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Sahoo P, Kollmeier JM, Wenkel N, Badura S, Gärtner J, Frahm J, Dreha-Kulaczewski S. CSF and venous blood flow from childhood to adulthood studied by real-time phase-contrast MRI. Childs Nerv Syst 2024; 40:1377-1388. [PMID: 38206441 PMCID: PMC11026278 DOI: 10.1007/s00381-024-06275-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE In vivo measurements of CSF and venous flow using real-time phase-contrast (RT-PC) MRI facilitate new insights into the dynamics and physiology of both fluid systems. In clinical practice, however, use of RT-PC MRI is still limited. Because many forms of hydrocephalus manifest in infancy and childhood, it is a prerequisite to investigate normal flow parameters during this period to assess pathologies of CSF circulation. This study aims to establish reference values of CSF and venous flow in healthy subjects using RT-PC MRI and to determine their age dependency. METHODS RT-PC MRI was performed in 44 healthy volunteers (20 females, age 5-40 years). CSF flow was quantified at the aqueduct (Aqd), cervical (C3) and lumbar (L3) spinal levels. Venous flow measurements comprised epidural veins, internal jugular veins and inferior vena cava. Parameters analyzed were peak velocity, net flow, pulsatility, and area of region of interest (ROI). STATISTICAL TESTS linear regression, student's t-test and analysis of variance (ANOVA). RESULTS In adults volunteers, no significant changes in flow parameters were observed. In contrast, pediatric subjects exhibited a significant age-dependent decrease of CSF net flow and pulsatility in Aqd, C3 and L3. Several venous flow parameters decreased significantly over age at C3 and changed more variably at L3. CONCLUSION Flow parameters varies depending on anatomical location and age. We established changes of brain and spinal fluid dynamics over an age range from 5-40 years. The application of RT-PC MRI in clinical care may improve our understanding of CSF flow pathology in individual patients.
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Affiliation(s)
- Prativa Sahoo
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany.
| | - Jost M Kollmeier
- Biomedical NMR, Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Nora Wenkel
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany
| | - Simon Badura
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany
| | - Jutta Gärtner
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany
| | - Jens Frahm
- Biomedical NMR, Max Planck Institute for Multidisciplinary Sciences, Göttingen, Germany
| | - Steffi Dreha-Kulaczewski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert Koch Street 40, 37075, Göttingen, Germany.
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Wardman JH, Andreassen SN, Toft-Bertelsen TL, Jensen MN, Wilhjelm JE, Styrishave B, Hamann S, Heegaard S, Sinclair AJ, MacAulay N. CSF hyperdynamics in rats mimicking the obesity and androgen excess characteristic of patients with idiopathic intracranial hypertension. Fluids Barriers CNS 2024; 21:10. [PMID: 38273331 PMCID: PMC10810013 DOI: 10.1186/s12987-024-00511-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/05/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a syndrome exhibiting elevated intracranial pressure (ICP), visual disturbances, and severe headache. IIH primarily affects young obese women, though it can occur in individuals of any age, BMI, and sex. IIH is characterized by systemic metabolic dysregulation with a profile of increased androgen hormones. However, the contribution of obesity/hormonal perturbations to cerebrospinal fluid (CSF) dynamics remains unresolved. METHODS We employed obese female Zucker rats and adjuvant testosterone to reveal IIH causal drivers. ICP and CSF dynamics were determined with in vivo experimentation and magnetic resonance imaging, testosterone levels assessed with mass spectrometry, and choroid plexus function revealed with transcriptomics. RESULTS Obese rats had undisturbed CSF testosterone levels and no changes in ICP or CSF dynamics. Adjuvant testosterone treatment of obese rats elevated the CSF secretion rate, although with no effect on the ICP, due to elevated CSF drainage capacity of these rats. CONCLUSIONS Obesity in itself therefore does not suffice to recapitulate the IIH symptoms in rats, but modulation of CSF dynamics appears with adjuvant testosterone treatment, which mimics the androgen excess observed in female IIH patients. Obesity-induced androgen dysregulation may thus contribute to the disease mechanism of IIH and could potentially serve as a future therapeutic target.
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Affiliation(s)
- Jonathan H Wardman
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, Copenhagen, DK-2200, Denmark
| | - Søren Norge Andreassen
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, Copenhagen, DK-2200, Denmark
| | - Trine L Toft-Bertelsen
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, Copenhagen, DK-2200, Denmark
| | - Mette Nyholm Jensen
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, Copenhagen, DK-2200, Denmark
| | - Jens E Wilhjelm
- Department of Neurophysiology, Rigshospitalet, Copenhagen, Denmark
- Department of Health Technology, Technical University of Denmark, Copenhagen, Denmark
| | - Bjarne Styrishave
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steffen Heegaard
- Department of Ophthalmology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, Copenhagen, DK-2200, Denmark.
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Wardman JH, Jensen MN, Andreassen SN, Styrishave B, Wilhjelm JE, Sinclair AJ, MacAulay N. Modelling idiopathic intracranial hypertension in rats: contributions of high fat diet and testosterone to intracranial pressure and cerebrospinal fluid production. Fluids Barriers CNS 2023; 20:44. [PMID: 37328884 DOI: 10.1186/s12987-023-00436-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/29/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a condition characterized by increased intracranial pressure (ICP), impaired vision, and headache. Most cases of IIH occur in obese women of childbearing age, though age, BMI, and female sex do not encompass all aspects of IIH pathophysiology. Systemic metabolic dysregulation has been identified in IIH with a profile of androgen excess. However, the mechanistic coupling between obesity/hormonal perturbations and cerebrospinal fluid dynamics remains unresolved. METHODS Female Wistar rats were either fed a high fat diet (HFD) for 21 weeks or exposed to adjuvant testosterone treatment for 28 days to recapitulate IIH causal drivers. Cerebrospinal fluid (CSF) and blood testosterone levels were determined with mass spectrometry, ICP and CSF dynamics with in vivo experimentation, and the choroid plexus function revealed with transcriptomics and ex vivo isotope-based flux assays. RESULTS HFD-fed rats presented with increased ICP (65%), which was accompanied by increased CSF outflow resistance (50%) without altered CSF secretion rate or choroid plexus gene expression. Chronic adjuvant testosterone treatment of lean rats caused elevated ICP (55%) and CSF secretion rate (85%), in association with increased activity of the choroid plexus Na+,K+,2Cl- cotransporter, NKCC1. CONCLUSIONS HFD-induced ICP elevation in experimental rats occurred with decreased CSF drainage capacity. Adjuvant testosterone, mimicking the androgen excess observed in female IIH patients, elevated the CSF secretion rate and thus ICP. Obesity-induced androgen dysregulation may thus contribute to the disease mechanism of IIH.
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Affiliation(s)
- Jonathan H Wardman
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Mette N Jensen
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Søren N Andreassen
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Bjarne Styrishave
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Jens E Wilhjelm
- Department of Health Technology, The Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Nanna MacAulay
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark.
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Wang MTM, Bhatti MT, Danesh-Meyer HV. Idiopathic intracranial hypertension: Pathophysiology, diagnosis and management. J Clin Neurosci 2021; 95:172-179. [PMID: 34929642 DOI: 10.1016/j.jocn.2021.11.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 12/13/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure, manifested by papilledema and radiological findings, in the absence of an identifiable casual factor. The primary symptoms include headache, vision loss, and pulsatile tinnitus, and are recognized to have profound impacts on quality of life and visual function. IIH demonstrates a strong predilection towards obese women of reproductive age, and the population incidence is rising with the growing prevalence of obesity worldwide. The pathophysiology involves dysregulation of cerebrospinal fluid (CSF) dynamics and venous sinus pressure, and recent studies highlighting the pathogenic role of metabolic and hormonal factors have led to the identification of several pharmacological targets and development of novel therapeutic agents. The overarching treatment goals include symptomatic alleviation and prevention of permanent vision loss. The Idiopathic Intracranial Hypertension Treatment Trial, the first of its kind randomized controlled trial on IIH, provides class I evidence for treatment with weight loss and acetazolamide. In medically refractive or fulminant cases, optic nerve sheath fenestration, CSF diversion, and venous sinus stenting, have been successfully implemented. However, there are few high-quality prospective studies investigating the treatment and natural history of IIH, highlighting the compelling need for further research to determine the optimal treatment regimen.
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Affiliation(s)
- Michael T M Wang
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand
| | - M Tariq Bhatti
- Departments of Ophthalmology and Neurology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand.
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Kaipainen AL, Martoma E, Puustinen T, Tervonen J, Jyrkkänen HK, Paterno JJ, Kotkansalo A, Rantala S, Vanhanen U, Leinonen V, Lehto SM, Iso-Mustajärvi M, Elomaa AP, Qvarlander S, Huuskonen TJ. Cerebrospinal fluid dynamics in idiopathic intracranial hypertension: a literature review and validation of contemporary findings. Acta Neurochir (Wien) 2021; 163:3353-3368. [PMID: 34453214 PMCID: PMC8599224 DOI: 10.1007/s00701-021-04940-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a rare disease of unknown aetiology related possibly to disturbed cerebrospinal fluid (CSF) dynamics and characterised by elevated intracranial pressure (ICP) causing optic nerve atrophy if not timely treated. We studied CSF dynamics of the IIH patients based on the available literature and our well-defined cohort. METHOD A literature review was performed from PubMed between 1980 and 2020 in compliance with the PRISMA guideline. Our study includes 59 patients with clinical, demographical, neuro-ophthalmological, radiological, outcome data, and lumbar CSF pressure measurements for suspicion of IIH; 39 patients had verified IIH while 20 patients did not according to Friedman's criteria, hence referred to as symptomatic controls. RESULTS The literature review yielded 19 suitable studies; 452 IIH patients and 264 controls had undergone intraventricular or lumbar CSF pressure measurements. In our study, the mean CSF pressure, pulse amplitudes, power of respiratory waves (RESP), and the pressure constant (P0) were higher in IIH than symptomatic controls (p < 0.01). The mean CSF pressure was higher in IIH patients with psychiatric comorbidity than without (p < 0.05). In IIH patients without acetazolamide treatment, the RAP index and power of slow waves were also higher (p < 0.05). IIH patients with excess CSF around the optic nerves had lower relative pulse pressure coefficient (RPPC) and RESP than those without (p < 0.05). CONCLUSIONS Our literature review revealed increased CSF pressure, resistance to CSF outflow and sagittal sinus pressure (SSP) as key findings in IIH. Our study confirmed significantly higher lumbar CSF pressure and increased CSF pressure waves and RAP index in IIH when excluding patients with acetazolamide treatment. In overall, the findings reflect decreased craniospinal compliance and potentially depleted cerebral autoregulation resulting from the increased CSF pressure in IIH. The increased slow waves in patients without acetazolamide may indicate issues in autoregulation, while increased P0 could reflect the increased SSP.
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Affiliation(s)
- Aku L Kaipainen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
- Institute of Clinical Medicine / Neurology, University of Eastern Finland, Kuopio, Finland.
| | - Erik Martoma
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tero Puustinen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Henna-Kaisa Jyrkkänen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi J Paterno
- Opthalmology KUH, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Anna Kotkansalo
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland
| | - Susanna Rantala
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ulla Vanhanen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ville Leinonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Soili M Lehto
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- R&D department, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Department of Psychiatry, University of Helsinki, Helsinki, Finland
| | | | - Antti-Pekka Elomaa
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Eastern Finland Microsurgery Center, Kuopio University Hospital, Kuopio, Finland
| | - Sara Qvarlander
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Terhi J Huuskonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Xie JS, Donaldson L, Margolin E. Papilledema: A review of etiology, pathophysiology, diagnosis, and management. Surv Ophthalmol 2021; 67:1135-1159. [PMID: 34813854 DOI: 10.1016/j.survophthal.2021.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023]
Abstract
Papilledema is optic nerve head edema secondary to raised intracranial pressure (ICP). It is distinct from other causes of optic disk edema in that visual function is usually normal in the acute phase. Papilledema is caused by transmission of elevated ICP to the subarachnoid space surrounding the optic nerve that hinders axoplasmic transport within ganglion cell axons. There is ongoing controversy as to whether axoplasmic flow stasis is produced by physical compression of axons or microvascular ischemia. The most common cause of papilledema, especially in patients under the age of 50, is idiopathic intracranial hypertension (IIH); however, conditions that decrease cerebrospinal fluid (CSF) outflow by either causing CSF derangements or mechanically blocking CSF outflow channels, and rarely conditions that increase CSF production, can be the culprit. When papilledema is suspected clinically, blood pressure should be measured, and pseudopapilledema should be ruled out. Magnetic resonance imaging of the brain and orbits with venography sequences is the preferred neuroimaging modality that should be performed next to look for indirect imaging signs of increased ICP and to rule out nonidiopathic causes. Lumbar puncture with measurement of opening pressure and evaluation of CSF composition should then be performed. In patients not in a typical demographic group for IIH, further investigations should be conducted to assess for underlying causes of increased ICP. Magnetic resonance imaging of the neck and spine, magnetic resonance angiography of the brain, computed tomography of the chest, complete blood count, and creatinine testing should be able to identify most secondary causes of intracranial hypertension. Treatment for patients with papilledema should be targeted toward the underlying etiology. Most patients with IIH respond to weight loss and oral acetazolamide. For patients with decreased central acuity and constricted visual fields at presentation, as well as patients who do not respond to treatment with acetazolamide, surgical treatments should be considered, with ventriculoperitoneal shunting being the typical procedure of choice.
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Affiliation(s)
- Jim Shenchu Xie
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Laura Donaldson
- Faculty of Medicine, Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Edward Margolin
- Faculty of Medicine, Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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Dural venous sinus stenting in the treatment of idiopathic intracranial hypertension: A systematic review and critique of literature. Surv Ophthalmol 2021; 67:271-287. [PMID: 34004224 DOI: 10.1016/j.survophthal.2021.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/23/2021] [Accepted: 05/03/2021] [Indexed: 12/19/2022]
Abstract
Idiopathic intracranial hypertension (IIH) is increased intracranial pressure without a known cause. Dural venous sinus stenting (DVSS) is a relatively new intervention for treatment of IIH refractory to medical therapy and lifestyle modifications. In this review, we outline various hypotheses of IIH pathogenesis and describe the role of venous sinus stenosis and the technical details of DVSS. We also present a summary and critique of the available evidence describing the outcomes of DVSS in IIH and review the evidence-based guidelines for this procedure. We conclude that, although many studies have shown generally favorable outcomes of DVSS in patients with IIH, most have serious limitations, the most common one being paucity of pre- and postprocedure ophthalmological data. Thus, there is not enough available evidence to conclude whether DVSS is an effective procedure for treatment of IIH. We also present the most commonly used indications for DVSS as described in the literature and stress the importance of neuro-ophthalmological assessment before and after the procedure to monitor response and potential complications.
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Eftekhari S, Westgate CSJ, Uldall MS, Jensen RH. Preclinical update on regulation of intracranial pressure in relation to idiopathic intracranial hypertension. Fluids Barriers CNS 2019; 16:35. [PMID: 31767019 PMCID: PMC6878629 DOI: 10.1186/s12987-019-0155-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/13/2019] [Indexed: 12/13/2022] Open
Abstract
Background Elevated intracranial pressure (ICP) is observed in association with a range of brain disorders. One of these challenging disorders is idiopathic intracranial hypertension (IIH), characterized by raised ICP of unknown cause with significant morbidity and limited therapeutic options. In this review, special focus is put on the preclinical research performed in order to understand the pathophysiology behind ICP regulation and IIH. This includes cerebrospinal fluid dynamics, molecular mechanisms underlying disturbances in brain fluids leading to elevated ICP, role of obesity in IIH, development of an IIH model and ICP measurements in rodents. The review also discusses existing and new drug targets for IIH that have been evaluated in vivo. Conclusions ICP monitoring in rodents is challenging and different methods have been applied. Some of these methods are invasive, depend on use of anesthesia and only allow short-term monitoring. Long-term ICP recordings are needed to study IIH but existing methods are hampered by several limitations. As obesity is one of the most common risk factors for IIH, a rodent obese model has been developed that mimics some key aspects of IIH. The most commonly used drugs for IIH have been evaluated in vivo for their efficacy at lowering ICP in the existing animal models. These studies suggest these drugs, including acetazolamide, might have limited or no reducing effect on ICP. Two drug targets that can impact ICP in healthy rodents are topiramate and a glucagon-like peptide-1 receptor (GLP-1R) agonist. However, it remains to evaluate their effect in an IIH model with more precise and valid ICP monitoring system. Therefore, continued evaluation in the preclinical research with refined tools is of great importance to further understand the pathophysiology behind disorders with raised ICP and to explore new drug targets.
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Affiliation(s)
- Sajedeh Eftekhari
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark.
| | - Connar Stanley James Westgate
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Maria Schmidt Uldall
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
| | - Rigmor Hoejland Jensen
- Danish Headache Center, Department of Neurology, Glostrup Research Institute, Rigshospitalet-Glostrup, University of Copenhagen, Nordstjernevej 42, 2600, Glostrup, Denmark
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Aktas G, Kollmeier JM, Joseph AA, Merboldt KD, Ludwig HC, Gärtner J, Frahm J, Dreha-Kulaczewski S. Spinal CSF flow in response to forced thoracic and abdominal respiration. Fluids Barriers CNS 2019; 16:10. [PMID: 30947716 PMCID: PMC6449937 DOI: 10.1186/s12987-019-0130-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/27/2019] [Indexed: 11/15/2022] Open
Abstract
Background Respiration-induced pressure changes represent a powerful driving force of CSF dynamics as previously demonstrated using flow-sensitive real-time magnetic resonance imaging (MRI). The purpose of the present study was to elucidate the sensitivity of CSF flow along the spinal canal to forced thoracic versus abdominal respiration. Methods Eighteen subjects without known illness were studied using real-time phase-contrast flow MRI at 3 T in the aqueduct and along the spinal canal at levels C3, Th1, Th8 and L3. Subjects performed a protocol of forced breathing comprising four cycles of 2.5 s inspiration and 2.5 s expiration. Results The quantitative results for spinal CSF flow rates and volumes confirm previous findings of an upward movement during forced inspiration and reversed downward flow during subsequent exhalation—for both breathing types. However, the effects were more pronounced for abdominal than for thoracic breathing, in particular at spinal levels Th8 and L3. In general, CSF net flow volumes were very similar for both breathing conditions pointing upwards in all locations. Conclusions Spinal CSF dynamics are sensitive to varying respiratory performances. The different CSF flow volumes in response to deep thoracic versus abdominal breathing reflect instantaneous adjustments of intrathoracic and intraabdominal pressure, respectively. Real-time MRI access to CSF flow in response to defined respiration patterns will be of clinical importance for patients with disturbed CSF circulation like hydrocephalus, pseudotumor cerebri and others. Electronic supplementary material The online version of this article (10.1186/s12987-019-0130-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gökmen Aktas
- School of Medicine, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - Jost M Kollmeier
- Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, 37077, Göttingen, Germany
| | - Arun A Joseph
- Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, 37077, Göttingen, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Germany
| | - Klaus-Dietmar Merboldt
- Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, 37077, Göttingen, Germany
| | - Hans-Christoph Ludwig
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - Jutta Gärtner
- Division of Pediatric Neurology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - Jens Frahm
- Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, 37077, Göttingen, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Germany
| | - Steffi Dreha-Kulaczewski
- Division of Pediatric Neurology, Department of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, 37075, Göttingen, Germany.
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Abstract
BACKGROUND Most patients with idiopathic intracranial hypertension (IIH) are obese. Weight loss is felt to be an important factor in improving IIH. The mechanism by which weight loss leads to a reduction in elevated intracranial pressure is unclear. Evidence from prospective studies evaluating the role of weight loss in IIH is lacking. EVIDENCE ACQUISITION We performed a detailed review of the published literature regarding the association of IIH and obesity, including proposed pathogenetic mechanisms, and the effect of weight loss and weight-loss interventions in IIH. References were identified by searching PubMed with the terms idiopathic intracranial hypertension and weight loss. Additional citations were found in the identified references. RESULTS Over 90% of IIH patients are obese or overweight. The risk of IIH increases as a function of body mass index (BMI) and weight gain over the preceding year. The risk of IIH-induced vision loss also increases with increasing BMI, especially with BMI >40 kg/m. Several mechanisms have been proposed linking obesity to the development of IIH but the pathophysiology remains unknown. Published studies and clinical observations strongly support weight loss as an effective treatment, although there are no prospective controlled trials. Weight loss in the range of 6%-10% often leads to IIH remission. Weight loss of ≥5% at 1 year is achieved in roughly 50%-70% of patients if they are enrolled in a high-intensity lifestyle modification program and in 20%-35% of patients if they direct their own weight loss. Weight is typically regained over 1-3 years but about a third of patients maintain ≥5% weight loss over the long term. Patients treated initially with lifestyle modification therapy show a modest persisting benefit over self-directed patients. Selected commercial weight loss programs also may improve long-term maintenance of weight loss. New antiobesity drugs significantly improve the proportion of obese patients who have ≥5% loss of weight at 1 year. CONCLUSIONS Obesity is an important contributing factor for the development of IIH, although the pathophysiological mechanism linking obesity to IIH is unknown. The risk of developing IIH and associated visual loss increases with increasing BMI. Weight loss is an effective treatment for IIH. Long-term maintenance of initial weight loss is helped modestly by lifestyle modification programs and possibly by selected commercial weight loss programs. New antiobesity drugs may provide further options for IIH therapy in the future.
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11
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Identification of the Upward Movement of Human CSF In Vivo and its Relation to the Brain Venous System. J Neurosci 2017; 37:2395-2402. [PMID: 28137972 DOI: 10.1523/jneurosci.2754-16.2017] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/13/2017] [Accepted: 01/18/2017] [Indexed: 01/01/2023] Open
Abstract
CSF flux is involved in the pathophysiology of neurodegenerative diseases and cognitive impairment after traumatic brain injury, all hallmarked by the accumulation of cellular metabolic waste. Its effective disposal via various CSF routes has been demonstrated in animal models. In contrast, the CSF dynamics in humans are still poorly understood. Using novel real-time MRI, forced inspiration has been identified recently as a main driving force of CSF flow in the human brain. Exploiting technical advances toward real-time phase-contrast MRI, the current work analyzed directions, velocities, and volumes of human CSF flow within the brain aqueduct as part of the internal ventricular system and in the spinal canal during respiratory cycles. A consistent upward CSF movement toward the brain in response to forced inspiration was seen in all subjects at the aqueduct, in 11/12 subjects at thoracic level 2, and in 4/12 subjects at thoracic level 5. Concomitant analyses of CSF dynamics and cerebral venous blood flow, that is, in epidural veins at cervical level 3, uniquely demonstrated CSF and venous flow to be closely communicating cerebral fluid systems in which inspiration-induced downward flow of venous blood due to reduced intrathoracic pressure is counterbalanced by an upward movement of CSF. The results extend our understanding of human CSF flux and open important clinical implications, including concepts for drug delivery and new classifications and therapeutic options for various forms of hydrocephalus and idiopathic intracranial hypertension.SIGNIFICANCE STATEMENT Effective disposal of brain cellular waste products via CSF has been demonstrated repeatedly in animal models. However, CSF dynamics in humans are still poorly understood. A novel quantitative real-time MRI technique yielded in vivo CSF flow directions, velocities, and volumes in the human brain and upper spinal canal. CSF moved upward toward the head in response to forced inspiration. Concomitant analysis of brain venous blood flow indicated that CSF and venous flux act as closely communicating systems. The finding of a human CSF-venous network with upward CSF net movement opens new clinical concepts for drug delivery and new classifications and therapeutic options for various forms of hydrocephalus and ideopathic intracranial hypertension.
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Sivasankar R, Pant R, Indrajit IK, Negi RS, Sahu S, Hashim PI, D'Souza J. Imaging and interventions in idiopathic intracranial hypertension: A pictorial essay. Indian J Radiol Imaging 2016; 25:439-44. [PMID: 26752823 PMCID: PMC4693393 DOI: 10.4103/0971-3026.169464] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Intracranial hypertension is a syndrome of elevated intracranial pressure that can be primary or secondary. The primary form, now termed idiopathic intracranial hypertension (IIH), was in the past a disease of exclusion and imaging played a limited role of excluding organic causes of raised intracranial pressure. However imaging markers have been described with patients with IIH at the orbit, sella and cerebral venous system. We wish to reiterate the characteristic imaging features of this poorly understood disease and also emphasise that stenting of the transverse sinus in select cases of IIH is an efficacious option.
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Affiliation(s)
- Rajeev Sivasankar
- Department of Imaging and Interventional Radiology, Command Hospital Air Force, Bangalore, Karnataka, India
| | - Rochan Pant
- Department of Imaging and Interventional Radiology, INHS Asvini Hospital, Mumbai, Maharashtra, India
| | - Inna K Indrajit
- Department of Imaging and Interventional Radiology, INHS Asvini Hospital, Mumbai, Maharashtra, India
| | - Raj S Negi
- Department of Imaging and Interventional Radiology, INHS Asvini Hospital, Mumbai, Maharashtra, India
| | - Samresh Sahu
- Department of Imaging and Interventional Radiology, INHS Asvini Hospital, Mumbai, Maharashtra, India
| | - P I Hashim
- Department of Imaging and Interventional Radiology, INHS Asvini Hospital, Mumbai, Maharashtra, India
| | - John D'Souza
- Department of Radiodiagnosis, Bharatiya Vidya Peeth, Pune, India
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Abstract
The mechanisms behind CSF flow in humans are still not fully known. CSF circulates from its primary production sites at the choroid plexus through the brain ventricles to reach the outer surface of the brain in the subarachnoid spaces from where it drains into venous bloodstream and cervical lymphatics. According to a recent concept of brain fluid transport, established in rodents, CSF from the brain surface also enters the brain tissue along para-arterial routes and exits through paravenous spaces again into subarachnoid compartments. This unidirectional flow is mainly driven by arterial pulsation. To investigate how CSF flow is regulated in humans, we applied a novel real-time magnetic resonance imaging technique at high spatial (0.75 mm) and temporal (50 ms) resolution in healthy human subjects. We observed significant CSF flow exclusively with inspiration. In particular, during forced breathing, high CSF flow was elicited during every inspiration, whereas breath holding suppressed it. Only a minor flow component could be ascribed to cardiac pulsation. The present results unambiguously identify inspiration as the most important driving force for CSF flow in humans. Inspiratory thoracic pressure reduction is expected to directly modulate the hydrostatic pressure conditions for the low-resistance paravenous, venous, and lymphatic clearance routes of CSF. Furthermore, the experimental approach opens new clinical opportunities to study the pathophysiology of various forms of hydrocephalus and to design therapeutic strategies in relation to CSF flow alterations.
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Margeta MA, Buckley EG, El-Dairi MA. Low cerebrospinal fluid protein in prepubertal children with idiopathic intracranial hypertension. J AAPOS 2015; 19:135-9. [PMID: 25828820 DOI: 10.1016/j.jaapos.2015.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/03/2015] [Accepted: 01/05/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate a clinical observation that prepubertal children with idiopathic intracranial hypertension (IIH) have low cerebrospinal fluid (CSF) protein levels compared to healthy children and pubertal patients with IIH. METHODS The medical records of prepubertal and pubertal IIH patients and controls seen in the pediatric neuro-ophthalmology clinic at Duke between 2003 and 2013 were retrospectively reviewed. The control group consisted of children who had normal intracranial pressure on lumbar puncture performed to evaluate for headaches or anomalous-looking optic nerves. The records were analyzed with attention to demographic characteristics, clinical presentation, course, and lumbar puncture results. RESULTS A total of 23 prepubertal children with IIH (age range, 0.75-13 years), 16 pubertal patients with IIH (age range, 13-21 years), and 12 controls (age range 3-14 years) were included. CSF analysis revealed that prepubertal children with IIH had significantly lower CSF protein levels (17.3 ± 5.7 mg/dL) compared to pubertal subjects with IIH (23.4 ± 8.4 mg/dL; P = 0.019) or healthy controls (23.5 ± 6.4 mg/dL; P = 0.011). Furthermore, 9 of 23 prepubertal IIH patients (39%) had abnormally low CSF protein level (<15 mg/dL), compared to zero pubertal IIH patients (P = 0.005) and zero controls (P = 0.015). Acetazolamide increased CSF protein level in 100% of patients who underwent repeat lumbar puncture after starting the medication (average increase, 10.3 ± 6.6 mg/dL). CONCLUSIONS Low CSF protein level may have diagnostic utility as a biomarker for prepubertal IIH. Furthermore, this finding suggests that some cases of prepubertal IIH may be caused by CSF overproduction rather than decreased CSF resorption.
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Affiliation(s)
- Milica A Margeta
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Edward G Buckley
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Mays A El-Dairi
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina.
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Graff-Radford SB, Schievink WI. High-pressure headaches, low-pressure syndromes, and CSF leaks: diagnosis and management. Headache 2014; 54:394-401. [PMID: 24433511 DOI: 10.1111/head.12283] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Headache resulting from idiopathic intracranial hypertension (IIH) in a population of moderately to obese women of childbearing age. The causes overall remain unclear. With this review, we provide an overview of clinical treatment and management strategies. RESULTS IIH management is dependent on the signs and symptoms presented. Symptomatic treatment should attempt to lower intracranial pressure, reduce pain, and protect the optic nerves. Consideration for lumbar puncture and draining fluid as an option for reducing pressure may be helpful; however, repeated treatment is not usually favored by patients. Traditional prophylactic medications used in migraine may help reduce the primary headache often induced by raised intracranial pressure. We suggested surgical intervention for patients experiencing visual loss or impending visual loss and not responding to medication therapy. CONCLUSION In this review, we discuss headache associated with IIH and spontaneous intracranial hypotension. Much needs to be learned about treatment options for patients with cerebrospinal fluid leaks including methods to strengthen the dura.
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Horsburgh A, Massoud TF. Is higher choroid plexus ‘load’ an aetiologic factor in idiopathic intracranial hypertension? A clinico-imaging morphometric correlative study. Cephalalgia 2012; 33:20-4. [DOI: 10.1177/0333102412465202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Idiopathic intracranial hypertension (IIH) is a condition of raised cerebrospinal fluid (CSF) pressure with normal ventricular size. Although the pathogenesis of IIH remains controversial, increased CSF formation may be important. We hypothesised that if increased CSF formation was an aetiologic factor, it might result in a macroscopic increase in size of the choroid plexus (CP). Method We retrospectively studied 50 patients with IIH. Total size of the CP was estimated on computed tomography (CT) venograms from the sum of axial areas measured at three locations. Results were compared with the CP load of 50 matched controls on post-contrast head CTs. Evans Index was measured to exclude ventriculomegaly. Results were analysed using a Student’s t test for independent samples ( p < 0.05), and the effect of ICP was tested on the dependent variable (area of CP) using regression analysis. Results There was no significant difference in the size of the CP glomus, total axial areas of the CP between IIH patients (183 mm2) and controls (178 mm2) and no correlation between the ‘load’ of CP and the degree of intracranial pressure (ICP) ( R2 < 0.02). Conclusion If increased CSF formation is an aetiologic factor in IIH, this is not reflected in a corresponding raised ‘load’ of CP.
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Affiliation(s)
| | - Tarik F Massoud
- Department of Radiology, Addenbrooke’s Hospital, UK
- University of Cambridge, UK
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Cui LG, Jiang L, Zhang HB, Liu B, Wang JR, Jia JW, Chen W. Monitoring of cerebrospinal fluid flow by intraoperative ultrasound in patients with Chiari I malformation. Clin Neurol Neurosurg 2011; 113:173-6. [DOI: 10.1016/j.clineuro.2010.10.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 10/12/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
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A comparison of the effects of preanesthetic administration of crystalloid versus colloid on intrathecal spread of isobaric spinal anesthetics and cerebrospinal fluid movement. Anesth Analg 2011; 112:924-30. [PMID: 21288972 DOI: 10.1213/ane.0b013e31820d93d8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Movement of the cerebrospinal fluid (CSF) is one of the most important factors in determining the intrathecal spread of isobaric spinal anesthetics. Preanesthetic administration of either crystalloid or colloid immediately before spinal anesthesia (preload) may result in different CSF pulsatile movement because of their different physical properties. We examined whether preload of crystalloid versus colloid may have different effects on the intrathecal spread of isobaric spinal anesthetics as a result of their different CSF dynamics regarding its pulsatile movement. METHODS In a clinical study of isobaric spinal anesthesia, patients were allocated into 1 of 2 groups according to preload with either crystalloid (n = 30) or colloid (n = 30) before spinal anesthesia with 0.5 isobaric tetracaine. The pulsatile movements of CSF at the L2-3 intervertebral space and midportion of the aqueduct of Sylvius were also examined by magnetic resonance images in healthy volunteers (n = 23) at 0, 30, and 60 minutes after administering either crystalloid or colloid. RESULTS In the clinical study, the time to reach the peak sensory block level was delayed significantly in the crystalloid preload group (27.2 ± 17.8 minutes; P < 0.01) compared with the colloid preload group (13.9 ± 7.0 minutes). The median sensory block levels of the crystalloid preload group at 15 minutes (T10, P < 0.05) and 20 minutes (T9.5, P < 0.05) were significantly lower than those (T8, T7, respectively) of the colloid preload group. In the magnetic resonance imaging study, cranially directed CSF pulsatile movement decreased significantly at the L2-3 intervertebral intrathecal space at 30 minutes after crystalloid administration, but not after colloid administration. The CSF production rate significantly increased at 30 minutes (637 μL/min, P < 0.05) after crystalloid preload compared with the baseline measurement (448 μL/min), and then slightly decreased (609 μL/min) at 60 minutes. In the colloid preload group, the CSF production rate was not statistically significant compared with the baseline measurement (464, 512, and 542 μL/min at baseline, 30, and 60 minutes, respectively). CONCLUSIONS Compared with a colloid preload, which may be comparable to the no-preload condition, crystalloid preload prolonged the time to reach the peak sensory block level in isobaric spinal anesthesia, which might have been caused by a significant decrease in CSF pulsatile movement. This attenuated CSF pulsatile movement in the crystalloid preload group might have resulted from significant increases of CSF production.
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Spennato P, Ruggiero C, Parlato RS, Buonocore MC, Varone A, Cianciulli E, Cinalli G. Pseudotumor cerebri. Childs Nerv Syst 2011; 27:215-35. [PMID: 20721668 DOI: 10.1007/s00381-010-1268-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 08/03/2010] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pseudotumor cerebri is a condition characterized by raised intracranial pressure, normal CSF contents, and normal brain with normal or small ventricles on imaging studies. It affects predominantly obese women of childbearing age; however, its incidence seems to be increasing among adolescent and children. While among older children the clinical picture is similar to that of adults, younger children present demographic and clinical peculiarities. Different diagnostic criteria for adults and pre-pubertal children have been proposed. Etiology and pathogenesis are still unclear, particular concerning the role of obstruction to venous outflow. METHODS An extensive literature review concerning all the aspects of pseudotumor cerebri has been performed, both among adults and pre-pubertal children. CONCLUSION Pseudotumor cerebri is an avoidable cause of visual loss, both in adults and children. Few diagnostic measures are usually sufficient to determine the correct diagnosis. Since pseudotumor cerebri is a diagnosis of exclusion, the differential diagnosis work out is of special importance. Modern neuroimaging techniques, especially magnetic resonance imaging and magnetic resonance venography may clarify the role of obstruction to venous outflow in each case. Various therapeutic options are available: medical, surgical, and endovascular procedures may be used to prevent irreversible visual loss. Treatment is usually effective, and most patients will experience complete resolution of symptoms without persistent deficits.
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Affiliation(s)
- Pietro Spennato
- Department of Neurosurgery, Santobono-Paulipon Pediatric Hospital, Via Mario Fiore 6, Naples, Italy.
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Laemmer R, Heckmann JG, Mardin CY, Schwab S, Laemmer AB. Detection of nerve fiber atrophy in apparently effectively treated papilledema in idiopathic intracranial hypertension. Graefes Arch Clin Exp Ophthalmol 2010; 248:1787-93. [PMID: 20677009 DOI: 10.1007/s00417-010-1465-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 07/09/2010] [Accepted: 07/12/2010] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Since papilledema in idiopathic intracranial hypertension is a passive event not primarily affecting the visual tract, resolution with restitution ad integrum is expected if intracranial pressure is rebalanced. Retinal nerve fiber swelling due to papilledema in the acute phase and possible axon loss after long-lasting elevated intracranial pressure was investigated in a controlled cross-sectional study by scanning laser polarimetry. METHODS A cohort of 23 patients with idiopathic intracranial hypertension according to the modified Dandy diagnostic criteria, and 23 controls matched for age and gender were investigated. All patients received neurological and ophthalmologic examination including scanning laser polarimetry (GDx VCC). Patients were divided into groups depending on the presence of a papilledema (group 1) or the regression of the papilledema after initiation of therapy (group 2). Therapy was based on recommendations of the German Society of Neurology. RESULTS Scanning laser polarimetry showed an increase of nerve fiber thickness in group 1, and a decrease of the nerve fiber thickness in group 2 compared to controls. Ten of 13 patients showed signs of a regional axon loss in the deviation map of the GDx report, and six had a Nerve Fiber Index above 30. All patients with regressive papilledema and coincidence of visual field damage and pale optic disc appearance had a pathologic result in the GDx examination, but only four of ten patients with a pathologic GDx examination showed coincidence of pale optic disc appearance and visual field damage as sign of underlying optic disc atrophy. CONCLUSION In patients with apparently effective treatment of clinical symptoms and a regression of papilledema in idiopathic intracranial hypertension, a retinal axon loss was detected by scanning laser polarimetry. Axon loss was even present in patients without clinical evidence of optic nerve atrophy.
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Affiliation(s)
- Robert Laemmer
- Department of Ophthalmology, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Obinata K, Kamata A, Kinoshita K, Nakazawa T, Haruna H, Hosaka A, Shimizu T. Prolonged Intracranial Hypertension after Recombinant Growth Hormone Therapy due to Impaired CSF Absorption. Clin Pediatr Endocrinol 2010; 19:39-44. [PMID: 23926377 PMCID: PMC3687619 DOI: 10.1297/cpe.19.39] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 11/20/2009] [Indexed: 11/29/2022] Open
Abstract
We experienced a case of a Japanese boy who developed intractable idiopathic intracranial hypertension (IIH)
during growth hormone (GH) treatment. At the age of 4 yr, the boy was diagnosed with idiopathic growth hormone
deficiency, and recombinant human GH replacement was initiated. Nine months after initiation of the GH
therapy, he began to complain of headache, but papilledema was not observed. His headache persisted
thereafter, and right esotropia occurred 10 mo after the initiation of GH therapy, at which time papilledema
was detected. No other neurological abnormalities were detected, and the findings of computed tomography and
magnetic resonance imaging were normal. In a cerebrospinal fluid (CSF) examination, the pressure was markedly
elevated to 450 mmH2O, but no other abnormality was recognized. Impaired CSF absorption was
detected using the pressure-volume index technique. The CSF levels of GH and insulin-like growth factor I were
not increased. GH therapy was withdrawn after it was suggested that the IIH was associated with the GH
therapy, but the headache persisted. The intracranial hypertension did not respond to diuretics, and
prednisolone was only transiently effective. Although the funduscopic findings were normalized, increased CSF
pressure was still observed. For over 2 yr, repeated lumbar puncture was necessary to protect against visual
defect. IIH is an uncommon adverse event during GH therapy, but it must be considered carefully.
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Affiliation(s)
- Kaoru Obinata
- Department of Pediatrics, Koshigaya Municipal Hospital, Saitama, Japan ; Department of Pediatrics, Juntendo University Urayasu Hospital, Chiba, Japan
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De Simone R, Ranieri A, Bonavita V. Advancement in idiopathic intracranial hypertension pathogenesis: focus on sinus venous stenosis. Neurol Sci 2010; 31 Suppl 1:S33-9. [PMID: 20464580 DOI: 10.1007/s10072-010-0271-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Roberto De Simone
- Department of Neurological Sciences, Headache Centre, University of Naples Federico II, via Pansini, 5, 80131, Naples, Italy.
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Yoshida K, Takahashi H, Saijo M, Ueguchi T, Tanaka H, Fujita N, Murase K. Phase-contrast MR studies of CSF flow rate in the cerebral aqueduct and cervical subarachnoid space with correlation-based segmentation. Magn Reson Med Sci 2010; 8:91-100. [PMID: 19783872 DOI: 10.2463/mrms.8.91] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Accurate measurement of cerebrospinal fluid (CSF) flow rate elucidates pathophysiological changes in the intracranial environment and is thus clinically useful. We investigated the feasibility of correlation coefficient (CC) analysis for extracting CSF lumens in the cerebral aqueduct and cervical subarachnoid space (SAS) to quantify CSF flow rate and net flow from data acquired by phase-contrast magnetic resonance imaging (PC-MRI). METHODS First, in phantom studies on pulsatile flow using a 1.5-tesla MR imaging system, we investigated the accuracy of CC analysis and used a statistical approach to determine an optimal threshold value for extracting the CSF lumens (CC(min)). Second, we performed phantom studies on constant flow with various flow rates to estimate the accuracy of low flow measurement by PC-MRI. Finally, in 6 healthy male volunteers aged 24 +/- 2 years, we estimated the CSF lumen areas, net flows, and peak flow rates in the cerebral aqueduct and cervical SAS using CC analysis with the optimal CC(min) value determined in phantom studies. Three observers analyzed results to compare reproducibility of CC analysis with that of manual segmentation. RESULTS The optimal CC(min) value for CC analysis was 0.41 for a matrix measuring 256 x 256. The CSF lumen area extracted by CC analysis was 6.15 +/- 2.52 mm(2), and the net flow in the cerebral aqueduct was 0.74 +/- 0.38 mL/min; in the cervical SAS, lumen area was 135.60 +/- 17.94 mm(2) and net flow, 12.55 +/- 12.67 mL/min. The reproducibility of CSF lumen extraction was better by CC analysis than manual segmentation. CONCLUSION CC analysis offers a quick and reproducible method for segmenting CSF lumens and calculating CSF flow rate.
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Affiliation(s)
- Keita Yoshida
- Department of Medical Physics and Engineering, Division of Medical Technology and Science, Course of Health Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Liu GT, Volpe NJ, Galetta SL. Optic disc swelling. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Hypothesis for lateral ventricular dilatation in communicating hydrocephalus: New understanding of the Monro-Kellie hypothesis in the aspect of cardiac energy transfer through arterial blood flow. Med Hypotheses 2009; 72:174-7. [DOI: 10.1016/j.mehy.2008.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2008] [Revised: 08/02/2008] [Accepted: 09/10/2008] [Indexed: 11/22/2022]
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Übeyli ED, Ilbay K, Ilbay G, Sahin D, Akansel G. Differentiation of Two Subtypes of Adult Hydrocephalus by Mixture of Experts. J Med Syst 2008; 34:281-90. [DOI: 10.1007/s10916-008-9239-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sinclair AJ, Ball AK, Burdon MA, Clarke CE, Stewart PM, Curnow SJ, Rauz S. Exploring the pathogenesis of IIH: An inflammatory perspective. J Neuroimmunol 2008; 201-202:212-20. [DOI: 10.1016/j.jneuroim.2008.06.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 06/12/2008] [Accepted: 06/12/2008] [Indexed: 12/18/2022]
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Bateman GA. Arterial inflow and venous outflow in idiopathic intracranial hypertension associated with venous outflow stenoses. J Clin Neurosci 2008; 15:402-8. [DOI: 10.1016/j.jocn.2007.03.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 03/24/2007] [Accepted: 03/26/2007] [Indexed: 10/22/2022]
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Taşdemir HA, Dilber C, Totan M, Onder A. Pseudotumor cerebri complicating measles: a case report and literature review. Brain Dev 2006; 28:395-7. [PMID: 16504441 DOI: 10.1016/j.braindev.2005.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Revised: 09/05/2005] [Accepted: 10/19/2005] [Indexed: 11/22/2022]
Abstract
A previously healthy 8-year-old girl patient was referred with the complaints of severe headache associated with nausea and vomiting. Three weeks prior to her admission, she had measles manifested with fever and typical skin eruptions. Fundoscopic examination revealed bilateral swollen optic discs with tortuous blood vessels. Other physical examinations were unremarkable, except for photophobia. Lumbar puncture demonstrated a cerebrospinal fluid opening pressure of 30 cm H(2)O, no cells, normal levels of glucose and protein. Serum measles immunoglobulin M level was elevated (183 AU). Our further investigations revealed that the patient had pseudotumor cerebri (PTC) following measles infection.
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Affiliation(s)
- Haydar Ali Taşdemir
- Division of Neurology, Department of Paediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Skau M, Brennum J, Gjerris F, Jensen R. What is new about idiopathic intracranial hypertension? An updated review of mechanism and treatment. Cephalalgia 2006; 26:384-99. [PMID: 16556239 DOI: 10.1111/j.1468-2982.2005.01055.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is the syndrome of raised intracranial pressure without clinical, laboratory or radiological evidence of intracranial pathology. IIH is a relatively rare disease but rapidly increasing incidence is reported due to a global increasing incidence of obesity. Disease course is generally said to be self-limiting within a few months. However, some patients experience a disabling condition of chronic severe headache and visual disturbances for years that limit their capacity to work. Permanent visual defects are serious and not infrequent complications. The pathophysiology of IIH is still not fully understood. Advances in neuroimaging techniques have facilitated the exclusion of associated conditions that may mimic IIH. No causal treatment is yet known for IIH and existing treatment is symptomatic and rarely sufficient. The aim of this review is to provide an updated overview of this potentially disabling disease which may show a future escalating incidence due to obesity. Theories of pathogenesis, diagnostic criteria and treatment strategies are discussed.
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Affiliation(s)
- M Skau
- Danish Headache Centre, Glostrup University Hospital, Glostrup, Denmark.
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Huang TY, Chung HW, Chen MY, Giiang LH, Chin SC, Lee CS, Chen CY, Liu YJ. Supratentorial Cerebrospinal Fluid Production Rate in Healthy Adults: Quantification with Two-dimensional Cine Phase-Contrast MR Imaging with High Temporal and Spatial Resolution. Radiology 2004; 233:603-8. [PMID: 15516623 DOI: 10.1148/radiol.2332030884] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A method for objectively determining supratentorial cerebrospinal fluid (CSF) production rate is described. The method employs cine phase-contrast magnetic resonance imaging with high temporal and spatial resolution at the level of the aqueduct of Sylvius. Automatic encircling of the aqueduct was accomplished by using a pulsatility-based segmentation approach. Results in 23 healthy adults (18 men, five women; age range, 21-39 years) yielded an average CSF production rate of 305 microL/min +/- 145 (standard deviation); this rate is in good agreement with literature-reported values obtained with invasive ventriculolumbar perfusion measurements. Average operator imprecision was 23.1% if automatic segmentation was not used. The proposed method is potentially an effective means for measuring supratentorial CSF production rate in humans.
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Affiliation(s)
- Teng-Yi Huang
- Department of Electrical Engineering, National Taiwan Univ, Taipei, Taiwan, ROC
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Loth F, Yardimci MA, Alperin N. Hydrodynamic modeling of cerebrospinal fluid motion within the spinal cavity. J Biomech Eng 2001; 123:71-9. [PMID: 11277305 DOI: 10.1115/1.1336144] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The fluid that resides within cranial and spinal cavities, cerebrospinal fluid (CSF), moves in a pulsatile fashion to and from the cranial cavity. This motion can be measured hy magnetic resonance imaging (MRI) and may he of clinical importance in the diagnosis of several brain and spinal cord disorders such as hydrocephalus, Chiari malformation, and syringomyelia. In the present work, a geometric and hydrodynamic characterization of an anatomically relevant spinal canal model is presented. We found that inertial effects dominate the flow field under normal physiological flow rates. Along the length of the spinal canal, hydraulic diameter was found to vary significantly from 5 to 15 mm. The instantaneous Reynolds number at peak flow rate ranged from 150 to 450, and the Womersle number ranged from 5 to 17. Pulsatile flow calculations are presented for an idealized geometric representation of the spinal cavity. A linearized Navier-Stokes model of the pulsatile CSF flow was constructed based on MRI flow rate measurements taken on a healthy volunteer. The numerical model was employed to investigate effects of cross-sectional geometry and spinal cord motion on unsteady velocity, shear stress, and pressure gradientfields. The velocity field was shown to be blunt, due to the inertial character of the flow, with velocity peaks located near the boundaries of the spinal canal rather than at the midpoint between boundaries. The pressure gradient waveform was found to be almost exclusively dependent on the flow waveform and cross-sectional area. Characterization of the CSF dynamics in normal and diseased states may be important in understanding the pathophysiology of CSF related disorders. Flow models coupled with MRI flow measurements mnay become a noninvasive tool to explain the abnormal dynamics of CSF in related brain disorders as well as to determine concentration and local distribution of drugs delivered into the CSF space.
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Affiliation(s)
- F Loth
- Department of Mechanical Engineering, University of Illinois at Chicago, 60607, USA
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Klose U, Strik C, Kiefer C, Grodd W. Detection of a relation between respiration and CSF pulsation with an echoplanar technique. J Magn Reson Imaging 2000; 11:438-44. [PMID: 10767073 DOI: 10.1002/(sici)1522-2586(200004)11:4<438::aid-jmri12>3.0.co;2-o] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The flow of cerebrospinal fluid (CSF) through the aqueduct was studied with an echoplanar imaging technique. Images (1024) of a slice perpendicular to the aqueduct were acquired with a repetition time of 107 msec and a flip angle of 90 degrees. This imaging technique is very sensitive for flow into the selected slice, although a quantitative assessment of flow velocities is not possible. Simultaneously with the image data acquisition, data from a pulse oximeter and a respiration belt were recorded. For each data point, a delay time to the preceding cardiac pulse was determined from the recorded pulse wave. The signal intensities could then be assigned to the cardiac cycle. Each cardiac interval was assigned to one of eight respiratory phases, and an average signal curve during the cardiac interval was calculated for each respiration phase. The evaluation showed to signal maxima within the cardiac interval, which could be identified as a downward flow at 10% and an upward flow at 80% of the cardiac pulse interval by measurements with additional saturation pulses. In examinations of 22 healthy volunteers, an influence of respiration on the flow through the aqueduct was found. In spite of interindividual variability, comparable effects could be observed in all volunteers. In the late expiration phase the caudally directed flow was at its maximum, whereas the cranially directed flow was maximal in the post-inspiration phase.
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Affiliation(s)
- U Klose
- Section of Experimental MR of the CNS, Department of Neuroradiology, University of Tübingen, D-72076 Tübingen, Germany.
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Gideon P, Thomsen C, Gjerris F, Sørensen PS, Ståhlberg F, Henriksen O. Measurement of blood flow in the superior sagittal sinus in healthy volunteers, and in patients with normal pressure hydrocephalus and idiopathic intracranial hypertension with phase-contrast cine MR imaging. Acta Radiol 1996; 37:171-6. [PMID: 8600956 DOI: 10.1177/02841851960371p135] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To measure blood flow and velocity in the superior sagittal ++sinus. MATERIAL AND METHODS MR velocity mapping was used to examine 14 healthy volunteers, 15 patients with normal pressure hydrocephalus (NPH), 3 patients with high pressure hydrocephalus (HPH), and 11 patients with idiopathic intracranial hypertension (IIH). RESULTS Mean blood flow was 443 ml/min in healthy volunteers with a tendency towards reduced blood flow with increasing age. In NPH patients significantly lower superior sagittal sinus blood flow values were found, but this difference was no longer significant when patients and controls were matched for age. In HPH and IIH patients blood flow and velocity were within the normal range. In one patient with thrombosis of the superior sagittal sinus the blood flow was reduced to 40 ml/min. CONCLUSION MR velocity mapping methods may be of value in the assessment of blood flow in the dural sinuses in various pathologies resulting in dural sinus occlusion, such as dural sinus thrombosis, and for following the progress of these patients while undergoing treatment.
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Affiliation(s)
- P Gideon
- Danish Research Centre of Magnetic Resonance, Hvidovre Hospital, University of Copenhagen, Denmark
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Affiliation(s)
- I Moseley
- Lysholm Department of Radiology, National Hospital for Neurology and Neurosurgery, London, UK
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