Use of Cerebrospinal Fluid Flow Rates Measured by Phase-Contrast MR to Predict Outcome of Ventriculoperitoneal Shunting for Idiopathic Normal-Pressure Hydrocephalus

doi:10.4065/77.6.509

Mayo Clinic Proceedings

Volume 77, Issue 6, June 2002, Pages 509-514

https://doi.org/10.4065/77.6.509 Get rights and content

Objective

To determine whether favorable clinical response and magnitude of improvement are associated with increased aqueductal cerebrospinal fluid (CSF) flow rates in patients who undergo ventriculoperitoneal shunting (VPS) for idiopathic normal-pressure hydrocephalus (NPH).

Patients and Methods

Between January 1995 and June 2000, 49 patients (14 men and 35 women; mean age, 72.9 years; range, 54-88 years) underwent magnetic resonance quantification of aqueductal CSF flow followed by VPS for presumed idiopathic NPH at the Mayo Clinic, Rochester, Minn. Logistic regression models for the odds of any improvement in score as a function of aqueductal CSF flow and separate models for any improvement in gait, incontinence, cognition, and total score were constructed.

Results

Forty-two patients (86%) had improvement in gait at postoperative follow-up (mean, 10 months). Of the 32 patients with incontinence, 27 (69%) improved. Of the 36 patients with cognitive impairment, 16 (44%) improved. In univariate and fully adjusted models, increased CSF flow through the aqueduct was not significantly associated with improvement or the magnitude of improvement in gait, cognition, or incontinence. Thirty-six patients underwent high-volume lumbar puncture preoperatively, of whom 5 (14%) had no response. The aqueductal CSF flow rates of these 5 patients were significantly higher than those of the patients who improved after lumbar puncture. Postoperative complications occurred in 15 patients. The aqueductal CSF flow rates in these 15 patients were not significantly different from those of patients who experienced no complications.

Conclusion

Among patients who underwent VPS for the treatment of NPH, measurement of CSF flow through the cerebral aqueduct did not reliably predict which patients would improve after shunting or the magnitude of improvement.

Section snippets

Clinical Material

The medical records of all patients who underwent VPS for NPH between January 1995 and June 2000 at the Mayo Clinic, Rochester, Minn, were reviewed. Patients without cine phase-contrast MR measurement of aqueductal CSF flow before VPS were excluded from analysis (32 patients during the study period). Seven patients had less than 1 month of postoperative follow-up and therefore were not analyzed. Patients with communicating hydrocephalus due to prior neurologic illness, such as subarachnoid

RESULTS

Postoperative improvement in each symptom category is shown in Table 3. With respect to gait, 42 patients (86%) improved, 6 patients (12%) had no change, and 1 patient (2%) worsened from moderate to severe gait impairment. Improvement in incontinence or cognition was less consistent. Of the 39 patients with incontinence, 27 (69%) were improved, 11 (28%) were unchanged, and 1 (3%) had worsened from moderate to severe incontinence. Of the 36 patients with cognitive impairment, 16 (44%) were

Predicting Outcome of VPS for NPH

Previously, we established that aqueductal CSF flow rate as measured by cine phase-contrast MR was substantially elevated in patients with idiopathic NPH compared with patients with other forms of dementia and healthy elderly controls.¹³ However, in the present study, we were unable to show a statistically significant association between CSF flow rate and outcome after VPS for NPH. This combination of findings suggests that, although phase-contrast MR measurement of aqueductal CSF flow may be

CONCLUSION

Among patients who underwent VPS for the treatment of NPH, measurement of CSF flow through the cerebral aqueduct did not reliably predict which patients improved after shunting or the magnitude of improvement. However, MR quantification of aqueductal CSF flow may have a role in selecting patients for VPS in whom the diagnosis is uncertain on clinical grounds alone.

Acknowledgments

We are indebted to Mary M. Soper for expert assistance in manuscript preparation.

REFERENCES (22)

DW Dippel et al.
Probabilistic diagnosis of normal pressure hydrocephalus and other treatable cerebral lesions in dementia
J Neurol Sci
(1993)
RD Adams et al.
Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure: a treatable syndrome
N Engl J Med
(1965)
S Hakim
Algunas observaciones sobre la presion del LCR sindrome hidrocefalio en el adulto con “presion normal” del LCR [thesis]
(1964)
JO Greenberg et al.
Idiopathic normal pressure hydrocephalus—a report of 73 patients
J Neurol Neurosurg Psychiatry
(1977)
K Tanaka et al.
Idiopathic normal pressure hydrocephalus in elderly patients: its pathophysiology and diagnosis [in Japanese]
No Shinkei Geka
(1993)
J Valk
Clinical and neuropsychological symptoms of normal pressure hydrocephalus [letter] [in Dutch]
Ned Tijdschr Geneeskd
(1987)
PM Black et al.
CSF shunts for dementia, incontinence, and gait disturbance
Clin Neurosurg
(1985)
RA Hurley et al.
Normal pressure hydrocephalus: significance of MRI in a potentially treatable dementia
J Neuropsychiatry Clin Neurosci
(1999)
ER Laws et al.
Occult hydrocephalus: results of shunting correlated with diagnostic tests
Clin Neurosurg
(1977)
RC Petersen et al.
Surgical treatment of idiopathic hydrocephalus in elderly patients
Neurology
(1985)

P Gideon et al.

Cerebrospinal fluid flow and production in patients with normal pressure hydrocephalus studied by MRI

Neuroradiology

(1994)

Cited by (101)

Accuracy of MRI derived cerebral aqueduct flow parameters in the diagnosis of idiopathic normal pressure hydrocephalus
2022, Journal of Clinical Neuroscience
Citation Excerpt :
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.
Communicating chronic hydrocephalus: A review
2021, Revue de Medecine Interne
Formerly called normal pressure hydrocephalus, communicating chronic hydrocephalus (CCH) is a condition affecting 0.1 to 0.5% of patients over 60 years of age. The pathophysiology of this disease is poorly understood, but a defect in cerebrospinal fluid (CSF) resorption appears to be commonly defined as the cause of the neurological disorders. The last important discovery is the description of the glymphatic system and its implication in CCH and CSF resorption. Comorbidities (Alzheimer's disease, microangiopathy, parkinsonism) are very frequent, and involve a diagnostic challenge. The clinical presentation is based on the Hakim and Adams triad, comprising gait disorders, mainly impairing walking, cognitive disorders, affecting executive functions, episodic memory, visuospatial cognition, and sphincter disorders as urinary incontinence (detrusor hyperactivity). The diagnosis is suspected through a set of arguments, combining the clinical presentation, the radiological data of the magnetic resonance imaging (MRI) showing a ventriculomegaly associated with signs of transependymomous resorption of the CSF and disappearance of the cortical sulci, and the clinical response to the depletion of CSF. In the presence of all these elements, or a strong clinical suspicion, the standard treatment will be of a permanent CSF shunt, using a ventriculoatrial or ventriculoperitoneal shunt. The effectiveness of this treatment defines the diagnosis. The clinical improvement is better when treatment occurs early after the onset of the disorders, reaching 75 to 90% of motor improvement.
Classiquement appelée hydrocéphalie à pression normale, l’hydrocéphalie chronique communicante (HCC) est une affection qui touche de 0,1 à 0,5 % des patients de plus de 60 ans. La physiopathologie de cette maladie reste mal comprise, mais un défaut de résorption du liquide céphalorachidien (LCR) semble être communément défini comme la cause des symptômes. La découverte du système glymphatique a permis de mettre en évidence son implication dans l’HCC. De plus, l’association avec des comorbidités neurodégénératives (maladie d’Alzheimer, microangiopathie, maladie de Parkinson) est fréquente. La présentation clinique s’appuie sur la triade de Hakim et Adams, comprenant des troubles de la marche, des troubles cognitifs, affectant les fonctions exécutives, la mémoire épisodique, la cognition visuospatiale et des troubles sphinctériens représentés par l’incontinence urinaire (hyperactivité du détrusor). Le diagnostic est suspecté par un ensemble d’arguments, combinant la présentation clinique, les données radiologiques de l’IRM montrant une ventriculomégalie associée à des signes de résorption transépendymaire du LCR et de disparition des sillons corticaux, et la réponse clinique à la déplétion de LCR. En présence de tous ces éléments, ou d’une forte suspicion clinique, le traitement sera la pose d’un shunt permanent du LCR par une dérivation ventriculo-atriale ou ventriculo-péritonéale. L’efficacité de ce traitement définit le diagnostic. L’amélioration clinique est meilleure lorsque le traitement intervient tôt après l’apparition des troubles, atteignant 75 à 90 % d’amélioration motrice.
Screening for idiopathic normal pressure hydrocephalus in the elderly after falls
2021, Clinical Neurology and Neurosurgery
Many patients with idiopathic normal pressure hydrocephalus (iNPH) have reportedly fallen prior to diagnosis. However, there are no previous reports on the iNPH prevalence among the elderly with history of falls. This study investigated the effectiveness of screening for iNPH in elderly patients presenting after a fall.
We retrospectively assessed the Evans’ index (EI) of 235 consecutive patients aged 60–89 who presented after falls between May and October 2020. We also assessed the presence of the iNPH triad (gait disturbance, cognitive impairment, and urinary incontinence). Patients with EI > 0.3 and with all 3 triad were defined as having possible iNPH; those with clinical improvement after a cerebrospinal fluid (CSF) tap test as having probable iNPH; and those with clinical improvement after a shunt surgery as having definite iNPH. We also examined the 235 patients’ EI, and performed a case-control study of EI using sex- and age-matched control patients.
Among the included 235 cases presenting after falls, 44 (18.7%) were diagnosed with possible iNPH, 29 (12.3%) with probable iNPH, and 25 (10.6%) with definite iNPH. The mean EI of these 235 patients was significantly larger than that of controls (0.30 ± 0.04 vs 0.26 ± 0.02, p < 0.0001). The proportion of possible iNPH in the cases was 44 out of 235 (18.7%), significantly higher than that of the controls (0%, p < 0.0001).
Screening for iNPH in the elderly presenting after falls can possibly identify iNPH patients in the earlier stage who may benefit more from surgical treatments.
Aqueductal Cerebrospinal Fluid Stroke Volume Flow in a Rodent Model of Chronic Communicating Hydrocephalus: Establishing a Homogeneous Study Population for Cerebrospinal Fluid Dynamics Exploration
2019, World Neurosurgery
Citation Excerpt :
Some human studies9,14-27 have shown an important correlation between aqueductal CSF hyperdynamism and shunt responsiveness. Other studies28-30 have obtained different observations, concluding ASV as a poor prognostic marker to shunt outcomes. This discrepancy is preventing the acceptance of ASV as a predictor.
Idiopathic normal pressure hydrocephalus (iNPH) is a cause of dementia that can be reversed when treated timely with cerebrospinal fluid (CSF) diversion. Understanding CSF dynamics throughout the development of hydrocephalus is crucial to identify prognostic markers to estimate benefit/risk to shunts.
To explore the cerebral aqueduct CSF flow dynamics with phase-contrast magnetic resonance imaging (MRI) in a novel rodent model of adult chronic communicating hydrocephalus.
Kaolin was injected into the subarachnoid space at the convexities in Sprague-Dawley adult rats. 11.7-T Bruker MRI was used to acquire T2-weighted images for anatomic identification and phase-contrast MRI at the cerebral aqueduct. Aqueductal stroke volume (ASV) results were compared with the ventricular volume (VV) at 15, 60, 90, and 120 days.
Significant ventricular enlargement was found in kaolin-injected animals at all times (P < 0.001). ASV differed between cases and controls/shams at every time point (P = 0.004, 0.001, 0.001, and <0.001 at 15, 60, 90, and 120 days, respectively). After correlation between the ASV and the VV, there was a significant correlation at 15 (P = 0.015), 60 (P = 0.001), 90 (P < 0.001), and 120 days. Moreover, there was a significant positive correlation between the VV expansion and the aqueductal CSF stroke between 15 and 60 days.
An initial active phase of rapid ventricular enlargement shows a strong correlation between the expansion of the VV and the increment in the ASV during the first 60 days, followed by a second phase with less ventricular enlargement and heterogeneous behavior in the ASV. Further correlation with complementary data from intracranial pressure and histologic/microstructural brain parenchyma assessments are needed to better understand the ASV variations after 60 days.
Normal pressure hydrocephalus, or Hakim syndrome: review and update
2024, Neurologia i Neurochirurgia Polska
Impact of Shunt Placement on CSF Dynamics
2024, Biomedicines

View all citing articles on Scopus

View full text

Original ArticleUse of Cerebrospinal Fluid Flow Rates Measured by Phase-Contrast MR to Predict Outcome of Ventriculoperitoneal Shunting for Idiopathic Normal-Pressure Hydrocephalus

Objective

Patients and Methods

Results

Conclusion

Section snippets

Clinical Material

RESULTS

Predicting Outcome of VPS for NPH

CONCLUSION

Acknowledgments

J Neurol Sci

Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure: a treatable syndrome

N Engl J Med

Algunas observaciones sobre la presion del LCR sindrome hidrocefalio en el adulto con “presion normal” del LCR [thesis]

Idiopathic normal pressure hydrocephalus—a report of 73 patients

J Neurol Neurosurg Psychiatry

Idiopathic normal pressure hydrocephalus in elderly patients: its pathophysiology and diagnosis [in Japanese]

No Shinkei Geka

Clinical and neuropsychological symptoms of normal pressure hydrocephalus [letter] [in Dutch]

Ned Tijdschr Geneeskd

CSF shunts for dementia, incontinence, and gait disturbance

Clin Neurosurg

Normal pressure hydrocephalus: significance of MRI in a potentially treatable dementia

J Neuropsychiatry Clin Neurosci

Occult hydrocephalus: results of shunting correlated with diagnostic tests

Clin Neurosurg

Surgical treatment of idiopathic hydrocephalus in elderly patients

Neurology

Cerebrospinal fluid flow and production in patients with normal pressure hydrocephalus studied by MRI

Neuroradiology

Original Article
Use of Cerebrospinal Fluid Flow Rates Measured by Phase-Contrast MR to Predict Outcome of Ventriculoperitoneal Shunting for Idiopathic Normal-Pressure Hydrocephalus