The Efficiency of PC-MRI in Diagnosis of Normal Pressure Hydrocephalus and Prediction of Shunt Response

doi:10.1016/j.acra.2009.08.011

Academic Radiology

Volume 17, Issue 2, February 2010, Pages 181-187

Presented as a poster presentation at 29th Turkish National Radiology Congress held in Antalya-Turkey in November 1–5, 2008.

https://doi.org/10.1016/j.acra.2009.08.011 Get rights and content

Rationale and Objectives

In this prospective study, we aimed to reveal the efficiency of phase-contrast magnetic resonance imaging (PC-MRI) in the diagnosis of idiopathic normal pressure hydrocephalus (INPH) and prediction of shunt response.

Materials and Methods

The study group consisted of 43 patients with INPH diagnosis and 15 asymptomatic age-matched controls. PC-MRI studies were applied on cerebral aqueduct and superior sagittal sinus (SSS) in all the cases.

Results

The maximum and mean cerebrospinal fluid (CSF) flow velocities were significantly higher in the INPH patients compared with the controls (P < .05). CSF stroke volume (43.2 ± 63.8 μL) and output/min (3921 ± 5668 μL) were remarkably higher in the NPH group compared with the control group (3.9 ± 3.9 μL, 439 ± 487 μL, respectively) (P < .05). Maximum and mean venous velocity values of the INPH patients (maximum, 19.2 ± 4.3 cm/s; mean, 16 ± 3.7 cm/s), were lower than those of the control group (maximum, 21.8 ± 4.6 cm/s; mean, 18.9 ± 3.9 cm/s) (P < .05). Stroke volume and venous output/min values of INPH patients in SSS, were significantly lower than those of the control group (P < .001, P = .007, respectively). The response of INPH patients against shunt treatment showed no statistical correlation with any of the PC-MRI parameters (P > .05).

Conclusion

The measurement of CSF venous flow velocities with PC-MRI is a noninvasive test that benefits INPH diagnosis, but remains inadequate in prediction of response against shunt treatment.

Section snippets

Study Group

In the present prospective study, 58 patients who presented to neurology and neurosurgery departments of our university between March 2006 and April 2008 were included. The control group consisted of cases with prediagnosis of intracranial arachnoid cyst (AC) or mega cisterna magna (MSM). Although the control group comprised 15 cases (mean age, 63 ± 8.5 years; 6 women and 9 men; range, 46–75), there was no pathological finding or coexisting disease in these cases except AC-MSM. Cases with an AC

Results

All the cases in INPH group showed ventriculomegaly without any marked dilatation in the sulci. Four patients, on which velocity measurement was carried out twice in different times, exhibited similar velocity values (no velocity difference above ±0.6 cm/s was found). In the sequence where venc was 20 cm/s, CSF flow parameters of two cases (because of CSF velocity >20) could not be measured accurately (because of aliasing artifact). CSF parameters of those two cases could be accurately measured

Discussion

INPH is a relatively rare disease that is generally encountered in older patients. Although the etiopathogenesis of the disease is still unclear, the most commonly observed symptoms are dementia, gait disorder, and urinary incontinence 1, 2, 13. Many methods have been employed for understanding the hydrodynamics of CSF in NPH such as imaging methods such as CT, MRI, radionuclide cisternography, and invasive tests such as spinal infusion test, lumbar drainage, and direct intracranial pressure

Conclusion

Despite hundreds of studies conducted in the past, investigators have failed to reveal the etiopathogenesis, hydrodynamics, diagnostic criteria, and therapeutic indications of NPH. Unfortunately, differential diagnosis of this disease, which cannot be discriminated from other dementia causes by clinical characteristics, is established according to the results of the invasive shunt operation in many health care centers. Moreover, aqueductal stenosis, raised intracranial pressure syndrome, and

Acknowledgment

We gratefully acknowledge Gökhan Ocakoğlu (biostatistician), Özlem Taşkapılıoğlu (neurologist), and Ahmet Bekar (neurosurgeon) for their suggestions and for reviewing the manuscript.

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Accuracy of MRI derived cerebral aqueduct flow parameters in the diagnosis of idiopathic normal pressure hydrocephalus
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Since then, the clinical utility of PC-MRI derived CSF flow measurements has been a topic of continued research. Hyperdynamic CSF flow through the cerebral aqueduct in iNPH patients has been observed in multiple studies [14,17,21,25], although the predictive power of various CSF flow parameters for diagnosis and prediction of shunting response in iNPH patients are variable across different studies [18,20,22,23,31]. Since there are currently no large-scale studies establishing a set of cut-off values for iNPH diagnosis, CSF flow studies have yet to be included in international clinical guidelines [2,32].
Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible cause of dementia-like symptoms among the elderly. Current diagnostic guidelines for iNPH rely on clinical manifestations and ventricular morphology, which often lack accuracy. While magnetic resonance imaging (MRI) CSF flowmetry of the cerebral aqueduct provides a noninvasive aid to differential diagnosis, previous studies suffered from small sample sizes. This study compares the accuracy of different CSF flow parameters for iNPH diagnosis in a general patient population. From 2016 to 2018, a total of 216 subjects over 60 years of age were retrospectively enrolled, including 38 patients with iNPH and 178 patients with non-iNPH neurological conditions. All participants received phase-contrast MRI (PC-MRI) CSF flowmetry, with measurements performed independently by two radiologists. Flow parameters of iNPH and non-iNPH groups were compared along with their diagnostic accuracy. Absolute stroke volume (ABSV), forward flow, backward flow, mean flux and peak velocity were significantly higher in iNPH patients (P < 0.001, P < 0.001, P < 0.001, P = 0.008, P = 0.038, respectively). Backward flow had the highest diagnostic accuracy, followed by ABSV and forward flow. Net caudocranial aqueductal flow was observed in both groups, but with greater volume in the iNPH group. PC-MRI provides a non-invasive method of CSF flowmetry across the cerebral aqueduct and may aid in iNPH diagnosis. ABSV and its component flow values may provide better accuracy in identifying iNPH than other parameters.
Using deep learning convolutional neural networks to automatically perform cerebral aqueduct CSF flow analysis
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In recent years, quantification of CSF flow via phase-contrast MRI (PC-MRI) has gained increasing prominence, with research focused on its use as an indicator of diseases such as normal pressure hydrocephalus (NPH) [1–3].
Since the development of phase-contrast magnetic resonance imaging (PC-MRI), quantification of cerebrospinal fluid (CSF) flow across the cerebral aqueduct has been utilized for diagnosis of conditions such as normal pressure hydrocephalus (NPH). This study aims to develop an automated method of aqueduct CSF flow analysis using convolution neural networks (CNNs), which can replace the current standard involving manual segmentation of aqueduct region of interest (ROI). Retrospective analysis was performed on 333 patients who underwent PC-MRI, totaling 353 imaging studies. Aqueduct flow measurements using manual ROI placement was performed independently by two radiologists. Two types of CNNs, MultiResUNet and UNet, were trained using ROI data from the senior radiologist, with PC-MRI studies being randomly divided into training (80%) and validation (20%) datasets. Segmentation performance was assessed using Dice similarity coefficient (DSC), and CSF flow parameters were calculated from both manual and CNN-derived ROIs. MultiResUNet, UNet and second radiologist (Rater 2) had DSCs of 0.933, 0.928, and 0.867, respectively, with p < 0.001 between CNNs and Rater 2. Comparison of CSF flow parameters showed excellent intraclass correlation coefficients (ICCs) for MultiResUNet, with lowest correlation being 0.67. For UNet, lower ICCs of −0.01 to 0.56 were observed. Only 3/353 (0.8%) studies failed to have appropriate ROIs placed by MultiResUNet, compared to 12/353 (3.4%) failed cases for UNet. In conclusion, CNNs were able to measure aqueductal CSF flow with similar performance to a senior neuroradiologist. MultiResUNet demonstrated fewer cases of segmentation failure and more consistent flow measurements compared to the widely adopted UNet.
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SEGMENTATION OF SPINAL SUBARACHNOID LUMEN WITH 3D ATTENTION U-NET
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Imaging research progress of abnormal brain function in idiopathic normal pressure hydrocephalus
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Can preoperative brain imaging features predict shunt response in idiopathic normal pressure hydrocephalus? A PRISMA review
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View full text

Original investigationThe Efficiency of PC-MRI in Diagnosis of Normal Pressure Hydrocephalus and Prediction of Shunt Response

Rationale and Objectives

Materials and Methods

Results

Conclusion

Section snippets

Study Group

Results

Discussion

Conclusion

Acknowledgment

Mayo Clin Proc

Mayo Clin Proc

Neurol Clin

Lancet

The pathophysiology of the aqueduct stroke volume in normal pressure hydrocephalus: can co-morbidity with other forms of dementia be excluded?

Neuroradiology

Aging effects on cerebral blood and cerebrospinal fluid flows

J Cerebral Blood Flow Metab

CSF spaces in idiopathic normal pressure hydrocephalus: Morphology and volumetry

AJNR Am J Neuroradiol

Magnetic resonance spectroscopic determination of a neuronal and axonal marker in white matter predicts reversibility of deficits in secondary normal pressure hydrocephalus

J Neurol Neurosurg Psychiatry

Is aqueductal stroke volume, measured with cine phase-contrast magnetic resonance imaging scans useful in predicting outcome of shunt surgery in suspected normal pressure hydrocephalus?

Neurosurgery

The pathophysiology of idiopathic normal pressure hydrocephalus: cerebral ischemia or altered venous hemodynamics?

AJNR Am J Neuroradiol

Is idiopathic normal pressure hydrocephalus an independent entity?

Acta Neurochir

Vascular compliance in normal pressure hydrocephalus

AJNR Am J Neuroradiol

Clinical guidelines for idiopathic normal pressure hydrocephalus

Neurol Med Chir

Narrow CSF space at high convexity and high midline areas in idiopathic normal pressure hydrocephalus detected by axial and coronal MRI

Neuroradiology

Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging

Radiology

Original investigation
The Efficiency of PC-MRI in Diagnosis of Normal Pressure Hydrocephalus and Prediction of Shunt Response