Cerebral perfusion measured by dynamic susceptibility contrast MRI is reduced in patients with idiopathic normal pressure hydrocephalus

Ziegelitz, Doerthe; Starck, Göran; Kristiansen, D; Jakobsson, Martin; Hultenmo, Maria; Mikkelsen, Irene Klærke; Hellström, Per; Tullberg, Mats; Wikkelsø, Carsten

doi:10.1002/jmri.24292

Cited by 52 publications

(77 citation statements)

References 46 publications

(72 reference statements)

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“…Our findings support the view that clinical improvement in iNPH after shunt surgery is mainly attributed to increased metabolism and extracellular fluid flow in predominantly periventricu-lar regions of the brain and not morphologic changes as measured on structural MR imaging. Support for this notion comes from imaging studies of perfusion [32][33][34][35] and diffusion 29,36 and CSF biomarker studies 37,38 as well as a recent study indicating reduced glymphatic clearance in patients with iNPH. 39 The results reported here imply that morphologic MR imaging markers only correlate with symptom severity in a limited way and cannot predict postoperative outcome.…”

Section: Discussionmentioning

confidence: 99%

Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery

Agerskov

Wallin

Hellström

et al. 2018

AJNR Am J Neuroradiol

101

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BACKGROUND AND PURPOSE: Several studies have evaluated the use of MR imaging markers for the prediction of outcome after shunt surgery in idiopathic normal pressure hydrocephalus with conflicting results. Our aim was to investigate the predictive value of a number of earlier proposed morphologic MR imaging markers in a large group of patients with idiopathic normal pressure hydrocephalus. MATERIALS AND METHODS: One hundred sixty-eight patients (mean age, 70 Ϯ 9.3 years) with idiopathic normal pressure hydrocephalus, subjected to standardized quantification of clinical symptoms before and after shunt surgery, were included in the study. Outcome was calculated using a composite score. Preoperative T1, FLAIR, and flow-sensitive images were analyzed regarding the presence of 13 different morphologic MR imaging markers. RESULTS: The median Evans index was 0.41 (interquartile range, 0.37-0.44). All patients had an aqueductal flow void sign present and white matter hyperintensities. The median callosal angle was 68.8°(interquartile range, 57.7°-80.8°). Dilated Sylvian fissures were found in 69%; focally dilated sulci, in 25%; and widening of the interhemispheric fissure, in 55%. Obliteration of the sulci at the convexity was found in 36%, and 36% of patients were characterized as having disproportionately enlarged subarachnoid space hydrocephalus. Sixty-eight percent of patients improved after surgery. None of the investigated MR imaging markers were significant predictors of improvement after shunt surgery. CONCLUSIONS: Disproportionately enlarged subarachnoid space hydrocephalus, a small callosal angle, and the other MR imaging markers evaluated in this study should not be used to exclude patients from shunt surgery. These markers, though they may be indicative of idiopathic normal pressure hydrocephalus, do not seem to be a part of the mechanisms connected to the reversibility of the syndrome. ABBREVIATIONS: DESH ϭ disproportionately enlarged subarachnoid space hydrocephalus; EI ϭ Evans index; iNPH ϭ idiopathic normal pressure hydrocephalus

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Section: Discussionmentioning

confidence: 99%

Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery

Agerskov

Wallin

Hellström

et al. 2018

AJNR Am J Neuroradiol

101

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“…Ziegelitz et al illustrated a significant reduction in cerebral blood flow, not only in the paraventricular area but also in the basal medial frontal cortex and deep grey matter in NPH patients compared to healthy controls. Also, they reported a positive correlation between decreased cerebral blood flow and severity of clinical symptoms [31]. Bugalho et al suggested that predominant frontal lobe white matter lesions observed by T2-weighted MRI may be a cause of irreversible symptoms in NPH [32].…”

Section: Methodsmentioning

confidence: 99%

MR Elastography Demonstrates Increased Brain Stiffness in Normal Pressure Hydrocephalus

Fattahi

Arani

Perry

et al. 2015

AJNR Am J Neuroradiol

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Introduction Normal pressure hydrocephalus (NPH) is a reversible neurologic disorder characterized by a triad of cognitive impairment, gait abnormality and urinary incontinence that is commonly treated with ventriculoperitoneal shunt placement. However, there are multiple overlapping symptoms which often make it difficult to differentiate NPH from other types of dementia and improved diagnostic techniques would help patient management. MR elastography (MRE) is a novel diagnostic tool that could potentially identify patients with NPH. The purpose of this study was to assess brain stiffness changes in NPH patients compared with age- and sex-matched cognitively normal individuals. Methods MRE was performed on 10 NPH patients and 21 age- and sex-matched volunteers with no known neurologic disorders. Image acquisition was conducted on a 3T MRI scanner. Shear waves with 60Hz vibration frequency were transmitted into the brain by a pillow-like passive driver. A novel postprocessing technique resistant to noise and edge artifacts was implemented to determine regional brain stiffness. The Wilcoxon rank sum test and linear regression were used for statistical analysis. Results A significant increase in stiffness was observed in the cerebrum (p = 0.001), occipital lobe (p = 0.0002), parietal lobe (p= 0.001), and the temporal lobe (p = 0.02) in the NPH group compared with normal controls. However, no significant difference was noted in other regions of the brain including the frontal lobe (p = 0.07), deep gray and white matter (p = 0.43), or the cerebellum (p = 0.20). Conclusion This study demonstrates increased brain stiffness in NPH patients compared to age- and sex-matched normal controls which motivates future studies investigating the use of MRE for NPH diagnosis and efficacy of shunt therapy.

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“…27 Previous studies have shown that cerebral blood flow increases after CSF removal, i.e., following lumbar puncture or shunt surgery. [28][29][30] Furthermore, postoperative reduction of WMLs in iNPH correlates with clinical improvement. 31,32 It is thus possible that clinical improvement after shunt surgery is attributable to reversal of white matter changes.…”

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confidence: 92%

Vascular factors in suspected normal pressure hydrocephalus

et al. 2016

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Objective: We examined clinical and imaging findings of suspected idiopathic normal pressure hydrocephalus (iNPH) in relation to vascular risk factors and white matter lesions (WMLs), using a nested case-control design in a representative, population-based sample.Methods: From a population-based sample, 1,235 persons aged 70 years or older were examined with CT of the brain between 1986 and 2000. We identified 55 persons with hydrocephalic ventricular enlargement, i.e., radiologic findings consistent with iNPH. Among these, 26 had clinical signs that fulfilled international guideline criteria for probable iNPH. These cases were labeled suspected iNPH. Each case was matched to 5 controls from the same sample, based on age, sex, and study cohort. Data on risk factors were obtained from clinical examinations and the Swedish Hospital Discharge Register. History of hypertension, diabetes mellitus (DM), smoking, overweight, history of coronary artery disease, stroke/TIA, and WMLs on CT were examined. Risk factors associated with iNPH with a p value ,0.1 in x 2 tests were included in conditional logistic regression models. Idiopathic normal pressure hydrocephalus (iNPH) is probably more common than previously supposed. We have recently reported that 5.9% of persons older than 80 years have this disorder. 1 Treatment with shunt surgery improves symptoms in more than 80% of patients. 2 Despite this, iNPH is underdiagnosed and undertreated.1,3 Furthermore, little is known about the underlying disease mechanisms. It is important to learn more about risk factors for the disease in order to understand pathophysiologic mechanisms and suggest preventive measures. Vascular risk factors, such as hypertension, diabetes, and ischemic heart disease, have previously been associated with iNPH in hospital-based, case-control studies.4-9 Also, cerebral white matter lesions (WMLs), which are associated with small vessel disease and white matter ischemia, 10 are common in iNPH. 11,12 It has therefore been suggested that vascular mechanisms may be related to the development of iNPH. However, previous studies on risk factors have not been population-based. Furthermore, there are no previous epidemiologic investigations regarding WMLs in iNPH.

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Cerebral perfusion measured by dynamic susceptibility contrast MRI is reduced in patients with idiopathic normal pressure hydrocephalus

Abstract: DSC MRI perfusion is a potentially useful diagnostic tool in iNPH and perfusion based criteria might be possible predictors of shunt response.

Cited by 52 publications

References 46 publications

Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery

Absence of Disproportionately Enlarged Subarachnoid Space Hydrocephalus, a Sharp Callosal Angle, or Other Morphologic MRI Markers Should Not Be Used to Exclude Patients with Idiopathic Normal Pressure Hydrocephalus from Shunt Surgery

MR Elastography Demonstrates Increased Brain Stiffness in Normal Pressure Hydrocephalus

Vascular factors in suspected normal pressure hydrocephalus

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