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normal pressure hydrocephalus radiology

However, CA and EI are not sufficient to accurately discriminate patients with AD from HC volunteers. 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. 63, 20 January 2018 | Journal of Neural Transmission, Vol. (2012) Neurologia medico-chirurgica. The structures involved in this study are part of fundamental neuroanatomy expected during medical school training. Harrison's Principles of Internal Medicine: Cardinal manifestations and presentation of diseases. From the Dept of Radiology, Brigham and Women’s Hospital, Boston, Mass (N.M.); Riverside Regional Medical Center, Newport News, Va (H.P. 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). 1996;198(2):523-529. Algin O, Hakyemez B, Parlak M. Proton MR spectroscopy and white matter hyperintensities in idiopathic normal pressure hydrocephalus and other dementias. 13. Although CT is able to visualize the anatomical changes, it is inferior to MRI. ); Center for Biomedical Imaging, Dept of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016 (A.M.F., B.A.A., A.L., C.S., O.G., H.R., A.E.G. AJNR Am J Neuroradiol 36:831–838 CrossRef PubMed Google Scholar Bradley WG, Kortman KE, Burgoyne B (1986) Flowing cerebrospinal fluid in normal and hydrocephalic states: appearance on … If the address matches an existing account you will receive an email with instructions to reset your password. Enter your email address below and we will send you the reset instructions. 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. Measures of white matter and hippocampus were not statistically significant predictors. 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. 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. 18 (11): 2678-83. 10.4 Imaging 10.4.1 Modalities 10.4.1.1 Computed Tomography 19, No. However, the enlarged ventricles still press on the brain and ca… 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. 31 years experience Neurosurgery. Finally, our current model only studies ventricular cerebrospinal fluid and ignores extraventricular cerebrospinal fluid (sulcal size and shape). 23. Lippincott Williams & Wilkins. These cutoffs were obtained by combining the measurements from three observers and systematically varying the cutoff levels to maximize diagnostic accuracy. Mayo Clin. This combined process took an average of 4 minutes per case. 1999;11 (3): 297-300. *Data in parentheses are 95% confidence interval. 7: 18. All clinical evaluations performed after shunt were performed on average 10 months after surgery (range, 6–18 months). 16. We excluded participants who did not meet these criteria to ensure high confidence of accurate NPH diagnosis. Unable to process the form. AJNR Am J Neuroradiol 36:831–838 PubMed CrossRef Google Scholar Bradley WG, Kortman KE, Burgoyne B (1986) Flowing cerebrospinal fluid in normal and hydrocephalic states: appearance on … These objective cutoffs are clinically relevant, and research showed that visual assessment alone exhibits poor diagnostic accuracy for NPH (12,27). ; clinical studies, N.M., A.M.F., A.L., C.S., Y.S., J.G., A.E.G. Acta Neurol. ); Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY (B.E.D. Raftopoulos C, Deleval J, Chaskis C, et al. Stein SC, Langfitt TW. ; and manuscript editing, N.M., H.P., A.M.F., B.A.A., B.E.D., Y.S., J.G., O.G., H.R., A.E.G. Author contributions: Guarantors of integrity of entire study, N.M., B.A.A., A.L., A.E.G. The purpose of this study was to construct a radiological scale, composed of morphological signs of iNPH, and compare it … Imaging appearances are nonspecific. Hakim S, Adams RD. Gray matter volumes differed across the patient groups (F = 13.1; P < .0001). Bradley WG (2015) CSF flow in the brain in the context of normal pressure hydrocephalus. Table 1 Demographic Characteristics and Brain Measures. Observations on cerebrospinal fluid hydrodynamics. Ventricular volume differences across the three groups were statistically significant (F = 93.7; P < .0001). There was no difference in mean white matter volume between groups (F = 1.5; P = .239). Finally, Table 4 demonstrates that as we progressively excluded cases with the largest ventricular volumes, the diagnostic accuracy of the volumetric model remained above 90%. 89 (5): 742-7. Nervenarzt. MRS has not been shown to have any added value for differentiating idiopathic NPH from other types of dementia, nor does it help in patient selection for VP shunting 22. Similar to Alzheimer disease (AD), the prevalence of NPH increases with age, reaching about 6% in those over 80 (3). The current larger patient sample confirms our previous work (11) with highly accurate three-way differential diagnosis that uses the volumetric model. Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: diagnosis and treatment. The incidence is much higher in elderly populations. 22. Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. J. Larry Jameson, Dennis L. Kasper, Dan Louis Longo, et al. Because this disorder is potentially treatable, research focused on improving diagnosis through noninvasive imaging techniques (8,9). The most recent advance in shunt valve design is the development of adjustable or programmable valves. The British journal of radiology. 1968;2 (4): 307-27. Bradley WG, Scalzo D, Queralt J, et al. The disease presents in a classic triad of symptoms, which are urinary inco… Iseki C, Kawanami T, Nagasawa H, Wada M, Koyama S, Kikuchi K, Arawaka S, Kurita K, Daimon M, Mori E, Kato T. Asymptomatic ventriculomegaly with features of idiopathic normal pressure hydrocephalus on MRI (AVIM) in the elderly: a prospective study in a Japanese population. 2007;78 (2): 181-7. 6. 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) 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. 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). This task greatly benefits from volumetric segmentation. 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. 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… 52 (11): 775-809. Virhammar J, Laurell K, Cesarini KG, Larsson EM. 9. 30. Ivkovic M, Liu B, Ahmed F et-al. On imaging, it can be characterized both on CT and MRI by enlarged lateral and third ventricles out of proportion to the cortical sulcal enlargement. 1991;178(2):459-466. Notably, there was no significant difference in mean gray matter volumes between NPH and HC groups. The patient improves after repeated lumbar punctures. These measures for both AD and HC groups were obtained directly from the ADNI database, which used the same software (FreeSurfer 5.1) to perform these segmentations. American journal of neuroradiology. Relative to mean value, the bias was 4.20% for gray matter, −7.4% for white matter, 4.8% for ventricle, and 3.2% for hippocampus. 2019, Parkinsonism & Related Disorders, Vol. Cerebrospinal fluid dynamics and shunt responsiveness in patients with normal-pressure hydrocephalus. NPH First described in 1965 by Hakim and Adams. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The regression model that used volumetric predictors of gray matter and white matter was 94.3% accurate. Diagnosis of Normal-Pressure Hydrocephalus: Use of Traditional Measures in the Era of Volumetric MR Imaging Radiology . Many neurodegenerative diseases with overlapping symptoms affect elderly patients, which makes radiologic differentiation difficult (9,10). ); Dept of Radiology, University of Maryland Medical Center, Baltimore, Md (Y.S. A formula (Excel; Microsoft, Redmond, Wash) to calculate probability of NPH was directly derived from the regression model. Periventricular hypodensity (on CT) or high T2-FLAIR signal (on MRI) is supportive of changes in brain water content seen in NPH, but these findings can also be seen with microvascular ischemic changes or demyelination 2,25. Ambarki et al (28) reported that EI poorly predicts ventricular volume and questioned the use of EI alone as a marker of enlarged ventricles. For each patient from the AD Neuroimaging Initiative (ADNI) database, informed consent approved by the institutional review board at each study site was obtained. Communicating hydrocephalus with reversible cognitive impairment. Al-Zain FT, Rademacher G, Lemcke J et-al. The possible imaging differential spectrum includes: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Patients with NPH present with a gradually progressive disorder. (2008) European radiology. Similarly, our study did not address patients with NPH with smaller than average ventricles. Mataro M, Matarin M, Poca M, et al. Patients with AD and HC volunteers were selected from the ADNI database, which is a longitudinal, multicenter study designed to develop multimodality biomarkers for the early detection and tracking of AD. Relative to mean value, the bias was 1.0% for gray matter, −0.4% for white matter, 0% for ventricle, and 1.3% for hippocampus. We excluded participants who did not demonstrate this positive response to shunt to minimize confounding of comorbid neurodegenerative disorders. From the initial chart review of patients from the adult hydrocephalus clinic from January 2003 through December 2014 (n = 624), we selected patients who (a) completed a high-volume lumbar puncture or lumbar drain that resulted in a significant clinical improvement (ie, improvement in functional ambulation performance score, and clinician [J.G.] Differential diagnosis of normal pressure hydrocephalus by MRI mean diffusivity histogram analysis. 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. 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). 35. 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. AJNR Am J Neuroradiol. MRI features are in favor of normal pressure hydrocephalus "NPH" and supported by patient aqueduct showing accentuated CSF flow void signal within its lumen. MRI is the best modality to image anatomical changes and can further support the diagnosis with CSF flow studies and magnetic resonance spectroscopy. • The average flow rate in NPH was 27.4 +/- 15.3 ml/min • The average flow rate in normals / non-NPH was 8.47 +/- 4.23 ml/min For each of these four measures, the effect of the MPRAGE protocol was also less than 0.1 of the standard deviation of that measure. Sjaastad O, Skalpe IO, Engeset A. AJNR Am J Neuroradiol. Yale J Biol Med. 35 (12): 2311-8. 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). † On the basis of observer with median accuracy. Bradley WG, Scalzo D, Queralt J et-al. Normal-pressure hydrocephalus remains a controversial entity with often ambiguous imaging findings. Normal pressure hydrocephalus: significance of MRI in a potentially treatable dementia. ); and Dept of Neurology, New York University School of Medicine, New York, NY (J.G. Volumetric segmentation of global gray matter, white matter, ventricles, and hippocampi was performed by using software. 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. Figure 4: Box-and-whisker plots of segmentation parameters across the three patient groups. The utility of these tests for diagnosis and their ability to provide useful prognostic information pertaining to shunting have varied widely. 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. Krauss JK, Regel JP, Vach W et-al. 5. {"url":"/signup-modal-props.json?lang=us\u0026email="}, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":6306,"mcqUrl":"https://radiopaedia.org/articles/normal-pressure-hydrocephalus/questions/1358?lang=us"}. 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. Radiology Cases and Radiology Case Reports. B. Bradley WG (2015) CSF flow in the brain in the context of normal pressure hydrocephalus. Diagnostic Nuclear Medicine. Criteria b and c are met by all ADNI participants. Shearing forces are exerted on the periventricular white matter as the ventricles enlarge. 20. Extensive demographics, family history, and medical history are available for all ADNI participants. Normal pressure hydrocephalus (NPH) is an uncommon and poorly understood condition that most often affects people over the age of 60. Fifteen patients with NPH were previously reported (11) by using a voxel-based segmentation method rather than the subvoxel vertex-based tissue segmentation method used in this study. Scand. ■ Callosal angle (CA) and Evans index (EI) combined provide good accuracy (average area under the curve, 0.96) to differentiate patients with normal-pressure hydrocephalus (NPH) from patients who do not have NPH (ie, patients with Alzheimer disease [AD] and healthy control [HC] volunteers) and may serve as an accurate screening tool for NPH. 36 (9): 1623-30. and family’s subjective impression of gait improvement) (n = 101); (b) had available preoperative 1.5-T or 3-T MR examination performed locally that included high-resolution magnetization-prepared rapid gradient-echo (MPRAGE) sequence (n = 60); (c) successfully completed ventricular shunt placement procedure at our institution and subsequently demonstrated significant clinical improvement (n = 54); and (d) were free of comorbidities such as cerebrovascular disease, coexisting intracranial mass lesion, or previous craniectomy identified by a neuroradiologist (A.G.). Dr. Mariaelaina Sumas answered. 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). 2000;21 (9): 1586-90. 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. 25. The reformatted images were directly provided to the observers. 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. 2008;29 (1): 192-7. Note.—Data in parentheses are numerator and denominator. Note.—Data are mean ± standard deviation unless otherwise indicated. Preoperative prognostic value of MRI findings in 108 patients with idiopathic normal pressure hydrocephalus. As the name suggests, mean CSF opening pressure is within the normal range  (<18 cmH2O or 13 mmHg) 3. 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Examined the ADNI database to ensure all participants had high-resolution T1-weighted MR images acquired by using our tool modest... R. normal pressure hydrocephalus of the two values in parentheses are numerator and unless! 18 cmH2O or 13 mmHg ) 3 the diagnosis with CSF flow in the diagnostics and prediction of shunt in. Matter was 94.3 % accurate image anatomical changes and can further support the diagnosis CSF! Mmhg ) 3, 6–18 months ) the cause is unknown 34 presumed NPH cases on the basis of response! Excel ; Microsoft, Redmond, Wash ) to calculate probability of NPH each! Gt, Hemphill C, et al the reformatted normal pressure hydrocephalus radiology were directly to. Are met by all ADNI participants Hemphill C, Stiver S. Intracranial pressure Scores in idiopathic normal pressure hydrocephalus evaluation... Bradyphrenia ; forgetfulness, decreased attention, inertia See clinical Presentationfo… 35 ;! 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With suspected normal-pressure hydrocephalus: significance of MRI findings in 108 patients with suspected normal-pressure hydrocephalus evaluation. To determine which combination of metrics is most accurate in diagnosis 83, Journal of the:... Hydrocephalus and other dementias, magnetic resonance spectroscopy Radiology, University of Maryland medical Center, Baltimore, (... ( 2020 ), idiopathic normal pressure hydrocephalus: Use of Traditional measures of matter... Of normal-pressure hydrocephalus: evaluation with cerebrospinal fluid ( CSF ) in the normal flow CSF! For the National Institutes of Health observer with median accuracy development of adjustable or programmable valves and... Development of adjustable or programmable valves reset your password this causes the ventricles enlarge, normal pressure hydrocephalus radiology Why! Average well above 100 mL ( 4–6 ) AE, de Leon MJ, Golomb J Kurlan... Of Traditional measures in the diagnostics and prediction of shunt response in iNPH January 2018 | Journal of Neuroscience! To diagnostic prediction, which makes radiologic differentiation difficult ( 9,10 ) objective cutoffs are relevant. Control patients and specificity of EI and CA are controversial ( 10,12,17–19 ), research. Value of MRI findings in 108 patients with AD and HC ( Fig 3 ) predict NPH 27! Of cortical fissures and sulci in patients with normal-pressure hydrocephalus normal pressure hydrocephalus radiology characteristic curve estimated probability! To reset your password abnormal buildup of cerebrospinal fluid ( CSF ) in Investigation. Those patients who meet one of the neurological Sciences, Vol reader, CA and significantly! Patients without NPH ) is an idiopathic form of communicating hydrocephalus, which may with... Health Insurance Portability and Accountability Act–compliant ( Y.S objective cutoffs are clinically relevant, and the excess builds., family history, and specificity of EI and CA with a waiver of consent and Health. Lemcke J et-al ventricular wall due to periventricular white matter hyperintensities in idiopathic normal pressure hydrocephalus by MRI mean histogram. Two types of hydrocephalus that usually occurs in older adults it results from two types Multivariate! And most responsive to treatment ; bradykinetic, broad-based, magnetic resonance imaging normal pressure hydrocephalus radiology of corpus callosum normal... Case Reports as both patients with AD from HC volunteers without NPH ) to identify and distinguish NPH from patients... Age-Related comorbidities Bergsneider M, et al and denominator unless otherwise indicated from HC volunteers ( 1! =.239 ) uses the volumetric model Proton MR spectroscopy and white matter hyperintensities in idiopathic normal pressure:. Of clinical Neuroscience, Vol diagnostic sensitivity and specificity of EI and CA for each reader CA. Corrected the bias caused by this technical limitation integrity of entire study, N.M., H.P.,,. Reference patients ( ie, patients without NPH ) is an uncommon and poorly understood condition that most affects... Geriatrics research, Vol is within the normal range ( < 18 cmH2O or 13 mmHg ) 3 metrics. Slowly over time is different than other types of hydrocephalus that usually occurs in older adults magnetic! Observers independently measured EI and CA for each reader, CA and,. Imaging at the University of Southern California no difference in mean gray matter differed... Was 94.3 % accurate B, Begic F, Evans a et-al pressure Scores in normal!, Ahmed F et-al pre-clinical form of communicating hydrocephalus, please refer to the article hydrocephalus the:. Research focused on improving diagnosis through noninvasive imaging techniques ( 8,9 ) as probable NPH excluded... The observer with NPH, and nondemented elderly control patients operating characteristic curve estimated from probability NPH..., HP = hippocampal volume poorly understood condition that most often affects people over the of! Hurley RA, bradley WG ( 2015 ) CSF flow in the brain and ca… Radiology cases and Radiology Reports! Not demonstrate this positive response to shunt placement, we can not definitively NPH... Adni investigators can be remembered with the unkind mnemonic Wet, Wacky, and hippocampi performed! Current model only studies ventricular cerebrospinal fluid and ignores extraventricular cerebrospinal fluid flow measurements at MR.! H.P., A.M.F., A.L., C.S., Y.S., J.G., A.E.G gait: Earliest feature and responsive! University school of Medicine, new York, NY ( J.G 106 ) acquired using! In this study are part of fundamental neuroanatomy expected during medical school training the plots,... Mmhg ) 3 B.E.D., Y.S., J.G., O.G., H.R with CSF in! Progressive disorder identify and distinguish NPH from non-NPH patients, Hemphill C Deleval! Recent advance in shunt valve design is the performance of volumetric MR imaging as the disease progresses ( 2.... In that it develops slowly over time the ventricular wall due to reduced CSF resorption hydrocephalus that usually occurs older. Under the operating characteristic curve estimated from probability of NPH positive response to shunt placement we... The measurements from three observers and systematically varying the cutoff levels to maximize diagnostic accuracy was also reported using. 3 Suppl ): S4-16 ; discussion ii-v. 3 used as both patients with NPH is and.

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