Search

Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

Applause sign (AS) was shown to be an indicator of frontal subcortical dysfunction in many neurodegenerative diseases. Idiopathic normal pressure hydrocephalus (INPH) is one of those in which frontosubcortical disconnection can be displayed. We aimed to examine the presence of AS in the elderly patients with INPH and its possible diagnostic role in the frontal dysfunction commonly seen in the disease. Sixty-six patients diagnosed with probable INPH, 32 with behavioral variant of frontotemporal dementia (bvFTD) and 325 healthy elderly subjects were included in this cross-sectional and retrospective study. AS was evaluated with the clapping test. Patients with INPH were further assessed with frontal assessment battery (FAB), Stroop test, verbal fluency test and clock drawing test (CDT). The concentration of total amyloid-beta 42 (A beta 42), A beta 40, total (t) tau and phosphorylated (p)-tau proteins were also measured in the cerebrospinal fluid (CSF). AS was observed in all groups (40% in bvFTD, 28.8% in INPH, 1.2% in controls, respectively). It was significantly more frequent in patients with bvFTD and INPH as compared to the controls (p < 0.001, for each). The frequency was similar in the patients with bvFTD and INPH (p = 0.802). Significant differences were found between the AS(+) and (-) INPH patients with regards to FAB, Stroop test-errors and verbal fluency test, except for the CSF proteins. AS can be used as a simple, useful and rapid clinical test that investigates executive dysfunction in elderly patients with INPH in both inpatient and outpatient settings.

Background: The amyloid-β oligomers, consisting of 10–20 monomers (AβO10–20), have strong neurotoxicity and are associated with cognitive impairment in Alzheimer’s disease (AD). However, their role in patients with idiopathic normal pressure hydrocephalus (iNPH) is poorly understood. Objective: We hypothesized that cerebrospinal fluid (CSF) AβO10–20 accumulates in patients with iNPH, and its clearance after CSF shunting contributes to neurological improvement. We measured CSF AβO10–20 levels before and after CSF shunting in iNPH patients evaluating their diagnostic and prognostic role. Methods: We evaluated two iNPH cohorts: “evaluation” (cohort-1) with 32 patients and “validation” (cohort-2) with 13 patients. Comparison cohorts included: 27 neurologically healthy controls (HCs), and 16 AD, 15 Parkinson’s disease (PD), and 14 progressive supranuclear palsy (PSP) patients. We assessed for all cohorts CSF AβO10–20 levels and their comprehensive clinical data. iNPH cohort-1 pre-shunting data were compared with those of comparison cohorts, using cohort-2 for validation. Next, we compared cohort-1’s clinical and CSF data: 1) before and after CSF shunting, and 2) increased versus decreased AβO10–20 levels at baseline, 1 and 3 years after shunting. Results: Cohort-1 had higher CSF AβO10–20 levels than the HCs, PD, and PSP cohorts. This result was validated with data from cohort-2. CSF AβO10–20 levels differentiated cohort-1 from the PD and PSP groups, with an area under receiver operating characteristic curve of 0.94. AβO10–20 levels in cohort-1 decreased after CSF shunting. Patients with AβO10–20 decrease showed better cognitive outcome than those without. Conclusion: AβO10–20 accumulates in patients with iNPH and is eliminated by CSF shunting. AβO10–20 can be an applicable diagnostic and prognostic biomarker.

Objective For idiopathic normal pressure hydrocephalus (iNPH), risk stratifying patients and identifying those who are likely to fare well after ventriculoperitoneal shunt (VP) surgery may help improve quality of care and reduce unplanned readmissions. The aim of this study was to investigate the drivers of 30- and 90-day readmissions after VP shunt surgery for iNPH in elderly patients. Methods The Nationwide Readmission Database, years 2013 to 2015, was queried. Elderly patients (≥65 years old) undergoing VP shunt surgery were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and identify 30- and 31- to 90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Results We identified 7199 elderly patients undergoing VP shunt surgery for iNPH. A total of 1413 (19.6%) patients were readmitted (30-R: n = 812 [11.3%] vs. 90-R: n = 601 [8.3%] vs. Non-R: n = 5786). The most prevalent 30- and 90-day complications seen among the readmitted cohort were mechanical complication of nervous system device implant (30-R: 16.1%, 90-R: 12.4%), extracranial postoperative infection (30-R: 10.4%, 90-R: 7.0%), and subdural hemorrhage (30-R: 6.0%, 90-R: 16.4%). On multivariate regression analysis, age, diabetes, and renal failure were independently associated with 30-day readmission; female sex, and 26th to 50th household income percentile were independently associated with reduced likelihood of 90-day readmission. Having any complication during the index admission independently associated with both 30- and 90-day readmission. Conclusions In this study, we identify the most common drivers for readmission for elderly patients with iNPH undergoing VP shunt surgery.

Background Comprehensively describe and compare (pre⁄postoperatively) the clinical symptomatology in adult non-communicated hydrocephalus. Associated hydrocephalus signs were analyzed with the idiopathic Normal Pressure Hydrocephalus Scale (iNPH Scale). A standardized clinical scale for non-communicated hydrocephalus is currently not in use. Methods Ten patients with hydrocephalus occlusus (HO) were analyzed. Hydrocephalus signs were examined with the iNPH Scale in gait, neuropsychology, continence, and balance before and three months after treatment with shunt operation or third endoscopic ventriculostomy. Results Patients significantly improved in iNPH total score (25.8%) and gait score (35.4%) three months after neurosurgical intervention. Domain scores in neuropsychology, continence, and balance reached statistical trends (p ≤ 0.066). Most clinical symptoms and signs at baseline improved after surgery (dizziness, lapse of concentration, gait instability, and headache). Conclusion Patients with non-communicated HO also showed classical hydrocephalus symptoms as communicated in iNPH patients. The iNPH Scale allows a structured neurological assessment over the disease’s progress and surgical intervention. Further studies with a larger patient samples are necessary to support our results.

Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients.Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome.Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P0.0001) Preoperative DESH correlated with improvement in mRS and GD (P0.0001).Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.

Lumboperitoneal (LP) shunting is a standard treatment for idiopathic normal pressure hydrocephalus (iNPH), with equivalent efficacy to ventriculoperitoneal (VP) shunting, and it is associated with a favorable outcome in approximately 75% of patients with iNPH. Despite the advantages, LP shunting can result in problems associated with the lumbar catheter, the obstruction of which has not been well described. This report presents two cases of LP shunt malfunction caused by lumbar catheter misplacement into the spinal subdural epiarachnoid space (SSES), and by subsequent obstruction. A 67-year-old man and a 69-year-old woman with iNPH underwent LP shunt placement without intraoperative fluoroscopy. Shortly after the surgery, they experienced a temporary improvement of their symptoms which was, however, followed by recurrence within a few months. This was suggestive of shunt malfunction. Although shunt pumping tests were normal, shuntography and subsequent computed tomography (CT) revealed lumbar catheter misplacement into the SSES. Shunt revisions, in which only the lumbar catheters were exchanged, were performed with intraoperative fluoroscopy and shuntography. Their symptoms have improved again following the revisions. In the present cases, lumbar catheter misplacement into the SSES caused LP shunt malfunction, and shuntography and CT were useful to detect the abnormality. Moreover, unrecognized lumbar catheter misplacement into the SSES might potentially have occurred in some patients considered as “non-responders” to LP shunting; hence, shuntography may be useful in those patients.

Idiopathic normal pressure hydrocephalus (iNPH) is a surgically treatable syndrome commonly observed in older adults. However, it is unclear whether clinical improvements after surgery can effectively reduce the long-term care burden (LTCB). In this study, we determined whether shunt surgery was effective in decreasing LTCB. We also investigated the degree of variability in patients and hospitals, using data from the iNPH multicenter study. This study involved 69 participants who underwent lumboperitoneal shunt surgery with follow-up for 12 months. A generalized linear mixed model was applied to analyze the fixed and random effects simultaneously. Regarding LTCB, the disability grades improved significantly. Although the dementia grades also improved, it was not statistically significant. The differences in the LTCB grades in most patients were within the range of the 95% confidence intervals, while in the case of hospitals, some were often out of the range. Further studies are needed to improve dementia in patients with iNPH. The incorporation of random variables, such as hospitals, is important for the analysis of data from multicenter studies.

BACKGROUND AND PURPOSE: Systematic analysis of angulation-related variability of idiopathic normal pressure hydrocephalus imaging biomarkers has not been published yet. Our aim was to evaluate the variability of these radiologic biomarkers with respect to imaging plane angulation. MATERIALS AND METHODS: Eighty subjects (35 with clinically confirmed idiopathic normal pressure hydrocephalus and 45 age- and sex-matched healthy controls) were prospectively enrolled in a 3T brain MR imaging study. Two independent readers assessed 12 radiologic idiopathic normal pressure hydrocephalus biomarkers on sections aligned parallel or perpendicular to the bicallosal, bicommissural, hypophysis-fastigium, and brain stem vertical lines, respectively. RESULTS: Disproportionately enlarged subarachnoid space hydrocephalus, simplified callosal angle, frontal horn diameter, z-Evans Index, and cella media vertical width did not show significant systematic differences in any of 6 section plane combinations studied. The remaining 7 biomarkers (including the Evans Index and callosal angle) showed significant differences in up to 4 of 6 mutually compared section plane combinations. The values obtained from sections aligned with the brain stem vertical line (parallel to the posterior brain stem margin) showed the most deviating results from other section angulations. CONCLUSIONS: Seven of 12 idiopathic normal pressure hydrocephalus biomarkers including the frequently used Evans Index and callosal angle showed statistically significant deviations when measured on sections whose angulations differed or did not comply with the proper section definition published in the original literature. Strict adherence to the methodology of idiopathic normal pressure hydrocephalus biomarker assessment is, therefore, essential to avoid an incorrect diagnosis. Increased radiologic and clinical attention should be paid to the biomarkers showing low angulation–related variability yet high specificity for idiopathic normal pressure hydrocephalus–related morphologic changes such as the z-Evans Index, frontal horn diameter, or disproportionately enlarged subarachnoid space hydrocephalus.

Background The cerebrospinal fluid tap test (CSF TT) is used for selecting shunt surgery candidates among patients with idiopathic normal pressure hydrocephalus (iNPH). We aimed to evaluate the predictive value of the CSF TT, by using the Hellström iNPH scale for shunted iNPH patients with a standardized method. Methods One hundred and sixteen shunt-operated iNPH patients were retrospectively included in this study. The gait and balance domains in the iNPH scale were used as outcome measures for the CSF TT and the total iNPH scale score as the postoperative outcome. A positive response to CSF TT was defined as a change of ≥ 5 points in the gait domain and ≥ 16 points in the balance domain. Differences between CSF TT responders and non-responders, sensitivity, specificity, positive and negative predictive values, accuracy, and correlations between changes from baseline to post CSF TT and from baseline to the postoperative follow-up, were calculated. Results In the CSF TT there were 63.8% responders in the gait domain and correspondingly 44.3% in the balance domain. CSF TT responders had a significantly better postoperative outcome in the total scale score (gait P ≤ 0.001, balance P ≤ 0.012) and gait CSF TT responders improved more in gait (P ≤ 0.001) and balance CSF TT responders in balance (P ≤ 0.001). No differences between CSF TT gait or balance responders could be found in neuropsychological or urinary continence assessments postoperatively. The sensitivity and specificity of the CSF TT and the outcome of the total iNPH scale score postoperatively were 68.1% and 52.0% for gait and 47.8% and 68.0% for balance, respectively. Conclusions The CSF TT, with the Hellström iNPH scale as the outcome measure, has clear limitations in predicting postoperative results. The gait domain may be used to predict outcomes for gait, but the balance domain is too insensitive.

BackgroundHealth-related quality of life (HRQoL) is severely impaired in persons with idiopathic normal pressure hydrocephalus (iNPH). The HRQoL improves in a number of patients after the placement of a cerebrospinal fluid (CSF) shunt, but long-term follow-up of HRQoL is rare.MethodsExtended follow-up (60 months) of a prospective cohort study involving 189 patients with iNPH who underwent shunt surgery. Preoperative variables were used to predict favorable HRQoL outcome (improvement or non-deterioration) measured by the 15D instrument 5 years after shunting.ResultsOut of the 189 initially enrolled study participants, 88 had completed 5-year HRQoL follow-up (46%), 64 had died (34%), and 37 (20%) failed to complete the HRQoL follow-up but were alive at the end of the study. After initial post-operative HRQoL improvement, HRQoL deteriorated so that 37/88 participants (42%) had a favorable HRQoL outcome 5 years after shunting. Multivariate binary logistic regression analysis indicated that younger age (adjusted OR 0.86, 95% CI 0.77–0.95;p p p ConclusionsThis extended follow-up showed that the self-evaluated HRQoL outcome is associated with iNPH patients’ pre-operative cognitive status, overweight and age. The post-operative deterioration may reflect the natural progression of iNPH, but also derive from aging and comorbidities. It indicates a need for long-term follow-up.

Idiopathic normal pressure hydrocephalus (iNPH) is a condition resulting from impaired cerebrospinal fluid (CSF) absorption and excretion characterized by a triad of symptoms comprising dementia, gait disturbance (impaired trunk balance), and urinary incontinence. CSF biomarkers not only assist in diagnosis but are also important for analyzing the pathology and understanding appropriate treatment indications. As the neuropathological findings characteristic of iNPH have yet to be defined, there remains no method to diagnose iNPH with 100% sensitivity and specificity. Neurotoxic proteins are assumed to be involved in the neurological symptoms of iNPH, particularly the appearance of cognitive impairment. The symptoms of iNPH can be reversed by improving CSF turnover through shunting. However, early diagnosis is essential as once neurodegeneration has progressed, pathological changes become irreversible and symptom improvement is minimal, even after shunting. Combining a variety of diagnostic methods may lead to a more definitive diagnosis and accurate prediction of the prognosis following shunt treatment. Identifying comorbidities in iNPH using CSF biomarkers does not contraindicate shunting-based intervention, but does limit the improvement in symptoms it yields, and provides vital information for predicting post-treatment prognosis.

Idiopathic normal pressure hydrocephalus (iNPH) is a rare neurological disorder with no clear prevalence factors and is a significant danger to the elderly. The intracranial glymphatic system is the internal environment that maintains brain survival and metabolism, and thus fluid exchange changes in the glymphatic system under various pathological conditions can provide important insights into the pathogenesis and differential diagnosis of many neurodegenerative diseases such as iNPH. iNPH can be diagnosed using a combination of clinical symptoms, imaging findings and history, and cerebrospinal fluid biomarkers due to the glymphatic system disorder. However, only few researchers have linked the two. Shunt surgery can improve the glymphatic system disorders in iNPH patients, and the surgical approach is determined using a combination of clinical diagnosis and trials. Therefore, we have composed this review to provide a future opportunity for elucidating the pathogenesis of iNPH based on the glymphatic system, and link the glymphatic system to the diagnosis and treatment of iNPH. The review will provide new insights into the medical research of iNPH.

Introduction: The indication of a ventriculoperitoneal shunt (VPS) is discussed in patients with idiopathic normal pressure hydrocephalus (iNPH), due to the heterogeneity of the response to treatment and the risks involved in neurosurgery. Objective: To search for clinical factors and complementary studies in order to determine predictors of a favorable response to the VPS placement in patients with iNPH. Methodology: A retrospective study of patients with probable iNPH (according to international guidelines) treated with VPS assisted in a neurological clinic from January 2014 to January 2017 was conducted. A univariate statisticalanalysis of the variables considered as possible prognostic factors was performed. Results: 58 patients were included. Women presented 3.68 times more chances of improvement after the VPS (p=0.019). Good response to the gait test was associated with better response to the VPS (p=0.024). Conclusions: Female sex and good response to the gait test could be considered as predictors of a favorable response to the VPS placement in patients with iNPH. A prospective study is necessary to achieve a homogeneous diagnostic evaluation and a more extensive longitudinal follow-up to evaluate the clinical evolution in this group of patients.

BackgroundThe workup for idiopathic normal pressure hydrocephalus (INPH) can be difficult to coordinate, and determining appropriate patients for ventriculoperitoneal shunting can be challenging. Therefore, we hypothesized that implementing a formalized protocol can improve patient selection for a shunt. In conjunction with neurology and neurosurgery, we instituted a standardized means of assessing patients whose presentation is concerning for INPH and compared their workup with similar patients seen without the Protocol (i.e., preprotocol [PP]) regarding baseline characteristics, assessment, and outcomes.MethodsTwenty-six PP patients were compared with 40 Protocol patients on measures, including baseline deficits, workup, neurosurgical evaluation, and response to shunt.ResultsAverage age was similar between groups, and the percentage of patients who had a decline in gait, cognition, and/or incontinence was not statistically different (p > 0.05). Significantly more Protocol patients underwent high-volume lumbar puncture (HVLP; 97.5%; PP, 61.5%; p < 0.001) and received formalized gait assessment with the Gait Scale (90%; PP, 0%, p < 0.001) and standardized cognitive testing (95%; PP, 38.5%; p < 0.001). Significantly more Protocol patients had no improvement after HVLP (33.3%; PP, 6.25%; p < 0.045); subsequently, fewer got shunted (57.5%; PP, 84.6%; p < 0.030). More Protocol patients who were shunted reported gait improvement (100%; PP, 72.7%; p = 0.009), although there was no difference in cognition (59.2%; PP, 82.6%; p = 0.108) or incontinence (18.2%; PP, 39.1%; p = 0.189).ConclusionsImplementing an INPH Protocol leads to standardized and more extensive assessment and better patient selection for and subsequent outcomes from shunting, specifically regarding gait.

Background Ventriculoatrial shunt (VAS) is a common alternative treatment option for hydrocephalus in patients with ventriculoperitoneal shunt (VPS) failure. Most previous reports on VAS discuss the atrial-related complications and none focus on simple removal (i.e., without specialized equipment). We report a case of simple VAS removal and simultaneous VPS revision, with no obvious shunt-related cardiac complications. Case presentation The patient was an 87-year-old female who had received a VAS for idiopathic normal pressure hydrocephalus 6 years prior. She developed a right thalamic hemorrhage with intraventricular hemorrhage and was admitted to our hospital. She had a recurrence of the hydrocephalus and was diagnosed with shunt malfunction, due to simple obstruction without obvious shunt-related cardiac complications. The VAS was simply and safely removed, and a VPS was simultaneously placed, as per the usual procedure in our institution. She remains well with no evidence of complications on postoperative day 10. Discussion Since VAS is mostly used in pediatric cases that are difficult to treat with VPS, the duration of time elapsed allows VAS catheters to form strong adhesions with the surrounding cardiac tissue. Therefore, the simple removal of VAS is usually not straightforward. Conclusion If the follow-up period is short and there are no specific cardiac complications at the time of replacement, VAS can be safely removed and VPS can be spontaneously placed, without any specialized surgical techniques or equipment.

Matrix metalloproteinases (MMPs) are extracellular enzymes involved in the degradation of extracellular matrix (ECM) proteins. Increased expression of MMPs have been described in traumatic brain injury (TBI) and may contribute to additional tissue injury and blood–brain barrier damage. The objectives of this study were to determine longitudinal changes in cerebrospinal fluid (CSF) concentrations of MMPs after acute TBI and in relation to clinical outcomes, with patients with idiopathic normal pressure hydrocephalus (iNPH) serving as a contrast group. The study included 33 TBI patients with ventricular CSF serially sampled, and 38 iNPH patients in the contrast group. Magnetic bead-based immunoassays were utilized to measure the concentrations of eight MMPs in ventricular human CSF. CSF concentrations of MMP-1, MMP-3 and MMP-10 were increased in TBI patients (at baseline) compared with the iNPH group (p

Идиопатическая нормотензивная гидроцефалия - хроническое прогрессирующее дегенеративное заболевание головного мозга, характеризующееся изменением конфигурации боковых желудочков и других ликворсодержащих пространств головного мозга на фоне нормального давления ликвора, проявляющееся клинически триадой симптомов: нарушением походки, развитием деменции и нарушением мочеиспускания. Патофизиология и патоморфогенез этого заболевания до конца не ясны. С появлением термина и описания клинической картины нормотензивной гидроцефалии в 1964 г. S. Hakim выполнено множество экспериментальных, морфологических и клинических исследований, направленных на выяснение ключевых звеньев патогенеза заболевания. В представленной работе приведена ретроспектива взглядов на закономерности патогенеза идиопатической нормотензивной гидроцефалии, анализируются современные исследования, посвящённые данной проблеме, а также обобщены и сформулированы основные теории, касающиеся ключевых звеньев патологического процесса. Idiopathic normal pressure hydrocephalus is a chronic, progressive degenerative brain disease characterized by ventricular enlargement disproportionate to other cerebrospinal fluid (CSF) spaces with normal CSF pressure. This disease presents with gait disturbance, cognitive impairment, and incontinence. The pathophysiology and morphogenesis of this condition are not well studied. Since the first description by S. Hakim in 1964, a number of experimental and morphological studies have focused on investigation of the disease mechanisms. This review retrospectively analyzed and summarized principal ideas about the pathogenesis of idiopathic normal pressure hydrocephalus.

BACKGROUND AND PURPOSE: Ventricular enlargement in idiopathic normal pressure hydrocephalus is often estimated using the Evans index. However, the sensitivity of the Evans index to estimate changes in ventricular size postoperatively has been questioned. Here, we evaluated the postoperative change in ventricle size in relation to shunt response in patients with idiopathic normal pressure hydrocephalus, by comparing ventricular volume and the Evans index. MATERIALS AND METHODS: Fifty-seven patients with idiopathic normal pressure hydrocephalus underwent high-resolution MR imaging preoperatively and 6 months after shunt insertion. Clinical symptoms of gait, balance, cognition, and continence were assessed according to the idiopathic normal pressure hydrocephalus scale. The ventricular volume of the lateral and third ventricles and the Evans index were measured using ITK-SNAP software. Semiautomatic volumetric analysis was performed, and postoperative changes in ventricular volume and the Evans index and their relationships to postoperative clinical improvement were compared. RESULTS: The median postoperative ventricular volume decrease was 25 mL (P < .001). The proportional decrease in ventricular volume was greater than that in the Evans index (P < .001). The postoperative decrease in ventricular volume was associated with a postoperative increase in the idiopathic normal pressure hydrocephalus scale score (P = .004). Shunt responders (75%) demonstrated a greater ventricular volume decrease than nonresponders (P = .002). CONCLUSIONS: Clinical improvement after shunt surgery in idiopathic normal pressure hydrocephalus is associated with a reduction of ventricular size. Ventricular volume is a more sensitive estimate than the Evans index and, therefore, constitutes a more precise method to evaluate change in ventricle size after shunt treatment in idiopathic normal pressure hydrocephalus.

Background and purpose The pathophysiology of idiopathic normal pressure hydrocephalus (iNPH) has not been completely clarified. We investigated the brain structure in iNPH using automatic ventricular volumetry, single-tensor diffusion tensor imaging (DTI) and bi-tensor free-water (FW) imaging analyses while focusing on cognitive impairments before and after lumboperitoneal shunt surgery. Materials and methods This retrospective study included 12 iNPH patients with structural magnetic resonance imaging (MRI) and diffusion MRI (dMRI) on a 3T-MRI scanner who underwent neuropsychological assessments before and after shunting and 8 healthy controls. Ventricular volumetry was conducted on structural MRI datasets using FreeSurfer. Ventricular volume was compared pre- and postoperatively. Correlation analyses were performed between ventricular volume or volume change and neuropsychological scores or score change. Tract-based spatial statistics were performed using dMRI datasets for group analyses between iNPH and controls and between pre- and post-surgery iNPH patients and for correlation analyses using neuropsychological scores. Tract-specific analyses were performed in the anterior thalamic radiation (ATR), followed by comparison and correlation analyses. Results The third ventricular volume was significantly decreased after shunting; its volume reduction negatively correlated with a neuropsychological improvement. Compared with controls, iNPH patients had lower fractional anisotropy and higher axial, radial, and mean diffusivities, and FW in the periventricular white matter including ATR, resulting in no difference in FW-corrected indices. Single-tensor DTI indices partially correlated with neuropsychological improvements, while FW-corrected indices had no correlations. Conclusion Third ventricle enlargement is possibly linked to cognitive impairment and FW imaging possibly provides better white matter characterization in iNPH.

Background Idiopathic normal pressure hydrocephalus and PSP share several clinical and radiological features, making differential diagnosis, at times, challenging. Objectives To differentiate idiopathic normal pressure hydrocephalus from PSP using MR volumetric and linear measurements. Methods Twenty-seven idiopathic normal pressure hydrocephalus patients, 103 probable PSP patients, and 43 control subjects were consecutively enrolled. Automated ventricular volumetry was performed using Freesurfer 6 on MR T1 -weighted images. Linear measurements, such as callosal angle and a new measure, termed MR Hydrocephalic Index, were calculated on MR T1 -weighted images. Receiver operating characteristic analyses were used for differentiating between patient groups. Generalizability and reproducibility of the results were validated, dividing each participant group in two cohorts used as training and testing subsets. Results Ventricular volumes and linear measurements (callosal angle and Magnetic Resonance Hydrocephalic Index) revealed greater ventricular enlargement in patients with idiopathic normal pressure hydrocephalus than in PSP patients and controls. PSP patients had ventricular volume larger than controls. Automated ventricular volumetry and Magnetic Resonance Hydrocephalic Index were the most accurate measures (98.5%) in differentiating patients with idiopathic normal pressure hydrocephalus from PSP patients, whereas callosal angle misclassified several PSP patients and showed low positive predictive value (70.0%) in differentiating between these two diseases. All measurements accurately differentiated idiopathic normal pressure hydrocephalus patients from controls. Accuracy values obtained in the training set (automated ventricular volumetry, 98.4%; Magnetic Resonance Hydrocephalic Index, 98.4%; callosal angle, 87.5%) were confirmed in the testing set. Conclusions Our study demonstrates that AVV and Magnetic Resonance Hydrocephalic Index were the most accurate measures for differentiation between idiopathic normal pressure hydrocephalus and PSP patients. Magnetic Resonance Hydrocephalic Index is easy to measure and can be used in clinical practice to prevent misdiagnosis and ineffective shunt procedures in idiopathic normal pressure hydrocephalus mimics. © 2020 International Parkinson and Movement Disorder Society.

Background: Normal-pressure hydrocephalus (NPH) affects the older people and the presentations are gait disturbance, incontinence and dementia. The reason is still unknown and there is increased CSF volume causing pressure to the periventricular brain causing the symptoms where there is no evidence of absorption failure or obstruction of the CSF pathway. Aims: The main objective of this study is to compare the surgical outcome of endoscopic third ventriculostomy (ETV) and VP shunt (VPS) in NPH. Methodology: A total of 24 patients were included in the study where 12 patients underwent ETV and 12 patients VPS. Patients having a definite cause of hydrocephalus and multiple co-morbid diseases were excluded from the study. Various Scoring systems were studied to see the efficiency of ETV. Results: About 60% of patients were successfully recovered. 40% needed to revision surgery either VP shunt or LP shunt. Some scales showed higher effieciency of ETV. Conclusion: ETV in NPH is a safe and effective procedure. Whether the CSF absorption is hampered at arachnoid granulation is doubtful for failure cases. ETV is a short procedure with a good success rate in selected patients.

Background: The image diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) is based on the ventriculomegaly, whose criterion is an Evans' Index (EI) >0.3. Recently, disproportionately enlarged subarachnoid space hydrocephalus (DESH) has been proposed as a morphological characteristic to iNPH. Several studies cast doubt on the reliability of these criteria in the diagnosis of iNPH. Furthermore, interobserver differences of these criteria have not yet been investigated. The objective of this study was to assess the diagnostic reliability and interobserver variability of EI and DESH. Materials and Methods: The preoperative magnetic resonance (MR) images of 84 definite iNPH patients were retrospectively evaluated by a neuroradiologist (NR) and physical therapist (PT). They independently assessed the EI and DESH. The MR images were evaluated preoperatively by a neurosurgeon (NS). The results were showed in mean (standard deviation). Results: The mean age was 78.4 (6.3) years (male:female = 49:35). The mean EI was 0.33 (0.04), 0.32 (0.04), and 0.31 (0.03) for NS, NR, and PT, respectively (P < 0.0001). The rate of accurate diagnosis of iNPH with EI >0.3 was 74%, 66%, and 61% for NS, NR, and PT, respectively, and there was a moderate level of agreement. By contrast, there was a substantial lower level of accuracy in assessment with DESH for all three evaluators as 50%, 44%, and 27% for NS, NR, and PT, respectively, again with a moderate level of agreement. However, the rates of patients fulfilling both EI >0.3 and DESH were remarkably lower than either of the two parameters individually at a mere 37%, 30%, and 16% for NS, NR, and PT, respectively, with a low level of agreement between the rates. Conclusion: This study suggests that DESH cannot be a diagnostic criterion for iNPH. If EI >0.3 and DESH were both necessary to diagnose iNPH, then more than 70% of patients would have been misdiagnosed and would have been deprived of the chance of treatment and its benefits. These results request a paradigm shift in the concepts of iNPH.

Objective: The aim was to examine the association between connectivity changes in the default mode network (DMN) and the progression of idiopathic normal pressure hydrocephalus (iNPH). Methods: We retrospectively recruited cases of preclinical and clinical iNPH from 2,196 patients who had received whole-body 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scanning. We included 31 cases with asymptomatic ventriculomegaly with features of iNPH on MRI (AVIM; reported as preclinical iNPH) and 12 with iNPH. We performed a voxel-based analysis of the brain FDG-PET images of the AVIM and iNPH groups as well as for each background-matched normal control (NC) group, using Statistical Parametric Mapping 12. Volume of interest (VOI)-based analysis was also performed. We set the VOI as the region from the precuneus to the posterior cingulate cortices (PCC), and compared the mean regional standardized uptake value ratio (SUVR) between the AVIM and iNPH group FDG-PET/CT images and each corresponding NC group. Results: The voxel-based analysis showed a greater decreased FDG uptake in the PCC in the iNPH group than in the AVIM group. The VOI-based analysis revealed no significant difference in the mean SUVR of the AVIM group and the corresponding NC group, but that of the iNPH group was significantly lower than that of its corresponding NC group. Conclusions: DMN connectivity was reduced in the clinical iNPH group but not in the preclinical group. These data suggest that alterations in the functional connectivity of the DMN are related to the onset of iNPH symptoms.

Introduction: Idiopathic normal pressure hydrocephalus (iNPH) is one of the potentially reversible dementias. Early and accurate diagnosis is important for patients’ prognosis. Emerging evidence shows fluid biomarkers are useful in diagnosis and pathophysiological research of iNPH. Methods: Probable iNPH and Alzheimer’s disease (AD) patients were recruited. Clinical diagnosis was performed according to international guidelines. CSF collection complied with a standard protocol. Commercial accessible ELISA kits were introduced for measurement of CSF t-tau, p-tau181, Aβ42, and NfL. Results: Twenty-seven iNPH, 27 AD, and 18 controls were included. The profiles of CSF t-tau, p-tau181, and t-tau/Aβ42 in the iNPH and AD were significantly different (p < 0.0001). The profiles of CSF t-tau, p-tau181, and t-tau/Aβ42 in the iNPH and control were not different (p > 0.05). Level of CSF Aβ42 in iNPH was significantly lower than control (p < 0.0001) and also significantly higher than AD (p < 0.05). NfL level in iNPH and AD was increased, but its level in iNPH was significantly lower than that in AD (p = 0.005). NfL and t-tau level in the iNPH group was significantly correlated (coefficient = 0.649, p = 0.005), but not in AD (coefficient = 0.298, p = 0.157). Conclusion: Alzheimer’s CSF biomarker profile of iNPH subjects showed moderately decreased Aβ42 and normal t-tau, p-tau181, and t-tau/Aβ42, which was distinguishable from AD. The different profiles and correlation of t-tau and NfL suggested different pathophysiology of AD and iNPH. t-tau was relatively an AD-specific neurodegenerative biomarker compared to NfL.

OBJECTIVESubdural hematomas and hygromas (SDHs) are common complications in idiopathic normal pressure hydrocephalus (iNPH) patients with shunts. In this registry-based study, patients with shunted iNPH were screened nationwide to identify perioperative variables that may increase the risk of SDH.METHODSThe Swedish Hydrocephalus Quality Registry was reviewed for iNPH patients who had undergone shunt surgery in Sweden in 2004–2014. Potential risk factors for SDH were recorded preoperatively and 3 months after surgery. Drug prescriptions were identified from a national pharmacy database. Patients who developed SDHs were compared with those without SDHs.RESULTSThe study population consisted of 1457 patients, 152 (10.4%) of whom developed an SDH. Men developed an SDH more often than women (OR 2.084, 95% CI 1.421–3.058, p < 0.001). Patients on platelet aggregation inhibitors developed an SDH more often than those who were not (OR 1.733, 95% CI 1.236–2.431, p = 0.001). At surgery, shunt opening pressures had been set 5.9 mm H2O lower in the SDH group than in the no-SDH group (109.6 ± 24.1 vs 115.5 ± 25.4 mm H2O, respectively, p = 0.009). Antisiphoning devices (ASDs) were used in 892 patients but did not prevent SDH. Mean opening pressures at surgery and the follow-up were lower with shunts with an ASD, without causing more SDHs. No other differences were seen between the groups.CONCLUSIONSiNPH patients in this study were diagnosed and operated on in routine practice; thus, the results represent everyday care. Male sex, antiplatelet medication, and a lower opening pressure at surgery were risk factors for SDH. Physical status and comorbidity were not. ASD did not prevent SDH, but a shunt with an ASD allowed a lower opening pressure without causing more SDHs.

The principle aim of the study was to demonstrate the value of performing delayed reassessment in the diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) and selection of suitable candidates for ventriculoperitoneal shunting (VPS). Thirty-one consecutive patients underwent the NPH protocol at the Flinders Medical Centre between March 2017 and November 2018. The protocol involved mobility and cognitive testing with reassessment post high-volume cerebrospinal fluid (CSF) removal at 24 h and 48 h. The Assessment of Quality of Life 6D (AQoL-6D) questionnaire and International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ-UI SF) were completed and repeated again at 6 weeks and 6 months post shunting. Results were analysed to determine the significance of delayed reassessment. Twenty patients (64.5%) underwent insertion of a VPS on the basis of objective improvements and specific criteria. Of these, 6 patients (30%) were shunted based on delayed reassessment at 48 h post CSF removal. Continued improvements were seen for all mobility and cognitive tests from baseline to 48 h post CSF removal. At 6 weeks and 6 months post shunting, there was an overall mean improvement in AQoL-6D and ICIQ-UI SF for the cohort and the improvement was also observed in the subgroup of patients who met shunt criteria at 48 h post CSF removal. In the diagnosis of shunt-responsive idiopathic normal-pressure hydrocephalus, delayed reassessment post CSF removal improves sensitivity and is therefore important.

BACKGROUND AND PURPOSE: The main radiological finding in progressive supranuclear palsy (PSP) is reduced midbrain volume. Both qualitative (e.g., hummingbird sign) and quantitative (e.g., area measurements) markers have been noted. Recent studies have shown a similar reduction also in idiopathic normal pressure hydrocephalus (iNPH). The purpose was to investigate the reliability and accuracy of these markers in discriminating PSP from iNPH and controls. METHODS: Eight neuroradiologists viewed sagittal MR images of the midbrain from 104 subjects: 26 PSP patients, 40 iNPH patients, and 38 healthy controls. They visually assessed whether the hummingbird sign was present or not, grading their confidence from 1 to 5. Assessments were translated into a score between +5 and -5: from maximum confidence of presence to maximum confidence of absence. A positive median score was considered to indicate hummingbird sign. Sagittal midbrain area was manually measured in each subject. RESULTS: Seventy-seven percent of PSP patients, 65% of iNPH, and 3% of controls were visually assessed as having the hummingbird sign. Manually measured midbrain area also showed overlap between PSP and iNPH. Regarding discrimination of PSP patients, midbrain area measurements, using a cutoff of 90 mm2 , yielded a higher area under the curve (AUC = 0.86) than visual assessment scores (AUC = 0.83), and higher reliability. CONCLUSIONS: Measuring sagittal midbrain area is more accurate and reliable than visual assessment. Due to significant overlap in appearance, a midbrain with a hummingbird sign or reduced sagittal area should raise the suspicion of PSP only after other signs of iNPH have been considered.

Objective: To evaluate the outcomes and prognostic factors of ventriculoperitoneal shunts (VP-shunts) in patients with idiopathic normal-pressure hydrocephalus (iNPH) at 6 months and 2 years after surgery.Method: We retrospectively analyzed 68 patients admitted to our institute and diagnosed with probable iNPH from January 2017 to March 2021. All patients underwent VP-shunt surgery with a programmable valve, and their outcomes were assessed via the Krauss index and modified Rankin scale (mRS) at 6 months and 2 years post-surgery. Univariate and multivariate regression analysis was performed to identify the prognostic factors.Results: The mean age of the patients was 71.1 ± 8.4 (mean ± standard deviation) years. On the Krauss improvement index, 6-month follow-up results were available for 68 patients. Of these patients, 91.2% experienced attenuation of their preoperative symptoms, with a mean Krauss index of 0.58 ± 0.27, and 48 patients (70.6%) had a Krauss index ≥0.5. Two-year follow-up results were available for 33 patients; 90.9% of them had sustained improvement, with a Krauss index of 0.54 ± 0.31, and 21 patients (66.3%) had a Krauss index ≥0.5. Thirty-three patients (58%) were living independently after 2 years (mRS 0–2). The outcomes were worse for patients with multiple comorbidities. Neither an increased patient age nor a prolonged history of illness was statistically significant prognostic factors for adverse outcomes of VP-shunt surgery.Conclusion: Surgical treatment was well-tolerated by patients with iNPH who received VP-shunts. Most patients experienced attenuation of their preoperative symptoms. Multiple concurrent comorbidities should be considered as adverse prognostic factors before shunt insertion in patients with iNPH.

Brain aquaporin 1 (AQP1) and AQP4 are involved in cerebrospinal fluid (CSF) homeostasis and might participate in the origin of hydrocephalus. Studies have shown alterations of perivascular AQP4 expression in idiopathic normal pressure hydrocephalus (iNPH) and Alzheimer’s disease (AD). Due to the overlapping of clinical signs between iNPH and certain neurological conditions, mainly AD, specific biomarkers might improve the diagnostic accuracy for iNPH. The goal of the present study was to analyze and quantify the presence of AQP1 and AQP4 in the CSF of patients with iNPH and AD to determine whether these proteins can be used as biomarkers of iNPH. We examined AQP1 and AQP4 protein levels in the CSF of 179 participants (88 women) classified into 5 groups: possible iNPH (81 participants), hydrocephalus associated with other neurological disorders (13 participants), AD (41 participants), non-AD dementia (32 participants) and healthy controls (12 participants). We recorded each participant’s demographic and clinical variables and indicated, when available in the clinical history, the record of cardiovascular and respiratory complications. An ELISA showed virtually no AQP content in the CSF. Information on the vascular risk factors (available for 61 patients) confirmed some type of vascular risk factor in 86% of the patients with possible iNPH and 58% of the patients with AD. In conclusion, the ELISA analysis showed insufficient sensitivity to detect the presence of AQP1 and AQP4 in CSF, ruling out the possible use of these proteins as biomarkers for diagnosing iNPH., This research was funded by grants PI16/00493 and PI19/01096 to M.E. from the Spanish Ministry of Economy and Competitiveness, co-financed by the Carlos III Health Institute (ISCIII) and European Regional Development Fund (FEDER). J.L.T-C. was partially supported by the Regional Government of Andalusia and FEDER funds through a program for recruitment of young researchers.

Idiopathic normal pressure hydrocephalus (iNPH) is an uncommon yet potentially reversible cause of dementia in the elderly. It is characterized by cognitive deterioration, urinary incontinence, ventriculomegaly (enlarged cerebral ventricles) and gait apraxia. The diagnosis and management of iNPH requires an organized approach, starting with a comprehensive history and neurologic examination, a review of neuroimaging, and an evaluation of diagnosis. It is important to treat comorbidities in patients prior to specific iNPH testing, which includes testing patient responses to temporary CSF removal and assessing CSF hydrodynamics. In carefully selected patients, all physiological and neurological symptoms improved with a ventriculoperitoneal (VP) shunt surgery, which allows for a gradual adjustment in pressure to prevent complications caused by over-drainage.

Cerebrospinal fluid (CSF) mask correction has been developed to reduce the influence by CSF area dilatation for 123I-FP-CIT accumulation. In this study, we assessed the effect of CSF mask correction on the specific binding ratio (SBR) for 25 patients with idiopathic normal pressure hydrocephalus (iNPH). The SBRs with and without CSF mask correction were calculated, and changes in quantitative values were verified. Additionally, the volume removed from striatal and background (BG) volume of interest (VOI) by the CSF mask correction was calculated, the volumes removed were compared to verify their effect on SBR. Twenty and five patients had low and high SBRs, respectively, after CSF mask correction. The images of 20 and 5 patients with SBRs that were decreased and increased, respectively, by CSF mask correction showed that the volumes removed from the BG region VOI were higher and lower, respectively, than those in the striatal region. In conclusion, the SBR before and after CSF mask correction was associated with the ratio of the volume removed from the striatal and BG VOIs, and the SBR was high or low according to the ratio. The results may indicate that CSF mask correction is effective in patients with iNPH. This study was registered in the UMIN Clinical Trials Registry (UMIN-CTR) as UMIN study ID: UMIN000044826.

Study Objectives Previous studies have shown sleep-disordered breathing (SDB) to be highly prevalent in patients with idiopathic normal pressure hydrocephalus (iNPH). The current study aimed to estimate and compare the prevalence of SDB in patients with different types of hydrocephalus and test if SDB was associated with changed CO2. Methods We investigated the prevalence of SDB in a prospective cohort of 48 hydrocephalus patients with nocturnal polysomnography (PSG). Twenty-three of the patients also had simultaneous CO2 measurements. Results The prevalence of SDB was high in patients with iNPH, with moderate-to-severe SDB in 21/22 (96%) of the patients and an apnea-hypopnea index (AHI) of 43.5 (95% CI 33.8–52.2). Patients with pediatric-onset hydrocephalus had moderate-to-severe SDB in 7/16 (44%), with an AHI of 16.1 (95% CI 8.16–23.8). Except for one patient, all patients with adult-onset obstructive hydrocephalus (9/10) had normal respiration or mild SDB with an AHI of 8.4 (95% CI 5.5–10.5). None of the 23 patients measured with CO2 had elevated CO2 associated with SDB and had normal CO2 during sleep, with 40.8 ± 5.5 mmHg, 42.7 ± 4.1 mmHg, 34.5–45.8 mmHg for patients with iNPH, pediatric-onset, and adult-onset, respectively. Conclusion We found a high prevalence of SDB in patients with iNPH, confirming previous findings. We extended this with the finding that the prevalence of SDB in patients with other types of hydrocephalus is not significantly different from that in the general population. Additionally, we did not find elevations of CO2 associated with SDB or CO2 retention during sleep.

BACKGROUND: Disproportionately enlarged subarachnoid space hydrocephalus is a specific radiologic marker for idiopathic normal pressure hydrocephalus. However, controversy exists regarding the prognostic utility of disproportionately enlarged subarachnoid space hydrocephalus. PURPOSE: Our aim was to evaluate the prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and its predictive utility regarding prognosis in patients treated with ventriculoperitoneal shunt surgery. DATA SOURCES: We used MEDLINE and EMBASE databases. STUDY SELECTION: We searched for studies that reported the prevalence or the diagnostic performance of disproportionately enlarged subarachnoid space hydrocephalus in predicting treatment response. DATA ANALYSIS: The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was obtained. Pooled sensitivity, specificity, and area under the curve of disproportionately enlarged subarachnoid space hydrocephalus to predict treatment response were obtained. Subgroup and sensitivity analyses were performed to explain heterogeneity among the studies. DATA SYNTHESIS: Ten articles with 812 patients were included. The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus was 44% (95% CI, 34%–54%). The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was higher in the studies using the second edition of the Japanese Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus compared with the studies using the international guidelines without statistical significance (52% versus 43%, P = .38). The pooled sensitivity and specificity of disproportionately enlarged subarachnoid space hydrocephalus for prediction of treatment response were 59% (95% CI, 38%–77%) and 66% (95% CI, 57%–74%), respectively, with an area under the curve of 0.67 (95% CI, 0.63–0.71). LIMITATIONS: The lack of an established method for assessing disproportionately enlarged subarachnoid space hydrocephalus using brain MR imaging served as an important cause of the heterogeneity. CONCLUSIONS: Our meta-analysis demonstrated a relatively low prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and a poor diagnostic performance for treatment response.

Object: To evaluate the relationship between idiopathic normal-pressure hydrocephalus (iNPH) and lumbar spinal stenosis (LSS).Methods: With the aging of society, the numbers of patients with iNPH and LSS are likely to increase. iNPH and LSS have similar symptoms including gait disturbance and urinary dysfunction. The prevalence of dementia is higher in older adults with LSS. However, the relationship of LSS with iNPH and the prevalence of LSS in patients with iNPH are unknown. In our department between April 2011 and March 2017, 226 patients were diagnosed with iNPH and underwent shunt operation including lumboperitoneal shunts and ventriculoperitoneal shunts. Two spine surgeons evaluated LSS on magnetic resonance imaging of the lumbar spine. Age, sex, body mass index, Timed Up and Go test, Mini Mental State Examination score, and urinary dysfunction were examined before and after surgery for iNPH. Changes in these variables were compared between patients with iNPH without LSS and with iNPH and LSS.Results: In the overall cohort, the median patient age was 78 years and there were 121 males. Among 226 patients with iNPH, 73 (32.3%) had LSS. Neurological symptoms were improved in all patients at final follow-up. The rate of symptom improvement was lower for the iNPH and LSS group compared with the iNPH without LSS group.Conclusions: Surgery to improve gait disturbance might be difficult in patients with iNPH with LSS. When examining patients with iNPH, we should consider the possibility of concomitant LSS.

The mainstay of treatment for idiopathic normal-pressure hydrocephalus (iNPH) is spinal fluid shunting. A tap test (TT) is recommended as an indication of shunting. Patients with iNPH are often elderly and have multiple comorbidities affecting the shunting outcome. We investigated the factors affecting TT in patients with iNPH.Seventy-five patients with iNPH were admitted to our department for a TT from April 2010 to May 2021. The patients were divided into a responsive group and an unresponsive group according to the clinical outcomes after TT on the Timed Up and Go Test (TUG), Mini-Mental State Examination (MMSE), or iNPH grading scale. Factors affecting the TT were compared between the responders and nonresponders.There were 38 patients (50.7%) in the TT responder group, and the prevalence of improvement was 82.9% in the TUG, 27.6% in the MMSE, and 76.3% in the iNPH grading scale. There were no significant differences in the vascular risk factors between the two groups. The prevalence of lumbar spondylosis, compression fracture, severe periventricular hyperintensity, deep and subcortical white matter hyperintensity (DSWMH), and old cerebral infarcts was significantly higher among the TT nonresponders. The logistic regression analysis showed that severe DSWMH and lumbar spondylosis were associated with a TT nonresponse (p 0.001 and p = 0.003, respectively). Shunting was performed in 22 patients, 19 of whom were TT responders.Severe DSWMH and lumbar spondylosis were associated with a poor response to the TT in iNPH patients. We should consider risk factors when selecting candidates for shunt surgery.

Background Atlas-based volumetry using three-dimensional T1-weighted (3D-T1W) magnetic resonance imaging (MRI) has been used previously to evaluate the volumes of intracranial tissues. Purpose To evaluate the detectability of volume difference and accuracy for volumetry using smoothed data with an atlas-based method. Material and Methods Twenty healthy individuals and 24 patients with idiopathic normal-pressure hydrocephalus (iNPH) underwent 3-T MRI, and sagittal 3D-T1W images were obtained in all participants. Signal values (as tissue probability) of voxels in five segmented data types (gray matter, white matter, cerebrospinal fluid [CSF], skull, soft tissue) derived from the 3D-T1W images with SPM 12 software were assigned simulated 3D-T1W signal intensities to each tissue image. The assigned data were termed “reference data.” We created a reference 3 D-T1W image that included the reference data of all five tissue types. Standard volumes were measured for the reference CSF data with region of interest of lateral ventricle in native space, and measured volumes were obtained for non-smoothed and smoothed-modulated data. Detectability was evaluated between measured volumes in the healthy control and iNPH groups. Accuracy was evaluated as the difference between the mean measured and standard volumes. Results In group comparison of measured volumes between the healthy control and iNPH groups, the lowest P value was for smoothed-modulated CSF data. In both groups, the largest difference from the standard volume was found for the mean of the measured volumes for smoothed-modulated CSF data. Conclusion Our study shows that using smoothed data can improve detectability in group comparison. However, using smoothed data reduces the accuracy of volumetry.

Objectives To clarify a characteristic of dynamic stability during gait in idiopathic normal pressure hydrocephalus (iNPH) and Parkinson's disease (PD), and to explore the association between dynamic stability and disease severity in each disease. Materials and methods The 5-m gait of 36 iNPH (precerebrospinal fluid drainage), 20 PD (medicated state), and 25 healthy controls (HC) were evaluated using three-dimensional motion analysis. Ambulatory dynamic stability was defined as the ability to maintain the extrapolated center of mass within the base of support at heel contact, with the distance between the two referred to as the margin of stability (MOS). Results Anteroposterior direction (AP) MOS was significantly larger in the iNPH and PD groups than in the HC group; no significant difference was found between the iNPH and PD groups. Mediolateral direction (ML) MOS was significantly larger in the iNPH and PD groups than in the HC group and significantly larger in the iNPH group than in the PD group. In the iNPH group, the disease severity was positively correlated with only ML MOS. In the PD group, the disease severity was positively correlated with the AP MOS and ML MOS. Conclusions Dynamic stability in iNPH increases in AP and ML, and it may be associated with not only iNPH-associated gait disturbance but also with a voluntarily cautious gait strategy. Dynamic stability in PD only increased in AP, and this may be associated with PD symptoms. These findings will help physicians understand the difference in pathological gait including dynamic stability between patients with iNPH and PD.

Background/aim In this study, we aimed to evaluate whether morphological changes in the mesencephalon which were previously described as a diagnostic tool for progressive supranuclear palsy could be associated also with idiopathic normal pressure hydrocephalus. Materials and Methods Consecutive 52 patients with a possible diagnosis of idiopathic normal pressure hydrocephalus (32 female, mean age 73.6 years) and 40 controls (23 female, mean age 72.7 years) with similar demographic characteristics were included the study. The morphologic changes in mesencephalon; hummingbird sign and the vascular compression to mesencephalon were noted. Besides three independent observers evaluated the imaging parameters for idiopathic normal pressure hydrocephalus in Magnetic Resonance Imaging. Inter-observer reliabilities for qualitative and quantitative data were assessed using the Cronbach's Alpha and Intra Class Correlation Coefficient. The correlation of the imaging parameters with each other was evaluated with Pearson correlation. Results Hummingbird sign was found to be significantly more common among patients with idiopathic normal pressure hydrocephalus (p