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PubMed2004

Magnetic resonance spectroscopic determination of a neuronal and axonal marker in white matter predicts reversibility of deficits in secondary normal pressure hydrocephalus.

BACKGROUND: Normal pressure hydrocephalus (NPH) is considered to be a treatable form of dementia, because cerebrospinal fluid (CSF) shunting can lessen symptoms. However, neuroimaging has failed to predict when shunting will be effective. OBJECTIVE: To investigate whether 1H (proton) magnetic resonance (MR) spectroscopy could predict functional outcome in patients after shunting. METHODS: Neurological state including Hasegawa's dementia scale, gait, continence, and the modified Rankin scale were evaluated in 21 patients with secondary NPH who underwent ventriculo-peritoneal shunting. Outcomes were measured postoperatively at one and 12 months and were classified as excellent, fair, or poor. MR spectra were obtained from left hemispheric white matter. RESULTS: Significant preoperative differences in N-acetyl aspartate (NAA)/creatine (Cr) and NAA/choline (Cho) were noted between patients with excellent and poor outcome at one month (p = 0.0014 and 0.0036, respectively). Multiple regression analysis linked higher preoperative NAA/Cr ratio, gait score, and modified Rankin scale to better one month outcome. Predictive value, sensitivity, and specificity for excellent outcome following shunting were 95.2%, 100%, and 87.5%. Multiple regression analysis indicated that NAA/Cho had the best predictive value for one year outcome (p = 0.0032); predictive value, sensitivity, and specificity were 89.5%, 90.0%, and 88.9%. CONCLUSIONS: MR spectroscopy predicted long term post-shunting outcomes in patients with secondary NPH, and it would be a useful assessment tool before lumbar drainage.

Adult↗
PubMed2006

The diagnosis and treatment of idiopathic normal pressure hydrocephalus.

Idiopathic normal pressure hydrocephalus (INPH) is a syndrome that is characterized by gait impairment, cognitive decline and urinary incontinence, and is associated with ventriculomegaly in the absence of elevated cerebrospinal fluid (CSF) pressure. There is significant variation in the clinical presentation and progression of this disorder, and its diagnosis often represents a challenge for neurologists and neurosurgeons. Various supplemental tests, including the CSF tap test, external CSF drainage via spinal catheter, and CSF outflow resistance determination, can improve the accuracy of predicting a response to surgical treatment. CSF shunting provides significant symptom improvement in the majority of appropriately evaluated patients. In 2005, an international study group published evidence-based guidelines for the diagnosis and management of INPH. This review will highlight the clinical presentation, radiographic findings, supplemental prognostic tests, differential diagnosis, surgical treatment and outcomes of INPH.

Diagnosis, Differential↗
PubMed1976

The physics of the cranial cavity, hydrocephalus and normal pressure hydrocephalus: mechanical interpretation and mathematical model.

It is intended for this research, to provide some basis for the understanding of the rational mechanics of the cranial content. There are many interesting and controversial facts derived from the experimental and clinical-pathological observations of hydrocephalus and increased intracranial pressure. For instance, in some patients a moderate increase of intracranial pressure is accompanied by hydrocephalus and mental changes, while in others, with high intracranial pressure, the ventricles and mental functions remain unaltered. What then is the parameter that changes the size of the ventricles and impairs brain function? It is shown how the transmission of intraventricular pressure throughout the brain parenchyma creates a stress distribution that varies in magnitude; how during the production, maintenance, and reversal of hydrocephalus, and normal pressure hydrocephalus the stress is distributed throughout the brain; and how in the presence of a sudden increase of intracranial pressure nature has arranged additional mechanisms for protecting the brain. It is important to recognize that some aspects of intracranial physiopathology can be explained through classical concepts of physics, prior to attempting to interpret such processes solely in terms of biological or auto-regulatory phenomena.

Adult↗
PubMed2000

[Clinical characteristics and indications for shunting in patients with idiopathic normal pressure hydrocephalus with brain atrophy (atypical idiopathic normal pressure hydrocephalus)].

PURPOSE: To clarify clinical characteristics of atypical idiopathic normal pressure hydrocephalus (AINPH) and indications for shunt operations. SUBJECTS AND METHODS: Subjects examined in the present study included 65 patients who satisfied the following 4 diagnostic criteria of AINPH and underwent V.P shunt with Medos type shunt system; set pressure: epidural standard pressure x 13.6 - 20 mmH2O (omission of a figure in the first place). The diagnostic criteria were: 1) no apparent history of intra- or extra-cranial disease; 2) dementia was present as a main complaint; 3) the presence of moderate to severe cerebral atrophy and ventricular enlargement and PVL around the anterior horn on CT scans; 4) normal cerebrospinal pressure and filling of ventricles or subarachnoid space with contrast medium at 24 hours on cisternography. The patients were aged 49-83 with the mean age of 62.9 years; the ratio of male to female was 37:28. They were categorized as shunt-effective (group E: 36 cases) or non-shunt-effective (group NE: 29 cases), and the following parameters in both groups were compared: 1. clinical characteristics: 2. the presence or absence of pressure wave (PW) during preoperative continuous epidural pressure measurement (EDPM) 3. CSF outflow resistance (Ro) 4. preoperative serum alpha-1-antichymotrpsin (alpha-1-ACT) 5. cerebral arteriovenous difference of oxygen content (c-AVDO2) before and after surgery 6. mean cerebral blood flow (mCBF; 99mTc-HMPAO-SPECT) before and after surgery. RESULTS AND CONCLUSIONS: 1. Group E had a shorter duration between symptom onset and hospital visit (within 16 months and showed hyporoluntary and hyporeactivity as their main complaints associated with gait disturbance; the time course of symptoms was classified as suddenly progressing and fluctuating in many cases. Group NE had a relatively longer duration between symptom onset and hospital visit and showed activeness, wandering, nervousness and quick temper as their main complaints; the time course of symptoms was classified as progressing in many cases. 2. PW-positive cases were all included in group E. but some PW-negative cases were also observed in group E. 3. Ro was significantly higher in group E (p < 0.01), and cases with a Ro value over 20 mmHg/ml/min. were all included in group E. 4. alpha-1-ACT was significantly lower in group E (p < 0.05), and cases with an alpha-1-ACT value over 55 mg/dl were all included in group NE. 5. Although preoperative c-AVDO2 was significantly higher in group E (p < 0.05), cases with a c-AVDO2 value over 8.5 ml% were all included in group NE. c-AVDO2 values were within 5-8.5 ml% in all cases of group E. 6. mCBF significantly increased after surgery in group E (p < 0.001). 7. It was confirmed that cerebral atrophy in group E on AINPH is caused by a cerebral circulation disturbance defined as a cerebral blood flow of penumbra or more due to cerebral arteriosclerosis, etc. 8. A flowchart of indications for shunt surgery for AINPH was prepared based on the results of the present study.

Aged↗
PubMedDate not supplied

[Magnetic resonance imaging of aqueductal flow in patients with normal hydrocephalus pressure].

The treatment of patients with the so-called Normal Pressure Hydrocephalus (NPH) consists of ventricular shunting, but only in some cases is there clinical improvement. The selection of patients for ventricular shunting is usually based on the response to the evacuating lumbar punctures of the cerebrospinal fluid (CSF), but new MRI techniques of flow measurement have been used successfully. In this study, a group of 58 patients, 28 of which with NPH, is presented. Flow quantification of the aqueductal CSF using the MR Phase Contrast technique was performed in all of them. The authors conclude that the method is sensitive and can be a valid criterium in the selection of patients for ventricular shunting.

Adolescent↗
PubMed1991

CSF monoamine metabolites, cholinesterases and lactate in the adult hydrocephalus syndrome (normal pressure hydrocephalus) related to CSF hydrodynamic parameters.

Monoamine metabolites, cholinesterases and lactic acid in lumbar cerebrospinal fluid (CSF) were investigated on patients with the adult hydrocephalus syndrome (idiopathic normal pressure syndrome; AHS, n = 15), Alzheimer's disease (AD, n = 14), multi-infarct dementia (MID, n = 13) and controls (n = 21). Patients had clinical and CSF hydrodynamic investigations. Monoamine concentrations were determined by reversed-phase liquid chromatography, cholinesterases and lactate were determined photometrically. In the AHS patients, CSF monoamine concentrations were not significantly different compared with controls, AD or MID patients. AHS and AD patients showed a similar reduction of CSF acetylcholinesterase activity compared with controls. Positive correlations were found in concentrations of CSF homovanillic acid, CSF 5-hydroxyindoleacetic acid and CSF lactic acid versus CSF outflow conductance (that is, resistance against CSF outflow) in the AHS patients. A similar pattern was observed in a subgroup of MID patients characterised by dilated ventricles and disturbed CSF hydrodynamics. These data suggest that a low CSF outflow conductance may facilitate the clearance of acidic substances from the arachnoid space at the probenecid sensitive active transport site. Alternative explanations would be that a pathologically low CSF outflow conductance is accompanied by an inverse caudorostral flow of CSF or a compromised trans-ependymal diffusion.

Aged↗
PubMed2000

Indications for shunting in patients with idiopathic normal pressure hydrocephalus presenting with dementia and brain atrophy (atypical idiopathic normal pressure hydrocephalus).

The indications for shunt operation in patients with idiopathic normal pressure hydrocephalus accompanied by brain atrophy (atypical idiopathic normal pressure hydrocephalus: AINPH) were investigated in 25 patients who satisfied the diagnostic criteria and underwent ventriculoperitoneal (VP) shunting. All patients had no apparent history of intra- or extracranial disease; dementia and gait disturbance as the main complaints; moderate to severe cerebral atrophy and ventricular dilatation and at least periventricular low density around the anterior horn on computed tomography; normal cerebrospinal fluid (CSF) pressure and filling of ventricles or cortical surface space with contrast medium at 24 hours on cisternography. The 15 male and 10 female patients were aged 47-83 years (mean 60.4 years). VP shunting was effective in 12 improved patients and not effective in 13 unimproved patients according to NPH grading. Pathological pressure wave on epidural pressure monitoring was observed in eight of 12 improved patients, but none of 13 unimproved patients. CSF outflow resistance was 35.33 +/- 11.16 mmHg/ml/min in improved patients and 9.12 +/- 3.51 mmHg/ml/min in unimproved patients. Preoperative serum alpha-1-antichymotrypsin value (alpha-1-ACT) was 42.02 +/- 8.64 mg/dl in improved patients and 61.72 +/- 11.03 mg/dl in unimproved patients. Alpha-1-ACT over 55 mg/dl occurred only in unimproved patients. Cerebral arteriovenous difference of oxygen content value (c-AVDO2) before and after surgery was 6.34 +/- 0.9 ml% and 5.91 +/- 0.78 ml% in improved patients and 4.75 +/- 1.85 ml% and 4.81 +/- 1.73 ml% in unimproved patients, respectively. The two cases with preoperative c-AVDO2 value over 8.5 ml% were both unimproved. Mean cerebral blood flow value before and after surgery was 23.51 +/- 4.20 ml/100 g/min and 45.22 +/- 8.11 ml/100 g/min in improved patients and 21.77 +/- 5.12 ml/100 g/min and 24.82 +/- 4.97 ml/100 g/min in unimproved patients, respectively. Cerebral atrophy in improved patients is caused by a cerebral circulation disturbance defined as a cerebral blood flow of penumbra or more due to cerebral arteriosclerosis, etc. A flow-chart of indications of shunt surgery for AINPH was prepared based on the results of the present study.

Aged↗
PubMed1997

Analysis of apolipoprotein E, alpha1-antichymotrypsin and presenilin-1 genes polymorphisms in dementia caused by normal pressure hydrocephalus in man.

Normal pressure hydrocephalus (NPH) is characterized by dementia, gait disorders and urinary incontinence. Apolipoprotein E (ApoE) epsilon4 allele has been associated with severity of dementia in Alzheimer's disease (AD) and in other forms of dementia. Moreover, homozygosity of the A allele of the alpha1-antichymotrypsin (ACT) gene and of allele 1 of the presenilin-1 (PS-1) gene was associated with an increased risk for late onset AD. We analyzed the distribution of ApoE, ACT and PS-1 genotypes and the corresponding allele frequencies in 13 NPH patients. No differences were found in ACT and PS-1 polymorphism distributions in the patients studied with respect to the control group. An increased ApoE epsilon4 allele frequency was observed in NPH patients with respect to controls, thus suggesting that epsilon4 allele may also be involved in the pathogenesis of the disease.

Adult↗
PubMed1997

Frontal brain and leptomeningeal biopsy specimens correlated with cerebrospinal fluid outflow resistance and B-wave activity in patients suspected of normal-pressure hydrocephalus.

OBJECTIVE: Normal-pressure hydrocephalus (NPH) is a potentially treatable syndrome with abnormal cerebrospinal fluid dynamics. Meningeal fibrosis and/or obliteration of the subarachnoid space has been suggested as the pathoanatomic basis. The purpose of the present study was to investigate whether meningeal fibrosis causes increased resistance to cerebrospinal fluid outflow (R(out)) and/or increased B-wave activity and whether pathological changes in the brain parenchyma after brain compliance, causing increased B-wave activity. METHODS: The study involved a group of 38 consecutively studied patients with clinical and radiological evidence of idiopathic NPH, for whom a frontal brain biopsy was obtained. For 29 patients, hydrodynamic criteria of NPH were fulfilled and a ventriculoperitoneal shunt was performed. RESULTS: Meningeal fibrosis was found in 12 of 25 biopsies containing arachnoid tissue, but no correlation with R(out) or B-waves was found. Pathological parenchymal changes, most often Alzheimer's disease (10 cases) or vascular changes (10 cases), were found in 21 biopsies, but no correlation with B-waves or R(out) was found. CONCLUSION: The results suggest that leptomeningeal fibrosis is not the only pathoanatomic basis of increased R(out) and/or B-wave activity in patients with NPH and that various degenerative changes in the parenchyma may be responsible for the altered cerebrospinal fluid dynamics characteristic of NPH.

Adult↗
PubMed1978

[Normal pressure hydrocephalus. Part 1. Dynamic study of CSF circulation in patients with normal pressure hydrocephalus (author's transl)].

To clarify the pathogenesis of normal pressure hydrocephalus (NPH), quantitative measurement of CSF dynamics was attempted using RI techniques. In this study results concerning RI ventriculography and RI transfer test from CSF to plasma were reported. "Barrier ratio" and regional cerebral blood flow study in NPH will be reported elsewhere. Fifty-three patients with chronic communicating hydrocephalus wer devided into two groups. Thus, twenty-seven cases were diagnosed as NPH according to clinical symptoms and signs, and others were considered as mere chronic communicating hydrocephalus without any NPH characteristics. Results are as follows: 1) 169Yb--DTPA ventriculography; In NPH group, there was longer retention of RI injected into lateral ventricle, and RI activity was not detected in the cisterna magna 60 minutes after the injection. These findings show remarkable delay of CSF flow in NPH patients. 2) Transfer test of 169Yb--DTPA from CSF to plasma; Immediately after the RI injection, Transfer ratio of RI activity from CSF to plasma was measured. It was revealed that intraventricular RI was more rapidly transfered to plasma in NPH group compared with in the control group, suggesting accelerated trans-ependymal absorption of RI in NPH group.

Aged↗
PubMed2000

[Clinical experience with various shunt systems in normal pressure hydrocephalus].

In patients with normal pressure hydrocephalus in the late stage conventional differential valves have the disadvantage that they open abruptly while changing the body position to the vertical line and that they can therefore induce a suction on the ventricles of the atrophic brain. Can these disadvantages and overdrainage complications be minimized by hydrostatic valves? In 117 patients diagnosed for normal pressure hydrocephalus we have implanted 47 Cordis Standard Valves (CSV), 20 Cordis Orbis Sigma Valves Type I (OSV) and 50 Miethke Dual Switch Valves (DSV). 95 patients (36/19/40) could be re-evaluated by means of a control examination. Normal pressure hydrocephalus was graduated according to the results of the intrathecal infusion test in an early and late stage. According to our NPH-Recovery-Rate and to the clinical grading of normal pressure hydrocephalus by Kiefer and Steudel we compared the post-operative results of each group of patients. There were no statistical differences in mechanical and infectious complications between the different valve types. We found significant differences in overdrainage and subdural hematomas. 4 patients (11%) with a CSV, 5 patients (26%) with an OSV and 2 patients (5%) with a DSV had a decrease of the ventricular width visualised in the CT. Of those patients 2 (6%) with a CSV, 3 patients (16%) with an OSV and 1 patient (3%) with a DSV developed clinical symptoms. The course of the disease in patients with normal pressure hydrocephalus is influenced by the stage of the disease--degree of cerebral atrophy--and also by the implanted valve type. The high amount of overdrainage complications and subdural hematomas in the Cordis Orbis Sigma Valve Type I group is an argument against its use. Our clinical experiences with the Miethke Dual Switch Valve show that this hydrostatic valve is of advantage for patients with a normal pressure hydrocephalus.

Cerebrospinal Fluid Shunts↗
PubMed1992

Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus?

Thirteen patients with normal pressure hydrocephalus were operated upon with an externally maneuverable shunt system (Sophy SU8) in order to investigate its influence on clinical outcome, intracranial pressure and cranial CT parameters. The opening pressure was set at high at surgery and lowered stepwise at intervals of three months to medium and low. The clinical condition, intracranial pressure and cranial CT parameters were examined at the end of the 3 months interval on each pressure level. The patients improved within the first 3 months inspite of an unchanged mean intracranial pressure and remained in a stable clinical condition during the rest of the study period. The intracranial pressure was significantly reduced at 9 months. The ventricular index, Evans index, temporal horn and third ventricle width were reduced 3 months post-operatively and did not change significantly during the rest of the study. The pre-operative third ventricle width was correlated to high psychometric test results after shunt surgery. Reduction in ventricular index, Evans index and third ventricle width after surgery correlated to improvement in psychometric scoring. The clinical improvement after shunt surgery for normal pressure hydrocephalus is seen within 3 months and is independent of the adjusted valve pressure.

Aged↗
PubMed2000

Clinical experiences with the dual-switch valve in patients with normal pressure hydrocephalus.

In patients with normal pressure hydrocephalus (NPH) we compared the postoperative results reference to the implanted valve type. In 117 patients diagnosed with normal pressure hydrocephalus there was placement of 47 Cordis Standard valves (CSV), 20 Cordis Orbis Sigma valves type I (OSV) and 50 Miethke Dual-switch valves (DSV). Ninety-five patients (36/19/40) were re-evaluated. Normal pressure hydrocephalus was graduated according to the results of the intrathecal infusion test in an early and late stage. There were no statistical differences in mechanical and infective complications between the different valve types. We found significant differences in overdrainages and subdural hematomas. Two patients (6%) with a CSV, 3 patients (16%) with an OSV and 1 patient (3%) with a DSV developed clinical symptoms due to this. The course of disease in patients with NPH is influenced by the stage of disease--degree of cerebral atrophy--and also by the implanted valve type. The great amount of overdrainage complications and subdural hematomas in the Cordis Orbis Sigma valve group may be an argument against this valve. Our clinical experiences with the Miethke Dual-switch valve show that this hydrostatic valve may be advantageous for patients with NPH.

Equipment Design↗
PubMed2003

Is decreased ventricular volume a correlate of positive clinical outcome following shunt placement in cases of normal pressure hydrocephalus?

It is well known that in patients with communicating hydrocephalus or normal pressure hydrocephalus, ventricular volume decreases following implantation of differential pressure valved shunts. Hydrostatic valves (Miethke dual-switch valves) were implanted in 60 normal pressure hydrocephalus patients at Unfallkrankenhaus Berlin between September 1997 and September 2001. One year postoperatively, these patients underwent CT scan, and their ventricular size was ascertained using the Evans index. Although 77% of these patients showed no postoperative change in ventricular volume, 65% nonetheless showed good to excellent clinical improvement, 13% satisfactory improvement and 22% no improvement. A moderate reduction in ventricular size was observed in 17% of the patients in our cohort. 40% of these patients showed good to excellent clinical improvement, 20% satisfactory improvement, and 40% unsatisfactory improvement. A marked reduction in ventricular size was observed in 6% of our patients. Of these latter patients, 50% showed good to excellent outcomes, while 50% had unsatisfactory outcomes. The favorable outcomes following implantation of a hydrostatic shunt in patients with normal pressure hydrocephalus did not correlate with decreased ventricular volume one year after operation. Better clinical outcomes were observed in patients with little or no alteration in ventricular size than in patients with a marked decrease in ventricular size. Postoperative change in ventricular volume should be assessed differently for patients with normal pressure hydrocephalus than in patients with hypertensive hydrocephalus.

Cerebral Ventriculography↗
PubMed1976

Computerized axial transverse tomography in normal pressure hydrocephalus.

Twenty patients with normal pressure hydrocephalus were examined by computerized axial transverse tomographic (CT) scanning and the results were compared with pneumoencephalographic findings and clinical responses to ventricular shunting. The CT scan revealed significant cortical atrophy, not demonstrated by pneumoencephalogram in seven patients. The cortical atrophy was confirmed by autopsy in one case. This examination also revealed greatly enlarged ventricles (25 to 40 per cent of intracranial volume) in eight patients up to 4 years after ventricular shunting. There was no relationship between the presence or absence of cortical atrophy, or the postoperative ventricular size, and the clinical responses to ventricular shunting. Current concepts of normal pressure hydrocephalus must be revised in view of these findings.

Adult↗
PubMed2004

Link between vasogenic waves of intracranial pressure and cerebrospinal fluid outflow resistance in normal pressure hydrocephalus.

Recent studies on normal pressure hydrocephalus (NPH) have pointed to a possible link between the disturbance in CSF circulation and cerebrovascular factors. We investigated the quantitative relationship between the resistance to CSF outflow (Rcsf) and vasogenic waves of ICP in patients with normal pressure hydrocephalus. Forty-five patients with NPH were investigated by an infusion study. The magnitudes of vasogenic ICP components: pulse, respiratory and slow vasogenic waves were assessed, and compared with Rcsf. Both baseline respiratory and slow waves of ICP were positively correlated with Rcsf. The respiratory wave at baseline was a single independent predictor of Rcsf (r = 0.66, p < 0.0002). All vasogenic components increased significantly during the infusion test. The magnitude of the increase was positively correlated with Rcsf. The vasogenic ICP waves, notably the respiratory wave of ICP, correlate with the resistance to CSF outflow.

Adult↗
PubMed2000

Vascular compliance in normal pressure hydrocephalus.

BACKGROUND AND PURPOSE: Normal pressure hydrocephalus (NPH) is considered to be a combination of altered CSF resorption and a reversible form of cerebral ischemia. The hypothesis tested in this study was that a reduction in venous compliance in the territory drained by the superior sagittal sinus (SSS) is associated with NPH and cerebral ischemia. METHODS: This prospective study involved 27 patients without evidence of hydrocephalus. This group was subdivided into those with normal MR findings and those with evidence of ischemia or atrophy. Ten patients with NPH then underwent MR flow quantification studies of the cerebral vessels. Five of these patients had the same studies performed after CSF drainage. Vascular compliance was measured in the SSS and straight sinus territory by use of MR flow quantification with net systolic pulse volume (NSPV) and arteriovenous delay (AVD) as markers. RESULTS: Vascular compliance of patients with ischemia or atrophy was significantly higher than that of healthy subjects (mean NSPV in the SSS, 417 microL and 274 microL, respectively). Patients with NPH showed lower compliance than that of the healthy subjects in the SSS (mean NSPV, 212 microL and 274 microL, respectively; mean AVD, 42 ms and 89 ms, respectively). After intervention, the NPH group showed compliance approximating the group with ischemia/atrophy. CONCLUSION: Vascular compliance is significantly different in the brains of healthy subjects as compared with that in patients with ischemia/atrophy or NPH.

Aged↗