Changes in Ventricular and Cortical Volumes following Shunt Placement in Patients with Idiopathic Normal Pressure Hydrocephalus

2021 ◽  
Author(s):  
P.M. Cogswell ◽  
M.C. Murphy ◽  
M.L. Senjem ◽  
H. Botha ◽  
J.L. Gunter ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Shunt Placement

scholarly journals Prevalence of Cervical Stenosis and Myelopathy in Patients With Idiopathic Normal Pressure Hydrocephalus

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Ryan M Naylor ◽  
Karina Lenartowicz ◽  
Jonathan Graff-Radford ◽  
Jeremy Cutsforth-Gregory ◽  
Benjamin D Elder
Keyword(s):  
Cervical Spine ◽  
Normal Pressure Hydrocephalus ◽  
Cervical Myelopathy ◽  
Clinical Manifestations ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Decompression Surgery ◽  
Consecutive Series ◽  
Cervical Stenosis ◽  
Shunt Placement

Abstract INTRODUCTION Both idiopathic normal pressure hydrocephalus (iNPH) and cervical myelopathy may result in progressive gait impairment. It is possible that some of the patients who do not respond to shunting despite a positive tap test may have gait dysfunction from cervical myelopathy. The objective of this study was to determine the prevalence of cervical stenosis with or without myelopathy in patients with iNPH. METHODS We screened a consecutive series of patients who underwent shunt placement for iNPH for comorbid cervical stenosis. Clinical manifestations of iNPH and cervical myelopathy, grade of cervical stenosis based on previously published criteria, cervical spine surgical intervention, timing of intervention, and outcomes were recorded. RESULTS A total of 42 patients with iNPH were included for analysis. Slightly more patients were male (65%), with a mean age of 75 yr (SD 7 yr) for the entire cohort. All patients presented with gait disturbances and underwent cervical spine MRI. 30/42 (71%) had at least cervical stenosis, while 7/42 (17%) had significant (grade 2-3) cervical stenosis with myelopathy requiring surgical decompression. All patients with grade 2-3 cervical stenosis and symptoms of cervical myelopathy in addition to iNPH underwent cervical decompression surgery. CONCLUSION Clinically significant cervical stenosis is highly prevalent in patients with iNPH, though this finding requires validation in a larger population. Based on these results, cervical imaging should be considered preoperatively or in patients whose gait does not improve after shunt placement.

scholarly journals Phase-contrast magnetic resonance imaging reveals net retrograde aqueductal flow in idiopathic normal pressure hydrocephalus

2016 ◽  
Vol 124 (6) ◽  
pp. 1850-1857 ◽  
Author(s):  
Geir Ringstad ◽  
Kyrre Eeg Emblem ◽  
Per Kristian Eide
Keyword(s):  
Flow Rate ◽  
Normal Pressure Hydrocephalus ◽  
Phase Contrast ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Conservative Group ◽  
Shunt Placement ◽  
Before And After ◽  
Shunt Group ◽  
Antegrade Flow

OBJECT The objective of this study was to assess the net aqueductal stroke volume (ASV) and CSF aqueductal flow rate derived from phase-contrast MRI (PC-MRI) in patients with probable idiopathic normal pressure hydrocephalus (iNPH) before and after ventriculoperitoneal shunt surgery, and to compare observations with intracranial pressure (ICP) scores. METHODS PC-MRI at the level of the sylvian aqueduct was undertaken in patients undergoing assessment for probable iNPH. Aqueductal flow in the craniocaudal direction was defined as positive, or antegrade flow, and net ASV was calculated by subtracting retrograde from antegrade aqueductal flow. Aqueductal flow rate per minute was calculated by multiplying net ASV by heart rate. During the same hospital admission, clinical examination was performed using NPH score and overnight continuous ICP monitoring. Twelve patients were followed prospectively 12 months after shunt placement with clinical assessment and a second PC-MRI. The study also included 2 healthy controls. RESULTS Among 21 patients examined for iNPH, 17 (81%) received a shunt (shunt group), and 4 were treated conservatively (conservative group). Among the patients with shunts, a clinical improvement was observed in 16 (94%) of the 17. Net ASV was negative in 16 (76%) of 21 patients before shunt placement and in 5 (42%) of 12 patients after shunt placement, and increased from a median of −5 μl (range −175 to 27 μl) to a median of 1 μl (range −61 to 30 μl; p = 0.04). Among the 12 patients with PC-MRI after shunt placement, 11 were shunt responders, and in 9 of these 11 either a reduced magnitude of retrograde aqueductal flow, or a complete reversal from retrograde to antegrade flow, occurred. Net ASV was significantly lower in the shunt group than in the conservative group (p = 0.01). The aqueductal flow rate increased from −0.56 ml/min (range −12.78 to 0.58 ml/min) to 0.06 ml/min (range −4.51 to 1.93 ml/min; p = 0.04) after shunt placement. CONCLUSIONS In this cohort of patients with iNPH, retrograde net aqueductal flow was observed in 16 (76%) of 21 patients. It was reversed toward the antegrade direction after shunt placement either by magnitude or completely in 9 (75%) of 12 patients examined using PC-MRI both before and after shunt placement (p = 0.04); 11 of the 12 were shunt responders. The study results question previously established concepts with respect to both CSF circulation pathways and CSF formation rate.

Ventriculoperitoneal Shunting of Idiopathic Normal Pressure Hydrocephalus Increases Midbrain Size: A Potential Mechanism for Gait Improvement

Neurosurgery ◽  
2006 ◽  
Vol 59 (4) ◽  
pp. 847-851 ◽  
Author(s):  
J Mocco ◽  
Matthew I. Tomey ◽  
Ricardo J. Komotar ◽  
William J. Mack ◽  
Steven J. Frucht ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Ventriculoperitoneal Shunt ◽  
Medical Center ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Cross Sectional ◽  
Mean Values ◽  
Shunt Placement ◽  
Ventriculoperitoneal Shunting ◽  
The Mean

Abstract OBJECTIVE: Idiopathic normal pressure hydrocephalus (INPH) is characterized by a classic clinical triad of symptoms, including dementia, urinary incontinence, and gait disturbance. Recent work has demonstrated that the maximal midbrain anteroposterior (AP) diameter is significantly smaller in patients with INPH than in healthy, age-matched controls. The current study was undertaken to determine the effect of ventriculoperitoneal shunt placement on midbrain dimensions in INPH patients. METHODS: Twelve consecutive INPH patients undergoing ventriculoperitoneal shunt placement with pre- and postoperative computed tomographic scans at the Columbia University Medical Center were enrolled. Each patient's pre- and postoperative maximum AP and left-to-right diameters of the midbrain at the pontomesencephalic junction were independently measured in a blinded fashion by two of the authors. The average value of each dimension was computed by calculating the mean values of the measurements of the two observers. RESULTS: Both the mean AP diameter (preoperative mean, 2.06 ± 0.04 cm; postoperative mean, 2.27 ± 0.05; P = 0.0007) and left-to-right diameter (preoperative mean, 2.80 ± 0.07; postoperative mean, 3.03 ± 0.08; P = 0.0029) increased from pre- to postoperative imaging. The approximate cross-sectional area determined as the product of AP and left-to-right diameters also increased from pre- to postoperative images (preoperative mean, 5.79 ± 0.22 cm2; postoperative mean, 6.90 ± 0.25 cm2; P = 0.00049). CONCLUSION: This study provides supportive evidence that midbrain cytoarchitecture may play a role in the pathophysiology and post-ventriculoperitoneal shunt gait improvement of INPH patients.

scholarly journals Postshunt Cognitive and Functional Improvement in Idiopathic Normal Pressure Hydrocephalus

Neurosurgery ◽  
2011 ◽  
Vol 68 (2) ◽  
pp. 416-419 ◽  
Author(s):  
Heather Katzen ◽  
Lisa D. Ravdin ◽  
Stephanie Assuras ◽  
Roberto Heros ◽  
Michael Kaplitt ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Repeated Measures ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Practice Effects ◽  
Control Group ◽  
Significant Group ◽  
Shunt Placement ◽  
Cognitive Improvement ◽  
Control Subjects

Abstract BACKGROUND: Improvement in gait after shunt placement has been well documented in idiopathic normal pressure hydrocephalus (iNPH); however, controversy remains regarding the extent and pattern of postsurgical cognitive changes. Conflicting findings may be explained by variability in both test selection and follow-up intervals across studies. Furthermore, most investigations lack a control group, making it difficult to disentangle practice effects from a true treatment effect. OBJECTIVE: To examine postshunt changes in a sample of well-characterized iNPH participants compared with a group of age- and education-matched healthy control subjects. METHODS: We identified 12 participants with iNPH undergoing shunt placement and 9 control participants. All participants were evaluated with comprehensive neuropsychological testing and standardized gait assessment at baseline and were followed up for 6 months. RESULTS: Repeated-measures analysis of variance revealed a significant group- (iNPH and control) by-time (baseline and 6 months) interaction for Trailmaking Test B: (P < .003) and Symbol Digit Modalities (P < .02), with greater improvement in iNPH participants relative to control subjects. In addition, the iNPH group showed greater improvement in gait (P < .001) and caregivers reported improved activities of daily living (P < .01) and reduced caregiver distress (P < .01). CONCLUSION: This study demonstrates improvements in mental tracking speed and sustained attention 6 months after shunt placement in iNPH. The present investigation is the first study to use a controlled design to show that cognitive improvement in iNPH is independent of practice effects. Furthermore, these findings indicate functional and quality-of-life improvements for both the shunt responder and their caregiver.

A prospective study of cerebral blood flow and cerebrovascular reactivity to acetazolamide in 162 patients with idiopathic normal-pressure hydrocephalus

2009 ◽  
Vol 111 (3) ◽  
pp. 610-617 ◽  
Author(s):  
Chia-Cheng Chang ◽  
Hiroyuki Asada ◽  
Toshiro Mimura ◽  
Shinichi Suzuki
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Cerebrovascular Reactivity ◽  
Healthy Controls ◽  
Shunt Placement ◽  
Significant Difference ◽  
A Prospective Study

Object Cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to acetazolamide were investigated prospectively in 162 patients with a proposed diagnosis of idiopathic normal-pressure hydrocephalus (NPH). The aim of this study was to assess the usefulness of the measurement of CBF and CVR in determining which patients would be likely to benefit from shunt placement. Methods The mean CBF of the whole brain was measured according to the Patlak plot method by using technetium-99m hexamethylpropyleneamine oxime. The CVR value was obtained from the response to administration of 500 mg acetazolamide and calculated as the percentage change from the baseline mean CBF value. Results One hundred forty-six patients (90.1%) responded to shunt placement (“responders”), but 16 patients (9.9%) did not (“nonresponders”). No significant difference in preoperative CBF was observed between responders and nonresponders. Preoperative CVR was significantly impaired (p < 0.0025) in responders compared with healthy controls, but not in nonresponders. Responders with the incomplete triad had a significant reduction (p < 0.001) in preoperative CVR, but not in preoperative CBF, compared with healthy controls. Responders with the complete triad had significantly lower preoperative CBF and CVR than those with the incomplete triad (p < 0.01 and p < 0.05, respectively). Postoperative CBF and CVR increased significantly (p < 0.025 and p < 0.001, respectively) in responders. Conclusions Both CBF and CVR decrease with the development of NPH, suggesting that hemodynamic ischemia may be responsible for manifestation of the symptoms. Impaired CVR and reduced CBF with the development of symptoms can be proposed as diagnostic criteria for idiopathic NPH.

Selection of patients with idiopathic normal-pressure hydrocephalus for shunt placement: a single-institution experience

2010 ◽  
Vol 113 (1) ◽  
pp. 64-73 ◽  
Author(s):  
Carmelo Anile ◽  
Pasquale De Bonis ◽  
Alessio Albanese ◽  
Alessandro Di Chirico ◽  
Annunziato Mangiola ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Csf Shunt ◽  
Group Iii ◽  
Shunt Placement ◽  
Group I ◽  
Csf Hydrodynamics ◽  
The Mean ◽  
Group Ii

Object The ability to predict outcome after shunt placement in patients with idiopathic normal-pressure hydrocephalus (NPH) represents a challenge. To date, no single diagnostic tool or combination of tools has proved capable of reliably predicting whether the condition of a patient with suspected NPH will improve after a shunting procedure. In this paper, the authors report their experience with 120 patients with the goal of identifying CSF hydrodynamics criteria capable of selecting patients with idiopathic NPH. Specifically, they focused on the comparison between CSF-outflow resistance (R-out) and intracranial elastance (IE). Methods Between January 1977 and December 2005, 120 patients in whom idiopathic NPH had been diagnosed (on the basis of clinical findings and imaging) underwent CSF hydrodynamics evaluation based on an intraventricular infusion test. Ninety-six patients underwent CSF shunt placement: 32 between 1977 and 1989 (Group I) on the basis of purely clinical and radiological criteria; 44 between 1990 and 2002 (Group II) on the basis of the same criteria as Group I and because they had an IE slope > 0.25; and 20 between 2003 and 2005 (Group III) on the basis of the same criteria as Group II but with an IE slope ≥ 0.30. Outcomes were evaluated by means of both Stein-Langfitt and Larsson scores. Patients' conditions were considered improved when there was a stable decrease (at 6- and 12-month follow-up) of at least 1 point in the Stein-Langfitt score and 2 points in the Larsson score. Results Group I: while no statistically significant difference in mean R-out value between improved and unimproved cases was observed, a clear-cut IE slope value of 0.25 differentiated very sharply between unimproved and improved cases. Group II: R-out values in the 2 unimproved cases were 20 and 47 mm Hg/ml/min, respectively. The mean IE slope in the improved cases was 0.56 (range 0.30–1.4), while the IE slopes in the 2 unimproved cases were 0.26 and 0.27. Group III: the mean IE slope was 0.51 (range 0.31–0.7). The conditions of all patients improved after shunting. A significant reduction of the Evans ratio was observed in 34 (40.5%) of the 84 improved cases and in none of the unimproved cases. Conclusions Our strategy based on the analysis of CSF pulse pressure parameters seems to have a great accuracy in predicting surgical outcome in clinical practice.

scholarly journals Systematic volumetric analysis predicts response to CSF drainage and outcome to shunt surgery in idiopathic normal pressure hydrocephalus

2021 ◽  
Author(s):  
Dan Wu ◽  
Abhay Moghekar ◽  
Wen Shi ◽  
Ari M. Blitz ◽  
Susumu Mori
Keyword(s):  
White Matter ◽  
Normal Pressure Hydrocephalus ◽  
Neurodegenerative Disorder ◽  
Brain Mri ◽  
Area Under The Curve ◽  
Normal Pressure ◽  
Volumetric Analysis ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Shunt Placement ◽  
Csf Drainage

Abstract Objectives Idiopathic normal pressure hydrocephalus (INPH) is a neurodegenerative disorder characterized by excess cerebrospinal fluid (CSF) in the ventricles, which can be diagnosed by invasive CSF drainage test and treated by shunt placement. Here, we aim to investigate the diagnostic and prognostic power of systematic volumetric analysis based on brain structural MRI for INPH. Methods We performed a retrospective study with a cohort of 104 probable INPH patients who underwent CSF drainage tests and another cohort of 41 INPH patients who had shunt placement. High-resolution T1-weighted images of the patients were segmented using an automated pipeline into 283 structures that are grouped into different granularity levels for volumetric analysis. Volumes at multi-granularity levels were used in a recursive feature elimination model to classify CSF drainage responders and non-responders. We then used pre-surgical brain volumes to predict Tinetti and MMSE scores after shunting, based on the least absolute shrinkage and selection operator. Results The classification accuracy of differentiating the CSF drainage responders and non-responders increased as the granularity increased. The highest diagnostic accuracy was achieved at the finest segmentation with a sensitivity/specificity/precision/accuracy of 0.89/0.91/0.84/0.90 and an area under the curve of 0.94. The predicted post-surgical neurological scores showed high correlations with the ground truth, with r = 0.80 for Tinetti and r = 0.88 for MMSE. The anatomical features that played important roles in the diagnostic and prognostic tasks were also illustrated. Conclusions We demonstrated that volumetric analysis with fine segmentation could reliably differentiate CSF drainage responders from other INPH-like patients, and it could accurately predict the neurological outcomes after shunting. Key Points • We performed a fully automated segmentation of brain MRI at multiple granularity levels for systematic volumetric analysis of idiopathic normal pressure hydrocephalus (INPH) patients. • We were able to differentiate patients that responded to CSF drainage test with an accuracy of 0.90 and area under the curve of 0.94 in a cohort of 104 probable INPH patients, as well as to predict the post-shunt gait and cognitive scores with a coefficient of 0.80 for Tinetti and 0.88 for MMSE. • Feature analysis showed the inferior lateral ventricle, bilateral hippocampus, and orbital cortex are positive indicators of CSF drainage responders, whereas the posterior deep white matter and parietal subcortical white matter were negative predictors.

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