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Otero Rodríguez Á, Arandia Guzmán DÁ, García Martín A, Torres Carretero L, Garrido Ruiz A, Sousa Casasnovas P, Roa Montes de Oca JC. Prognostic value of the pulse pressure amplitudes, time to reach the plateau and the slope obtained in the lumbar infusion test for the study of idiophatic normal pressure hydrocephalus. ACTA ACUST UNITED AC 2021; 33:120-129. [PMID: 34217635 DOI: 10.1016/j.neucie.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 02/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE To study the prognostic value of the resistance to the cerebrospinal fluid outflow (Rout) obtained in the lumbar infusion test in idiopathic normal pressure hydrocephalus (iNPH), as well as the pulse pressure amplitudes in the different periods of the test and other new variables extracted by Neuropicture® software. MATERIAL AND METHODS Patients with 'probable iNPH' who underwent a lumbar infusion test were retrospectively revised. The positive predictive values (PPV) of the cutoff point of the best prognostic accuracy of the Rout, the basal pulse pressure amplitude (AMPo), the pulse pressure amplitude during the first 10 min (AMP10min), the plateau pulse pressure amplitude (AMPmes), the Rout pulse pressure amplitude (AMPRout), the time to reach the plateau (T), and the slope until reaching the plateau were determined. Patients were categorized either as responders or non-responders. RESULTS The study included 64 responders patients and 16 non-responders patients. The PPV of Rout > 15 mmHg/mL/min was 91.7%; AMPo > 2.34 mmHg: 91.3%; AMP10 min > 4.34 mmHg: 83.3%; AMPmes > 12.44 mmHg: 84.6%; AMPRout > 6.34 mmHg: 85%; T < 634 s: 86.7%; p > 0.040 mmHg/s: 96.3%. CONCLUSIONS Rout is a valid criterion to indicate a ventricular shunt. Pulse pressure amplitudes in the different periods of the lumbar infusion test, in addition to T and P, are other variables whose positivity is indicative of shunt response and should be considered in the diagnostic protocol of the iNPH.
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Affiliation(s)
- Álvaro Otero Rodríguez
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain.
| | | | - Andoni García Martín
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Luis Torres Carretero
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Alejandra Garrido Ruiz
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Pablo Sousa Casasnovas
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
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Otero Rodríguez Á, Arandia Guzmán DÁ, García Martín A, Torres Carretero L, Garrido Ruiz A, Sousa Casasnovas P, Roa Montes de Oca JC. Prognostic value of the pulse pressure amplitudes, time to reach the plateau and the slope obtained in the lumbar infusion test for the study of idiophatic normal pressure hydrocephalus. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00030-0. [PMID: 33875381 DOI: 10.1016/j.neucir.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/10/2021] [Accepted: 02/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE To study the prognostic value of the resistance to the cerebrospinal fluid outflow (Rout) obtained in the lumbar infusion test in idiopathic normal pressure hydrocephalus (iNPH), as well as the pulse pressure amplitudes in the different periods of the test and other new variables extracted by Neuropicture® software. MATERIAL AND METHODS Patients with ́probable iNPH́ who underwent a lumbar infusion test were retrospectively revised. The positive predictive values (PPV) of the cutoff point of the best prognostic accuracy of the Rout, the basal pulse pressure amplitude (AMP0), the pulse pressure amplitude during the first 10minutes (AMP10min), the plateau pulse pressure amplitude (AMPmes), the Rout pulse pressure amplitude (AMPRout), the time to reach the plateau (T), and the slope until reaching the plateau were determined. Patients were categorized either as responders or non-responders. RESULTS The study included 64 responders patients and 16 non-responders patients. The PPV of Rout> 15mmHg/ml/min was 91.7%; AMP0> 2.34mmHg: 91.3%; AMP10min>4.34mmHg: 83.3%; AMPmes>12.44mmHg: 84.6%; AMPRout>6.34mmHg: 85%; T <634seconds: 86.7%; P>0.040mmHg/sec: 96.3%. CONCLUSIONS Rout is a valid criterion to indicate a ventricular shunt. Pulse pressure amplitudes in the different periods of the lumbar infusion test, in addition to T and P, are other variables whose positivity is indicative of shunt response and should be considered in the diagnostic protocol of the iNPH.
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Affiliation(s)
- Álvaro Otero Rodríguez
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, España.
| | | | - Andoni García Martín
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Luis Torres Carretero
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Alejandra Garrido Ruiz
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Pablo Sousa Casasnovas
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, España
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Afonso JM, Falcão M, Schlichtenbrede F, Falcão-Reis F, Silva SE, Schneider TM. Spectral Domain-Optical Coherence Tomography As a New Diagnostic Marker for Idiopathic Normal Pressure Hydrocephalus. Front Neurol 2017; 8:172. [PMID: 28507532 PMCID: PMC5410594 DOI: 10.3389/fneur.2017.00172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/12/2017] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Characterized by a progressive onset of gait disturbances, dementia, and urinary incontinence, idiopathic normal pressure hydrocephalus (iNPH) is considered a rare, but under-diagnosed disease. Non-invasive diagnostic markers are still insufficient to enable the diagnosis of iNPH with certainty and yet early treatment with ventriculoperitoneal (VP) shunting can reverse symptoms and stop disease progression. Vascular circulation abnormalities in iNPH may be reflected by changes in subfoveal and peripapillary choroidal thickness (PPChT). This study uses spectral domain-optical coherence tomography (SD-OCT)-based measures of retinal and choroidal thickness to test this hypothesis and to assess ophthalmological non-invasive markers for iNPH. METHODS Twelve patients who displayed neurological and neuroradiological characteristics of iNPH were subject to a full ophthalmological examination including enhanced depth imaging (EDI) SD-OCT. Of the 12 included iNPH patients, 6 had undergone VP shunting with beneficial outcome. Parameters studied with EDI SD-OCT were macular retinal thickness (MT), subfoveal choroidal thickness (SFChT), retinal nerve fiber layer thickness (RNFL), and PPChT. Results were compared with 13 healthy, age-matched controls. RESULTS Macular thickness and RNFL and MT values of iNPH patients did not reflect atrophy. Non-shunted iNPH patients showed significantly lowered median PPChT and SFChT values compared to healthy controls. Shunted iNPH patients displayed a significantly higher median PPChT and SFChT compared to non-shunted iNPH patients. SFChT and PPChT values in shunted patients were not significantly different to values in healthy controls. CONCLUSION Although limited by small sample size, SD-OCT measures in this study reveal significant changes of choroidal thickness and support the hypothesis of choroidal susceptibility to hemodynamic alterations in iNPH. Non-shunted iNPH patients in this study show choroidal thinning in combination with normal RNFL and MT values. In addition to neurological and neuroradiological exams, this pattern may aid in the challenging diagnosis of iNPH.
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Affiliation(s)
- Joana M Afonso
- Department of Ophthalmology, São João University Hospital, Porto, Portugal.,Department of Ophthalmology, University Hospital Mannheim, Mannheim, Germany
| | - Manuel Falcão
- Department of Ophthalmology, São João University Hospital, Porto, Portugal.,Faculty of Medicine, Department of Sense Organs, University of Porto, Porto, Portugal
| | | | - Fernando Falcão-Reis
- Department of Ophthalmology, São João University Hospital, Porto, Portugal.,Faculty of Medicine, Department of Sense Organs, University of Porto, Porto, Portugal
| | | | - Till M Schneider
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Raneri F, Zella MAS, Di Cristofori A, Zarino B, Pluderi M, Spagnoli D. Supplementary Tests in Idiopathic Normal Pressure Hydrocephalus: A Single-Center Experience with a Combined Lumbar Infusion Test and Tap Test. World Neurosurg 2017; 100:567-74. [PMID: 28089835 DOI: 10.1016/j.wneu.2017.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/30/2016] [Accepted: 01/02/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The lumbar infusion test (LIT) and tap test (TT) have previously been described for the diagnosis and selection of appropriate surgical candidates in idiopathic normal pressure hydrocephalus (iNPH). METHODS We retrospectively reviewed 81 consecutive patients with a clinical diagnosis of iNPH selected for supplementary testing. Clinical evaluation was scored with the Japanese Grading Scale for Normal Pressure Hydrocephalus, the Global Deterioration Score, and the modified Rankin Scale (mRS). The test protocol included a cerebrospinal fluid pressure monitoring (PMi), an LIT, and a TT. Patients were selected for surgery if outflow resistance was ≥14 mm Hg/mL/minute or if a clinical improvement was recorded after TT. RESULTS Sixty-eight patients were selected for ventriculoperitoneal shunting; 72.8% had a positive PMi or LIT, 74.1% had a positive TT, and 63.0% were positive to both tests. Complications were all transient. Clinical evaluation at 12 months after shunting showed a global improvement in 60 patients (88.2%). Overall, 75.0% of patients had no significant disability (mRS score, 1 and 2), 20.6% had an mRS score of 3 or 4, and 4.4% had severe disability after surgery. The positive predictive value of PMi/LIT, TT, or both combined was similar (89.8, 90.0, and 88.2%); however, 21.7% of patients who improved after surgery were selected with either a positive LIT or TT alone. CONCLUSIONS LIT and TT are complementary and they can easily be combined in sequence with a low complication rate and high probability of selecting patients with iNPH who may benefit from ventriculoperitoneal shunt surgery.
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Nucci CG, De Bonis P, Mangiola A, Santini P, Sciandrone M, Risi A, Anile C. Intracranial pressure wave morphological classification: automated analysis and clinical validation. Acta Neurochir (Wien) 2016; 158:581-8; discussion 588. [PMID: 26743919 DOI: 10.1007/s00701-015-2672-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/14/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recently, different software has been developed to automatically analyze multiple intracranial pressure (ICP) parameters, but the suggested methods are frequently complex and have no clinical correlation. The objective of this study was to assess the clinical value of a new morphological classification of the cerebrospinal fluid pulse pressure waveform (CSFPPW), comparing it to the elastance index (EI) and CSF-outflow resistance (Rout), and to test the efficacy of an automatic ICP analysis. METHODS An artificial neural network (ANN) was trained to classify 60 CSFPPWs in four different classes, according to their morphology, and its efficacy was compared to an expert examiner's classification. The morphology of CSFPPW, recorded in 60 patients at baseline, was compared to EI and Rout calculated at the end of an intraventricular infusion test to validate the utility of the proposed classification in patients' clinical evaluation. RESULTS The overall concordance in CSFPPW classification between the expert examiner and the ANN was 88.3 %. An elevation of EI was statistically related to morphological class' progression. All patients showing pathological baseline CSFPPW (class IV) revealed an alteration of CSF hydrodynamics at the end of their infusion test. CONCLUSIONS The proposed morphological classification estimates the global ICP wave and its ability to reflect or predict an alteration in CSF hydrodynamics. An ANN can be trained to efficiently recognize four different CSF wave morphologies. This classification seems helpful and accurate for diagnostic use.
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Affiliation(s)
- Carlotta Ginevra Nucci
- Institute of Neurosurgery, Catholic University School of Medicine, Largo A. Gemelli 8, Rome, Italy.
| | - Pasquale De Bonis
- Institute of Neurosurgery, Catholic University School of Medicine, Largo A. Gemelli 8, Rome, Italy
| | - Annunziato Mangiola
- Institute of Neurosurgery, Catholic University School of Medicine, Largo A. Gemelli 8, Rome, Italy
| | - Pietro Santini
- Institute of Neurosurgery, Catholic University School of Medicine, Largo A. Gemelli 8, Rome, Italy
| | - Marco Sciandrone
- Department of Information Engineering, University of Florence, Via di Santa Marta 3, Florence, Italy
| | - Arnaldo Risi
- Institute of System Analysis and Informatics, National Research Council, Viale Manzoni 30, Rome, Italy
| | - Carmelo Anile
- Institute of Neurosurgery, Catholic University School of Medicine, Largo A. Gemelli 8, Rome, Italy
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Behrens A, Lenfeldt N, Qvarlander S, Koskinen LO, Malm J, Eklund A. Are intracranial pressure wave amplitudes measurable through lumbar puncture? Acta Neurol Scand 2013; 127:233-41. [PMID: 22784234 DOI: 10.1111/j.1600-0404.2012.01701.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether pulsations measured in the brain correspond to those measured in lumbar space, and subsequently whether lumbar punctures could replace invasive recordings. METHODS In ten patients with normal pressure hydrocephalus, simultaneous recordings of the intracranial pressure (ICP; intraparenchymal) and lumbar pressure (LP; cerebrospinal fluid pressure) were performed. During registration, pressure was altered between resting pressure and 45 mmHg using an infusion test. Data were analyzed regarding pulsations (i.e., amplitudes). Also, the pressure sensors were compared in a bench test. RESULTS The correlation between intracranial and lumbar amplitudes was 0.98. At resting pressure, and moderately elevated ICP, intracranial pulse amplitudes exceeded that of lumbar space with about 0.9 mmHg. At the highest ICP, the difference changed to -0.2 mmHg. The bench test showed that the agreement of sensor readings was good at resting pressure, but reduced at higher amplitudes. CONCLUSIONS Compared to intracranial registrations, amplitudes measured through lumbar puncture were slightly attenuated. The bench test showed that differences were not attributable to dissimilarities of the sensor systems. A lumbar pressure amplitude measurement is an alternative to ICP recording, but the thresholds for what should be interpreted as elevated amplitudes need to be adjusted.
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Affiliation(s)
| | | | - S. Qvarlander
- Department of Radiation Sciences - Biomedical Enigneering; Umeå University; Umeå; Sweden
| | - L.-O. Koskinen
- Department of Clinical Neuroscience; Umeå University; Umeå; Sweden
| | - J. Malm
- Department of Clinical Neuroscience; Umeå University; Umeå; Sweden
| | - A. Eklund
- Centre for Biomedical Engineering and Physics; Umeå University; Umeå; Sweden
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Anile C, De Bonis P, Albanese A, Di Chirico A, Mangiola A, Petrella G, Santini P. Selection of patients with idiopathic normal-pressure hydrocephalus for shunt placement: a single-institution experience. J Neurosurg 2010; 113:64-73. [PMID: 20151782 DOI: 10.3171/2010.1.jns091296] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The ability to predict outcome after shunt placement in patients with idiopathic normal-pressure hydrocephalus (NPH) represents a challenge. To date, no single diagnostic tool or combination of tools has proved capable of reliably predicting whether the condition of a patient with suspected NPH will improve after a shunting procedure. In this paper, the authors report their experience with 120 patients with the goal of identifying CSF hydrodynamics criteria capable of selecting patients with idiopathic NPH. Specifically, they focused on the comparison between CSF-outflow resistance (R-out) and intracranial elastance (IE). METHODS Between January 1977 and December 2005, 120 patients in whom idiopathic NPH had been diagnosed (on the basis of clinical findings and imaging) underwent CSF hydrodynamics evaluation based on an intraventricular infusion test. Ninety-six patients underwent CSF shunt placement: 32 between 1977 and 1989 (Group I) on the basis of purely clinical and radiological criteria; 44 between 1990 and 2002 (Group II) on the basis of the same criteria as Group I and because they had an IE slope > 0.25; and 20 between 2003 and 2005 (Group III) on the basis of the same criteria as Group II but with an IE slope > or = 0.30. Outcomes were evaluated by means of both Stein-Langfitt and Larsson scores. Patients' conditions were considered improved when there was a stable decrease (at 6- and 12-month follow-up) of at least 1 point in the Stein-Langfitt score and 2 points in the Larsson score. RESULTS Group I: while no statistically significant difference in mean R-out value between improved and unimproved cases was observed, a clear-cut IE slope value of 0.25 differentiated very sharply between unimproved and improved cases. Group II: R-out values in the 2 unimproved cases were 20 and 47 mm Hg/ml/min, respectively. The mean IE slope in the improved cases was 0.56 (range 0.30-1.4), while the IE slopes in the 2 unimproved cases were 0.26 and 0.27. Group III: the mean IE slope was 0.51 (range 0.31-0.7). The conditions of all patients improved after shunting. A significant reduction of the Evans ratio was observed in 34 (40.5%) of the 84 improved cases and in none of the unimproved cases. CONCLUSIONS Our strategy based on the analysis of CSF pulse pressure parameters seems to have a great accuracy in predicting surgical outcome in clinical practice.
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Affiliation(s)
- Carmelo Anile
- Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
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Eide PK, Brean A. Cerebrospinal fluid pulse pressure amplitude during lumbar infusion in idiopathic normal pressure hydrocephalus can predict response to shunting. Cerebrospinal Fluid Res 2010; 7:5. [PMID: 20205911 PMCID: PMC2829499 DOI: 10.1186/1743-8454-7-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 02/12/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We have previously seen that idiopathic normal pressure hydrocephalus (iNPH) patients having elevated intracranial pressure (ICP) pulse amplitude consistently respond to shunt surgery. In this study we explored how the cerebrospinal fluid pressure (CSFP) pulse amplitude determined during lumbar infusion testing, correlates with ICP pulse amplitude determined during over-night ICP monitoring and with response to shunt surgery. Our goal was to establish a more reliable screening procedure for selecting iNPH patients for shunt surgery using lumbar intrathecal infusion. METHODS The study population consisted of all iNPH patients undergoing both diagnostic lumbar infusion testing and continuous over-night ICP monitoring during the period 2002-2007. The severity of iNPH was assessed using our NPH grading scale before surgery and 12 months after shunting. The CSFP pulse was characterized from the amplitude of single pressure waves. RESULTS Totally 62 iNPH patients were included, 45 of them underwent shunt surgery, in whom 78% were shunt responders. Among the 45 shunted patients, resistance to CSF outflow (R(out)) was elevated (>or= 12 mmHg/ml/min) in 44. The ICP pulse amplitude recorded over-night was elevated (i.e. mean ICP wave amplitude >or= 4 mmHg) in 68% of patients; 92% of these were shunt responders. In those with elevated overnight ICP pulse amplitude, we found also elevated CSFP pulse amplitude recorded during lumbar infusion testing, both during the opening phase following lumbar puncture and during a standardized period of lumbar infusion (15 ml Ringer over 10 min). The clinical response to shunting after 1 year strongly associated with the over-night ICP pulse amplitude, and also with the pulsatile CSFP during the period of lumbar infusion. Elevated CSFP pulse amplitude during lumbar infusion thus predicted shunt response with sensitivity of 88 and specificity of 60 (positive and negative predictive values of 89 and 60, respectively). CONCLUSIONS In iNPH patients, shunt response can be anticipated in 9/10 patients with elevated overnight ICP pulse amplitude, while in only 1/10 with low ICP pulse amplitude. Additionally, the CSFP pulse amplitude during lumbar infusion testing was elevated in patients with elevated over-night ICP pulse amplitude. In particular, measurement of CSFP pulse amplitude during a standardized infusion of 15 ml Ringer over 10 min was useful in predicting response to shunt surgery and can be used as a screening procedure for selection of iNPH patients for shunting.
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Affiliation(s)
- Per K Eide
- Department of Neurosurgery, Rikshospitalet University Hospital, Oslo, Norway.
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Kim DJ, Czosnyka Z, Keong N, Radolovich DK, Smielewski P, Sutcliffe MP, Pickard JD, Czosnyka M. INDEX OF CEREBROSPINAL COMPENSATORY RESERVE IN HYDROCEPHALUS. Neurosurgery 2009; 64:494-501; discussion 501-2. [DOI: 10.1227/01.neu.0000338434.59141.89] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
An index of cerebrospinal compensatory reserve (RAP) has been introduced as a potential descriptor of neurological deterioration after head trauma. It is numerically computed as a linear correlation coefficient between the mean intracranial pressure and the pulse amplitude of the pressure waveform. We explore how RAP varies with different forms of physiological or nonphysiological intracranial volume loads in adult hydrocephalus, with and without a functioning cerebrospinal fluid (CSF) shunt.
METHODS
A database of intracranial pressure recordings during CSF infusion studies and overnight monitoring in hydrocephalic patients was reviewed for clinical comparison of homogeneous subgroups of patients with hypothetical differences of pressure-volume compensatory reserve. The database includes 980 patients of mixed etiology: idiopathic normal pressure hydrocephalus (NPH), 47%; postsubarachnoid hemorrhage NPH, 12%; noncommunicating hydrocephalus, 22%; others, 19%. All CSF compensatory parameters were calculated by using intracranial pressure waveforms.
RESULTS
In NPH, RAP correlated strongly with the resistance to CSF outflow (rs = 0.35; P = 0.045), but weakly correlated with ventriculomegaly (rs = 0.13; P = 0.41). In idiopathic nonshunted NPH patients, RAP did not correlate significantly with elasticity calculated from the CSF infusion test (rs = 0.11; P = 0.21). During infusion studies, RAP increased in comparison to values recorded at baseline (from a median of 0.45–0.86, P = 0.14 * 10−8), indicating a narrowing of the volume-pressure compensatory reserve. During B-waves associated with the REM (rapid eye movement) phase of sleep, RAP increased from a median of 0.53 to 0.89; P = 1.2 * 10−5. After shunting, RAP decreased (median before shunting, 0.59; median after shunting, 0.34; P = 0.0001). RAP also showed the ability to reflect the functional state of the shunt (patent shunt median, 0.36; blocked shunt median, 0.84; P = 0.0002).
CONCLUSION
RAP appears to characterize pressure-volume compensatory reserve in patients with hydrocephalus.
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Affiliation(s)
- Dong-Joo Kim
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
- Micromechanics Laboratory, Department of Engineering, University of Cambridge, Cambridge, England
| | - Zofia Czosnyka
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
| | - Nicole Keong
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
| | - Danila K. Radolovich
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
- Department of Anaesthesiology, University of Pavia, Pavia, Italy
| | - Peter Smielewski
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
| | | | - John D. Pickard
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
| | - Marek Czosnyka
- Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, England
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Kawaguchi T, Fujimura M, Tominaga T. Syringomyelia with obstructive hydrocephalus at the foramens of Luschka and Magendie successfully treated by endoscopic third ventriculostomy. ACTA ACUST UNITED AC 2009; 71:349-52, discussion 352. [DOI: 10.1016/j.surneu.2007.08.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 08/02/2007] [Indexed: 11/28/2022]
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Johanson CE, Duncan JA, Klinge PM, Brinker T, Stopa EG, Silverberg GD. Multiplicity of cerebrospinal fluid functions: New challenges in health and disease. Cerebrospinal Fluid Res 2008; 5:10. [PMID: 18479516 PMCID: PMC2412840 DOI: 10.1186/1743-8454-5-10] [Citation(s) in RCA: 513] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 05/14/2008] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED This review integrates eight aspects of cerebrospinal fluid (CSF) circulatory dynamics: formation rate, pressure, flow, volume, turnover rate, composition, recycling and reabsorption. Novel ways to modulate CSF formation emanate from recent analyses of choroid plexus transcription factors (E2F5), ion transporters (NaHCO3 cotransport), transport enzymes (isoforms of carbonic anhydrase), aquaporin 1 regulation, and plasticity of receptors for fluid-regulating neuropeptides. A greater appreciation of CSF pressure (CSFP) is being generated by fresh insights on peptidergic regulatory servomechanisms, the role of dysfunctional ependyma and circumventricular organs in causing congenital hydrocephalus, and the clinical use of algorithms to delineate CSFP waveforms for diagnostic and prognostic utility. Increasing attention focuses on CSF flow: how it impacts cerebral metabolism and hemodynamics, neural stem cell progression in the subventricular zone, and catabolite/peptide clearance from the CNS. The pathophysiological significance of changes in CSF volume is assessed from the respective viewpoints of hemodynamics (choroid plexus blood flow and pulsatility), hydrodynamics (choroidal hypo- and hypersecretion) and neuroendocrine factors (i.e., coordinated regulation by atrial natriuretic peptide, arginine vasopressin and basic fibroblast growth factor). In aging, normal pressure hydrocephalus and Alzheimer's disease, the expanding CSF space reduces the CSF turnover rate, thus compromising the CSF sink action to clear harmful metabolites (e.g., amyloid) from the CNS. Dwindling CSF dynamics greatly harms the interstitial environment of neurons. Accordingly the altered CSF composition in neurodegenerative diseases and senescence, because of adverse effects on neural processes and cognition, needs more effective clinical management. CSF recycling between subarachnoid space, brain and ventricles promotes interstitial fluid (ISF) convection with both trophic and excretory benefits. Finally, CSF reabsorption via multiple pathways (olfactory and spinal arachnoidal bulk flow) is likely complemented by fluid clearance across capillary walls (aquaporin 4) and arachnoid villi when CSFP and fluid retention are markedly elevated. A model is presented that links CSF and ISF homeostasis to coordinated fluxes of water and solutes at both the blood-CSF and blood-brain transport interfaces. OUTLINE 1 Overview2 CSF formation2.1 Transcription factors2.2 Ion transporters2.3 Enzymes that modulate transport2.4 Aquaporins or water channels2.5 Receptors for neuropeptides3 CSF pressure3.1 Servomechanism regulatory hypothesis3.2 Ontogeny of CSF pressure generation3.3 Congenital hydrocephalus and periventricular regions3.4 Brain response to elevated CSF pressure3.5 Advances in measuring CSF waveforms4 CSF flow4.1 CSF flow and brain metabolism4.2 Flow effects on fetal germinal matrix4.3 Decreasing CSF flow in aging CNS4.4 Refinement of non-invasive flow measurements5 CSF volume5.1 Hemodynamic factors5.2 Hydrodynamic factors5.3 Neuroendocrine factors6 CSF turnover rate6.1 Adverse effect of ventriculomegaly6.2 Attenuated CSF sink action7 CSF composition7.1 Kidney-like action of CP-CSF system7.2 Altered CSF biochemistry in aging and disease7.3 Importance of clearance transport7.4 Therapeutic manipulation of composition8 CSF recycling in relation to ISF dynamics8.1 CSF exchange with brain interstitium8.2 Components of ISF movement in brain8.3 Compromised ISF/CSF dynamics and amyloid retention9 CSF reabsorption9.1 Arachnoidal outflow resistance9.2 Arachnoid villi vs. olfactory drainage routes9.3 Fluid reabsorption along spinal nerves9.4 Reabsorption across capillary aquaporin channels10 Developing translationally effective models for restoring CSF balance11 Conclusion.
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Affiliation(s)
- Conrad E Johanson
- Department of Clinical Neurosciences, Warren Alpert Medical School at Brown University, Providence, RI 02903, USA
| | - John A Duncan
- Department of Clinical Neurosciences, Warren Alpert Medical School at Brown University, Providence, RI 02903, USA
| | - Petra M Klinge
- International Neuroscience Institute Hannover, Rudolph-Pichlmayr-Str. 4, 30625 Hannover, Germany
| | - Thomas Brinker
- International Neuroscience Institute Hannover, Rudolph-Pichlmayr-Str. 4, 30625 Hannover, Germany
| | - Edward G Stopa
- Department of Clinical Neurosciences, Warren Alpert Medical School at Brown University, Providence, RI 02903, USA
| | - Gerald D Silverberg
- Department of Clinical Neurosciences, Warren Alpert Medical School at Brown University, Providence, RI 02903, USA
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Brean A, Eide PK. Assessment of idiopathic normal pressure patients in neurological practice: the role of lumbar infusion testing for referral of patients to neurosurgery. Eur J Neurol 2008; 15:605-12. [PMID: 18410369 DOI: 10.1111/j.1468-1331.2008.02134.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE In neurological practice patients with tentative idiopathic normal pressure hydrocephalus (iNPH) usually are referred to neurosurgery based on clinical and radiological findings. Hydrodynamic assessment using lumbar infusion testing might be helpful in selecting patients. To retrospectively analyse lumbar infusion tests done in neurological practice in iNPH patients to see how infusion test results relate to the clinical course and shunt response. MATERIALS AND METHODS Sixty-three consecutive patients with Possible/Probable iNPH were tested during a 1-year period. The pre-operative lumbar infusion tests were assessed according to two strategies: (i) Determining the resistance to cerebrospinal fluid (CSF) outflow (R(out)). (ii) Quantification of the CSF pressure (CSFP) pulsatility during lumbar infusion (Q(pulse)). The results were related to the prospectively followed clinical course and shunt response after 12 months. RESULTS The lumbar infusion-derived parameters R(out) and Q(pulse) related weakly. Shunt response after 12 months was not related to R(out), but was highly related to the Q(pulse). False negative results of lumbar infusion testing were observed in 16% of the patients. DISCUSSION In neurological practice lumbar infusion testing may be useful for determining which patients to refer to neurosurgery. Our data favour determination of CSFP pulsatility (Q(pulse)) rather than R(out) for prediction of shunt response.
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Affiliation(s)
- A Brean
- Department of Neurology, Vestfold Country Hospital, Oslo, Norway
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Abstract
The aim of this study was to explore how the lumbar cerebrospinal fluid pressure (CSFP) waves recorded during lumbar infusion compared with the intracranial pressure (ICP) waves recorded, either during lumbar infusion or during long-term, overnight monitoring. For this purpose, we assessed 27 simultaneous lumbar CSFP/ICP recordings made during lumbar infusion and 27 long-term, overnight ICP recordings in 27 consecutive idiopathic normal pressure hydrocephalus (iNPH) patients. Pressure waves during lumbar infusion were explored by computing pulse pressure amplitude and mean single wave pressure of every corresponding CSFP/ICP wave pair; among our 27 lumbar CSFP/ICP recordings a total of 35,532 CSFP/ICP wave pairs were available for analysis. We as well computed mean values of pulse pressure amplitude (i.e. mean CSFP wave amplitude or mean ICP wave amplitude) and mean values of mean single wave pressure (i.e. mean CSFP or mean ICP) during consecutive 6-s time windows, as well as average values for the individual recordings. During lumbar infusion, the cerebrospinal fluid pulse pressure amplitudes were about 2 mmHg smaller than the corresponding intracranial pulse pressure amplitudes. The mean CSFP wave amplitudes recorded during lumbar infusion correlated significantly with the mean ICP wave amplitudes recorded either during lumbar infusion or during long-term, overnight ICP monitoring. In 21 of 27 lumbar infusion tests (78%), the presence of elevated lumbar mean CSFP waves was related to presence of elevated mean ICP wave amplitudes during long-term, overnight ICP monitoring. Hence, the lumbar cerebrospinal fluid pulse pressure amplitudes recorded during lumbar infusion could be used to predict the intracranial pulse pressure amplitudes recorded during long-term, overnight ICP monitoring.
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Affiliation(s)
- P K Eide
- Department of Neurosurgery, The National Hospital, Rikshospitalet, Oslo, Norway.
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