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Normal Pressure Hydrocephalus: Vascular White Matter Changes on MR Images Must Not Exclude Patients from Shunt Surgery

Mats Tullberga, Christer Jensena, Sven Ekholma and Carsten Wikkelsøa

a From the Institute of Clinical Neuroscience (M.T., C.W.) and Department of Radiology (C.J., S.E.), Sahlgrenska University Hospital, Göteborg University, Göteborg, Sweden.



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  		FIG 1. MR imaging of representative patients with NPH, before and after shunting.

Periventricular hyperintensity (PVH): P1 = normal; P2S = thin (5-10 mm) continuous PVH, smooth lateral borders; P2I = thin (5-10 mm) continuous PVH, irregular lateral borders; P3S = thick (>10 mm) continuous PVH, smooth lateral borders; P3I = thick (>10 mm) continuous PVH, irregular lateral borders. Deep white matter hyperintensity (DWMH): D1 = No DWMH or few (<=3) small discontinuous areas; D2 = several (>3) small (<10 mm) discontinuous areas of DWMH; D3 = several (>3) small and large (>=10 mm) areas of DWMH, beginning confluence; D4 = confluent DWMH.

Patient 1. Top row. Preoperative MR image (left) shows smooth PVH (P2S) at the anterior third and irregular PVH (P2I and P3I) at the posterior third of the lateral ventricles (TR/TE/excitations, 1960/60/6). Postoperative MR image (right) shows normalization (P1) of smooth PVH anteriorly and irregular PVH posteriorly. The patient improved (MoD, 0.34) after surgery (TR/TE/excitations, 2000/48/6).

Patient 2. Second row. Preoperative MR image (left) shows irregular PVH (P3I) at the anterior third of the lateral ventricles. There is no DWMH (D1) to the right and several small areas of DWMH (D2) to the left (TR/TE/excitations, 2035/60/4). Postoperatively (right), there is complete normalization of anterior PVH (P1), whereas DWMH remains unchanged. The patient improved (MoD, 0.73) after surgery (TR/TE/excitations, 1960/60/6).

Patient 3. Third row. Preoperative MR image (left) shows marked irregular PVH (P3I) at the anterior and central third of lateral ventricles and confluent DWMH (D4) bilaterally (TR/TE/excitations, 2168/30/1). Postoperative MR image (right) is unchanged. The patient deteriorated (MoD,-0.70) after surgery. Note the flow void sign indicating a patent shunt (TR/TE/excitations, 2034/60/4).

Patient 4. Fourth row. Preoperative MR image (left) shows marked irregular PVH (P3I) at the anterior and posterior third of the lateral ventricles (TR/TE/excitations, 1959/60/4). Postoperative MR image (right) shows smooth PVH at the anterior third (P2S) and normalization of PVH at posterior third (P1). The patient improved slightly (MoD, 0.52) after surgery (TR/TE/excitations, 1959/60/6).



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  		FIG 2. Postoperative reduction in PVH. Note the reduction in irregular but not smooth PVH around the frontal horns in improved patients



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  		FIG 3. Postoperative reduction in ventricular size is numerically equal in both improved and unimproved patients, although significant only in the larger group of improved patients





Copyright © 2008 by the American Society of Neuroradiology. Print ISSN: 0195-6108 Online ISSN: 1936-959X