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Andrén K, Wikkelsø C, Laurell K, Kollén L, Hellström P, Tullberg M. Symptoms and signs did not predict outcome after surgery: a prospective study of 143 patients with idiopathic normal pressure hydrocephalus. J Neurol 2024:10.1007/s00415-024-12248-w. [PMID: 38438818 DOI: 10.1007/s00415-024-12248-w] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/14/2024] [Accepted: 02/07/2024] [Indexed: 03/06/2024]
Abstract
OBJECTIVE To determine the utility of symptoms, signs, comorbidities and background variables for the prediction of outcome of treatment in iNPH. METHODS A prospective observational study of consecutively included iNPH patients, who underwent neurological, physiotherapeutic and neuropsychological assessments before and after shunt surgery. The primary outcome measure was the total change on the iNPH scale, and patients were defined as improved postoperatively if they had improved by at least five points on that scale. RESULTS 143 iNPH patients were included, and 73% of those were improved after surgery. None of the examined symptoms or signs could predict which patients would improve after shunt surgery. A dominant subjective complaint of memory problems at baseline was predictive of non-improvement. The reported comorbidities, duration of symptoms and BMI were the same in improved and non-improved patients. Each of the symptom domains (gait, neuropsychology, balance, and continence) as well as the total iNPH scale score improved significantly (from median 53 to 69, p < 0.001). The proportions of patients with shuffling gait, broad-based gait, paratonic rigidity and retropulsion all decreased significantly. DISCUSSION This study confirms that the recorded clinical signs, symptoms, and impairments in the adopted clinical tests are characteristic findings in iNPH, based on that most of them improved after shunt surgery. However, our clinical data did not enable predictions of whether patients would respond to shunt surgery, indicating that the phenotype is unrelated to the reversibility of the iNPH state and should mainly support diagnosis. Absence of specific signs should not be used to exclude patients from treatment.
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Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Laurell
- Department of Biomedical and Clinical Sciences, Neurobiology, Linköping University, Linköping, Sweden
| | - Lena Kollén
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Tullberg M, Toma AK, Yamada S, Laurell K, Miyajima M, Watkins LD, Wikkelsø C. Classification of Chronic Hydrocephalus in Adults: A Systematic Review and Analysis. World Neurosurg 2024; 183:113-122. [PMID: 38143036 DOI: 10.1016/j.wneu.2023.12.094] [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: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Chronic hydrocephalus in adults (CHiA) includes all nonacute forms of hydrocephalus occurring in adulthood. It covers a spectrum of disorders. Some of these have relatively agreed on definitions, while others are less well characterized. The existing medical classification systems lack adequate structure and are neither clinically oriented nor easy to use, which severely hampers research and clinical care efforts. METHODS A systematic literature review and data analysis were performed, focusing on the terms "adult hydrocephalus" and "classification," using the PubMed, Scopus, and Cochrane Library databases. Data on terminology, definitions, patient demographics, symptom duration, and clinical presentations were extracted, analyzed, and compiled. A Delphi process was followed to define CHiA disorders. RESULTS A total of 33 studies collectively used 48 terms to define various CHiA disorders. Different terms were used to describe similar conditions. CHiA disorders were found to be clustered into 7 distinctive clinical entities based on the clinical characteristics. CONCLUSIONS An evidence-based new clinical classification for CHiA is suggested. Our review identified gaps in knowledge and areas for further research.
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Affiliation(s)
- Mats Tullberg
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Shigeki Yamada
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Katarina Laurell
- Department of Biomedical and Clinical Sciences, Neurobiology, Linköping University, Linköping, Sweden
| | - Masakazu Miyajima
- Department of Neurosurgery, Juntendo Tokyo Koto Geriatric Medical Centre, Tokyo, Japan
| | - Laurence D Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Carsten Wikkelsø
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Constantinescu C, Wikkelsø C, Westman E, Ziegelitz D, Jaraj D, Rydén L, Skoog I, Tullberg M. Prevalence of Possible Idiopathic Normal Pressure Hydrocephalus in Sweden: A Population-Based MRI Study in 791 70-Year-Old Participants. Neurology 2024; 102:e208037. [PMID: 38165321 PMCID: PMC10962905 DOI: 10.1212/wnl.0000000000208037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Very divergent prevalence rates for idiopathic normal pressure hydrocephalus (iNPH) are reported, probably due to differences in study sample selection and diagnostic criteria. This MRI-based study aimed to determine the prevalence of iNPH and iNPH-specific radiologic changes and their association with clinical symptoms in a large, 70-year-old population-based cohort (Gothenburg H70). METHODS In this cross-sectional study, disturbances in gait and balance, cognition, and urinary continence were assessed using clinical examination and self-report. MRI was evaluated for iNPH-specific imaging markers. iNPH was diagnosed according to International Guidelines (I.G.). Based on radiologic findings, participants were allocated to 1 of 4 groups: (A) Evans index (EI) ≤0.3 (reference), (B) EI >0.3 without other iNPH-typical radiologic findings, (C) radiologically probable iNPH according to I.G., and (D) radiologically holistically probable (h-probable) iNPH fulfilling radiologic criteria according to I.G. plus highly iNPH-specific changes according to an experienced neuroradiologist. RESULTS The Gothenburg H70 Studies include 791 individuals (377 men, 414 women) born in 1944 who underwent brain MRI. The prevalence of iNPH was 1.5% (2.1% for men, 0.96% for women) according to I.G. Ninety participants (11%) had EI >0.3 without other iNPH-typical radiologic findings, 29 (3.7%) fulfilled the I.G. radiologic probable iNPH criteria alone, and 11 (1.4%) were classified as radiologically h-probable iNPH. Forty participants (5.1%) had I.G. radiologic features of iNPH (70% men vs 30% women, p = 0.005). Gait disturbances were more common in participants with EI >0.3 without other radiologic iNPH features (B) (33%) compared with the reference group (A) (19%) (p = 0.006). All clinical symptoms were more common in participants with I.G. radiologic features of iNPH (C + D) than they were in the reference group (A) (p < 0.03). DISCUSSION The iNPH prevalence of 1.5% among 70-year-olds, which is considerably higher than earlier reported in this age group, suggests that iNPH may be more common than previously assumed. This is supported by the 5.1% total prevalence of imaging signs of iNPH. Ventriculomegaly without other iNPH-typical radiologic findings may be an early sign of developing iNPH in some patients.
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Affiliation(s)
- Clara Constantinescu
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Carsten Wikkelsø
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Eric Westman
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Doerthe Ziegelitz
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Daniel Jaraj
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Lina Rydén
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Ingmar Skoog
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
| | - Mats Tullberg
- From the Hydrocephalus Research Unit (C.C., C.W., D.Z., D.J., M.T.), Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg; Division of Clinical Geriatrics (E.W.), Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institute, Stockholm; and Neuropsychiatric Epidemiology Unit (L.R., I.S.), Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Center for Ageing and Health (AGECAP) at the University of Gothenburg, Mölndal, Sweden
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Ziegelitz D, Hellström P, Björkman-Burtscher IM, Agerskov S, Stevens-Jones O, Farahmand D, Tullberg M. Evaluation of a Fully Automated Method for Ventricular Volume Segmentation Before and After Shunt Surgery in Idiopathic Normal Pressure Hydrocephalus. World Neurosurg 2024; 181:e303-e311. [PMID: 37838163 DOI: 10.1016/j.wneu.2023.10.045] [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: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Determination of the ventricle size in idiopathic normal pressure hydrocephalus (iNPH) is essential for diagnosis and follow-up of shunt results. Fully automated segmentation methods are anticipated to optimize the accuracy and time efficiency of ventricular volume measurements. We evaluated the accuracy of preoperative and postoperative ventricular volume measurements in iNPH by a magnetic resonance imaging (MRI)-based licensed software for fully automated quantitative assessment. METHODS Forty-eight patients diagnosed with iNPH were retrospectively analyzed. All patients received a ventriculoperitoneal shunt and had symptom grading and routine MRI preoperatively and 3-6 months postoperatively. Ventricular volumes, generated by fully automated T1-weighted imaging volume sequence segmentation, were compared with semiautomatic measurements and routine radiologic reports. The relation of postoperative ventricular size change to clinical response was evaluated. RESULTS Fully automated segmentation was achieved in 95% of the MRIs, but showed various rates of 8 minor segmentation errors. The correlation between both segmentation methods was very strong (r >0.9) and the agreement very good using Bland-Altman analyses. The ventricular volumes differed significantly between semiautomated and fully automated segmentations and between preoperative and postoperative MRI. The fully automated method systematically overestimated the ventricles by a median 15 mL preoperatively and 14 mL postoperatively; hence, the magnitudes of volume changes were equivalent. Routine radiologic reports of ventricular size changes were inaccurate in 51% and lacked association with treatment response. Objectively measured ventricular volume changes correlated moderately with postoperative clinical improvement. CONCLUSIONS A fully automated volumetric method permits reliable evaluation of preoperative ventriculomegaly and postoperative ventricular volume change in idiopathic normal pressure hydrocephalus.
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Affiliation(s)
- Doerthe Ziegelitz
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Hellström
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Isabella M Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Simon Agerskov
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Stevens-Jones
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Farahmand
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Grønning R, Jeppsson A, Hellström P, Laurell K, Farahmand D, Zetterberg H, Blennow K, Wikkelsø C, Tullberg M. Association between ventricular CSF biomarkers and outcome after shunt surgery in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2023; 20:77. [PMID: 37880775 PMCID: PMC10601279 DOI: 10.1186/s12987-023-00475-8] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION The relationship between neurochemical changes and outcome after shunt surgery in idiopathic normal pressure hydrocephalus (iNPH), a treatable dementia and gait disorder, is unclear. We used baseline ventricular CSF to explore associations to outcome, after shunting, of biomarkers selected to reflect a range of pathophysiological processes. METHODS In 119 consecutive patients with iNPH, the iNPH scale was used before and after shunt surgery to quantify outcome. Ventricular CSF was collected perioperatively and analyzed for biomarkers of astrogliosis, axonal, amyloid and tau pathology, and synaptic dysfunction: glial fibrillary acidic protein (GFAP), chitinase-3-like protein 1 (YKL40/CHI3L1), monocyte chemoattractant protein-1 (MCP-1) neurofilament light (NfL), amyloid beta 38 (Aβ38), Aβ40, Aβ42, amyloid beta 42/40 ratio (Aβ42/40), soluble amyloid precursor protein alfa (sAPPα), sAPPβ, total tau (T-tau), phosphorylated tau (P-tau), growth-associated protein 43 (GAP43), and neurogranin. RESULTS The neurogranin concentration was higher in improved (68%) compared to unimproved patients (median 365 ng/L (IQR 186-544) vs 330 (205-456); p = 0.046). A linear regression model controlled for age, sex and vascular risk factors including neurogranin, T-tau, and GFAP, resulted in adjusted R2 = 0.06, p = 0.047. The Aβ42/40 ratio was bimodally distributed across all samples, as well as in the subgroups of improved and unimproved patients but did not contribute to outcome prediction. The preoperative MMSE score was lower within the low Aβ ratio group (median 25, IQR 23-28) compared to the high subgroup (26, 24-29) (p = 0.028). The T-Tau x Aβ40/42 ratio and P-tau x Aβ40/42 ratio did not contribute to shunt response prediction. The prevalence of vascular risk factors did not affect shunt response. DISCUSSION A higher preoperative ventricular CSF level of neurogranin, which is a postsynaptic marker, may signal a favorable postoperative outcome. Concentrations of a panel of ventricular CSF biomarkers explained only 6% of the variability in outcome. Evidence of amyloid or tau pathology did not affect the outcome.
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Affiliation(s)
- Rebecca Grønning
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
| | - Anna Jeppsson
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Katarina Laurell
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Dan Farahmand
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Kaj Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden
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Jeppsson A, Sandelius Å, Zettergren A, Kern S, Skoog I, Blennow K, Zetterberg H, Wikkelsø C, Hellström P, Tullberg M. Plasma and cerebrospinal fluid concentrations of neurofilament light protein correlate in patients with idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2023; 20:54. [PMID: 37415175 DOI: 10.1186/s12987-023-00455-y] [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: 03/14/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Neurofilament light chain protein (NFL), a marker of neuronal axonal degeneration, is increased in cerebrospinal fluid (CSF) of patients with idiopathic normal pressure hydrocephalus (iNPH). Assays for analysis of NFL in plasma are now widely available but plasma NFL has not been reported in iNPH patients. Our aim was to examine plasma NFL in iNPH patients and to evaluate the correlation between plasma and CSF levels, and whether NFL levels are associated with clinical symptoms and outcome after shunt surgery. METHODS Fifty iNPH patients with median age 73 who had their symptoms assessed with the iNPH scale and plasma and CSF NFL sampled pre- and median 9 months post-operatively. CSF plasma was compared with 50 healthy controls (HC) matched for age and gender. Concentrations of NFL were determined in plasma using an in-house Simoa method and in CSF using a commercially available ELISA method. RESULTS Plasma NFL was elevated in patients with iNPH compared to HC (iNPH: 45 (30-64) pg/mL; HC: 33 (26-50) (median; Q1-Q3), p = 0.029). Plasma and CSF NFL concentrations correlated in iNPH patients both pre- and postoperatively (r = 0.67 and 0.72, p < 0.001). We found only weak correlations between plasma or CSF NFL and clinical symptoms and no associations with outcome. A postoperative NFL increase was seen in CSF but not in plasma. CONCLUSIONS Plasma NFL is increased in iNPH patients and concentrations correlate with CSF NFL implying that plasma NFL can be used to assess evidence of axonal degeneration in iNPH. This finding opens a window for plasma samples to be used in future studies of other biomarkers in iNPH. NFL is probably not a very useful marker of symptomatology or for prediction of outcome in iNPH.
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Affiliation(s)
- A Jeppsson
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 7, 41345, Gothenburg, Sweden
| | - Å Sandelius
- Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - A Zettergren
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - S Kern
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - I Skoog
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - K Blennow
- Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - H Zetterberg
- Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - C Wikkelsø
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 7, 41345, Gothenburg, Sweden
| | - P Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 7, 41345, Gothenburg, Sweden
| | - M Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 7, 41345, Gothenburg, Sweden.
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Rydja J, Kollén L, Ulander M, Tullberg M, Lundin F. Physical Capacity and Activity in Patients With Idiopathic Normal Pressure Hydrocephalus. Front Neurol 2022; 13:845976. [PMID: 35418936 PMCID: PMC8996117 DOI: 10.3389/fneur.2022.845976] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/28/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Most patients with idiopathic normal pressure hydrocephalus (iNPH) improve gait after surgery. However, knowledge on physical capacity and activity after shunt surgery is limited. One of the aims of this study was to evaluate the effect of shunt surgery in patients with iNPH on short-distance walking, functional exercise capacity, functional strength, and variables of activity and sleep, 3 and 6 months postoperatively. Another aim was to evaluate the effect of a physical exercise program. Additionally, we studied how changes in short-distance walking were correlated with functional exercise capacity and voluntary walking. Methods In total, 127 patients were consecutively included and randomized to the exercise group (n = 62) or the control group (n = 65). Participants in the exercise group underwent the supervision of a 12-week exercise program. All patients were assessed before surgery, at 3 and 6 months postoperatively with the 10-m walk test (10MWT), the 6-min walk test (6MWT), 30-s chair stand test (30sCST), and with the actigraphic recordings of activity variables measured for a total of 24 h/day for at least 3 days. Results All patients improved at 3 months postoperatively in the 10MWT (p < 0.001), 6MWT (p < 0.001), and 30sCST (p < 0.001). These results were maintained after 6 months. Actigraphic recordings for voluntary walking (steps per minute) were improved and nighttime sleep (%) increased after 6 months (p = 0.01, p = 0.04). There were no significant differences between the exercise group and the control group, except for the postoperative change in the proportion of daytime sleep after 3 months, which was slightly more reduced compared to baseline in the exercise group (p = 0.04). Changes after 3 months in the 10MWT and 6MWT were moderately correlated (ρ= −0.49, p = 0.01) whereas the correlation between the 10MWT and voluntary walking was weak (ρ = −0.34, p = 0.01). Conclusion Shunt surgery improved short-distance walking, functional exercise capacity, functional strength, and voluntary walking. An exercise program did not affect these outcomes. Short-distance walking was weakly correlated with voluntary walking, indicating improved physical capacity does not directly translate to increased physical activity. Further research should address how interventions should be tailored to promote physical activity after shunt surgery. Trial Registration clinicaltrials.gov, Id: NCT02659111.
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Affiliation(s)
- Johanna Rydja
- Department of Activity and Health and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lena Kollén
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Ulander
- Department of Clinical Neurophysiology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Lundin
- Department of Neurology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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8
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Sundström N, Lundin F, Arvidsson L, Tullberg M, Wikkelsø C. The demography of idiopathic normal pressure hydrocephalus: data on 3000 consecutive, surgically treated patients and a systematic review of the literature. J Neurosurg 2022; 137:1-11. [PMID: 35395629 DOI: 10.3171/2022.2.jns212063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 08/27/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to describe the demographic characteristics of patients with idiopathic normal pressure hydrocephalus (iNPH) through an analysis of 3000 consecutive, surgically treated Swedish patients and a systematic review of the literature. METHODS Data on age, sex, comorbidities, diagnostic delay, initial symptoms, and severity of symptoms at diagnosis were extracted from the Swedish Hydrocephalus Quality Registry. In addition, a systematic PRISMA-based review of the literature published from database inception until August 2019 was performed using the PubMed, Cochrane, and Scopus databases on the basis of two concepts: normal pressure hydrocephalus and demography and their association with related terms. Of 1020 unique articles, 16 were eligible for study inclusion and were assessed for quality using the Newcastle-Ottawa Scale. Mean and weighted mean values were calculated. RESULTS The mean patient age at the time of surgery was 74.4 years, 79% of patients were in their 70s, and 60% of the patients were men. Almost 50% of the patients had symptoms from four main domains (i.e., balance, gait, cognition, and urinary dysfunction) at disease onset. Patients aged < 60 years (2%) reported more headaches and fewer balance problems than those aged ≥ 60. Women were more impaired in function than men at the time of diagnosis. Dementia (Mini-Mental State Examination score < 25) was found in 47% of the patients. Men had more diabetes, heart disease, hypertension, and stroke than women, and comorbidity correlated with increased impairment. The incidence of surgery for iNPH was 20%-40% of the disease incidence according to survey and operation-based studies. CONCLUSIONS Most iNPH patients undergo surgery in their 70s. Those aged < 60 years show slightly different symptomatology and probably present with a specific disease entity, indicating that the lower age limit for iNPH should be 60 years. iNPH patients have severe impairment preceded by a long diagnostic delay. Even though the included study designs differed, the systematic review showed that the disorder has a very low treatment incidence. The importance of diagnosing and treating iNPH is further emphasized by the fact that iNPH may account for a considerable part of all cases of dementia.
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Affiliation(s)
- Nina Sundström
- 1Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå
| | - Fredrik Lundin
- Departments of2Neurology and
- 3Biomedical and Clinical Sciences, Linköping University, Linköping
| | - Lisa Arvidsson
- 4Department of Neurosurgery, Karolinska University Hospital, Stockholm
- 5Department of Clinical Neuroscience, Karolinska Institutet, Stockholm; and
| | - Mats Tullberg
- 6Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carsten Wikkelsø
- 6Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Jeppsson A, Bjerke M, Hellström P, Blennow K, Zetterberg H, Kettunen P, Wikkelsø C, Wallin A, Tullberg M. Shared CSF Biomarker Profile in Idiopathic Normal Pressure Hydrocephalus and Subcortical Small Vessel Disease. Front Neurol 2022; 13:839307. [PMID: 35309577 PMCID: PMC8927666 DOI: 10.3389/fneur.2022.839307] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 12/19/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionIn this study, we examine similarities and differences between 52 patients with idiopathic normal pressure hydrocephalus (iNPH) and 17 patients with subcortical small vessel disease (SSVD), in comparison to 28 healthy controls (HCs) by a panel of cerebrospinal fluid (CSF) biomarkers.MethodsWe analyzed soluble amyloid precursor protein alpha (sAPPα) and beta (sAPPβ), Aβ isoforms −38, −40, and −42, neurofilament light protein (NFL), glial fibrillary acidic protein (GFAP), myelin basic protein (MBP), matrix metalloproteinases (MMP −1, −2, −3, −9, and −10), and tissue inhibitors of metalloproteinase 1 (TIMP1). Radiological signs of white matter damage were scored using the age-related white matter changes (ARWMC) scale.ResultsAll amyloid fragments were reduced in iNPH and SSVD (p < 0.05), although more in iNPH than in SSVD in comparison to HC. iNPH and SSVD showed comparable elevations of NFL, MBP, and GFAP (p < 0.05). MMPs were similar in all three groups except for MMP-10, which was increased in iNPH and SSVD. Patients with iNPH had larger ventricles and fewer WMCs than patients with SSVD.ConclusionThe results indicate that patients with iNPH and SSVD share common features of subcortical neuronal degeneration, demyelination, and astroglial response. The reduction in all APP-derived proteins characterizing iNPH patients is also present, indicating that SSVD encompasses similar pathophysiological phenomena as iNPH.
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Affiliation(s)
- Anna Jeppsson
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- *Correspondence: Anna Jeppsson
| | - Maria Bjerke
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Department of Clinical Chemistry, Universitair Ziekenhuis Brussel and Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Biomedical Sciences, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Per Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong, Hong Kong SAR, China
| | - Petronella Kettunen
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Wallin
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Lukkarinen H, Jeppsson A, Wikkelsö C, Blennow K, Zetterberg H, Constantinescu R, Remes AM, Herukka SK, Hiltunen M, Rauramaa T, Nägga K, Leinonen V, Tullberg M. Cerebrospinal fluid biomarkers that reflect clinical symptoms in idiopathic normal pressure hydrocephalus patients. Fluids Barriers CNS 2022; 19:11. [PMID: 35123528 PMCID: PMC8817565 DOI: 10.1186/s12987-022-00309-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/20/2022] [Indexed: 02/07/2023] Open
Abstract
Background The relationship between cerebrospinal fluid (CSF) biomarkers and the clinical features of idiopathic normal pressure hydrocephalus (iNPH) has been inconclusive. We aimed to evaluate CSF biomarkers reflecting Alzheimer’s disease (AD)-related amyloid β (Aβ) aggregation, tau pathology, neuroinflammation and axonal degeneration in relation to the clinical features of pre- and post-shunt surgery in iNPH patients. Methods Mini Mental State Examination (MMSE) scores and gait velocity were evaluated pre- and postoperatively in cohorts of 65 Finnish (FIN) and 82 Swedish (SWE) iNPH patients. Lumbar CSF samples were obtained prior to shunt surgery and analysed for soluble amyloid precursor protein alpha (sAPPα) and beta (sAPPβ); amyloid-β isoforms of 42, 40 and 38 (Aβ42, Aβ40, Aβ38); total tau (T-tau); phosphorylated tau (P-tau181); neurofilament light (NfL) and monocyte chemoattractant protein 1 (MCP1). Results Preoperative patient characteristics showed no significant differences between patients in the FIN and SWE cohorts. Patients in both cohorts had significantly improved gait velocity after shunt surgery (p < 0.0001). Low CSF T-tau and absence of apolipoprotein E ε4 predicted over 20% gait improvement postoperatively (p = 0.043 and p = 0.008). Preoperative CSF T-tau, P-tau181 and NfL correlated negatively with MMSE scores both pre- (p < 0.01) and post-surgery (p < 0.01). Furthermore, T-tau, NfL and Aβ42 correlated with MMSE outcomes (p < 0.05). Low preoperative CSF P-tau181 (p = 0.001) and T-tau with NfL (p < 0.001 and p = 0.049) best predicted pre- and postoperative MMSE scores greater than or equal to 26. Conclusions CSF biomarkers of neurodegeneration appeared to correlate with pre- and postoperative cognition, providing a window into neuropathological processes. In addition, preoperative CSF neurodegeneration biomarkers may have potential in the prediction of gait and cognitive outcomes after shunt surgery.
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11
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Sundström N, Rydja J, Virhammar J, Kollén L, Lundin F, Tullberg M. The timed up and go test in idiopathic normal pressure hydrocephalus: a Nationwide Study of 1300 patients. Fluids Barriers CNS 2022; 19:4. [PMID: 35012586 PMCID: PMC8750754 DOI: 10.1186/s12987-021-00298-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 10/01/2021] [Accepted: 12/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to describe the outcome measure timed up and go (TUG) in a large, nationwide cohort of patients with idiopathic normal pressure hydrocephalus (iNPH) pre- and post-operatively. Furthermore, to compare the TUG test to the 10-m walk test (10MWT), the iNPH scale, the modified Rankin scale (mRS) and the Mini Mental State Examination (MMSE), which are commonly applied in clinical assessment of iNPH. METHODS Patients with iNPH (n = 1300), registered in the Swedish Hydrocephalus Quality Registry (SHQR), were included. All data were retrieved from the SHQR except the 10MWT, which was collected from patient medical records. Clinical scales were examined pre- and 3 months post-operatively. Data were dichotomised by sex, age, and preoperative TUG time. RESULTS Preoperative TUG values were 19.0 [14.0-26.0] s (median [IQR]) and 23 [18-30] steps. Post-operatively, significant improvements to 14.0 [11.0-20.0] s and 19 [15-25] steps were seen. TUG time and steps were higher in women compared to men (p < 0.001) but there was no sex difference in improvement rate. Worse preoperative TUG and younger age favoured improvement. TUG was highly correlated to the 10MWT, but correlations of post-operative changes were only low to moderate between all scales (r = 0.22-0.61). CONCLUSIONS This study establishes the distribution of TUG in iNPH patients and shows that the test captures important clinical features that improve after surgery independent of sex and in all age groups, confirming the clinical value of the TUG test. TUG performance is associated with performance on the 10MWT pre- and post-operatively. However, the weak correlations in post-operative change to the 10MWT and other established outcome measures indicate an additional value of TUG when assessing the effects of shunt surgery.
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Affiliation(s)
- Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden.
| | - Johanna Rydja
- Department of Activity and Health, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Virhammar
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Lena Kollén
- Department of Neurology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Fredrik Lundin
- Department of Neurology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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12
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Rydja J, Kollén L, Hellström P, Owen K, Lundgren Nilsson Å, Wikkelsø C, Tullberg M, Lundin F. Physical exercise and goal attainment after shunt surgery in idiopathic normal pressure hydrocephalus: a randomised clinical trial. Fluids Barriers CNS 2021; 18:51. [PMID: 34809666 PMCID: PMC8607575 DOI: 10.1186/s12987-021-00287-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 09/23/2021] [Accepted: 11/11/2021] [Indexed: 02/06/2023] Open
Abstract
Background Rehabilitation in iNPH is suggested to be an important factor to improve patients’ functions but there are lack of clinical trials evaluating the effect of rehabilitation interventions after shunt surgery in iNPH. The objective of this study was to evaluate the effect of a physical exercise programme and goal attainment for patients with idiopathic normal pressure hydrocephalus (iNPH) after surgery compared to a control group. Methods This was a dual centre randomised controlled trial with assessor blinding, intention-to-treat (ITT) and per protocol (PP) analysis. Individuals diagnosed with iNPH scheduled to undergo shunt surgery at the Linköping University Hospital in Linköping and Sahlgrenska University Hospital in Gothenburg, Sweden were consecutively eligible for inclusion. Inclusion was conducted between January 2016 and June 2018. The patients were randomised 1:1 using sequentially numbered sealed envelopes to receive either written exercise information (control group) or written information and an additional supervised high-intensity, functional exercise programme (HIFE) executed twice weekly over 12 weeks (exercise group). Preoperatively, the patients set individual goals. The primary outcome was change from baseline in the total iNPH scale score at the post-intervention follow-up. Secondary outcomes were goal attainment, and change in the separate scores of gait, balance, neuropsychology and continence and in the total score after 6 months. Results In total, 127 participants were randomised to the exercise group (n = 62) and to the control group (n = 65). In the ITT population (exercise group, n = 50; control group, n = 59), there were no between-group differences in the primary outcome, but the attrition rate in the exercise group was high. The exercise group improved more than the control group in the balance domain scores after 6 months. Post-intervention, the PP exercise population achieved their set goals to a greater extent than the controls. Conclusions An additional effect of the 12-week HIFE-programme on the overall improvement according to the iNPH-scale after shunt surgery in iNPH was not shown. This could be due to high attrition rate. However, the long-term effect on balance and higher goal achievement indicate beneficial influences of supervised physical exercise. Trial registration clinicaltrials.gov, NCT02659111. Registered 20 January 2016, https://clinicaltrials.gov/ct2/show/NCT02659111 Supplementary Information The online version contains supplementary material available at 10.1186/s12987-021-00287-8.
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Affiliation(s)
- Johanna Rydja
- Department of Activity and Health, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping University Hospital, 581 85, Linköping, Sweden.
| | - Lena Kollén
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Hellström
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Owen
- Department of Activity and Health, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Åsa Lundgren Nilsson
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carsten Wikkelsø
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Tullberg
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Lundin
- Department of Neurology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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13
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Minta K, Jeppsson A, Brinkmalm G, Portelius E, Zetterberg H, Blennow K, Tullberg M, Andreasson U. Lumbar and ventricular CSF concentrations of extracellular matrix proteins before and after shunt surgery in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2021; 18:23. [PMID: 33985551 PMCID: PMC8120927 DOI: 10.1186/s12987-021-00256-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/05/2021] [Indexed: 12/17/2022] Open
Abstract
Background Idiopathic normal pressure hydrocephalus (iNPH) is a reversible CNS disease characterized by disturbed cerebrospinal fluid (CSF) dynamics. Changes in the extracellular matrix (ECM) composition might be involved in the pathophysiology of iNPH. The aim of this study was to explore possible differences between lumbar and ventricular CSF concentrations of the ECM markers brevican and neurocan, matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinase-1 (TIMP-1) and their relation to clinical symptoms in iNPH patients before and after shunt surgery. Methods Paired lumbar and ventricular CSF was collected from 31 iNPH patients, before and four months after shunt surgery. CSF was analysed for concentrations of tryptic peptides originating from brevican and neurocan using a mass spectrometry-based panel, and for MMP-1, -2, -9, -10 and TIMP-1 using fluorescent or electrochemiluminescent immunoassays. Results Brevican and neurocan peptide levels were not influenced by CSF origin, but MMP-1, -2, -10 and TIMP-1 were increased (p ≤ 0.0005), and MMP-9 decreased (p ≤ 0.0003) in lumbar CSF compared with ventricular CSF. There was a general trend of ECM proteins to increase following shunt surgery. Ventricular TIMP-1 was inversely correlated with overall symptoms (rho = − 0.62, p < 0.0001). CSF concentrations of the majority of brevican and neurocan peptides were increased in iNPH patients with a history of cardiovascular disease (p ≤ 0.001, AUC = 0.84–0.94) compared with those without. Conclusion Levels of the CNS-specific proteins brevican and neurocan did not differ between the lumbar and ventricular CSF, whereas the increase of several CNS-unspecific MMPs and TIMP-1 in lumbar CSF suggests contribution from peripheral tissues. The increase of ECM proteins in CSF following shunt surgery could indicate disturbed ECM dynamics in iNPH that are restored by restitution of CSF dynamics. Supplementary Information The online version contains supplementary material available at 10.1186/s12987-021-00256-1.
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Affiliation(s)
- Karolina Minta
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden.
| | - Anna Jeppsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Mölndal, Sweden
| | - Gunnar Brinkmalm
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Erik Portelius
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute At UCL, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Mölndal, Sweden
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy At the University of Gothenburg, Sahlgrenska University Hospital/Mölndal, 431 80, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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14
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Andrén K, Wikkelsø C, Hellström P, Tullberg M, Jaraj D. Early shunt surgery improves survival in idiopathic normal pressure hydrocephalus. Eur J Neurol 2021; 28:1153-1159. [PMID: 33316127 PMCID: PMC7986742 DOI: 10.1111/ene.14671] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 12/07/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE To examine the effect of delayed compared to early planning of shunt surgery on survival, in patients with idiopathic normal pressure hydrocephalus (iNPH), a long-term follow-up case-control study of patients exposed to a severe delay of treatment was performed. METHODS In 2010-2011 our university hospital was affected by an administrative and economic failure that led to postponement of several elective neurosurgical procedures. This resulted in an unintentional delay of planning of treatment for a group of iNPH patients, referred to as iNPHDelayed (n = 33, waiting time for shunt surgery 6-24 months). These were compared to patients treated within 3 months, iNPHEarly (n = 69). Primary outcome was mortality. Dates and underlying causes of death were provided by the Cause of Death Registry. Survival was analysed by Kaplan-Meier plots and a Cox proportional hazard model adjusted for potential confounders. RESULTS Median follow-up time was 6.0 years. Crude 4-year mortality was 39.4% in iNPHDelayed compared to 10.1% in iNPHEarly (p = 0.001). The adjusted hazard ratio in iNPHDelayed was 2.57; 95% confidence interval 1.13-5.83, p = 0.024. Causes of death were equally distributed between the groups except for death due to malignancy which was not seen in iNPHDelayed but in 4/16 cases in iNPHEarly (p = 0.044). CONCLUSIONS The present data indicate that shunt surgery is effective in iNPH and that early treatment increases survival.
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Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research UnitInstitute of Neuroscience and PhysiologyDepartment of Clinical NeuroscienceSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Carsten Wikkelsø
- Hydrocephalus Research UnitInstitute of Neuroscience and PhysiologyDepartment of Clinical NeuroscienceSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Per Hellström
- Hydrocephalus Research UnitInstitute of Neuroscience and PhysiologyDepartment of Clinical NeuroscienceSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Mats Tullberg
- Hydrocephalus Research UnitInstitute of Neuroscience and PhysiologyDepartment of Clinical NeuroscienceSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Daniel Jaraj
- Hydrocephalus Research UnitInstitute of Neuroscience and PhysiologyDepartment of Clinical NeuroscienceSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Molecular and Clinical MedicineInstitute of MedicineSahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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15
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Andrén K, Wikkelsø C, Hellström P, Tullberg M, Jaraj D. Response to the Letter to the Editor regarding the article entitled 'Early shunt surgery improves survival in idiopathic normal pressure hydrocephalus'. Eur J Neurol 2021; 28:e90. [PMID: 33682295 DOI: 10.1111/ene.14804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Jaraj
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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16
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Minta K, Brinkmalm G, Thelin EP, Al Nimer F, Piehl F, Tullberg M, Jeppsson A, Portelius E, Zetterberg H, Blennow K, Andreasson U. Cerebrospinal fluid brevican and neurocan fragment patterns in human traumatic brain injury. Clin Chim Acta 2020; 512:74-83. [PMID: 33275942 DOI: 10.1016/j.cca.2020.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 09/24/2020] [Revised: 11/04/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Altered levels of two extracellular matrix (ECM) proteoglycans, brevican and neurocan, have been found in brain injury models; however, their proteolytic processing in traumatic brain injury (TBI) remains unexplored. A disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) is a possible contributor to ECM remodelling following TBI. The aims of this study were to evaluate proteolytic brevican/neurocan patterns and ADAMTS-like activity in cerebrospinal fluid (CSF) in the context of TBI. MATERIALS AND METHODS Forty-two acute TBI patients and 37 idiopathic normal pressure hydrocephalus (iNPH) patients were included in the analysis of tryptic brevican and neurocan peptides in CSF using parallel reaction monitoring mass spectrometry. Twenty-nine TBI and 36 iNPH patients were analysed for ADAMTS-like activity in CSF using a quenched fluorescent substrate. RESULTS The majority of CSF concentrations of brevican peptides significantly decreased in TBI patients compared with the iNPH group (p ≤ 0.002), while ADAMTS-like activity increased (p < 0.0001). Two C-terminal brevican peptides strongly correlated with unfavourable outcome of TBI patients (rho = 0.85-0.93, p ≤ 0.001). CONCLUSIONS The decreased CSF concentrations of brevican peptides in TBI are associated with their increased degradation by ADAMTS enzymes. Furthermore, the N- and C-terminal parts of brevican are differentially regulated following TBI and may serve as outcome markers.
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Affiliation(s)
- Karolina Minta
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden.
| | - Gunnar Brinkmalm
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Faiez Al Nimer
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Anna Jeppsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Erik Portelius
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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17
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Minta K, Cullen NC, Nimer FA, Thelin EP, Piehl F, Clarin M, Tullberg M, Jeppsson A, Portelius E, Zetterberg H, Blennow K, Andreasson U. Dynamics of extracellular matrix proteins in cerebrospinal fluid and serum and their relation to clinical outcome in human traumatic brain injury. Clin Chem Lab Med 2020; 57:1565-1573. [PMID: 30980710 DOI: 10.1515/cclm-2019-0034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 10/26/2018] [Accepted: 02/24/2019] [Indexed: 12/20/2022]
Abstract
Background Brevican, neurocan, tenascin-C and tenascin-R are extracellular matrix proteins present in brain that show increased expression in experimental animal models of brain injury. However, little is known about the dynamics of these proteins in human body fluids, such as cerebrospinal fluid (CSF) and serum, after traumatic brain injury (TBI). The aims of this study were to investigate if matrix proteins in CSF and serum are associated with functional outcome following traumatic brain injury, if their concentrations change over time and to compare their levels between brain injured patients to controls. Methods In total, 42 traumatic brain injury patients, nine healthy controls and a contrast group consisting of 38 idiopathic normal pressure hydrocephalus patients were included. Enzyme-linked immunosorbent assays (ELISAs) were used to measure the concentrations of proteins. Results Increased concentrations of brevican, tenascin-C and tenascin-R in CSF correlated with unfavourable outcome, with stronger outcome prediction ability compared to other biomarkers of brain tissue injury. CSF brevican, tenascin-R and serum neurocan gradually decreased with time (p = 0.04, p = 0.008, p = 0.005, respectively), while serum tenascin-C (p = 0.01) increased. CSF concentrations of brevican, neurocan and tenascin-R (only in time point 3) after TBI were lower than in the idiopathic normal pressure hydrocephalus group (p < 0.0001, p < 0.0001, and p = 0.0008, respectively). In serum, tenascin-C concentration was higher and neurocan lower compared to healthy controls (p = 0.02 and p = 0.0009). Conclusions These findings indicate that levels of extracellular matrix proteins are associated with clinical outcome following TBI and may act as markers for different pathophysiology than currently used protein biomarkers.
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Affiliation(s)
- Karolina Minta
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Nicholas C Cullen
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Faiez Al Nimer
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Clarin
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Anna Jeppsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Erik Portelius
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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18
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Neikter J, Agerskov S, Hellström P, Tullberg M, Starck G, Ziegelitz D, Farahmand D. Ventricular Volume Is More Strongly Associated with Clinical Improvement Than the Evans Index after Shunting in Idiopathic Normal Pressure Hydrocephalus. AJNR Am J Neuroradiol 2020; 41:1187-1192. [PMID: 32527841 DOI: 10.3174/ajnr.a6620] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 04/27/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Ventricular enlargement in idiopathic normal pressure hydrocephalus is often estimated using the Evans index. However, the sensitivity of the Evans index to estimate changes in ventricular size postoperatively has been questioned. Here, we evaluated the postoperative change in ventricle size in relation to shunt response in patients with idiopathic normal pressure hydrocephalus, by comparing ventricular volume and the Evans index. MATERIALS AND METHODS Fifty-seven patients with idiopathic normal pressure hydrocephalus underwent high-resolution MR imaging preoperatively and 6 months after shunt insertion. Clinical symptoms of gait, balance, cognition, and continence were assessed according to the idiopathic normal pressure hydrocephalus scale. The ventricular volume of the lateral and third ventricles and the Evans index were measured using ITK-SNAP software. Semiautomatic volumetric analysis was performed, and postoperative changes in ventricular volume and the Evans index and their relationships to postoperative clinical improvement were compared. RESULTS The median postoperative ventricular volume decrease was 25 mL (P < .001). The proportional decrease in ventricular volume was greater than that in the Evans index (P < .001). The postoperative decrease in ventricular volume was associated with a postoperative increase in the idiopathic normal pressure hydrocephalus scale score (P = .004). Shunt responders (75%) demonstrated a greater ventricular volume decrease than nonresponders (P = .002). CONCLUSIONS Clinical improvement after shunt surgery in idiopathic normal pressure hydrocephalus is associated with a reduction of ventricular size. Ventricular volume is a more sensitive estimate than the Evans index and, therefore, constitutes a more precise method to evaluate change in ventricle size after shunt treatment in idiopathic normal pressure hydrocephalus.
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Affiliation(s)
- J Neikter
- From the Department of Clinical Neuroscience (J.N., S.A., P.H., M.T., D.F.)
| | - S Agerskov
- From the Department of Clinical Neuroscience (J.N., S.A., P.H., M.T., D.F.)
| | - P Hellström
- From the Department of Clinical Neuroscience (J.N., S.A., P.H., M.T., D.F.)
| | - M Tullberg
- From the Department of Clinical Neuroscience (J.N., S.A., P.H., M.T., D.F.)
| | - G Starck
- Institute of Neuroscience and Physiology, Hydrocephalus Research Unit, and Departments of Radiation Physics (G.S.)
| | - D Ziegelitz
- Neuroradiology (D.Z.), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - D Farahmand
- From the Department of Clinical Neuroscience (J.N., S.A., P.H., M.T., D.F.)
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19
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Andrén K, Wikkelsø C, Sundström N, Israelsson H, Agerskov S, Laurell K, Hellström P, Tullberg M. Survival in treated idiopathic normal pressure hydrocephalus. J Neurol 2019; 267:640-648. [PMID: 31713102 PMCID: PMC7035239 DOI: 10.1007/s00415-019-09598-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 08/27/2019] [Accepted: 10/19/2019] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To describe survival and causes of death in 979 treated iNPH patients from the Swedish Hydrocephalus Quality Registry (SHQR), and to examine the influence of comorbidities, symptom severity and postoperative outcome. METHODS All 979 patients operated for iNPH 2004-2011 and registered in the SHQR were included. A matched control group of 4890 persons from the general population was selected by Statistics Sweden. Data from the Swedish Cause of Death Registry was obtained for patients and controls. RESULTS At a median 5.9 (IQR 4.2-8.1) year follow-up, 37% of the iNPH patients and 23% of the controls had died. Mortality was increased in iNPH patients by a hazard ratio of 1.81, 95% CI 1.61-2.04, p < 0.001. More pronounced symptoms in the preoperative ordinal gait scale and the Mini-mental State Examination were the most important independent predictors of mortality along with the prevalence of heart disease. Patients who improved in both the gait scale and in the modified Rankin Scale postoperatively (n = 144) had a similar survival as the general population (p = 0.391). Deaths due to cerebrovascular disease or dementia were more common in iNPH patients, while more controls died because of neoplasms or disorders of the circulatory system. CONCLUSIONS Mortality in operated iNPH patients is 1.8 times increased compared to the general population, a lower figure than previously reported. The survival of iNPH patients who improve in gait and functional independence is similar to that of the general population, indicating that shunt surgery for iNPH, besides improving symptoms and signs, can normalize survival.
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Affiliation(s)
- Kerstin Andrén
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden.
| | - Carsten Wikkelsø
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Hanna Israelsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Simon Agerskov
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Katarina Laurell
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Per Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Blå Stråket 7, 413 45, Gothenburg, Sweden
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20
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Jeppsson A, Wikkelsö C, Blennow K, Zetterberg H, Constantinescu R, Remes AM, Herukka SK, Rauramaa T, Nagga K, Leinonen V, Tullberg M. CSF biomarkers distinguish idiopathic normal pressure hydrocephalus from its mimics. J Neurol Neurosurg Psychiatry 2019; 90:1117-1123. [PMID: 31167811 PMCID: PMC6817981 DOI: 10.1136/jnnp-2019-320826] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/29/2019] [Accepted: 05/12/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the differential diagnostic significance of cerebrospinal fluid (CSF) biomarkers reflecting Alzheimer's disease-related amyloid β (Aβ) production and aggregation, cortical neuronal damage, tau pathology, damage to long myelinated axons and astrocyte activation, which hypothetically separates patients with idiopathic normal pressure hydrocephalus (iNPH) from patients with other neurodegenerative disorders. METHODS The study included lumbar CSF samples from 82 patients with iNPH, 75 with vascular dementia, 70 with Parkinson's disease, 34 with multiple system atrophy, 34 with progressive supranuclear palsy, 15 with corticobasal degeneration, 50 with Alzheimer's disease, 19 with frontotemporal lobar degeneration and 54 healthy individuals (HIs). We analysed soluble amyloid precursor protein alpha (sAPPα) and beta (sAPPβ), Aβ species (Aβ38, Aβ40 and Aβ42), total tau (T-tau), phosphorylated tau, neurofilament light and monocyte chemoattractant protein 1 (MCP-1). RESULTS Patients with iNPH had lower concentrations of tau and APP-derived proteins in combination with elevated MCP-1 compared with HI and the non-iNPH disorders. T-tau, Aβ40 and MCP-1 together yielded an area under the curve of 0.86, differentiating iNPH from the other disorders. A prediction algorithm consisting of T-tau, Aβ40 and MCP-1 was designed as a diagnostic tool using CSF biomarkers. CONCLUSIONS The combination of the CSF biomarkers T-tau, Aβ40 and MCP-1 separates iNPH from cognitive and movement disorders with good diagnostic sensitivity and specificity. This may have important implications for diagnosis and clinical research on disease mechanisms for iNPH.
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Affiliation(s)
- Anna Jeppsson
- Hydrocephalus Research Unit, Department of clinical neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden .,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carsten Wikkelsö
- Hydrocephalus Research Unit, Department of clinical neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Radu Constantinescu
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anne M Remes
- Unit of Clinical Neuroscience, Neurology, University of Oulu, Oulu, Finland.,Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - Sanna-Kaisa Herukka
- Department of Neurology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Tuomas Rauramaa
- Department of Pathology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Katarina Nagga
- Department of Acute Internal Medicine and Geriatrics, Linköping University, Linköping, Sweden
| | - Ville Leinonen
- Medical Research Center, Oulu University Hospital, Oulu, Finland.,Unit of Clinical Neuroscience, Neurosurgery, University of Oulu, Oulu, Finland.,Department of Neurosurgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of clinical neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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21
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Agerskov S, Wallin M, Hellström P, Ziegelitz D, Wikkelsö C, Tullberg M. Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery. AJNR Am J Neuroradiol 2018; 40:74-79. [PMID: 30523139 DOI: 10.3174/ajnr.a5910] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/24/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have evaluated the use of MR imaging markers for the prediction of outcome after shunt surgery in idiopathic normal pressure hydrocephalus with conflicting results. Our aim was to investigate the predictive value of a number of earlier proposed morphologic MR imaging markers in a large group of patients with idiopathic normal pressure hydrocephalus. MATERIALS AND METHODS One hundred sixty-eight patients (mean age, 70 ± 9.3 years) with idiopathic normal pressure hydrocephalus, subjected to standardized quantification of clinical symptoms before and after shunt surgery, were included in the study. Outcome was calculated using a composite score. Preoperative T1, FLAIR, and flow-sensitive images were analyzed regarding the presence of 13 different morphologic MR imaging markers. RESULTS The median Evans index was 0.41 (interquartile range, 0.37-0.44). All patients had an aqueductal flow void sign present and white matter hyperintensities. The median callosal angle was 68.8° (interquartile range, 57.7°-80.8°). Dilated Sylvian fissures were found in 69%; focally dilated sulci, in 25%; and widening of the interhemispheric fissure, in 55%. Obliteration of the sulci at the convexity was found in 36%, and 36% of patients were characterized as having disproportionately enlarged subarachnoid space hydrocephalus. Sixty-eight percent of patients improved after surgery. None of the investigated MR imaging markers were significant predictors of improvement after shunt surgery. CONCLUSIONS Disproportionately enlarged subarachnoid space hydrocephalus, a small callosal angle, and the other MR imaging markers evaluated in this study should not be used to exclude patients from shunt surgery. These markers, though they may be indicative of idiopathic normal pressure hydrocephalus, do not seem to be a part of the mechanisms connected to the reversibility of the syndrome.
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Affiliation(s)
- S Agerskov
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - M Wallin
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - P Hellström
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - D Ziegelitz
- Department of Neuroradiology (D.Z.), Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - C Wikkelsö
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
| | - M Tullberg
- From the Hydrocephalus Research Unit (S.A., M.W., P.H., C.W., M.T.), Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology
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22
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Agerskov S, Hellström P, Andrén K, Kollén L, Wikkelsö C, Tullberg M. The phenotype of idiopathic normal pressure hydrocephalus-a single center study of 429 patients. J Neurol Sci 2018; 391:54-60. [PMID: 30103972 DOI: 10.1016/j.jns.2018.05.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 02/16/2018] [Revised: 05/06/2018] [Accepted: 05/28/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Idiopathic Normal Pressure Hydrocephlaus (iNPH) is, despite a vastly improved knowledge of the disorder since its first description still underdiagnosed and undertreated. Because of this, there is a need for further large studies describing the typical symptomatology and reversibility of symptoms in iNPH, which was the aim of this study. METHODS In all, 429 patients (mean age 71 years) were included. Detailed pre- and postoperative examinations of symptoms and signs were analyzed. A composite outcome measure was constructed. RESULTS Sixty-eight % improved after surgery. Preoperatively, 72% exhibited symptoms from three or four of the assessed domains (gait, balance, neuropsychology and continence) while 41% had symptoms from all four domains. Ninety % had gait disturbances, of which 75% had broad-based gait, 65% shuffling gait and 30% freezing of gait. These disturbances coexisted in most patients preoperatively, but were more likely to appear as isolated findings after surgery. Impaired balance was seen in 53% and retropulsion in 46%. MMSE <25 was seen in 53% and impaired continence in 86%. Improvements were seen in all symptom domains postoperatively. CONCLUSIONS The iNPH phenotype is characterized by a disturbance in at least 3/4 symptom domains in most patients, with improvements in all domains after shunt surgery. Most patients present with a broad-based and shuffling gait as well as paratonia. Present symptoms in all domains and a shuffling gait at the time of diagnosis seem to predict a favorable postoperative outcome, whereas symptom severity does not.
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Affiliation(s)
- Simon Agerskov
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Per Hellström
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Kerstin Andrén
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Lena Kollén
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carsten Wikkelsö
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Department of Clinical Neuroscience Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden
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23
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Edsbagge M, Andreasson U, Ambarki K, Wikkelsø C, Eklund A, Blennow K, Zetterberg H, Tullberg M. Alzheimer's Disease-Associated Cerebrospinal Fluid (CSF) Biomarkers do not Correlate with CSF Volumes or CSF Production Rate. J Alzheimers Dis 2018; 58:821-828. [PMID: 28505972 DOI: 10.3233/jad-161257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neuropathologically, Alzheimer's disease (AD) is characterized by accumulation of a 42 amino acid peptide called amyloid-β (Aβ42) in extracellular senile plaques together with intraneuronal inclusions of hyperphosphorylated tau protein in neurofibrillary tangles and neuronal degeneration. These changes are reflected in the cerebrospinal fluid (CSF), the volumes and production rates of which vary considerably between individuals, by reduced concentration of Aβ42, increased concentration of phosphorylated tau (P-tau) protein, and increased concentration of total tau (T-tau) protein, respectively. OBJECTIVE To examine the outstanding question if CSF concentrations of AD associated biomarkers are influenced by variations in CSF volumes, CSF production rate, and intracranial pressure in healthy individuals. METHODS CSF concentrations of Aβ42, P-tau, and T-tau, as well as a number of other AD-related CSF biomarkers were analyzed together with intracranial subarachnoid, ventricular, and spinal CSF volumes, as assessed by magnetic resonance imaging volumetric measurements, and CSF production rate in 19 cognitively normal healthy subjects (mean age 70.6, SD 3.6 years). RESULTS Negative correlations were seen between the concentrations of three CSF biomarkers (albumin ratio, Aβ38, and Aβ40), and ventricular CSF volume, but apart from this finding, no significant correlations were observed. CONCLUSION These results speak against inter-individual variations in CSF volume and production rate as important confounds in the AD biomarker research field.
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Affiliation(s)
- Mikael Edsbagge
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ulf Andreasson
- Department of Psychiatry and Neurochemistry, Clinical Neurochemistry Laboratory,Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Khalid Ambarki
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Carsten Wikkelsø
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Clinical Neurochemistry Laboratory,Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Clinical Neurochemistry Laboratory,Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,UCL Institute of Neurology, Queen Square, London, UK
| | - Mats Tullberg
- Department of Clinical Neuroscience, Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ziegelitz D, Arvidsson J, Hellström P, Tullberg M, Wikkelsø C, Starck G. Pre-and postoperative cerebral blood flow changes in patients with idiopathic normal pressure hydrocephalus measured by computed tomography (CT)-perfusion. J Cereb Blood Flow Metab 2016; 36:1755-1766. [PMID: 26661191 PMCID: PMC5076781 DOI: 10.1177/0271678x15608521] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/01/2015] [Indexed: 11/16/2022]
Abstract
In idiopathic normal pressure hydrocephalus (iNPH), the cerebral blood flow (CBF) is of pathophysiological interest and a potential biomarker. Computed tomography perfusion (CTP), an established technique with high spatial resolution and quantitative measurements, has not yet been used in the iNPH context. If CTP were sensitive to the CBF levels and changes in iNPH, this technique might provide diagnostic and prognostic absolute perfusion thresholds. The aim of this work was to determine the applicability of CTP to iNPH. CBF measurements of 18 patients pre- and 17 three months postoperatively, and six healthy individuals (HI) were evaluated in 12 cortical and subcortical regions of interest. Correlations between CBF and symptomatology were analyzed in shunt-responders. Compared to HI, the preoperative CBF in iNPH was significantly reduced in normal appearing and periventricular white matter (PVWM), the lentiform nucleus and the global parenchyma. No CBF differences were shown between responders and non-responders. In responders, the CBF recovered postoperatively by 2.5-32% to approximately the level of HI, but remained significantly decreased in the PVWM of non-responders. The pre- and postoperative CBF of cortical and subcortical regions correlated with the intensity of symptoms. In spite of limited spatial coverage, CTP can measure CBF changes in iNPH.
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Affiliation(s)
- Doerthe Ziegelitz
- Department of Neuroradiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathan Arvidsson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Hellström
- Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Carsten Wikkelsø
- Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Göran Starck
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
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Jeppsson A, Höltta M, Zetterberg H, Blennow K, Wikkelsø C, Tullberg M. Amyloid mis-metabolism in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2016; 13:13. [PMID: 27472944 PMCID: PMC4967298 DOI: 10.1186/s12987-016-0037-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 05/24/2016] [Accepted: 07/18/2016] [Indexed: 01/21/2023] Open
Abstract
Background Patients with idiopathic normal pressure hydrocephalus (iNPH) have reduced cerebrospinal fluid (CSF) concentrations of amyloid-β (Aβ) and α- and β-cleaved soluble forms of amyloid precursor protein (sAPPα and sAPPβ). The aims of this study were to examine if changes could also be seen in the CSF for secreted metabolites of APP-like protein 1 (APLP1) and to explore the prognostic value of amyloid-related CSF biomarkers, as well as markers of neuronal injury and astroglial activation, as regards to clinical outcome after shunt surgery. Methods Twenty patients diagnosed with iNPH, 10 improved and 10 unchanged by shunt surgery, and 20 neurologically healthy controls were included. All patients were examined clinically prior to surgery and at 6-month follow-up after surgery using the iNPH scale. Lumbar puncture was performed pre-operatively. CSF samples were analyzed for neurofilament light (NFL), Aβ isoforms Aβ38, Aβ40 and Aβ42, sAPPα, sAPPβ, APLP1 β-derived peptides APL1β25, APL1β 27 and APL1β 28 and YKL40 by immunochemical methods. Results The concentrations of all soluble forms of APP, all Aβ isoforms and APL1β28 were lower, whilst APL1β25 and APL1β27 were higher in the CSF of iNPH patients compared to controls. There was no difference in biomarker concentrations between patients who improved after surgery and those who remained unchanged. Conclusions The reduced CSF concentrations of Aβ38, Aβ40, Aβ42, sAPPα and sAPPβ suggest that APP expression could be downregulated in iNPH. In contrast, APLP1 concentration in the CSF seems relatively unchanged. The increase of APL1β25 and APL1β27 in combination with a slight decreased APL1β28 could be caused by more available γ-secretase due to reduced availability of its primary substrate, APP. The data did not support the use of these markers as indicators of shunt responsiveness.
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Affiliation(s)
- A Jeppsson
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.
| | - Mikko Höltta
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - H Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Molndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, UK
| | - K Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Molndal, Sweden
| | - C Wikkelsø
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
| | - Mats Tullberg
- Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
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Yang Y, Tullberg M, Mehlig K, Rosengren A, Torén K, Zetterberg H, Wikkelsö C. The APOE Genotype in Idiopathic Normal Pressure Hydrocephalus. PLoS One 2016; 11:e0158985. [PMID: 27441602 PMCID: PMC4956274 DOI: 10.1371/journal.pone.0158985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 04/20/2016] [Accepted: 06/26/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Amyloid plaque has been reported in brain biopsies from patients with idiopathic normal-pressure hydrocephalus (iNPH) and proposed as a significant feature of the pathophysiology. Presence of the apolipoprotein E ε4 (APOE ε4) allele is associated with increased risk of Alzheimer's disease (AD). AIMS To compare the distribution of APOE genotype in iNPH patients with an age-matched population-based control group and with Alzheimer's disease (AD) patients. METHODS APOE genotype frequencies were determined in 77 iNPH patients (50 men and 27 women, mean age 71.7 years) diagnosed with iNPH, a sample of 691 AD patients and 638 age-matched population controls (299 men and 339 women) from the INTERGENE cohort. RESULTS The APOE distribution did not differ significantly between the iNPH patients and the control population. The per e4-allele odds-ratio (OR) of iNPH was given by OR = 0.90, 95% confidence interval (CI) = (0.50, 1.60) that was considerably smaller than the per-allele OR of AD, OR = 5.34 (4.10, 7.00). CONCLUSION The results suggest that the APOE-related risk of AD in patients with iNPH is not higher than in the general population.
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Affiliation(s)
- Yi Yang
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Tullberg
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kirsten Mehlig
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kjell Torén
- Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Occupational Medicine, Respiratory Diseases and Toxicology, University of Perugia, Perugia, Italy
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Carsten Wikkelsö
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Wallin M, Tullberg M, Wikkelsö C, Hellström P. Neuropsychological effects of shunting in iNPH – determining major and minor responses. Fluids Barriers CNS 2015. [PMCID: PMC4582256 DOI: 10.1186/2045-8118-12-s1-o53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Andrén K, Wikkelsö C, Sundström N, Laurell K, Kahlon B, Hellström P, Tullberg M. Influence of vascular risk factors and vascular disease on long-term outcome in idiopathic Normal Pressure Hydrocephalus; a Quality Registry based study. Fluids Barriers CNS 2015. [PMCID: PMC4582598 DOI: 10.1186/2045-8118-12-s1-o16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Wallin M, Tullberg M, Wikkelsö C, Hellström P. Predicting neuropsychological outcome following shunt operation in iNPH using reliable change indices (RCIs). Fluids Barriers CNS 2015. [PMCID: PMC4582216 DOI: 10.1186/2045-8118-12-s1-o45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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30
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Tullberg M, Petersen J, Persson J, Jaraj D, Andrén K, Hellström P, Wikkelsö C, Lundgren-Nilsson Å. Shunt surgery in iNPH patients is cost-effective – a cost-utility analysis in the Western Sweden setting. Fluids Barriers CNS 2015. [PMCID: PMC4582606 DOI: 10.1186/2045-8118-12-s1-o50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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31
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Agerskov S, Wallin M, Hellström P, Wikkelsö C, Tullberg M. The role of hypertension and diabetes mellitus in the severity of gait and balance disturbances in iNPH. Fluids Barriers CNS 2015. [PMCID: PMC4582360 DOI: 10.1186/2045-8118-12-s1-o11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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32
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Ziegelitz D, Arvidsson J, Hellström P, Tullberg M, Wikkelsö C, Starck G. Pre-and postoperative cerebral blood flow changes in patients with idiopathic normal pressure hydrocephalus measured by computed tomography (CT)-perfusion. Fluids Barriers CNS 2015. [PMCID: PMC4582217 DOI: 10.1186/2045-8118-12-s1-p59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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33
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Ziegelitz D, Starck G, Kristiansen D, Jakobsson M, Hultenmo M, Mikkelsen IK, Hellström P, Tullberg M, Wikkelsø C. Cerebral perfusion measured by dynamic susceptibility contrast MRI is reduced in patients with idiopathic normal pressure hydrocephalus. J Magn Reson Imaging 2013; 39:1533-42. [PMID: 24006249 DOI: 10.1002/jmri.24292] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [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: 01/24/2013] [Accepted: 05/29/2013] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To demonstrate in idiopathic normal pressure hydrocephalus (iNPH) patients by dynamic susceptibility contrast MRI a reduced preoperative cerebral blood flow (CBF) which correlates with the severity of clinical symptoms and predicts shunt outcome. MATERIALS AND METHODS In cortical, subcortical, periventricular regions and along peri-and paraventricular profiles absolute perfusion values were estimated by multi-slice DSC MRI in 21 iNPH patients and 16 age-matched healthy individuals (HI). Relative CBF (rCBF), calculated with the occipital cortex as internal reference, was used for comparison between groups and for correlation analysis between regional rCBF and symptoms or outcome. RESULTS iNPH patients showed significantly decreased rCBF in the basal medial frontal cortex, hippocampus, lentiform nucleus, periventricular white matter (PVWM), central grey matter and the global parenchyma as compared to HI. iNPH patients with higher preoperative rCBF in the PVWM performed better in clinical tests. A lower overall preoperative function resulted in a more obvious recovery after shunt insertion. Shunt-responders had higher rCBF values in the basal medial frontal cortex than non-responders. CONCLUSION DSC MRI perfusion is a potentially useful diagnostic tool in iNPH and perfusion based criteria might be possible predictors of shunt response.
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Affiliation(s)
- Doerthe Ziegelitz
- Department of Neuroradiology, Institute of Clinical Sciences, Gothenburg, Sweden
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Malm J, Graff-Radford NR, Ishikawa M, Kristensen B, Leinonen V, Mori E, Owler BK, Tullberg M, Williams MA, Relkin NR. Influence of comorbidities in idiopathic normal pressure hydrocephalus - research and clinical care. A report of the ISHCSF task force on comorbidities in INPH. Fluids Barriers CNS 2013; 10:22. [PMID: 23758953 PMCID: PMC3689166 DOI: 10.1186/2045-8118-10-22] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 05/28/2013] [Indexed: 01/18/2023] Open
Abstract
Idiopathic normal pressure hydrocephalus (INPH) is a syndrome of ventriculomegaly, gait impairment, cognitive decline and incontinence that occurs in an elderly population prone to many types of comorbidities. Identification of the comorbidities is thus an important part of the clinical management of INPH patients. In 2011, a task force was appointed by the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders (ISHCSF) with the objective to compile an evidence-based expert analysis of what we know and what we need to know regarding comorbidities in INPH. This article is the final report of the task force. The expert panel conducted a comprehensive review of the literature. After weighing the evidence, the various proposals were discussed and the final document was approved by all the task force members and represents a consensus of expert opinions. Recommendations regarding the following topics are given: I. Musculoskeletal conditions; II. Urinary problems; III. Vascular disease including risk factors, Binswanger disease, and white matter hyperintensities; IV. Mild cognitive impairment and Alzheimer disease including biopsies; V. Other dementias (frontotemporal dementia, Lewy body, Parkinson); VI. Psychiatric and behavioral disorders; VII. Brain imaging; VIII. How to investigate and quantify. The task force concluded that comorbidity can be an important predictor of prognosis and post-operative outcome in INPH. Reported differences in outcomes among various INPH cohorts may be partly explained by variation in the rate and types of comorbidities at different hydrocephalus centers. Identification of comorbidities should thus be a central part of the clinical management of INPH where a detailed history, physical examination, and targeted investigations are the basis for diagnosis and grading. Future INPH research should focus on the contribution of comorbidity to overall morbidity, mortality and long-term outcomes.
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Affiliation(s)
- Jan Malm
- Department of Clinical Neuroscience, Umeå University, Umeå, 901 85, Sweden.
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Lundin F, Tisell A, Dahlqvist Leinhard O, Tullberg M, Wikkelsö C, Lundberg P, Leijon G. Reduced thalamic N-acetylaspartate in idiopathic normal pressure hydrocephalus: a controlled 1H-magnetic resonance spectroscopy study of frontal deep white matter and the thalamus using absolute quantification. J Neurol Neurosurg Psychiatry 2011; 82:772-8. [PMID: 21217158 DOI: 10.1136/jnnp.2010.223529] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patients with idiopathic normal pressure hydrocephalus (INPH) frequently have a reduction in cerebral blood flow in the subcortical frontal lobe/basal ganglia/thalamic areas. With magnetic resonance spectroscopy, the metabolism in the brain can be examined. The aim of this study was to investigate if there was a compromised metabolism in the thalamus and in the subcortical frontal areas in INPH patients. This was done by measuring total creatine, myo-inositol, total choline, N-acetylaspartate (NAA), total N-acetylaspartate (tNA), glutamate and lactate levels. A comparison was made with healthy individuals (HI). SUBJECTS AND METHODS 16 patients (nine males, seven females, mean age 74 years, range 49-83) diagnosed as INPH and 15 HI (nine males, six females, mean age 74 years, range 62-89) were examined. (1)H magnetic resonance spectroscopy (1.5 T, point-resolved spectroscopy, echo time/relaxation time 30/3000 ms, volume of interest 2.5-3 ml) was performed in frontal deep white matter and in the thalamus. Absolute quantification with internal water as a reference was used. RESULTS INPH patients had lower NAA (p=0.02) and lower tNA (p=0.05) concentrations in the thalamus compared with HI. NAA and tNA in the frontal deep white matter did not differ between patients and HI. The absolute metabolic concentrations of total creatine, myo-inositol total choline, tNA, lactate and Cr ratios in frontal deep white matter and in the thalamus were similar in INPH patients and HI. CONCLUSION Reduced thalamic NAA and tNA in INPH patients suggest a compromised metabolic neuronal function in these regions. Thus, the thalamus might have an important role in the pathogenesis of INPH.
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Affiliation(s)
- F Lundin
- Department of Clinical and Experimental Medicine, Division of Neuroscience, Linköping University, Linköping, Sweden.
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Tisell M, Tullberg M, Hellström P, Edsbagge M, Högfeldt M, Wikkelsö C. Shunt surgery in patients with hydrocephalus and white matter changes. J Neurosurg 2011; 114:1432-8. [DOI: 10.3171/2010.11.jns10967] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Patients with idiopathic normal pressure hydrocephalus (iNPH) often present with impaired gait and cognition together with ventricular enlargement and normal intracranial pressure. Many have vascular risk factors as well as periventricular and deep white matter changes on MR imaging. Abnormal CSF dynamics, that is, high resistance to outflow or improvement after CSF drainage, indicate good effects of shunt surgery.
The authors examined whether the worst-case iNPH patients with extensive vascular white matter disease and normal CSF dynamics would benefit from shunt surgery. These patients also fulfilled the criteria for Binswanger disease. Therefore, a randomized controlled double-blind study was performed.
Methods
Fourteen consecutive patients fulfilling the above criteria were randomized to receive either open or closed shunts. At 3 months after surgery, the patients with initially ligated shunts had their shunts opened. Clinical evaluation consisting of 7 quantitative psychometric and 6 continuous gait tests was performed preoperatively and 3 and 6 months after surgery.
Results
Patients randomized to receive open shunts had improved motor (30% increase) and psychometric (23% increase) scores 3 months after shunt placement. There were no significant changes between the 3- and 6-month follow-up in these same patients. Conversely, those with initially ligated shunts were unchanged during the first 3-month period, although they improved in both motor (28%) and cognitive (18%) functions following removal of the ligature.
Conclusions
Patients with enlarged ventricles, hydrocephalic symptoms, and extensive vascular white matter changes benefit from shunt surgery.
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Tullberg M, Ziegelitz D, Ribbelin S, Ekholm S. White matter diffusion is higher in Binswanger disease than in idiopathic normal pressure hydrocephalus. Acta Neurol Scand 2009; 120:226-34. [PMID: 19485951 DOI: 10.1111/j.1600-0404.2009.01165.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To explore diagnostic differences in periventricular white matter (PWM) and deep white matter (DWM) diffusion patterns in patients diagnosed with Binswanger disease (BD) and in patients diagnosed with probable idiopathic normal pressure hydrocephalus (INPH) using diffusion-weighted imaging (DWI). MATERIALS AND METHODS Apparent diffusion coefficient (ADC) values were calculated in the PWM and DWM in patients with INPH (n = 14) and BD (n = 9) and in controls (n = 10) using an spin echo echo planar imaging single-shot diffusion sequence and region of interest (ROI) analysis. RESULTS Patients with BD had higher ADC values than patients with INPH in the PWM and DWM in the frontal and occipital regions (P < 0.05) and higher values than controls in the frontal PWM and DWM (P < 0.01). After shunt surgery, ADC values were reduced in the frontal PWM in patients with INPH (P < 0.05). CONCLUSIONS Increased diffusion in the PWM and DWM in patients with BD may reflect irreversible breakdown of axonal integrity caused by the subcortical ischaemic vascular disease. By contrast, the normal white matter diffusion in patients with INPH indicates structurally intact axons, compatible with the reversibility of this disorder. DWI may be an important non-invasive diagnostic tool for differentiating between INPH and BD and identifying shunt responders and reversible brain damage in patients with INPH. However, the overlap between patients with INPH and BD in this study restricts the predictive value of the method.
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Affiliation(s)
- M Tullberg
- Institute of Neuroscience and Physiology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Tisell M, Hellström P, Ahl-Börjesson G, Barrows G, Blomsterwall E, Tullberg M, Wikkelsö C. Long-term outcome in 109 adult patients operated on for hydrocephalus. Br J Neurosurg 2009; 20:214-21. [PMID: 16954071 DOI: 10.1080/02688690600852324] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
To examine the long-term effects of surgery in adult hydrocephalus we conducted a cross-sectional questionnaire study assessing both the patients' sense of well-being, and changes in gait, living conditions, daily need of sleep and bladder function. One-hundred-and-nine consecutive patients operated for non-communicating hydrocephalus (N-CH) (22) and communicating normal pressure hydrocephalus (NPH), both idiopathic (38) and secondary (49) were included. For survival analyses, three reference groups were selected from the general population and from the Northern Sweden MONICA Project. At long-term follow-up, 29 (27%) patients had died. Sixty-eight patients (62%) returned the questionnaire, while 12 (11%) patients did not reply. The median follow-up time was 4.2 years (range 2.3 - 6.2 years). Fifty-four (79%) of these patients reported that they still felt improved and 60% had persisting observable improvement of gait, living conditions, bladder function and need of sleep. Intention-to-treat analyses revealed that 54 (50%) of the patients still felt better and 37% remained functionally improved. The standardized mortality ratio (observed/expected) was 3.01 (CI: 2.01 - 4.32).
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Affiliation(s)
- M Tisell
- Hydrocephalus Research Unit, Institute of Clinical Neuroscience, Sahlgrenska Academy at Göteborg University, Sweden.
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Ziegelitz D, Starck G, Mikkelsen IK, Tullberg M, Edsbagge M, Wikkelsö C, Forssell-Aronson E, Holtås S, Knutsson L. Absolute quantification of cerebral blood flow in neurologically normal volunteers: Dynamic-susceptibility contrast MRI-perfusion compared with computed tomography (CT)-perfusion. Magn Reson Med 2009; 62:56-65. [DOI: 10.1002/mrm.21975] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Skagervik I, Edsbagge M, Tullberg M, Hellström P, Wikkelsö C. O.001 Symptoms and signs in 158 patients with idiopathic normal pressure hydrocephalus (iNPH). Clin Neurol Neurosurg 2008. [DOI: 10.1016/s0303-8467(08)00349-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lundin F, Tisell A, Leinhard O, Lundberg A, Tullberg M, Wikkelsö C, Leijon G. O.051 Magnetic Resonance Spectroscopy of INPH-metabolism in the frontal deep white matter and in thalamus. Clin Neurol Neurosurg 2008. [DOI: 10.1016/s0303-8467(08)70056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hellström P, Edsbagge M, Blomsterwall E, Archer T, Tisell M, Tullberg M, Wikkelsø C. NEUROPSYCHOLOGICAL EFFECTS OF SHUNT TREATMENT IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS. Neurosurgery 2008; 63:527-35; discussion 535-6. [DOI: 10.1227/01.neu.0000325258.16934.bb] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [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
To prospectively evaluate the effects of shunting on the neuropsychological performance of patients with idiopathic normal pressure hydrocephalus (INPH), to compare their performance with that of healthy individuals, and to estimate the predictive utility of putatively important factors.
METHODS
A consecutive series of 47 patients with INPH underwent neurological, radiological, and neuropsychological examinations before and 3 months after shunt surgery. The same neuropsychological tests, measuring simple and target reaction times, dexterity, memory and learning, working memory, and aspects of executive functioning, were also administered to 159 healthy individuals.
RESULTS
Performance on all neuropsychological tests, except Simple Reaction Time and Digit Span, significantly improved after surgery, with more severe functional deficits showing greatest improvement. Age, education, duration, vascular comorbidity, sex, and onset symptom all failed to predict the neuropsychological effects of treatment. Despite improvement 3 months after shunt surgery, INPH patients were still outperformed by healthy individuals.
CONCLUSION
Most of the wide range of neuropsychological functions that are affected by INPH are markedly improved by shunt treatment, but not completely restored.
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Affiliation(s)
- Per Hellström
- Institute of Neuroscience and Physiology, Göteborg University, Gothenburg, Sweden
| | - Mikael Edsbagge
- Institute of Neuroscience and Physiology, Göteborg University, Gothenburg, Sweden
| | | | - Trevor Archer
- Department of Psychology, Göteborg University, Gothenburg, Sweden
| | - Magnus Tisell
- Department of Neurosurgery, The National Hospital, Rikshospitalet, Oslo, Norway
| | - Mats Tullberg
- Institute of Neuroscience and Physiology, Göteborg University, Gothenburg, Sweden
| | - Carsten Wikkelsø
- Institute of Neuroscience and Physiology, Göteborg University, Gothenburg, Sweden
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Tisell M, Hellström P, Edsbagge M, Tullberg M, Wikkelsö C. O.061 Treatment of Binswanger's disease (BD) by ventriculo-peritoneal shunting: An ongoing interventional, randomized, double blind study. Clin Neurol Neurosurg 2008. [DOI: 10.1016/s0303-8467(08)70066-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tullberg M, Blennow K, Månsson JE, Fredman P, Tisell M, Wikkelsö C. Cerebrospinal fluid markers before and after shunting in patients with secondary and idiopathic normal pressure hydrocephalus. Cerebrospinal Fluid Res 2008; 5:9. [PMID: 18439296 PMCID: PMC2387137 DOI: 10.1186/1743-8454-5-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [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: 06/10/2007] [Accepted: 04/25/2008] [Indexed: 11/26/2022] Open
Abstract
Background The aim of this study was to explore biochemical changes in the cerebrospinal fluid (CSF) induced by shunt surgery and the relationship between these changes and clinical improvement. Methods We measured clinical symptoms and analysed lumbar CSF for protein content, neurodegeneration and neurotransmission markers in patients with secondary (SNPH, n = 17) and idiopathic NPH (INPH, n = 18) before and 3 months after shunt surgery. Patients were divided into groups according to whether or not there was improvement in clinical symptoms after surgery. Results Preoperatively, the only pathological findings were elevated neurofilament protein (NFL), significantly more so in the SNPH patients than in the INPH patients, and elevated albumin content. Higher levels of NFL correlated with worse gait, balance, wakefulness and neuropsychological performance. Preoperatively, no differences were seen in any of the CSF biomarkers between patients that improved after surgery and those that did not improve. Postoperatively, a greater improvement in gait and balance performance correlated with a more pronounced reduction in NFL. Levels of albumin, albumin ratio, neuropeptide Y, vasoactive intestinal peptide and ganglioside GD3 increased significantly after shunting in both groups. In addition, Gamma amino butyric acid increased significantly in SNPH and tau in INPH. Conclusion We conclude that a number of biochemical changes occur after shunt surgery, but there are no marked differences between the SNPH and INPH patients. The results indicate that NFL may be a marker that can predict a surgically reversible state in NPH.
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Affiliation(s)
- Mats Tullberg
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Göteborg University, Sahlgrenska University Hospital, SE 413 45 Göteborg, Sweden.
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Abstract
Normal pressure hydrocephalus (NPH) is the most frequent form of chronic hydrocephalus in adults. NPH remains underdiagnosed although between 5% and 10% of all demented patients may suffer from this disorder. As dementia is an increasing demographic problem, treatable forms such as in NPH have become a central issue in neurology. Despite the traditional perception of hydrocephalus being a disorder of disturbed CSF dynamics, in NPH metabolic impairment seems at least as important. So far, the only valid animal model of NPH is chronic adult kaolin hydrocephalus. In this model, opening of alternative CSF outflow pathways leads to normal or near-normal intracranial pressure and CSF outflow resistance. Yet, various metabolic disturbances cause ongoing ventricular enlargement and characteristic symptoms including cognitive decline and gait ataxia. Delayed hippocampal neuronal death, accumulation of beta-amyloid and disturbed cholinergic neurotransmission may contribute to memory dysfunction. Compromised periventricular blood flow, decreased dopamine levels in the substantia nigra and damaged striatal GABAergic interneurons may reflect basal ganglia symptoms. At least in human hydrocephalus cerebrovascular co-morbidity of the white matter plays an important role as well. It seems that in hydrocephalus from a certain 'point of no return' metabolic impairment becomes decoupled from CSF dynamics and, at least partly, self-sustained. This is probably the reason why despite restored CSF circulation by shunting many patients with chronic hydrocephalus still suffer from severe neurological deficits. The present paper offers a comprehensive review of the experimental and clinical data suggesting metabolic disturbances in chronic hydrocephalus.
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Sahlgrenska University Hospital, Göteborg, Sweden.
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46
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Hellström P, Edsbagge M, Archer T, Tisell M, Tullberg M, Wikkelsø C. THE NEUROPSYCHOLOGY OF PATIENTS WITH CLINICALLY DIAGNOSED IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS. Neurosurgery 2007; 61:1219-26; discussion 1227-8. [DOI: 10.1227/01.neu.0000306100.83882.81] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Per Hellström
- Institute of Neuroscience and Physiology, Göteborg University, Göteborg, Sweden
| | - Mikael Edsbagge
- Institute of Neuroscience and Physiology, Göteborg University, Göteborg, Sweden
| | - Trevor Archer
- Department of Psychology, Göteborg University, Göteborg, Sweden
| | - Magnus Tisell
- Department of Neurosurgery, The National Hospital, Rikshospitalet, Oslo, Norway
| | - Mats Tullberg
- Institute of Neuroscience and Physiology, Göteborg University, Göteborg, Sweden
| | - Carsten Wikkelsø
- Institute of Neuroscience and Physiology, Göteborg University, Göteborg, Sweden
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47
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Anckarsäter H, Piechnik S, Tullberg M, Ziegelitz D, Sörman M, Bjellvi J, Karlsson E, Fernandez NV, Wikkelso C, Forsman A. Persistent regional frontotemporal hypoactivity in violent offenders at follow-up. Psychiatry Res 2007; 156:87-90. [PMID: 17689934 DOI: 10.1016/j.pscychresns.2006.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 11/29/2006] [Accepted: 12/26/2006] [Indexed: 11/17/2022]
Abstract
Since cross-sectional brain-imaging studies demonstrating frontotemporal cerebral hypoactivity in violent offenders have generally been carried out around the time of trial and sentencing, the findings might be influenced by the stressful situation of the subjects. It seems that no group of offenders with this finding has yet been followed longitudinally. We have re-examined nine offenders convicted of lethal or near-lethal violence in whom single photon emission tomography (SPECT) previously had demonstrated frontotemporal hypoperfusion. The mean interval between the initial and the follow-up examination was 4 years. The initially observed hypoactivity was found to have remained virtually unchanged at follow-up: no mean change in the group exceeded 5% in 12 assessed regions of interest. Although preliminary due to the small sample size, this study suggests that frontotemporal brain hypoactivity is a trait rather than a state in perpetrators of severe violent crimes.
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Affiliation(s)
- Henrik Anckarsäter
- Forensic Psychiatric Clinic, Malmö University Hospital, Lund University, Sweden
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48
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Tullberg M, Blennow K, Månsson JE, Fredman P, Tisell M, Wikkelsö C. Ventricular cerebrospinal fluid neurofilament protein levels decrease in parallel with white matter pathology after shunt surgery in normal pressure hydrocephalus. Eur J Neurol 2007; 14:248-54. [PMID: 17355543 DOI: 10.1111/j.1468-1331.2006.01553.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Normal pressure hydrocephalus (NPH) is characterized by disturbed cerebrospinal fluid (CSF) dynamics and white matter lesions (WML). Although the morphology of these lesions is described, little is known about the biochemistry. Our aim was to explore the relationship between ventricular CSF markers, periventricular WML and postoperative clinical outcome in patients with NPH. We analysed lumbar and ventricular concentrations of 10 CSF markers, 12 clinical symptoms and signs, magnetic resonance imaging (MRI) periventricular white matter hyperintensities (PVH) and ventricular size before and 3 months after shunt surgery in 35 patients with NPH. Higher ventricular CSF neurofilament protein (NFL), an axonal marker, correlated with more extensive PVH. A larger postoperative reduction in NFL correlated with larger reduction in PVH and a more pronounced overall improvement. Albumin ratio, HMPG, NPY, VIP and GD3 increased postoperatively whereas NFL, tau and HVA decreased. Variations in ventricular size were not associated with CSF concentrations of any marker. We conclude that NPH is characterized by an ongoing periventricular neuronal dysfunction seen on MRI as PVH. Clinical improvement after shunt surgery is associated with CSF changes indicating a restitution of axonal function. Other biochemical effects of shunting may include increased monoaminergic and peptidergic neurotransmission, breakdown of blood brain barrier function, and gliosis.
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Affiliation(s)
- M Tullberg
- Institute of Clinical Neuroscience, The Sahlgrenska Academy, Göteborg University, Göteborg, Sweden.
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49
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Ost M, Nylén K, Csajbok L, Ohrfelt AO, Tullberg M, Wikkelsö C, Nellgård P, Rosengren L, Blennow K, Nellgård B. Initial CSF total tau correlates with 1-year outcome in patients with traumatic brain injury. Neurology 2006; 67:1600-4. [PMID: 17101890 DOI: 10.1212/01.wnl.0000242732.06714.0f] [Citation(s) in RCA: 201] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We investigated if tau, microtubular binding protein, in serum and ventricular CSF (vCSF) in patients with severe traumatic brain injury (TBI) during the initial posttraumatic days correlated to 1-year outcome. METHODS Patients with severe TBI (n = 39, Glasgow Coma Scale score <or=8) were included. We measured serum and vCSF total tau on days 0 to 14, using ELISA. vCSF total tau correlated to 1-year Extended Glasgow Outcome Scale (GOSE), the NIH Stroke Scale (NIHSS) neurologic status, and the Bartel Daily Living Index. Patients (n = 20) with normal pressure hydrocephalus (NPH) served as reference. RESULTS Higher levels of tau were found in TBI patients vs patients with NPH. A correlation was found between initial vCSF total tau and GOSE levels (R = 0.42, p < 0.001) but not between vCSF total tau and NIHSS or Bartel scores at 1 year. A vCSF total tau level of >2,126 pg/mL on days 2 to 3 discriminated between dead and alive (sensitivity of 100% and a specificity of 81%). A vCSF total tau level of >702 pg/mL on days 2 to 3 discriminated between bad (GOSE 1 to 4) and good (GOSE 5 to 8) outcome (sensitivity of 83% and a specificity of 69%). Patients with GOSE 1 (dead) had higher vCSF total tau levels on days 2 to 3 (p < 0.001) vs both surviving patients (GOSE 2 to 8) and those with NPH. Total tau was not detected in serum throughout the study. CONCLUSION The increase in ventricular CSF (vCSF) total tau probably reflects axonal damage, known to be a central pathologic mechanism in traumatic brain injury (TBI). These results suggest that vCSF total tau may be an important early biochemical neuromarker for predicting long-term outcome in patients with a severe TBI.
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Affiliation(s)
- M Ost
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
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DeCarli C, Massaro J, Harvey D, Hald J, Tullberg M, Au R, Beiser A, D'Agostino R, Wolf PA. Measures of brain morphology and infarction in the framingham heart study: establishing what is normal. Neurobiol Aging 2005; 26:491-510. [PMID: 15653178 DOI: 10.1016/j.neurobiolaging.2004.05.004] [Citation(s) in RCA: 484] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2003] [Revised: 05/26/2004] [Accepted: 05/28/2004] [Indexed: 12/31/2022]
Abstract
Numerous anatomical and brain imaging studies find substantial differences in brain structure between men and women across the span of human aging. The ability to extend the results of many of these studies to the general population is limited, however, due to the generally small sample size and restrictive health criteria of these studies. Moreover, little attention has been paid to the possible impact of brain infarction on age-related differences in regional brain volumes. Given the current lack of normative data on gender and aging related differences in regional brain morphology, particularly with regard to the impact of brain infarctions, we chose to quantify brain MRIs from more than 2200 male and female participants of the Framingham Heart Study who ranged in age from 34 to 97 years. We believe that MRI analysis of the Framingham Heart Study more closely represents the general population enabling more accurate estimates of regional brain changes that occur as the consequence of normal aging. As predicted, men had significantly larger brain volumes than women, but these differences were generally not significant after correcting for gender related differences in head size. Age explained approximately 50% of total cerebral brain volume differences, but age-related differences were generally small prior to age 50, declining substantially thereafter. Frontal lobe volumes showed the greatest decline with age (approximately 12%), whereas smaller differences were found for the temporal lobes (approximately 9%). Age-related differences in occipital and parietal lobe were modest. Age-related gender differences were generally small, except for the frontal lobe where men had significantly smaller lobar brain volumes throughout the age range studied. The prevalence of MRI infarction was common after age 50, increased linearly with age and was associated with significantly larger white matter hyperintensity (WMH) volumes beyond that associated with age-related differences in these measures. Amongst men, the presence of MRI infarction was associated with significant age-related reductions in total brain volume. Finally, statistically significant associations were found between the volume of MRI infarcts in cubic centimeters and all brain measures with the exception of parietal lobe volume for individuals where the volume of MRI infarctions was measured. These data serve to define age and gender differences in brain morphology for the Framingham Heart Study. To the degree participants of the Framingham Heart Study are representative the general population, these data can serve as norms for comparison with morphological brain changes associated with aging and disease. In this regard, these cross-sectional quantitative estimates suggest that age-related tissue loss differs quantitatively and qualitatively across brain regions with only minor differences between men and women. In addition, MRI evidence of cerebrovascular disease is common to the aging process and associated with smaller regional brain volumes for a given age, particularly for men. We believe quantitative MRI studies of the Framingham community enables exploration of numerous issues ranging from understanding normal neurobiology of brain aging to assessing the impact of various health factors, particularly those related to cerebrovascular disease, that appear important to maintaining brain health for the general population.
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Affiliation(s)
- Charles DeCarli
- Department of Neurology and Center for Neuroscience, 4860 Y Street, Suite 3700, Sacramento, CA 95817, USA.
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