determine associations between imaging parameters and clinical outcome. RESULTS The final analysis included 37 patients. The median duration between shunt surgery and telephone interview was 30 months (range, 12-56 months). Gait improvement after shunting was present more often in patients without focally dilated sulci (95% vs. 71%, P = 0.04), but a statistically significant relationship was not established after logistic regression. Patients with cognitive improvement after shunting had a higher preoperative Evans index (mean 0.41 vs. 0.36, P < 0.01), and Evans index was a predictor of cognitive improvement (odds ratio = 1.40, scale of 0.01, P = 0.01). CONCLUSIONS Higher Evans index is a predictor of long-term cognitive improvement after shunt placement; however, no cutoff value demonstrates sufficient accuracy for the selection of shunt candidates. None of the evaluated imaging features was predictive of long-term gait or urinary improvement. The utility of imaging to predict a response to shunting is limited, and no imaging feature alone can be used to exclude patients from shunt surgery.
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Affiliation(s)
- Harry E Subramanian
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sandra A Fadel
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA; Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vahe M Zohrabian
- Department of Radiology, Northwell Health, Zucker Hofstra School of Medicine at Northwell, North Shore University Hospital, Hempstead, New York, USA
| | - Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA.
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32
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Köster H, Müller-Schmitz K, Kolman AGJ, Seitz RJ. Deficient visuomotor hand coordination in normal pressure hydrocephalus. J Neurol 2021; 268:2843-2850. [PMID: 33594453 PMCID: PMC8289764 DOI: 10.1007/s00415-021-10445-5] [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: 11/05/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 11/29/2022]
Abstract
Objective To investigate if visuomotor coordination of hand movements is impaired in patients with normal pressure hydrocephalus (NPH) identified by dedicated testing procedures. Methods Forty-seven patients admitted for diagnostic workup for suspected NPH were studied prospectively with MRI, testing of cognitive and motor functions, lumbar puncture, and visuomotor coordination of hand movements using the PABLOR-device before and after a spinal tap of 40–50 ml CSF. Statistical analyses were carried out with repeated measures ANOVA and non-parametric correlation analyses. Results Fourteen patients were found to suffer from ideopathic NPH. They were severely impaired in visuomotor control of intermittent arm movements in comparison to patients who were found not to be affected by NPH (n = 18). In the patients with NPH the deficient arm control was improved after the spinal tap in proportion to the improvement of gait. There was no improvement of cognitive and motor functions in the patients not affected by NPH, while the patients with possible NPH (n = 15) showed intermediate deficit and improvement patterns. Interpretation: Our data underline the importance of a multiparametric assessment of NPH and provide evidence for a motor control deficit in idiopathic NPH involving leg and arm movements. It is suggested that this motor control deficit resulted from an affection of the output tracts from the supplementary motor area in the periventricular vicinity.
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Affiliation(s)
- Hannah Köster
- Department of Neurology, Medical Faculty, Centre for Neurology and Neuropsychiatry, LVR-Klinikum Düsseldorf, Heinrich-Heine-University Düsseldorf, Bergische Landstrasse 2, 40629, Düsseldorf, Germany
| | - Katharina Müller-Schmitz
- Department of Neurology, Medical Faculty, Centre for Neurology and Neuropsychiatry, LVR-Klinikum Düsseldorf, Heinrich-Heine-University Düsseldorf, Bergische Landstrasse 2, 40629, Düsseldorf, Germany
| | - Aschwin G J Kolman
- Department of Neurology, Medical Faculty, Centre for Neurology and Neuropsychiatry, LVR-Klinikum Düsseldorf, Heinrich-Heine-University Düsseldorf, Bergische Landstrasse 2, 40629, Düsseldorf, Germany
| | - Rüdiger J Seitz
- Department of Neurology, Medical Faculty, Centre for Neurology and Neuropsychiatry, LVR-Klinikum Düsseldorf, Heinrich-Heine-University Düsseldorf, Bergische Landstrasse 2, 40629, Düsseldorf, Germany. .,Florey Neuroscience Institutes, Melbourne, VIC, Australia.
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33
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Yamada S, Ito H, Ishikawa M, Yamamoto K, Yamaguchi M, Oshima M, Nozaki K. Quantification of Oscillatory Shear Stress from Reciprocating CSF Motion on 4D Flow Imaging. AJNR Am J Neuroradiol 2021; 42:479-486. [PMID: 33478942 DOI: 10.3174/ajnr.a6941] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/05/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Oscillatory shear stress could not be directly measured in consideration of direction, although cerebrospinal fluid has repetitive movements synchronized with heartbeat. Our aim was to evaluate the important of oscillatory shear stress in the cerebral aqueduct and foramen magnum in idiopathic normal pressure hydrocephalus by comparing it with wall shear stress and the oscillatory shear index in patients with idiopathic normal pressure hydrocephalus. MATERIALS AND METHODS By means of the 4D flow application, oscillatory shear stress, wall shear stress, and the oscillatory shear index were measured in 41 patients with idiopathic normal pressure hydrocephalus, 23 with co-occurrence of idiopathic normal pressure hydrocephalus and Alzheimer-type dementia, and 9 age-matched controls. These shear stress parameters at the cerebral aqueduct were compared with apertures and stroke volumes at the foramen of Magendie and cerebral aqueduct. RESULTS Two wall shear stress magnitude peaks during a heartbeat were changed to periodic oscillation by converting oscillatory shear stress. The mean oscillatory shear stress amplitude and time-averaged wall shear stress values at the dorsal and ventral regions of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus groups were significantly higher than those in controls. Furthermore, those at the ventral region of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus group were also significantly higher than those in the co-occurrence of idiopathic normal pressure hydrocephalus with Alzheimer-type dementia group. The oscillatory shear stress amplitude at the dorsal region of the cerebral aqueduct was significantly associated with foramen of Magendie diameters, whereas it was strongly associated with the stroke volume at the upper end of the cerebral aqueduct rather than that at the foramen of Magendie. CONCLUSIONS Oscillatory shear stress, which reflects wall shear stress vector changes better than the conventional wall shear stress magnitude and the oscillatory shear index, can be directly measured on 4D flow MR imaging. Oscillatory shear stress at the cerebral aqueduct was considerably higher in patients with idiopathic normal pressure hydrocephalus.
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Affiliation(s)
- S Yamada
- From the Department of Neurosurgery (S.Y., K.N.), Shiga University of Medical Science, Shiga, Japan .,Department of Neurosurgery and Normal Pressure Hydrocephalus Center (S.Y., K.Y., M.Y.), Rakuwakai Otowa Hospital, Kyoto, Japan.,Interfaculty Initiative in Information Studies/Institute of Industrial Science (S.Y., M.O.), The University of Tokyo, Tokyo, Japan
| | - H Ito
- Medical System Research and Development Center (H.I.), Fujifilm Corporation, Tokyo, Japan
| | | | - K Yamamoto
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center (S.Y., K.Y., M.Y.), Rakuwakai Otowa Hospital, Kyoto, Japan
| | - M Yamaguchi
- Department of Neurosurgery and Normal Pressure Hydrocephalus Center (S.Y., K.Y., M.Y.), Rakuwakai Otowa Hospital, Kyoto, Japan
| | - M Oshima
- Interfaculty Initiative in Information Studies/Institute of Industrial Science (S.Y., M.O.), The University of Tokyo, Tokyo, Japan
| | - K Nozaki
- From the Department of Neurosurgery (S.Y., K.N.), Shiga University of Medical Science, Shiga, Japan
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34
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Tan C, Wang X, Wang Y, Wang C, Tang Z, Zhang Z, Liu J, Xiao G. The Pathogenesis Based on the Glymphatic System, Diagnosis, and Treatment of Idiopathic Normal Pressure Hydrocephalus. Clin Interv Aging 2021; 16:139-153. [PMID: 33488070 PMCID: PMC7815082 DOI: 10.2147/cia.s290709] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 12/16/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a rare neurological disorder with no clear prevalence factors and is a significant danger to the elderly. The intracranial glymphatic system is the internal environment that maintains brain survival and metabolism, and thus fluid exchange changes in the glymphatic system under various pathological conditions can provide important insights into the pathogenesis and differential diagnosis of many neurodegenerative diseases such as iNPH. iNPH can be diagnosed using a combination of clinical symptoms, imaging findings and history, and cerebrospinal fluid biomarkers due to the glymphatic system disorder. However, only few researchers have linked the two. Shunt surgery can improve the glymphatic system disorders in iNPH patients, and the surgical approach is determined using a combination of clinical diagnosis and trials. Therefore, we have composed this review to provide a future opportunity for elucidating the pathogenesis of iNPH based on the glymphatic system, and link the glymphatic system to the diagnosis and treatment of iNPH. The review will provide new insights into the medical research of iNPH.
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Affiliation(s)
- Changwu Tan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Xiaoqiang Wang
- Pediatric Neurological Disease Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, People's Republic of China
| | - Yuchang Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Chuansen Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Zhi Tang
- Department of Neurosurgery, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Zhiping Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Jingping Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Gelei Xiao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
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35
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Zhang H, He WJ, Liang LH, Zhang HW, Zhang XJ, Zeng L, Luo SP, Lin F, Lei Y. Diffusion Spectrum Imaging of Corticospinal Tracts in Idiopathic Normal Pressure Hydrocephalus. Front Neurol 2021; 12:636518. [PMID: 33716939 PMCID: PMC7947286 DOI: 10.3389/fneur.2021.636518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/05/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose: The purpose of this study was to measure the diffusion spectrum imaging (DSI) parameters of corticospinal tracts (CSTs) and evaluate diffusional changes in CSTs in patients with idiopathic normal pressure hydrocephalus (iNPH) by DSI. Methods: Twenty-three iNPH patients and twenty-one healthy controls (HCs) were involved in this study. Brain DSI data for all participants were collected through the same MR scanning procedure. The diffusion parameters measured and analyzed included quantitative anisotropy (QA), the isotropic diffusion component (ISO), general fractional anisotropy (GFA), fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) of corticospinal tracts. Results: The QA and ISO values of corticospinal tracts in iNPH patients were significantly lower than those in HCs (PLQA = 0.008, PRQA = 0.016, PLISO = 0.024, PRISO = 0.016). The mean MD, AD, and RD values in iNPH patients were significantly higher than those in HCs (PMD = 0.032, PAD = 0.032, PRD = 0.048,). No significant differences in GFA and FA values were noted between iNPH patients and HCs. Conclusion: Decreased QA and ISO values of corticospinal tracts were found in iNPH patients. Quantitative CST evaluation using DSI may lead to information that can improve the present understanding of the disease mechanism.
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Affiliation(s)
- Hong Zhang
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Wen-Jie He
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Li-Hong Liang
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Han-Wen Zhang
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xie-Jun Zhang
- Department of Neurosurgery, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Liang Zeng
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Si-Ping Luo
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Fan Lin
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Fan Lin
| | - Yi Lei
- Department of Radiology, Health Science Center, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- *Correspondence: Yi Lei
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36
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Hamilton M, Isaacs A. Natural History, Treatment Outcomes and Quality of Life in Idiopathic Normal Pressure Hydrocephalus (iNPH). Neurol India 2021; 69:S561-S568. [DOI: 10.4103/0028-3886.332281] [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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37
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Tripathi M, Vibha D. Normal-Pressure Hydrocephalus - Patient Evaluation and Decision-Making. Neurol India 2021; 69:S406-S412. [DOI: 10.4103/0028-3886.332267] [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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38
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Alshehri Y, Salem I, Alamri Z, Alharbi A, Alshehri A, Alqurashi A, Alsaeedi A, Alotaibi A, Sabbagh AJ. Knowledge and attitude towards hydrocephalus among healthcare providers and the general population in Saudi Arabia. J Family Med Prim Care 2020; 9:6240-6248. [PMID: 33681071 PMCID: PMC7928086 DOI: 10.4103/jfmpc.jfmpc_916_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/21/2020] [Accepted: 12/05/2020] [Indexed: 11/09/2022] Open
Abstract
Background: Hydrocephalus is a worldwide disorder characterized by abnormal flow or rarely excessive production of cerebrospinal fluid, leading to the widening of the cerebral ventricles system due to the accumulation of the cerebrospinal fluid in the brain. Previous researches have shown that knowledge about the disorder is limited among healthcare providers and the population, affecting attitudes toward patients, as well as patient outcomes. Aim: To investigate healthcare providers and population's knowledge and attitudes towards hydrocephalus in Saudi Arabia. Methodology: A descriptive cross-sectional study was conducted through an electronic questionnaire. The survey was self-constructed in Arabic and English by the research team and inspired by other awareness questionnaires and validated before use by three experts. Results: There were 444 participants in this study, aged between 17 and 73 years with a mean age of 32.60 ± 10.98. Most of the participants were from the general population (74.8%). More than half of the participants had a bachelor's degree (60.1%). 38.4% of healthcare providers had negative knowledge while 61.6% had positive knowledge. In addition, 82.5% of the general population had negative knowledge, although 17.5% had positive knowledge. Moreover, it was observed that 17.0% of the healthcare providers had a bad attitude while 83.0% had a good attitude. In addition, 60.2% of the general population had a bad attitude, whereas 39.8% had a good attitude. Conclusion: This study revealed that the level of knowledge and attitude towards hydrocephalus among healthcare providers was good on both aspects, while it was poor among the general population.
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Affiliation(s)
- Yusuf Alshehri
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Iman Salem
- Saudi Arabia, Rabigh, King Abdul-Aziz University, Community Medicine Department, Jeddah, Egypt.,Egypt, Al Azhar University, Community Medicine Department, Egypt
| | - Zeyad Alamri
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ammar Alharbi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Ahmed Alqurashi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmad Alsaeedi
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Abdulrahman Jafar Sabbagh
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Jeddah, Saudi Arabia.,Research and Development Unit, Surgical Skills and Simulation Center, King Abdulaziz University, Jeddah, Saudi Arabia
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Onder H, Goksungur G. The Utility of Neuroimaging Parameters in Discriminating Patients of Normal-Pressure Hydrocephalus with Positive Cerebrospinal Fluid Tap Test Response from Healthy Controls. Ann Indian Acad Neurol 2020; 23:625-631. [PMID: 33623262 PMCID: PMC7887480 DOI: 10.4103/aian.aian_583_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 11/09/2022] Open
Abstract
Objective: To investigate the frequency of previously defined neuroimaging signs of normal pressure hydrocephalus in our NPH patient group with positive cerebrospinal fluid (CSF) tap test response. Methods: Twenty-two patients with probable NPH and 33 healthy control individuals were enrolled in this study. Previously defined 9 parameters including Evan’s index, narrow high convexity sulci, dilation of the Sylvian fissures, focally enlarged sulci, enlargement of the temporal horns, callosal angle, periventricular hyperintensities, bulging of the lateral ventricular roof, and disproportionately enlarged subarachnoid space hydrocephalus were evaluated on conventional magnetic resonance imaging. A total radiological score was formed in both groups. The total radiological score, scores, and frequency of each radiological parameters were compared between patient and healthy control groups. Results: The mean age of the patient group was 67.31 ± 7.27 (F/M ratio was 7/15), whereas it was 69.09 ± 4.89 (F/M ratio was 11/22) in healthy control group. The result of these analyses revealed that scores of all the radiological parameters, except callosal angle score, were found to be higher in NPH patient group. The parameters with the highest positive predictive values were narrow high convexity sulci, narrowing of callosal angle, and DESH (100%, 100%, and 100%, respectively). On the other hand, enlargement of temporal horns had the highest negative predictive value among all parameters (96%). Conclusion: The results of our study support the use of neuroimaging parameters as an alternative method for CSF tap test. We suggest that in the presence of narrow high convexity sulci and/or narrowing of callosal angle, the decision of shunt surgery may be made in patients with suspicion of NPH, without performing CSF tap test. Confirmation of these results, in the future, large-scale studies may certainly provide critical perspectives to be used in the clinical practice.
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Affiliation(s)
- Halil Onder
- Neurology Clinic, Yozgat City Hospital, Yozgat, Turkey
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40
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Kamohara C, Nakajima M, Kawamura K, Akiba C, Ogino I, Xu H, Karagiozov K, Arai H, Miyajima M. Neuropsychological tests are useful for predicting comorbidities of idiopathic normal pressure hydrocephalus. Acta Neurol Scand 2020; 142:623-631. [PMID: 32619270 PMCID: PMC7689708 DOI: 10.1111/ane.13306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/14/2020] [Accepted: 06/24/2020] [Indexed: 01/12/2023]
Abstract
Objectives Comorbidities of idiopathic normal pressure hydrocephalus (iNPH), such as Alzheimer's disease (AD) and Parkinson's spectrum (PS) disorder, can affect the long‐term prognosis of cerebrospinal fluid (CSF) shunting. Therefore, it is important to be able to predict comorbidities in the early stage of the disease. This study aimed to predict the comorbidities of iNPH using neuropsychological tests and cognitive performance evaluation. Materials & Methods Forty‐nine patients with possible iNPH were divided into three groups: iNPH without AD or PS comorbidity (group‐1), iNPH with AD comorbidity (group‐2), and iNPH with PS comorbidity (group‐3), according to CSF biomarkers such as phosphorylated tau and dopamine transporter imaging. Scores on the new EU‐iNPH‐scale, which is based on 4 neuropsychological tests (Rey Auditory Verbal Learning Test, Grooved Pegboard test, Stroop colour‐naming test and interference test), were compared for each group. In addition, the scores before and 12 months after CSF shunting for each group were compared. Results EU‐iNPH‐scale using 4 neuropsychological tests could distinguish group‐1 from group‐2 or group‐3 by area under the curve values of 0.787 and 0.851, respectively. Patients in group‐1 showed a remarkable increase in memory and learning ability after surgery. Group‐2 performed significantly poorer than group‐1 patients on memory testing, but otherwise showed improvements in most of the neuropsychological tests. Group‐3 performed significantly worse than group‐1 patients—especially on Stroop tests—but showed post‐surgery improvement on only the Stroop colour‐naming test. Conclusions The 4 neuropsychological tests of the EU‐iNPH‐scale can help predict iNPH comorbidities and evaluate the prognosis of CSF shunting.
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Affiliation(s)
| | | | - Kaito Kawamura
- Department of Neurosurgery Juntendo University Tokyo Japan
| | - Chihiro Akiba
- Department of Neurosurgery Juntendo Tokyo Koto Geriatric Medical Center Tokyo Japan
| | - Ikuko Ogino
- Department of Neurosurgery Juntendo University Tokyo Japan
| | - Hanbing Xu
- Department of Neurosurgery Juntendo University Tokyo Japan
| | | | - Hajime Arai
- Department of Neurosurgery Juntendo University Tokyo Japan
| | - Masakazu Miyajima
- Department of Neurosurgery Juntendo Tokyo Koto Geriatric Medical Center Tokyo Japan
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Laviv Y, Nimni M, Ben Shalom N, Eisen A, Vaknin-Assa H, Harnof S. Acute Presentation of Normal Pressure Hydrocephalus After Transcatheter Aortic Valve Implantation: A Novel Interaction Between the First and Third Circulations. World Neurosurg 2020; 146:e731-e738. [PMID: 33181380 DOI: 10.1016/j.wneu.2020.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Idiopathic normal pressure hydrocephalus (iNPH) negatively affects gait and cognition abilities and urine continence in the elderly. It is associated with systemic hypertension, although the exact pathophysiology is still unknown. A correlation to increased intracranial pulsatility and decreased compliance was suggested. Transcatheter aortic valve implantation (TAVI) is increasingly used in the treatment of severe AS. New-onset systemic hypertension affects some patients after TAVI. OBJECTIVE To identify any association between aortic valve replacement and the development of NPH. METHODS A cohort was created retrospectively of all patients who were evaluated for NPH with cerebrospinal fluid (CSF) tap test at a single institute during 2014-2019. Patients were reviewed for a past medical history of aortic valvular disease or aortic valve replacement. RESULTS A total of 242 patients underwent evaluations for NPH. Of these patients, 133 were considered to have iNPH. Six patients underwent aortic valve replacement before the initial symptoms of NPH: 1 surgical and 5 TAVI. The time from aortic valve replacement to the initial NPH symptoms was <6 months in 3 patients (as low as 1 month in 2 of them). Two patients had functional improvement after CSF tap test and proceeded to receive a shunt, 4 and 6 months after TAVI, respectively. Two patients developed hypertension after TAVI. Pulse pressure increased by >10 mm Hg in 3 patients after TAVI. CONCLUSIONS This is the first case series of symptomatic NPH after TAVI. In this unique subgroup, NPH symptoms can develop rapidly. Post-TAVI iNPH represents a novel interaction between the blood and CSF circulations.
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Affiliation(s)
- Yosef Laviv
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel.
| | - Mor Nimni
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Nati Ben Shalom
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Alon Eisen
- Department of Cardiology, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Hana Vaknin-Assa
- Department of Cardiology, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Sagie Harnof
- Department of Neurosurgery, Beilinson Hospital, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
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Lilja-Lund O, Kockum K, Hellström P, Söderström L, Nyberg L, Laurell K. Wide temporal horns are associated with cognitive dysfunction, as well as impaired gait and incontinence. Sci Rep 2020; 10:18203. [PMID: 33097796 PMCID: PMC7584644 DOI: 10.1038/s41598-020-75381-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 10/13/2020] [Indexed: 11/09/2022] Open
Abstract
The association between morphology of the brain and symptoms of suspected idiopathic normal pressure hydrocephalus (iNPH) is largely unknown. We investigated how ventricular expansion (width of the temporal horns [TH], callosal angle [CA], and Evans' index [EI]) related to symptom severity in suspected iNPH. Participants (n = 168; 74.9 years ± SD 6.7; 55% females) from the general population underwent neurological examination, computed tomography, and neuropsychological testing. Multiple linear regression analysis revealed that wide TH was independently associated with all examined iNPH symptoms (p < 0.01) except for fine-motor performance, whereas a narrow CA only was associated to specific motor and cognitive functions (p < 0.05). TH and EI correlated significantly with incontinence (rs 0.17 and rs 0.16; p < 0.05). In conclusion, wide TH was significantly associated with most iNPH-symptoms. This finding potentially reflects the complex nature of the hippocampus, however further studies are needed to demonstrate functional connectivity.
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Affiliation(s)
- Otto Lilja-Lund
- Department of Clinical Science, Neuroscience, Umeå University, Östersunds sjukhus, 831 83, Östersund, Sweden.
| | - Karin Kockum
- Department of Clinical Science, Neuroscience, Umeå University, Östersunds sjukhus, 831 83, Östersund, Sweden
| | - Per Hellström
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Lars Söderström
- Unit of Research, Education and Development, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Lars Nyberg
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
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Gómez-Amarillo DF, Pulido LF, Mejía I, García-Baena C, Cárdenas MF, Gómez LM, Fuentes YV, Volcinschi-Moros D, Jaramillo-Velásquez D, Ramón JF, Mejía JA, Jiménez E, Hakim F. Cerebrospinal fluid closing pressure-guided tap test for the diagnosis of idiopathic normal pressure hydrocephalus: A descriptive cross-sectional study. Surg Neurol Int 2020; 11:315. [PMID: 33093992 PMCID: PMC7568097 DOI: 10.25259/sni_380_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/03/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Tap test improves symptoms of idiopathic normal pressure hydrocephalus (iNPH); hence, it is widely used as a diagnostic procedure. However, it has a low sensitivity and there is no consensus on the parameters that should be used nor the volume to be extracted. We propose draining cerebrospinal fluid (CSF) during tap test until a closing pressure of 0 cm H2O is reached as a standard practice. We use this method with all our patients at our clinic. Methods: This is a descriptive cross-sectional study where all patients with presumptive diagnosis of iNPH from January 2014 to December 2019 were included in the study. We used a univariate descriptive analysis and stratified analysis to compare the opening pressure and the volume of CSF extracted during the lumbar puncture, between patients in whom a diagnosis of iNPH was confirmed and those in which it was discarded. Results: A total of 92 patients were included in the study. The mean age at the time of presentation was 79.4 years and 63 patients were male. The diagnosis of iNPH was confirmed in 73.9% patients. The mean opening pressure was 14.4 cm H2O mean volume of CSF extracted was 43.4 mL. Conclusion: CSF extraction guided by a closing pressure of 0 cm H2O instead of tap test with a fixed volume of CSF alone may be an effective method of optimizing iNPH symptomatic improvement and diagnosis.
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44
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Gimsing LN, Hejl AM. Normal pressure hydrocephalus secondary to Lyme disease, a case report and review of seven reported cases. BMC Neurol 2020; 20:347. [PMID: 32938426 PMCID: PMC7493413 DOI: 10.1186/s12883-020-01917-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/02/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Infection with tick borne Borrelia Burgdorferi (Lyme disease) can without treatment rarely develop into a chronic phase. Secondary Normal Pressure Hydrocephalus (sNPH) based on chronic infection with Borrelia Burgdorferi (Bb) is an even rarer entity, that with the right treatment is potentially curable. CASE PRESENTATION A 67-year-old male with a slow onset of progressive balance problems, also presented unspecified dizziness, urge feeling, neck soreness and discrete cognitive complaints. An MRI scan revealed an enlarged ventricular system compatible with NPH. After further liquor dynamic procedures, cerebrospinal fluid (CSF) was analysed with the surprising results of lymphocytic pleocytosis, and signs of increased antibody production. Microbiology revealed chronic neuroborreliosis and the patient was treated with antibiotics accordingly. At the one-year follow-up no symptoms remained and the ventricular system almost normalized. CONCLUSIONS We describe the 7th published case of sNPH secondary to chronic Borreliosis in a previous healthy adult. Existing published literature has been reviewed and previous cases showed similarly nearly full clinical recovery. Primary/idiopathic NPH (iNPH) is treated with the surgical intervention of ventriculoperitoneal shunt and can be mistaken for a sNPH. The awareness of rare causes of sNPH like chronic Borreliosis is important as it is easily treated non surgically.
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Affiliation(s)
- Louise Nørreslet Gimsing
- Department of Specialized Neurorehabilitation, Hvidovre Hospital, Kettegårds Allé 30, 2650, Hvidovre, Denmark.
| | - Anne-Mette Hejl
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke, 2400, Copenhagen, Denmark
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Müller-Schmitz K, Krasavina-Loka N, Yardimci T, Lipka T, Kolman AGJ, Robbers S, Menge T, Kujovic M, Seitz RJ. Normal Pressure Hydrocephalus Associated with Alzheimer's Disease. Ann Neurol 2020; 88:703-711. [PMID: 32662116 DOI: 10.1002/ana.25847] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/24/2020] [Accepted: 07/05/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim was to investigate whether neurodegenerative biomarkers in cerebrospinal fluid (CSF) differentiate patients with suspected normal pressure hydrocephalus (NPH) who respond to CSF drainage from patients who do not respond. METHODS Data from 62 consecutive patients who presented with magnetic resonance imaging changes indicative of NPH were studied with regard to cognitive and gait functions before and after drainage of 40-50ml of CSF. Additionally, S100 protein, neuron-specific enolase, β-amyloid protein, tau protein and phospho-tau were determined in CSF. Statistical analyses were carried out with ANOVA and multiple linear regression. RESULTS Patients with CSF constellations typical for Alzheimer's disease (n = 28) improved significantly in cognitive and gait-related functions after CSF drainage. In contrast, those patients without a CSF constellation typical for Alzheimer's disease (n = 34) did not improve in cognitive and gait-related functions after CSF drainage. In addition, positive CSF biomarkers for Alzheimer's disease predicted these improvements. INTERPRETATION Our data suggest an association between Alzheimer's disease and NPH changes, supporting the recently suggested dichotomy of a neurodegenerative NPH and a true idiopathic NPH, with the latter appearing to be rare. ANN NEUROL 2020;88:703-711.
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Affiliation(s)
- Katharina Müller-Schmitz
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Natalia Krasavina-Loka
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tugba Yardimci
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tim Lipka
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Aschwin G J Kolman
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sabine Robbers
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Til Menge
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Milenko Kujovic
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Rüdiger J Seitz
- Centre for Neurology and Neuropsychiatry, Landschaftsverband Rheinland-Klinikum Düsseldorf, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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46
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Effect of Lumbar Drainage on Cortical Excitability in Normal Pressure Hydrocephalus. Can J Neurol Sci 2020; 48:253-258. [DOI: 10.1017/cjn.2020.169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground:Idiopathic normal pressure hydrocephalus (iNPH) is characterized by the clinical triad of gait disturbance, urinary incontinence, and memory impairment with normal cerebrospinal fluid (CSF) pressure. Transcranial magnetic stimulation (TMS) has been used to assess the corticospinal motor pathways in patients with iNPH with conflicting results.Methods:Our study included 11 patients with iNPH and 13 healthy controls. All the subjects underwent TMS and resting motor threshold (RMT), central motor conduction time (CMCT), short-interval intracortical inhibition (SICI), intracortical facilitation, and silent period (SP) were recorded in the upper limb. Besides, RMT and CMCT in lower limb were also recorded. Cognitive assessments were done using mini-mental status examination, Montreal cognitive assessment (MoCA), and Addenbrooke’s cognitive evaluation III (ACE III). Same parameters were recorded 24 h of CSF (lumbar puncture, LP) drainage.Results:Mean age of the iNPH patients was 69.00 ± 6.71 years with age at onset being 66.64 ± 7.10 years. Duration of disease was 1.80 ± 1.25 years. A significant difference was noted in CMCT for the lower limb (CMCT-LL), SICI, and ipsilateral SP between pre-LP NPH and controls. Also, there was a significant difference in MoCA and ACE III between pre-LP NPH and controls. A significant reduction was observed in lower limb RMT between pre- and post-LP NPH patients. Post LP, there was a reduction in the lower limb CMCT and improvement in SICI.Conclusion:A significant prolongation of CMCT-LL was observed in NPH patients. Lumbar CSF drainage in them resulted in a significant reduction in lower limb RMT thereby suggesting an increase in cortical excitability.
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47
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Arnts H, van Erp WS, Sanz LRD, Lavrijsen JCM, Schuurman R, Laureys S, Vandertop WP, van den Munckhof P. The Dilemma of Hydrocephalus in Prolonged Disorders of Consciousness. J Neurotrauma 2020; 37:2150-2156. [PMID: 32484029 DOI: 10.1089/neu.2020.7129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prolonged disorders of consciousness (DOC) are considered to be among the most severe outcomes after acquired brain injury. Medical care for these patients is mainly focused on minimizing complications, given that treatment options for patients with unresponsive wakefulness or minimal consciousness remain scarce. The complication rate in patients with DOC is high, both in the acute hospital setting, as in the rehabilitation or long-term care phase. Hydrocephalus is one of these well-known complications and usually develops quickly after acute changes in cerebrospinal fluid (CSF) circulation after different types of brain damage. However, hydrocephalus may also develop with a significant delay, weeks, or even months after the initial injury, reducing the potential for natural recovery of consciousness. In this phase, hydrocephalus is likely to be missed in DOC patients, given that their limited behavioral responsiveness camouflages the classic signs of increased intracranial pressure or secondary normal-pressure hydrocephalus. Moreover, the development of late-onset hydrocephalus may exceed the period of regular outpatient follow-up. Several controversies remain about the diagnosis of clinical hydrocephalus in patients with ventricular enlargement after severe brain injury. In this article, we discuss both the difficulties in diagnosis and dilemmas in the treatment of CSF disorders in patients with prolonged DOC and review evidence from the literature to advance an active surveillance protocol for the detection of this late, but treatable, complication. Moreover, we advocate a low threshold for CSF diversion when hydrocephalus is suspected, even months or years after brain injury.
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Affiliation(s)
- Hisse Arnts
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willemijn S van Erp
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.,GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - Leandro R D Sanz
- GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - Jan C M Lavrijsen
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Steven Laureys
- GIGA Consciousness, University of Liège, Liège, Belgium; Coma Science Group, University Hospital of Liège, Liège, Belgium
| | - William P Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Bunevicius A, Vernon A, Golby A. Abdominal Insufflation Is Associated With Increase of Intracranial Pressure in Patients With Normal Pressure Hydrocephalus. Oper Neurosurg (Hagerstown) 2020; 19:53-56. [PMID: 31620775 DOI: 10.1093/ons/opz319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/29/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunting (VPS) is effective for the treatment of normal-pressure hydrocephalus (NPH) and sometimes requires laparoscopic assistance with abdominal insufflation. OBJECTIVE To evaluate the association of abdominal insufflation with opening pressure (OP) in NPH patients undergoing VPS implantation. METHODS Between March 2016 and April 2019, 52 consecutive patients who underwent first-time VPS implantation surgery were retrospectively identified by reviewing electronic health records. OP during the large volume lumbar tap test (OPLP) and VPS implantation surgery (OPSURGERY) were measured in 29 patients. RESULTS Laparoscopic assistance with abdominal insufflation was used in 20 (69%) cases. There were no differences in patient age (P = .589), gender (P = .822), body mass index (P = .289), weight (P = .789), height (P = .542), and OPLP (P = .476) in patients operated with and without laparoscopic assistance. When compared to patients operated without laparoscopic assistance, laparoscopic assistance was associated with a greater rate of OP increase during surgery relative to OPLP (40% vs 100%, P = .002), a greater increase in OPSURGERY relative to OPLP (-0.40 ± 5.38 vs 10.17 ± 5.53 cm H2O, P < .001), and a greater proportion of patients with OPSURGERY of ≥25 cm H2O during the VPS surgery (0% vs 78%, P < .001). CONCLUSION Abdominal insufflation is associated with an increase in intracranial pressure with OPs often exceeding 25 cm H2O. This should be considered when selecting optimal VPS pressure settings.
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Affiliation(s)
- Adomas Bunevicius
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Ashley Vernon
- Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Alexandra Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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Outcomes Following LSVT BIG in a Person With Idiopathic Normal Pressure Hydrocephalus: A Case Report. J Neurol Phys Ther 2020; 44:220-227. [PMID: 32516302 DOI: 10.1097/npt.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE There is no literature exploring physical therapy interventions for individuals with idiopathic normal pressure hydrocephalus (iNPH). There are parallels between symptoms of iNPH and Parkinson disease (PD), suggesting that similar interventions may be beneficial. An approach that promotes recalibration of movements to produce bigger motions (Lee Silverman Voice Treatment BIG [LSVT BIG]) is an evidence-based intervention for individuals with PD, which could potentially improve function in individuals with iNPH. This case report documents functional outcomes of LSVT BIG in an individual with iNPH. CASE DESCRIPTION The participant was a 62-year-old man with a 16-year history of iNPH. He demonstrated hypokinesia, impaired balance, and cognitive deficits. These resulted in frequent falls and limited community ambulation. INTERVENTION The participant completed the standardized 4-week LSVT BIG program in addition to 5 tune-up sessions 7 months later. Outcome measures included the Berg Balance Scale (BBS), Timed Up and Go (TUG), TUG cognitive and manual, Activities-Specific Balance and Confidence (ABC) scale, Five Times Sit to Stand (5TSTS) test, and a timed floor transfer. OUTCOMES Improvements, exceeding minimal detectable change values, were noted on the BBS and the ABC scale immediately following intervention. Scores declined at 4-month follow-up, but BBS scores increased again after the tune-up sessions. Quicker floor transfer times were also noted. There were no changes in TUG, TUG cognitive and manual, or 5TSTS times. DISCUSSION Therapists may wish to consider the use of the LSVT BIG program in persons with iNPH; however, a longer program and/or regular tune-up sessions may be necessary for best outcomes.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A315).
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50
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Gutowski P, Rot S, Fritsch M, Meier U, Gölz L, Lemcke J. Secondary deterioration in patients with normal pressure hydrocephalus after ventriculoperitoneal shunt placement: a proposed algorithm of treatment. Fluids Barriers CNS 2020; 17:18. [PMID: 32127017 PMCID: PMC7055114 DOI: 10.1186/s12987-020-00180-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this group of patients with secondary deterioration and to evaluate the performed shunt management. Methods For this investigation, we retrospectively reviewed our NPH registry for patients included between 1999 and 2013 with a decrease by a minimum of two points in the Kiefer score in the first year of follow up and an increase of two points in the Kiefer score between the second and the fifth year after shunt surgery (secondary deterioration). Then, we analyzed the patient’s shunt management (adapting the valve pressure setting, shuntography, valve replacement, catheter replacement, implant an adjustable gravitational unit). Additionally, we searched for risk factors for secondary deterioration. Results Out of 259 iNPH patients, 53 (20%) patients showed secondary deterioration on an average of 2.7 (2–4 years) years after shunt surgery. Fourteen (26%) patients with secondary deterioration improved after shunt or valve management and 58% remained without clinical benefit after management. We had a drop-out rate of 15% due to incomplete datasets. Our shunt management reduced the rate of secondary deterioration from 20 to 15%. On the basis of our findings, we developed an algorithm for shunt management. Risk factors for secondary deterioration are the age of the patient at the time of shunting, newly diagnosed neurodegenerative diseases, and overdrainage requiring adjusting the valve to higher-pressure levels. Conclusion Twenty percent of patients with iNPH were at risk for secondary clinical worsening about 3 years after shunt surgery. About one-fourth of these patients benefited for additional years from pressure level management and/or shunt valve revision. Our findings underline the need for long-term follow-ups and intensive shunt management to achieve a favorable long-term outcome for patients with iNPH and VPS.
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Affiliation(s)
- Pawel Gutowski
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany.
| | - Sergej Rot
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Ullrich Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - Leonie Gölz
- Department of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
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