Correlation Between Lumbo-Ventricular Perfusion and MRI-CSF Flow Studies in Idiopathic Normal Pressure Hydrocephalus

doi:10.1016/S0090-3019(97)00032-3

Surgical Neurology

Volume 49, Issue 1, January 1998, Pages 14-20

https://doi.org/10.1016/S0090-3019(97)00032-3 Get rights and content

Abstract

Background

After the initial description of normal pressure hydrocephalus (NPH) and its clinical triad, there has been a continuous interest from clinicians and researchers to set different diagnostic criteria that would make the selection of candidates for shunt surgery easier and more precise.

MethodS

A preliminary group of 12 patients was given a diagnosis of idiopathic normal pressure hydrocephalus by clinical and radiologic criteria. Each patient underwent two different tests: a magnetic resonance imaging-cerebrospinal fluid (MRI-CSF) flow study and a lumbo-ventricular perfusion test. The purpose was to compare the correlation of the results obtained with these tests and the clinical results obtained after CSF diversion. Eleven patients were given shunts and one was managed with lumbar punctures.

Results

One year after treatment, 10 of the 12 patients had improved with good results. The MRI-CSF flow studies were reliable in six patients; there were five false negatives and one false positive. The lumbo-ventricular perfusion test showed reliability in nine patients; there were two false negatives and one false positive. In only three patients were the results of both of these tests in accordance with the outcome.

Conclusions

Even though there are few patients in this study so far, the data suggests that at the present time the most predictive guides for the diagnosis of NPH and its outcome after shunting are the clinical criteria and the radiological findings in computed tomography (CT) and/or MRI rather than lumbo-ventricular perfusion and CSF flow studies.

Section snippets

Materials and Methods

MRI-CSF flow studies and lumbo-ventricular CSF perfusions were performed in 12 patients who had been diagnosed with idiopathic NPH. There were seven men and five women with ages from 17–88 years (mean age: 65.8 years).

Results

Twelve patients from our institution with an initial diagnosis of idiopathic NPH were entered in the protocol to be studied with both phase-contrast cine MRI and lumbo-ventricular perfusion to determine the accuracy of these tests for assessment in the diagnosis of NPH and predicting the outcome after shunting. Eleven of the 12 patients were shunted; the twelfth patient was managed with lumbar punctures for removal of CSF. The findings of these tests are summarized in Table 1.

Discussion

During the last 30 years, several papers have been written on the difficulty of diagnosing NPH, especially the idiopathic or occult type.

Experience has shown that those patients whose triad is initiated with gait difficulty are the most likely to improve after shunting 17, 23, 33. Only about one-third of the patients with idiopathic NPH improve, while one-half to three-fourths of the patients with a known cause improve after shunting [39].

We believe that the two patients who had some

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Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus
2012, Journal of Clinical Neuroscience
Citation Excerpt :
At present the diagnosis is made by clinical symptoms in the presence of enlarged ventricles on imaging, and is confirmed by a positive response to CSF diversion.7,8 Numerous confirmatory tests, including CSF drainage by single lumbar puncture or extended lumbar drainage, CSF pressure dynamic measurements, and dynamic flow MRI have been advocated to assist with diagnosis.6,9–16 There is no unified standard to diagnose NPH or to identify appropriate surgical candidates.
Ventriculoperitoneal shunt placement is the standard of care for idiopathic normal pressure hydrocephalus (iNPH). Studies have reported shunt complication rates up to 38%, with subdural hemorrhage rates as high as 10%. Lumboperitoneal (LP) shunts with horizontal–vertical valves (HVV) are an alternative for cerebrospinal fluid (CSF) diversion that avoids direct cerebral injury and may reduce the risk of overdrainage. Here we reviewed our experience with LP–HVV shunt placement for iNPH. We retrospectively reviewed our 33 patients with LP–HVV shunts inserted for the treatment of iNPH from 1998 to 2009. Patients were evaluated for improvements in gait, urinary function, and dementia after shunt placement. All patients had evidence of ventriculomegaly and a positive response to pre-operative lumbar puncture or extended lumbar drainage. All 33 (100%) patients had pre-operative gait dysfunction, 28 (85%) had incontinence, and 20 (61%) had memory deficits. Mean follow-up time was 19 months. Following shunt placement, 33/33 (100%) patients demonstrated improved gait, 13/28 (46%) had improvement in incontinence, and 11/20 (55%) had improvement in memory. Shunt failures requiring revision occurred in nine patients (27%), with an average time to failure of 11 months. Infections occurred in two patients (6%). There were no neurologic complications, including no hemorrhages. Thus, LP–HVV shunt placement is a safe and effective alternative to ventriculoperitoneal shunting for iNPH, resulting in significant symptomatic improvement with a low risk of overdrainage. It should be considered as an option for the treatment of patients with iNPH who demonstrate clinical improvement following lumbar drainage.
Clinical aspects and biology of normal pressure hydrocephalus
2008, Handbook of Clinical Neurology
Citation Excerpt :
It has been assumed that a marked flow void on T2‐weighted sagittal images may indicate hyperdynamic CSF pulsations (Bradley et al., 1991b, 1996). The correlation between the degree of the flow void and postoperative improvement, however, has been low or negative in recent studies (Krauss et al., 1997c; Hakim and Black, 1998). Phase‐contrast MR imaging may be more suitable to quantify the aqueductal CSF stroke volume and to differentiate between true hyperdynamic CSF flow and increased CSF flow velocity related to the ratio of the width of the ventricular system and the aqueduct (Naidich et al., 1993).
The chapter describes normal pressure hydrocephalus (NPH) as a clinical and radiographic syndrome, which is characterized clinically by gait disturbance, dementia, and urinary incontinence in patients with communicating hydrocephalus and normal mean intracranial pressure. The chapter explains that only a minority of patients are present with the complete triad of clinical symptoms ― gait disturbance being the most frequent and important symptom of NPH. The chapter explains that the only reasonably effective treatment for the gait disorder of NPH is shunt surgery, whereas non-shunt methods of treatment as alternatives to shunting remain marginal or speculative. The results of CSF shunting for the dementia of NPH are less striking. Because the benefit of CSF shunting is contingent primarily upon the preoperative selection of appropriate candidates, the differential diagnosis of NPH with special regard to the dementia of NPH continues to be a major challenge in clinical neurology and neurosurgery.
Normal Pressure Hydrocephalus
2007, Neurologic Clinics
Citation Excerpt :
Further, the extent of the flow void extension into the third, fourth, and lateral ventricles did not correlate with amount of improvement in these patients but correlated with rather the width of the ventricles. Hakim and Black [38], in a small study of 12 patients of whom 10 improved, found that the MRI-CSF flow studies were correct in six, but five had false negatives and one a false positive. Dixon and colleagues [39] also found in 49 patients that CSF flow through the cerebral aqueduct did not reliably predict those who improved with shunt surgery.
Doctors find the management of normal pressure hydrocephalus (NPH) difficult because their diagnosis often is uncertain and the treatment with shunt surgery carries a significant risk. With the aim of bringing to the attention of physicians the useful, but largely anecdotal, information available regarding this problem, this article discusses the epidemiology, reasons why the diagnosis is difficult, differential diagnosis, features of the history, examination, neuropsychologic assessment, radiologic evaluation, and special tests that may help clinicians with management.
Hydrocephalus and Disorders of Cerebrospinal Fluid Flow
2003, Office Practice of Neurology
Normal Pressure Hydrocephalus
2003, Neurological Disorders: Course and Treatment: Second Edition
This chapter discusses normal pressure hydrocephalus (NPH). The most frequent and characteristic symptom of NPH is disturbance of gait. It is usually the first sign of NPH and also the most likely to improve after shunting. The classic clinical triad becomes evident with progression of the disease and also includes urinary problems and cognitive deficits. In addition to these three cardinal symptoms, a variety of other signs and symptoms may be present, in particular, akinetic and bradykinetic movement disorders. Cognitive deficits are almost always present; however, they are usually mild in the early phase of the disease and may be detected only by neuropsychological examination. The cognitive deficits are characterized mainly by impaired memory, decreased speed of information processing, and impaired executive function. The characteristic features of gait disturbance in NPH during this second phase of clinical deterioriation have been described as magnetic gait or as walking as if the feet are glued to the floor. With further progression, hydrocephalic gait is characterized by increasing slowness.
Diagnostic tools in hydrocephalus
2001, Neurosurgery Clinics of North America
MR imaging is the premier imaging modality for diagnosing the various forms and causes of hydrocephalus. Although CT is satisfactory for imaging in the axial plane, MR imaging is capable of imaging in any plane to better demonstrate any cause of observation. MR imaging also is more sensitive than CT to interstitial edema (transependymal flow of cerebrospinal fluid [CSF]) and to the hyperdynamic CSF flow seen with shunt-responsive normal-pressure hydrocephalus (NPH). MR imaging also is sensitive to the presence of deep white matter ischemia that may contribute to the cause of the idiopathic form of NPH.

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Original ArticlesCorrelation Between Lumbo-Ventricular Perfusion and MRI-CSF Flow Studies in Idiopathic Normal Pressure Hydrocephalus

Abstract

Section snippets

Materials and Methods

Results

Discussion

Lancet

J Neurol Sci

Quantitative cine-mode magnetic resonance imaging of Chiari I malformationsan analysis of cerebrospinal fluid dynamics

Neurosurgery

Surgical indications in normotensive hydrocephalus. A retrospective analysis of the relations of some diagnostic findings to the results of surgical treatment

Acta Neurochir

Diagnosis of normal-pressure hydrocephalus

N Engl J Med

Choroid plexus and arterial pulsations of cerebrospinal fluiddemonstration of the choroid plexus as a cerebrospinal fluid pump

Arch Neurol Psychiatry

Normal-pressure hydrocephalus. Results of shunting in 62 patients

J Neurosurg

Intracranial pressure and conductance to outflow of cerebrospinal fluid in normal pressure hydrocephalus

J Neurosurg

The resistance to cerebrospinal fluid absorption in humans. A method of evaluation by lumbo-ventricular perfusion, with particular reference to normal pressure hydrocephalus

Acta Neurol Scand

Marked cerebrospinal fluid voidindicator of successful shunt in patients with suspected normal pressure hydrocephalus

Radiology

Intracranial pressure in patients with dementia and communicating hydrocephalus

J Neurosurg

The mechanism of drainage of the cerebrospinal fluid

Brain

The lumbar subarachnoid infusion test in infants

Childs Nerv Syst

The mechanism of hydromyelia in Chiari type I malformations

Br J Radiol

CSF hydrodynamic studies in man2. normal hydrodynamic variables related to CSF pressure and flow

J Neurol Neurosurg Psychiatry

Normal flow patterns of intracranial and spinal cerebrospinal fluid defined with phase-contrast cine MR imaging

Radiology

Hydrocephalus as a cause of disturbances of gait in the elderly

Neurology

Idiopathic normal pressure hydrocephalus—a report of 73 patients

J Neurol Neurosurg Psychiatry

Original Articles
Correlation Between Lumbo-Ventricular Perfusion and MRI-CSF Flow Studies in Idiopathic Normal Pressure Hydrocephalus