Updated physiology and pathophysiology of CSF circulation—the pulsatile vector theory

Preuß, Matthias; Hoffmann, Karl‐Titus; Reiss-Zimmermann, M; Hirsch, Wolfgang; Merkenschlager, Andreas; Meixensberger, Jürgen; Dengl, Markus

doi:10.1007/s00381-013-2219-0

Cited by 51 publications

(44 citation statements)

References 74 publications

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“…[8][9][10] In clinical practice, imaging is often used to work-up hydrocephalus in search of obstructing lesions or the presence of ventriculomegaly. However, ventricular size, a frequently used imaging feature, does not always correlate with underlying CSF pressures or resorptive capacity for CSF [11][12][13][14][15][16] and, therefore, may not reliably identify compensated hydrocephalus without signs of raised intracranial pressure (ICP) and progressive hydrocephalus with raised ICP.…”

mentioning

confidence: 99%

Hydrocephalus Decreases Arterial Spin-Labeled Cerebral Perfusion

Yeom¹,

Lober²,

Alexander³

et al. 2014

AJNR Am J Neuroradiol

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mentioning

confidence: 99%

Hydrocephalus Decreases Arterial Spin-Labeled Cerebral Perfusion

Yeom¹,

Lober²,

Alexander³

et al. 2014

AJNR Am J Neuroradiol

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“…These results support the hydrocephalus theory of a multifaceted condition of hydraulic, mechanical, and metabolic disorders as well as counter-regulatory mechanisms that may secondarily lead to impaired neuronal function and damage. 1,12,15,18 …”

Section: Discussionmentioning

confidence: 99%

“…4,7,8,10,15,19,20,23 In all patients, clinical evaluation prompted the indication for further invasive diagnostic examinations. Patients with a history of severe traumatic brain injury, previous CNS tumor surgery, cerebral infection, or hemorrhage were not included to avoid secondary normal pressure hydrocephalus.…”

mentioning

confidence: 99%

Idiopathic normal pressure hydrocephalus: diagnostic and predictive value of clinical testing, lumbar drainage, and CSF dynamics

Mahr¹,

Dengl²,

Nestler³

et al. 2016

JNS

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591CliNiCal artiCle J Neurosurg 125:591-597, 2016 I dIopathIc normal pressure hydrocephalus (iNPH) has been a challenging entity for the past 50 years, since its first description by Hakim.21 Despite extensive research, its pathophysiological basis and pathogenesis remain matters of ongoing debate. Due to the uncertainty in diagnostic measures, several algorithms, diagnostic tools, and scoring systems have been proposed. A recent multicenter trial based the decision for surgical therapy on clinical signs and symptoms only, dividing cases into questionable and typical iNPH.23 Given the multitude of noninvasive and invasive measures to select symptomatic patients for hydrocephalus therapy, a prospective analysis of diagnostic and predictive parameters and their individual contributions within the diagnostic algorithm was warranted. Patients and MethodsPatients with suspicious clinical and MRI signs for iNPH were examined in a prospective study. Local ethics committee approval was obtained.abbreviatioNs AMP Q = ICP amplitude quotient; ELD = external lumbar drainage; ETV = endoscopic third ventriculostomy; ICP = intracranial pressure; iNPH = idiopathic normal pressure hydrocephalus; LIFT = lumbar infusion test; MMSE = Mini-Mental State Examination; mRS = modified Rankin Scale; OVM = overnight ICP monitoring; RAP = correlation coefficient between pulse amplitude and ICP; ROC = receiver operating characteristic; ROut = resistance to outflow of CSF; SLHS = Stein and Langfitt Hydrocephalus Score; VP = ventriculoperitoneal; ∆Kiefer = change in Kiefer score. obJeCtive The aim of the study was to analyze the diagnostic and predictive values of clinical tests, CSF dynamics, and intracranial pulsatility tests, compared with external lumbar drainage (ELD), for shunt response in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods Sixty-eight consecutive patients with suspected iNPH were prospectively evaluated. Preoperative assessment included clinical tests, overnight intracranial pressure (ICP) monitoring, lumbar infusion test (LIFT), and ELD for 24-72 hours. Simple and multiple linear regression analyses were conducted to identify predictive parameters concerning the outcome after shunt therapy. results Positive response to ELD correctly predicted improvement after CSF diversion in 87.9% of the patients. A Mini-Mental State Examination (MMSE) value below 21 was associated with nonresponse after shunt insertion (specificity 93%, sensitivity 67%). Resistance to outflow of CSF (ROut) > 12 mm Hg/ml/min was false negative in 21% of patients. Intracranial pulsatility parameters yielded different results in various parameters (correlation coefficient between pulse amplitude and ICP, slow wave amplitude, and mean ICP) but did not correlate to outcome. In multiple linear regression analysis, a calculation of presurgical MMSE versus the value after ELD, ROut, and ICP amplitude quotient during LIFT was significantly associated with outcome (p = 0.04). CoNClusioNs Despite a multitude of invasive tests, presurgical cl...

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“…This dysfunction might be generated either by a direct pressure effect or by an indirect effect of microvascular pressure-mediated ischemia due to an enlarged third ventricle [32]. The functional importance of the post-erolateral and centromedian thalamus as relay stations for vestibular input to the cortex (with a right hemispheric predominance in right handers) has been shown in several animal and human studies [24,27,29,[33][34][35].…”

Section: Mechanisms Underlying Postural Instability In the Pitch Planmentioning

confidence: 99%

Subjective body vertical: a promising diagnostic tool in idiopathic normal pressure hydrocephalus?

et al. 2016

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Postural instability is a frequent symptom of patients with idiopathic normal pressure hydrocephalus (iNPH), and might be due to the misperception of body verticality. The objective of this study was to assess the usefulness of the subjective body vertical (SBV) as a potential tool for diagnosing iNPH. Twenty patients with iNPH underwent tests of SBV in the pitch and roll planes before and after cerebrospinal fluid (CSF) drainage. Ten patients with other central gait disorders served as controls and also underwent tests for SBV. Before CSF drainage, patients with iNPH showed an impaired verticality perception in the pitch plane with a significant backward deviation of the SBV as compared to the control group (iNPH: mean ± SD -3.7 ± 3.6°; control group: -0.8 ± 2.2°; t value = -2.30, p t-test = 0.03). After CSF drainage, the SBV of the iNPH patients normalized for the pitch plane (-0.9 ± 1.9°). There was a correlation between the backward deviation of the SBV and the ventricular enlargement of the frontal horns (Evan's index; r = -0.52; p Pearson = 0.02). An even stronger correlation was found with the enlargement of the third ventricle (Thalamus index; r = -0.64; p Pearson = 0.002). The new and clinically relevant finding of this study is that verticality perception of patients with iNPH is primarily impaired the pitch plane, and it improves after CSF drainage. This disturbance in pitch might be due to a bilateral central vestibular dysfunction of the thalamus. Determination of the SBV in pitch promises to increase diagnostic accuracy in the cases of suspected iNPH.

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Updated physiology and pathophysiology of CSF circulation—the pulsatile vector theory

Cited by 51 publications

References 74 publications

Hydrocephalus Decreases Arterial Spin-Labeled Cerebral Perfusion

Hydrocephalus Decreases Arterial Spin-Labeled Cerebral Perfusion

Idiopathic normal pressure hydrocephalus: diagnostic and predictive value of clinical testing, lumbar drainage, and CSF dynamics

Subjective body vertical: a promising diagnostic tool in idiopathic normal pressure hydrocephalus?

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