The incidence is much higher in elderly populations. In patients with NPH, CSF shunt placement is effective for improving these symptoms . Cerebrospinal fluid dynamics and shunt responsiveness in patients with normal-pressure hydrocephalus. 127 (6): 1436-1442. Whereas our NPH population was limited to patients who responded to shunt placement, it is controversial whether this exclusion constitutes a selection bias. Average gray matter volume in AD was significantly lower than in NPH or HC volunteers (Tukey honest significant difference test, P < .01). This is an idiopathic form of communicating hydrocephalus, which features clinically as a triad of dementia, incontinence & gait disturbances. It is possible that these patients may fall into the aforementioned comorbid category. Utility of MRI-based disproportionately enlarged subarachnoid space hydrocephalus scoring for predicting prognosis after surgery for idiopathic normal pressure hydrocephalus: clinical research. 28. People who have NPH are usually aged over 60. In the normal conditions of compliance, P1 > P2 > P3. Diagnosing idiopathic normal-pressure hydrocephalus. It is important to note that there are many causes of communicating hydrocephalus without elevated opening CSF pressures, such as trauma, prior subarachnoid hemorrhage, and meningitis. magnetization-prepared rapid gradient echo, Journal of Clinical Neuroscience, Vol. LeMay M, New PF. 125, No. The mainstay of treatment is the placement of a ventricular shunt. 2007;78 (2): 181-7. The structures involved in this study are part of fundamental neuroanatomy expected during medical school training. 13. Symptoms may be relieved by ventricular shunting. The drainage of CSF is blocked gradually, and the excess fluid builds up slowly. Notably, there was no significant difference in mean gray matter volumes between NPH and HC groups. From the Dept of Radiology, Brigham and Women’s Hospital, Boston, Mass (N.M.); Riverside Regional Medical Center, Newport News, Va (H.P. NPH First described in 1965 by Hakim and Adams. Sci. and N.M., with 1 and 2 years of experience, respectively) and one neuroradiologist (A.G., with 45 years of experience). We also showed that the predictive model on the basis of combined CA and EI measures demonstrated comparable accuracy to our previously proposed model, which was based on ventricular and gray matter volumes (11) in the distinction between NPH and non-NPH. One of the outcomes of the logistic regression model is the estimated probability of NPH for each patient. normal pressure hydrocephalus radiology. 89 (5): 742-7. The aim of this study was to perform a whole-brain analysis of alterations in brain mechanical properties due to normal pressure hydrocephalus (NPH). Many neurodegenerative diseases with overlapping symptoms affect elderly patients, which makes radiologic differentiation difficult (9,10). Normal-pressure hydrocephalus (NPH) is characterized by a clinical triad of ataxia, incontinence, and dementia, as well as dilated ventricles but normal cerebrospinal fluid (CSF) pressures. 23. Case 1: showing a flow void at the aqueduct, periventricular white matter ischemic damage, disproportionately enlarged subarachnoid space hydrocephalus (DESH), asymptomatic ventriculomegaly with features of idiopathic normal pressure hydrocephalus on MRI (AVIM), J Neuropsychiatry Clin Neurosci (full text), approximately 20% of patients in nursing homes have gait impairment, approximately 10% of these patients also have dementia, 3.3 per 100,000 for people 50 to 59 years of age, 49.3 per 100,000 for people 60 to 69 years of age, 181.7 per 100,000 for people 70 to 79 years of age, disproportionate changes in subarachnoid spaces, tight high convexity (narrow sulci and subarachnoid spaces at the vertex and medial/parafalcine region), focal/isolated dilation of sulci over the medial surface or convexity (sometimes called transport sulci), aqueductal CSF stroke volume is the average volume of CSF flowing through the cerebral aqueduct during both systole and diastole, various publications have set various normal and abnormal ranges, flow rate of >24.5 mL/min 95% specific for NPH, stroke volume of ≥42 μL shown in one paper to predict a good response to shunting, stroke volume upper limit is now suggested to be variable between institutions due to intrinsic scanner differences; thus each center should obtain their own "normal values", with the upper limit being suggested as two times the normal value, studies have shown that aqueductal stroke volume decreases later in the disease process despite clinical progression, this has been theorized to be caused by cerebral atrophy, which indicates that the patient is unlikely to respond to shunt surgery, early detection of the radiotracer into lateral ventricles giving a heart-shaped appearance of lateral ventricles rather than a normal trident pattern, persistence of radiopharmaceutical beyond 24-48 hours due to impaired absorption, radiotracer does not extend to the superior aspect of convexities of lateral ventricles, retrograde CSF flow into lateral ventricles, short duration of presurgical symptoms (less than 6 months), onset of gait disturbance before dementia, temporary symptom relief from a CSF tap test (removal of 40ml of CSF via lumbar puncture), absence of significant cerebral vascular disease, presence of an aqueductal flow void on T2 imaging. Normal pressure hydrocephalus (NPH) is characterized by gait disturbance, mental deterioration, and urinary incontinence in patients with an enlarged ventricular system and normal CSF pressure .An important pathophysiological feature of NPH is dysfunctional CSF dynamics with reduced absorption through the arachnoid villi, compensatory CSF flow into the periventricular white matter, … Radiology. Algin O, Hakyemez B, Parlak M. Proton MR spectroscopy and white matter hyperintensities in idiopathic normal pressure hydrocephalus and other dementias. We used local three-dimensional MPRAGE sequence for 3-T imaging (repetition time msec/echo time msec/inversion time msec, 2100–2200/2.3–4.0/1100; flip angle, 9°–12°; 256 × 256 × 192 matrix; voxel size, 0.8–1.0 mm; and bandwidth, 200/260 Hz/pixel) and 1.5-T imaging (2100–2200/3.8–4.0/1100; flip angle, 12°; 256 × 256 × 160 matrix; voxel size, 0.1–1.0 mm; and bandwidth, 160/200 Hz/pixel). Patients with NPH present with a gradually progressive disorder. The range of areas under the curve was 0.96–0.97, depending on the observer. Mean volume of the hippocampus in patients with AD was less than mean volume of the hippocampus in HC and NPH groups (Tukey honest significant difference test, P < .01). (2009) ISBN:3211855785. For patients from ADNI, we used T1-weighted MPRAGE sequences performed with a 3-T imager (2300/2.98/853; flip angle, 9°; 256 × 256 × 192 matrix; nonisotropic 1.0 × 1.0 × 1.2 mm voxels; and bandwidth, 240 Hz/pixel) and a 1.5-T imager (2400/3.5/1000; flip angle, 8°; 192 × 192 × 160 matrix; 1.2 × 1.2 × 1.25 mm voxels; and bandwidth, 180 Hz/pixel). 1996;198 (2): 523-9. [27,28,29,30,31] These valves, which are designed to enable a range of pressure … AJNR Am J Neuroradiol. 22. We also plan to analyze volumetric measures of patients presumed to have NPH who did not respond to high-volume lumbar puncture or spinal drain procedures to identify imaging features that may predict response to cerebrospinal fluid removal. By using thresholds of CA of 90° or less and EI of 30% or greater to predict NPH, they reported accuracy of 96%, sensitivity of 97%, and specificity of 94% in the distinction between probable NPH (defined as symptomatic improvement after lumbar puncture) and AD. ); Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY (B.E.D. J. Neurol. Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. ■ Segmentation metrics may be used as a secondary tool after CA and EI in equivocal cases for more resource intensive but more accurate distinction of NPH from AD or HC. The classical clinical findings of normal pressure hydrocephalus are 1-3 1. urinary incontinence 2. deterioration in cognition (dementia) 3. gait disturbances These can be remembered with the unkind mnemonic Wet, Wacky, and Wobbly. ; statistical analysis, N.M., B.A.A., B.E.D., Y.S., H.R. Finally, our current model only studies ventricular cerebrospinal fluid and ignores extraventricular cerebrospinal fluid (sulcal size and shape). Multivariable logistic regression models were used to predict NPH (27). Manley GT, Hemphill C, Stiver S. Intracranial Pressure and Brain Monitoring XIII. 83 (993): 747-52. This study compared the accuracy of traditional measures of NPH, namely CA and EI, with segmentation metrics for diagnosis. In addition, the mean volume of hippocampus in the HC group was greater than that of the NPH group (Tukey honest significant difference test, P < .01). The majority (65 patients) excluded from the study failed to meet criteria mentioned in a. Gait impairment is the principal symptom that affects older adults with NPH (22) and the parameter most likely to improve with shunt surgery (23,24); hence, we chose gait impairment as the primary criterion for verifying shunt and lumbar puncture response. Radiology. Segmentation of global gray matter, white matter, ventricle, and hippocampus (left and right) was performed by using software (FreeSurfer version 5.1; http://surfer.nmr.mgh.harvard.edu). Raftopoulos C, Deleval J, Chaskis C, et al. Analysis of variance was used to compare mean values of individual variables across study groups. Also included is the performance of volumetric model by using two predictors: gray matter volume and ventricle volume. Functional ambulation performance is a quantitative, well-validated composite gait measure on the basis of step length, symmetry, and velocity, and the scores range from 95 to 100 in healthy adults (20,21). Here we seek to assess the diagnostic performance of CA and EI measures and to determine their role versus automated volumetric methods in clinical radiology. Part of the data used in preparation of this article was obtained from the ADNI database (adni.loni.usc.edu). 16. If the address matches an existing account you will receive an email with instructions to reset your password. These objective cutoffs are clinically relevant, and research showed that visual assessment alone exhibits poor diagnostic accuracy for NPH (12,27). A formula (Excel; Microsoft, Redmond, Wash) to calculate probability of NPH was directly derived from the regression model. The British journal of radiology. We now know that brain interstitial fluid is the source of 30-40% of CSF2 and 20-40% is absorbed by cranial and spinal nerve sheaths and at the cribriform plate rather than arachnoid granulations.2,3 He… Normal pressure hydrocephalus: significance of MRI in a potentially treatable dementia. Hurley RA, Bradley WG Jr, Latifi HT, Taber KH. 2. Table 2 Results from Two Types of Multivariate Logistic Regression Models to Distinguish NPH from Non-NPH Patients. Bradley WG, Scalzo D, Queralt J, et al. Radiology. The Canadian Institutes of Health Research provided funds to support ADNI clinical sites in Canada. AJNR Am J Neuroradiol. ■ Clinically useful simple cutoffs may be used as part of a screening tool for patients with NPH versus patients who do not have NPH at MR imaging. Unlike the model based on the volumetric measures, the model based on CA and EI performs poorly in classifying both patients with AD and HC volunteers. 1996;198(2):523-529. 21. There is, however, a well-established correlation between higher flow velocities and the favorable outcome after ventriculoperitoneal (VP) shunting; hence, quantitative (rather than qualitative) methods have been developed which can be useful not only in patient selection for shunting but also in diagnosis and predicting prognosis 12-15. Dr. Mariaelaina Sumas answered. There is a general agreement that NPH is complex and underdiagnosed, and a detailed characterization of its severity is lacking (2). A survey of 284 physicians. Several signs of normal pressure hydrocephalus: narrow callosal angle of 74 degrees; coronal T2: periventricular edema (green arrows) sagittal T1: wide cerebral aqueduct (red arrow) and normal floor of the 3rd ventricle (green arrow) axial T2: increased flow void in the aqueduct (green arrow) axial T2: narrow parasagittal CSF fissures (green arrows) J. Larry Jameson, Dennis L. Kasper, Dan Louis Longo, et al. Ishii K, Kanda T, Harada A, Miyamoto N, Kawaguchi T, Shimada K, Ohkawa S, Uemura T, Yoshikawa T, Mori E. Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus. 1991;178(2):459-466. One theory is that the condition is an obstructive type of communicating hydrocephalus due to reduced CSF resorption. Cognitive recovery in idiopathic normal pressure hydrocephalus. As the name suggests, mean CSF opening pressure is within the normal range (<18 cmH2O or 13 mmHg) 3. Cerebral atrophy versus normal pressure hydrocephalus, Focal dilation and paradoxical collapse of cortical fissures and sulci in patients with normal-pressure hydrocephalus, Noninvasive biomarkers in normal pressure hydrocephalus: evidence for the role of neuroimaging, Analysis of movement through utilisation of clinical instrumentation, The validity of the GaitRite and the Functional Ambulation Performance scoring system in the analysis of Parkinson gait, Hydrocephalus as a cause of disturbances of gait in the elderly, Normal-pressure hydrocephalus. Proc. Estimated tissue volume bias (V3T − V1.5T) because of differences in magnetic field strength was 25.0 mL for gray matter, −34.3 mL for white matter, 2.0 mL for ventricle, and 0.10 mL for hippocampus. VNT = ventricular volume. Overall, the overlap was 14.1% (15 of 106). Harrison's Principles of Internal Medicine: Cardinal manifestations and presentation of diseases. The final sample size was 36 patients. As the name suggests, mean CSF opening pressure is within the normal range (<18 cmH2O or 13 mmHg) 3. Aqueductal Stroke Volume: Comparisons with Intracranial Pressure Scores in Idiopathic Normal Pressure Hydrocephalus. Images of control patients (both HC patients and patients with AD from ADNI) were acquired with a variety of 1.5-T and 3-T MR imaging systems that used the same T1-weighted MPRAGE sequence. Curr Neurol Neurosci Rep. 2008;8 (5): 371-6. Data collection and sharing for ADNI supported by National Institutes of Health (U01 AG024904), including the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through contributions from Alzheimer’s Association; Alzheimer’s Drug Discovery Foundation; BioClinica; Biogen Idec; Bristol-Myers Squibb; Eisai; Elan Pharmaceuticals; Eli Lilly and Company; F. Hoffmann-La Roche and its affiliated company Genentech; GE Healthcare; Innogenetics; IXICO; Janssen Alzheimer Immunotherapy Research and Development; Johnson and Johnson Pharmaceutical Research and Development; Medpace; Merck; Meso Scale Diagnostics; NeuroRx Research; Novartis Pharmaceuticals Corporation; Pfizer; Piramal Imaging; Servier; Synarc; and Takeda Pharmaceutical Company. 19 (7): 1277-84. Holodny AI, George AE, de Leon MJ, Golomb J, Kalnin AJ, Cooper PR. (2008) European radiology. Check for errors and try again. Because this disorder is potentially treatable, research focused on improving diagnosis through noninvasive imaging techniques (8,9). We examined the ADNI database to ensure all participants met the remaining requirement a. Volumetric assessments require more infrastructure and may take several hours to generate, but they further categorize patients with age-related comorbidities. There was no significant difference among the three groups regarding age (analysis of variance; F = 0.33; P = .72) or sex (χ2 = 0.03; P = .98). 2006;78(4):395-398. The majority of cases are idiopathic. Marked cerebrospinal fluid void: indicator of successful shunt in patients with suspected normal-pressure hydrocephalus. 277 (1-2): 54-7. The utility of these tests for diagnosis and their ability to provide useful prognostic information pertaining to shunting have varied widely. 2013;34 (6): 1168-74. Table 1 Demographic Characteristics and Brain Measures. Kitagaki H, Mori E, Ishii K, Yamaji S, Hirono N, Imamura T. CSF spaces in idiopathic normal pressure hydrocephalus: morphology and volumetry. The sensitivity and diagnostic accuracy of these groups overlapped, indicating no statistically significant difference in this subgroup analysis. Participants in the ADNI were used as both patients with AD and HC volunteers (Table 1). Thus, our proposed prediction model on the basis of CA and EI may serve as a screening tool to help the radiologist identify patients with possible NPH and recommend further volumetric assessment. 52 (11): 775-809. We then matched the AD and HC groups with the NPH group for sex and sample size.For the groups, we obtained 34 patients with AD and 36 HC volunteers. ). However, the enlarged ventricles still press on the brain and ca… The sensitivity and specificity for this cutoff were 87.0% (94 of 108) and 89.5% (188 of 210), respectively. Hayhow B, Begic F, Evans A et-al. The quantitative functional ambulation performance gait score showed a significant (P = .02) improvement from 71.1 ± 16.3 (standard deviation) before shunt to 80.3 ± 14.5 after shunt. Patients who meet one of the criteria should be categorized as probable NPH. It's important to make a correct diagnosis because, unlike Alzheimer’s disease, the … Communicating hydrocephalus with reversible cognitive impairment. 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