normal pressure hydrocephalus radiology

We examined the ADNI database to ensure all participants met the remaining requirement a. These can be remembered with the unkind mnemonic Wet, Wacky, and Wobbly. We selected patients with NPH from our adult hydrocephalus clinic. 2008;81 (1): 19-29. ; experimental studies, N.M., H.P., B.A.A., C.S., Y.S., J.G., O.G., H.R. For EI, a cutoff of 0.32 was 81.4% (259 of 318) accurate for identification of patients with NPH, and measurements above the cutoff suggested NPH. The final sample size was 36 patients. 18 (11): 2678-83. Note—Data in parentheses are numerator and denominator unless otherwise indicated. 402, Current Gerontology and Geriatrics Research, Vol. and N.M., with 1 and 2 years of experience, respectively) and one neuroradiologist (A.G., with 45 years of experience). A Picture Archiving and Communications in Medicine multiplanar reconstruction tool (Intellispace PACS Enterprise v4.4.516; Philips Healthcare, Amsterdam, the Netherlands) was used for three-dimensional reformatting. Imaging biomarkers of NPH include linear measures such as the Evans index (EI) (12,13), callosal angle (CA) (14), disproportionate sulci (15), and volumetric analysis (11,16). 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. 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). 2007;78 (2): 181-7. Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population. Normal Pressure Hydrocephalus-MRI. However, the enlarged ventricles still press on the brain and ca… Imaging appearances are nonspecific. 408, Parkinsonism & Related Disorders, Vol. Three blinded observers independently measured EI and CA for each patient. Focal dilation and paradoxical collapse of cortical fissures and sulci in patients with normal-pressure hydrocephalus. (2005) Neurosurgery. A treatable syndrome, Diagnosis and management of idiopathic normal-pressure hydrocephalus, Incidence of idiopathic normal-pressure hydrocephalus in Northern Spain, Intracranial cerebrospinal fluid measurement studies in suspected idiopathic normal pressure hydrocephalus, secondary normal pressure hydrocephalus, and brain atrophy, Intracranial compartment volumes in normal pressure hydrocephalus: volumetric assessment versus outcome, Comparison of CSF distribution between idiopathic normal pressure hydrocephalus and Alzheimer disease, Prevalence of idiopathic normal-pressure hydrocephalus, Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging, Noninvasive MRI assessment of intracranial compliance in idiopathic normal pressure hydrocephalus, Brain MRI as a predictor of CSF tap test response in patients with idiopathic normal pressure hydrocephalus, Differentiating shunt-responsive normal pressure hydrocephalus from Alzheimer disease and normal aging: pilot study using automated MRI brain tissue segmentation, Evans’ index revisited: the need for an alternative in normal pressure hydrocephalus, An encephalographic ratio for estimating ventricular enlargement and cerebral atrophy, Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus, Study of INPH on neurological improvement (SINPHONI). 83, Journal of the Neurological Sciences, Vol. 1968;2 (4): 307-27. Clinical FDG and Amyloid Brain PET in the Investigation of Cognitive Impairment: How, When & Why? Finally, our current model only studies ventricular cerebrospinal fluid and ignores extraventricular cerebrospinal fluid (sulcal size and shape). There was no overlap in remaining 70 reference patients (ie, patients without NPH). (2012) Neurologia medico-chirurgica. Manley GT, Hemphill C, Stiver S. Intracranial Pressure and Brain Monitoring XIII. 63, 20 January 2018 | Journal of Neural Transmission, Vol. 23. We performed two prospective analyses for an additional 13 patients (seven men, six women; age range, 39–94 years) to examine the within-patient effects of different MPRAGE protocols. 23. Viewer, The Quest for Predicting Sustained Shunt Response in Normal-Pressure Hydrocephalus: An Analysis of the Callosal Angle's Utility, A new MR imaging index for differentiation of progressive supranuclear palsy-parkinsonism from Parkinson's disease, Cerebrospinal fluid biomarkers profile of idiopathic normal pressure hydrocephalus, Journey to the Center of the Brain: The Ventricular System, Discrimination between Alzheimer Disease, Mild Cognitive Impairment, and Normal Aging by Using Automated Segmentation of the Hippocampus, Predicting Cognitive Decline in Subjects at Risk for Alzheimer Disease by Using Combined Cerebrospinal Fluid, MR Imaging, and PET Biomarkers, Alzheimer Disease: Quantitative Structural Neuroimaging for Detection and Prediction of Clinical and Structural Changes in Mild Cognitive Impairment, White Matter Degeneration in Atypical Alzheimer Disease, The Radiologist's Role in Shunt Evaluation: A Resident Primer and Review of What the Neurosurgeon Wants to Know. Volumetric assessments require more infrastructure and may take several hours to generate, but they further categorize patients with age-related comorbidities. AIC = Akaike information criterion. The disease presents in a classic triad of symptoms, which are urinary inco… What do physicians know about normal pressure hydrocephalus and when did they know it? Hayhow B, Begic F, Evans A et-al. (2014) AJNR. Clinically useful cutoffs were obtained to identify and distinguish NPH from the non-NPH patient groups of AD and HC (Fig 3). 19 (7): 1277-84. Normal pressure hydrocephalus (NPH) is an uncommon and poorly understood condition that most often affects people over the age of 60. Hakim S, Adams RD. In a review, Klinge et al (25) determined there is no consensus regarding the use of any standardized clinical scale for defining a positive response to shunt placement. Our results support this result. It occurs if the normal flow of CSF throughout the brain and spinal cord is blocked in some way. Table 3 Performance of Three-Way Diagnostic Classification Models. We also demonstrated the utility of a prediction model that combines CA and EI to diagnose shunt-responsive NPH and differentiate it from confounding imaging features of both patients with AD and HC volunteers. Private-sector contributions are facilitated by the Foundation for the National Institutes of Health. Idiopathic normal pressure hydrocephalus: new findings and thoughts on etiology. Overall, the overlap was 14.1% (15 of 106). Although CT is able to visualize the anatomical changes, it is inferior to MRI. ); and Dept of Neurology, New York University School of Medicine, New York, NY (J.G. Springer. Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: diagnosis and treatment. Figure 3: Scatterplot demonstrates the cutoff values of CA and EI that separate patients with NPH from patients who do not have NPH (ie, patients with AD and HC volunteers). Differential diagnosis of normal pressure hydrocephalus by MRI mean diffusivity histogram analysis. 20. As the name suggests, mean CSF opening pressure is within the normal range  (<18 cmH2O or 13 mmHg) 3. AJNR Am J Neuroradiol. Normal-pressure hydrocephalus remains a controversial entity with often ambiguous imaging findings. The patient on the left (a), reveals normal involution of the brain characterized by deepening of the sulci and prominence of the gyri together with a prominent ventricular system. Diagnosis of idiopathic normal pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort study, Diagnosing idiopathic normal-pressure hydrocephalus, The differential diagnosis of Alzheimer’s disease. 1970 Aug; 96 (2):347–358. In our patients, functional ambulation performance was determined by using the GaitRite system (CIR Syst… Radiological diagnosis of occult normal-pressure hydrocephalus. Extensive demographics, family history, and medical history are available for all ADNI participants. CA and EI may serve as a screening tool to help the radiologist differentiate patients with NPH from patients without NPH, which would allow for designation of patients for further volumetric assessment. 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. 22. Normal pressure hydrocephalus (NPH) happens when too much fluid builds up in a person’s brain without increasing pressure in their brain tissue. Bradley WG (2015) CSF flow in the brain in the context of normal pressure hydrocephalus. Demonstration of the obtained regions of interest is shown in Figure 2. Differences in the hippocampus across the three groups were significant (F = 28.49; P < .0001). The sensitivity and diagnostic accuracy of these groups overlapped, indicating no statistically significant difference in this subgroup analysis. The British journal of radiology. ADNI data are disseminated by the Laboratory for Neuro Imaging at the University of Southern California. CA was determined by using the methods of Ishii et al (14) as the angle between the medial superior borders of the left and right lateral ventricles (Fig 1). ■ 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. Radiology Cases and Radiology Case Reports. People who have NPH are usually aged over 60. ■ 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. Although prominent aqueductal flow void due to increased CSF velocity across the aqueduct is often seen in patients with NPH - best seen on T2 and PD spin-echo sequences 14 - it is no longer considered a useful sign, as in modern higher field strength MRI machines aqueductal CSF flow void is present in most of the normal subjects. 16. Gait disorders are the initial manifestations; other symptoms appear as the disease progresses (2). Radiology. GM = gray matter, WM = white matter, VNT = ventricular volume, HP = hippocampal volume. 4, © 2021 Radiological Society of North America, For the Alzheimer’s Disease Neuroimaging Initiative, Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure. We excluded participants who did not meet these criteria to ensure high confidence of accurate NPH diagnosis. As the corticospinal tracts to the legs run medially, these tangential shearing forces cause gait disturbance. 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. Many neurodegenerative diseases with overlapping symptoms affect elderly patients, which makes radiologic differentiation difficult (9,10). J Neuropsychiatry Clin Neurosci. 29. The patient improves after repeated lumbar punctures. Each ADNI MR imaging examination had to pass screening for blurring, ghosting, and flow artifacts; image homogeneity; signal-to-noise ratio; susceptibility artifacts; and gray-white cerebrospinal fluid contrast. We classified patients as having improved on the basis of an increase in the functional ambulation performance score, clinician judgement of gait improvement after comparing pre- and postsurgical video clips, and the opinion of the patient or his or her family that a favorable response occurred. 1991;178(2):459-466. Note.—Data are mean ± standard deviation unless otherwise indicated. Aust N Z J Psychiatry. In future studies, we plan to incorporate sulcal morphologic analysis into our predictive model and discriminate between AD, NPH, and comorbid categories. 13. (2009) ISBN:3211855785. Holodny AI, George AE, de Leon MJ, Golomb J, Kalnin AJ, Cooper PR. 1. The challenge is identifying those patients who will benefit from shunting. Sjaastad O, Skalpe IO, Engeset A. Ivkovic M, Liu B, Ahmed F et-al. This study compared the accuracy of traditional measures of NPH, namely CA and EI, with segmentation metrics for diagnosis. A German epidemiologic study found that normal-pressure hydrocephalus had a prevalence of 0.41% (4:982 individuals) in the over-65 age group. The term normal pressure hydrocephalus was based on the finding that all 3 patients reported by Hakim and Adams showed low CSF pressures at lumbar puncture, namely 150, 180, and 160 mm H … 31 years experience Neurosurgery. Flow void of cerebrospinal fluid in idiopathic normal pressure hydrocephalus of the elderly: can it predict outcome after shunting?. Bradley WG, Scalzo D, Queralt J et-al. 2008;29 (1): 192-7. Hurley RA, Bradley WG Jr, Latifi HT, Taber KH. Infection with tick borne Borrelia Burgdorferi (Lyme disease) can without treatment rarely develop into a chronic phase. Notably, there was no significant difference in mean gray matter volumes between NPH and HC groups. It is possible that these patients may fall into the aforementioned comorbid category. A 25-year-old male asked: Is a prominent cistern magma dangerous in any way? A complete listing of ADNI investigators can be found at http://adni.loni.usc.edu/wp-content/uploads/how_to_apply/ADNI_Acknowledgement_List.pdf. 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. There are several limitations to this study that need to be considered when interpreting the data. Dementia: Prominent memory loss and bradyphrenia; forgetfulness, decreased attention, inertia See Clinical Presentationfo… [Idiopathic normal-pressure hydrocephalus. 24. 36. Prominent periventricular hyperintensity consistent with transependymal flow of CSF. Similarly, our study did not address patients with NPH with smaller than average ventricles. Functional and magnetic resonance imaging correlates of corpus callosum in normal pressure hydrocephalus before and after shunting. By using T1-weighted MPRAGE sequences at the midsagittal plane, a reformatted coronal section was generated at the level of the posterior commissure, perpendicular to a plane that intersected the anterior and posterior commissure (Fig 1). 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). Diagnosing idiopathic normal-pressure hydrocephalus. Patients with NPH have variable ventriculomegaly, which may overlap with other populations. Radiology. The regression model that used volumetric predictors of gray matter and white matter was 94.3% accurate. J. Neurol. Hurley RA, Bradley WG, Latifi HT et-al. All statistical analyses were performed by using statistical software (SPSS version 23; IBM, Armonk, NY). Radiology. 26. To assess the diagnostic performance of the callosal angle (CA) and Evans index (EI) measures and to determine their role versus automated volumetric methods in clinical radiology. A clinical entity consist of the triad of 1) gait disturbance, 2) dementia, and 3) incontinence with normal cerebrospinal fluid (CSF) pressures and radiographic findings of Ventriculomegaly out of proportion to atrophy. Cerebrospinal fluid dynamics and shunt responsiveness in patients with normal-pressure hydrocephalus. 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 current larger patient sample confirms our previous work (11) with highly accurate three-way differential diagnosis that uses the volumetric model. MRI is the best modality to image anatomical changes and can further support the diagnosis with CSF flow studies and magnetic resonance spectroscopy. Normal pressure hydrocephalus (NPH) is remarkable for two reasons: 1) it is one of the few treatable causes of dementia, and 2) neuroradiologists are usually involved in making the diagnosis. Marked cerebrospinal fluid void: indicator of successful shunt in patients with suspected normal-pressure hydrocephalus. There was no difference in mean white matter volume between groups (F = 1.5; P = .239). AJNR Am J Neuroradiol. Note.—Data in parentheses are numerator and denominator. AJNR. 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. Note.—Data in parentheses are numerator and denominator. This process took approximately 8 hours per case. 24. 23. 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. Predicting the results of cerebrospinal fluid shunting. 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. For example, when neuroradiologists were asked to independently evaluate T1-weighted brain magnetic resonance (MR) images as either of patients with NPH, patients with AD, or elderly healthy control (HC) volunteers, the diagnostic accuracy was 68%–78%, and the agreement was only fair (intraclass correlation coefficient [ICC], 0.51; 95% confidence interval: 0.34, 0.66) (11). 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. For CA, a cutoff of 100° was 88.7% (282 318) accurate for identification of patients with NPH, and measurements below the cutoff suggested NPH. Al-Zain FT, Rademacher G, Lemcke J et-al. 89 (5): 742-7. The combination of ventriculomegaly, Sylvian fissure widening, and crowding at the vertex has been termed disproportionately enlarged subarachnoid space hydrocephalus (DESH), reflecting disproportionality between the superior and inferior CSF spaces 1,23,27. A formula (Excel; Microsoft, Redmond, Wash) to calculate probability of NPH was directly derived from the regression model. (2009) Journal of the neurological sciences. The Akaike information criterion was used as a measure of the relative quality of a model that included a penalty for increasing the number of free variables to discourage overfitting. Multivariable logistic regression models were used to predict NPH (27). We excluded participants who did not demonstrate this positive response to shunt to minimize confounding of comorbid neurodegenerative disorders. Diagnosis of Normal-Pressure Hydrocephalus: Use of Traditional Measures in the Era of Volumetric MR Imaging Radiology . Unfortunately, the diagnostic sensitivity and specificity of EI and CA are controversial (10,12,17–19), and therefore their role has remained limited. However, they did not attempt a three-way discrimination between patients with AD, patients with NPH, and nondemented elderly control patients. Enter your email address below and we will send you the reset instructions. 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, … Most clinicians will assume that one is referring to idiopathic normal pressure hydrocephalus if no qualifier is used. It is thought to have been initially described by Colombian neurosurgeon Salomón Hakim and R D Adams in 1965, although it may actually have been described earlier under a different name by McHugh 4,6,7. 236 patients studied, • 47 normal elderly patients • 115 patients with cognitive impairment including 46 with Alzheimer’s disease • 31 patients in whom NPH was suspected but ultimately excluded, • 43 patients with a final clinical diagnosis of NPH. VNT = ventricular volume. 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. Table 3 demonstrates the performance of multinomial regression models to distinguish patients with NPH versus AD versus HC volunteers (ie, for simultaneous diagnosis of one of the three outcomes). 1996;198(2):523-529. (1998) Journal of neurosurgery. An online tool (NPH Calculator; http://cai2r.net/sites/default/files/software/NPH_calculator.xlsx) derived from this multivariate regression model was created to quantify probability of NPH on the basis of input CA and EI values. Shearing forces are exerted on the periventricular white matter as the ventricles enlarge. MRI features are in favor of normal pressure hydrocephalus "NPH" and supported by patient aqueduct showing accentuated CSF flow void signal within its lumen. Because this disorder is potentially treatable, research focused on improving diagnosis through noninvasive imaging techniques (8,9). Preoperative prognostic value of MRI findings in 108 patients with idiopathic normal pressure hydrocephalus.

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