AUC = area under the curve, GM = gray matter volume, VNT = ventricular volume. EI is a component of the NPH diagnostic criteria in both the United States (16) and Japan (14). ■ Callosal angle (CA) and Evans index (EI) combined provide good accuracy (average area under the curve, 0.96) to differentiate patients with normal-pressure hydrocephalus (NPH) from patients who do not have NPH (ie, patients with Alzheimer disease [AD] and healthy control [HC] volunteers) and may serve as an accurate screening tool for NPH. Normal-pressure hydrocephalus (NPH) is characterized by often incapacitating gait dysfunction, cognitive impairment, and urinary incontinence, with the presence of enlarged ventricles despite normal intracranial pressure (1). These objective cutoffs are clinically relevant, and research showed that visual assessment alone exhibits poor diagnostic accuracy for NPH (12,27). We selected patients with NPH from our adult hydrocephalus clinic. Urinary incontinence: Urinary frequency, urgency, or frank incontinence 3. The sensitivity and diagnostic accuracy of these groups overlapped, indicating no statistically significant difference in this subgroup analysis. Aust N Z J Psychiatry. This is an idiopathic form of communicating hydrocephalus, which features clinically as a triad of dementia, incontinence & gait disturbances. The regression model that used volumetric predictors of gray matter and white matter was 94.3% accurate. EI was determined on transaxial view by measuring the largest left-to-right width of the frontal horns divided by the largest left-to-right extent the skull (red arrows, right). Virhammar J, Laurell K, Cesarini KG, Larsson EM. Manley GT, Hemphill C, Stiver S. Intracranial Pressure and Brain Monitoring XIII. All patients with NPH were imaged by using one of several local MR imaging systems (Siemens AG, Erlangen, Germany) 1–5 months before shunt placement. The range of areas under the curve was 0.96–0.97, depending on the observer. . Onset of gait abnormality before dementia predicts good surgical outcome, Alzheimer’s disease comorbidity in normal pressure hydrocephalus: prevalence and shunt response, Outcome of shunting in idiopathic normal-pressure hydrocephalus and the value of outcome assessment in shunted patients, Categorical data analysis, Brain ventricular size in healthy elderly: comparison between Evans index and volume measurement, https://doi.org/10.1148/radiol.2017161216, Open in Image AJNR Am J Neuroradiol 36:831–838 CrossRef PubMed Google Scholar Bradley WG, Kortman KE, Burgoyne B (1986) Flowing cerebrospinal fluid in normal and hydrocephalic states: appearance on … 236 patients studied, • 47 normal elderly patients • 115 patients with cognitive impairment including 46 with Alzheimer’s disease • 31 patients in whom NPH was suspected but ultimately excluded, • 43 patients with a final clinical diagnosis of NPH. ); Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY (B.E.D. Overall, the overlap was 14.1% (15 of 106). For comparison between 1.5-T versus 3-T magnetic field strength, we randomly selected five individuals from the ADNI database who underwent two MR examinations within 6 months: one examination with a 1.5-T imager (Avanto; Siemens) and the second with a 3-T imager (Prisma; Siemens). We also demonstrated the utility of a prediction model that combines CA and EI to diagnose shunt-responsive NPH and differentiate it from confounding imaging features of both patients with AD and HC volunteers. A Picture Archiving and Communications in Medicine multiplanar reconstruction tool (Intellispace PACS Enterprise v4.4.516; Philips Healthcare, Amsterdam, the Netherlands) was used for three-dimensional reformatting. contributed equally to this work. Bradley WG, Scalzo D, Queralt J et-al. Extensive demographics, family history, and medical history are available for all ADNI participants. 1970 Aug; 96 (2):347–358. Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. We excluded participants who did not demonstrate this positive response to shunt to minimize confounding of comorbid neurodegenerative disorders. Sandler MP, Coleman RE, Patton JA et-al. Observations on cerebrospinal fluid hydrodynamics. Normal pressure hydrocephalus (NPH) is an abnormal buildup of cerebrospinal fluid (CSF) in the brain's ventricles, or cavities. The traditional bulk flow model of CSF posits that CSF is secreted by choroid plexus epithelium in the ventricles, flows through the ventricular system, enters the spinal and cerebral subarachnoid spaces, and is absorbed by the arachnoid granulations into the superior sagittal sinus, to enter the systemic venous system. The periventricular white matter ischemic change has also been hypothesized to slow the flow of CSF through the extracellular spaces, resulting in a "back-pressure" effect, leading to ventricular enlargement. A complete listing of ADNI investigators can be found at http://adni.loni.usc.edu/wp-content/uploads/how_to_apply/ADNI_Acknowledgement_List.pdf. Sci. Communicating hydrocephalus with reversible cognitive impairment. (2009) ISBN:3211855785. Finally, our current model only studies ventricular cerebrospinal fluid and ignores extraventricular cerebrospinal fluid (sulcal size and shape). For EI, a cutoff of 0.32 was 81.4% (259 of 318) accurate for identification of patients with NPH, and measurements above the cutoff suggested NPH. Volumetric segmentation of global gray matter, white matter, ventricles, and hippocampi was performed by using software. We examined the usefulness of radiological markers in the diagnostics and prediction of shunt response in iNPH. The clinical diagnosis of probable NPH was performed on the basis of enlarged ventricles, a characteristic dyspraxic disorder, and exclusion of other confounding diagnoses (eg, neurodegenerative diseases and myelopathy). 29. A survey of 284 physicians. Favorable prognostic factors include 3. Furthermore, our study groups were imaged by using different protocols, but we corrected the bias caused by this technical limitation. {"url":"/signup-modal-props.json?lang=us\u0026email="}, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":6306,"mcqUrl":"https://radiopaedia.org/articles/normal-pressure-hydrocephalus/questions/1358?lang=us"}. Differences in the hippocampus across the three groups were significant (F = 28.49; P < .0001). Conn HO, Lobo FM. ). Similarly, our study did not address patients with NPH with smaller than average ventricles. 10. 2017 Oct;285(1):197-205. doi: 10.1148/radiol.2017161216. ICC was used to assess interobserver variability. Our results yielded cutoffs for CA and EI (≤100° and ≥0.32, respectively). Functional ambulation performance is a quantitative, well-validated composite gait measure on the basis of step length, symmetry, and velocity, and the scores range from 95 to 100 in healthy adults (20,21). Imaging biomarkers of NPH include linear measures such as the Evans index (EI) (12,13), callosal angle (CA) (14), disproportionate sulci (15), and volumetric analysis (11,16). Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: diagnosis and treatment. Radiology. Cerebrospinal fluid dynamics and shunt responsiveness in patients with normal-pressure hydrocephalus. Also included is the performance of volumetric model by using two predictors: gray matter volume and ventricle volume. Bradley WG (2015) CSF flow in the brain in the context of normal pressure hydrocephalus. Exact epidemiology is difficult to establish, as the diagnosis is often not made in nursing home patients for the following reasons: A large study in Norway found a striking increase in incidence with increasing age 3: The classical clinical findings of normal pressure hydrocephalus are 1-3. Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. Radiology. Dementia: Prominent memory loss and bradyphrenia; forgetfulness, decreased attention, inertia See Clinical Presentationfo… 16. Diagnosis derived from these rapidly obtainable values by using our tool demonstrated modest accuracy, sensitivity, and sensitivity. 23. The majority (65 patients) excluded from the study failed to meet criteria mentioned in a. Gait impairment is the principal symptom that affects older adults with NPH (22) and the parameter most likely to improve with shunt surgery (23,24); hence, we chose gait impairment as the primary criterion for verifying shunt and lumbar puncture response. Estimated tissue volume bias (V3T − V1.5T) because of differences in magnetic field strength was 25.0 mL for gray matter, −34.3 mL for white matter, 2.0 mL for ventricle, and 0.10 mL for hippocampus. We performed two prospective analyses for an additional 13 patients (seven men, six women; age range, 39–94 years) to examine the within-patient effects of different MPRAGE protocols. Functional ambulation performance is a quantitative, well-validated composite gait measure on the basis of step length, symmetry, and velocity, and the scores range from 95 to 100 in healthy adults (20,21). Mobility problems, dementia and urinary incontinence are the main symptoms of … Nervenarzt. Imaging appearances are nonspecific. 1968;2 (4): 307-27. 408, Parkinsonism & Related Disorders, Vol. The Akaike information criterion was used as a measure of the relative quality of a model that included a penalty for increasing the number of free variables to discourage overfitting. This study was approved by the institutional research board with a waiver of consent and was Health Insurance Portability and Accountability Act–compliant. 2000;21 (9): 1586-90. AJNR Am J Neuroradiol. 1997;40 (1): 67-73. 1. The normal systolic-diastolic pressure wave of the CSF causes three peaks: P1 (systolic pressure), P2 (viscoelastic response of the vessels, parenchyma, and dural sac, i.e., the compliance), and P3 (venous systolic wave). Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. We then computed the model’s accuracy, sensitivity, and specificity. Aqueductal Stroke Volume: Comparisons with Intracranial Pressure Scores in Idiopathic Normal Pressure Hydrocephalus. Patients with NPH present with a gradually progressive disorder. ); Center for Biomedical Imaging, Dept of Radiology, New York University School of Medicine, 660 First Ave, New York, NY 10016 (A.M.F., B.A.A., A.L., C.S., O.G., H.R., A.E.G. Magnetic resonance (MR) examinations performed before surgery (within 1–5 months of the MR examination) in 36 shunt-responsive patients with normal-pressure hydrocephalus (NPH; mean age, 75 years; age range, 58–87 years; 26 men, 10 women) and MR examinations of age- and sex-matched patients with Alzheimer disease (n = 34) and healthy control volunteers (n = 36) were studied. Utility of MRI-based disproportionately enlarged subarachnoid space hydrocephalus scoring for predicting prognosis after surgery for idiopathic normal pressure hydrocephalus: clinical research. A treatable syndrome, Diagnosis and management of idiopathic normal-pressure hydrocephalus, Incidence of idiopathic normal-pressure hydrocephalus in Northern Spain, Intracranial cerebrospinal fluid measurement studies in suspected idiopathic normal pressure hydrocephalus, secondary normal pressure hydrocephalus, and brain atrophy, Intracranial compartment volumes in normal pressure hydrocephalus: volumetric assessment versus outcome, Comparison of CSF distribution between idiopathic normal pressure hydrocephalus and Alzheimer disease, Prevalence of idiopathic normal-pressure hydrocephalus, Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging, Noninvasive MRI assessment of intracranial compliance in idiopathic normal pressure hydrocephalus, Brain MRI as a predictor of CSF tap test response in patients with idiopathic normal pressure hydrocephalus, Differentiating shunt-responsive normal pressure hydrocephalus from Alzheimer disease and normal aging: pilot study using automated MRI brain tissue segmentation, Evans’ index revisited: the need for an alternative in normal pressure hydrocephalus, An encephalographic ratio for estimating ventricular enlargement and cerebral atrophy, Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus, Study of INPH on neurological improvement (SINPHONI). 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