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The callosal angle measured on MRI as a predictor of outcome in idiopathic normal-pressure hydrocephalus
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurology.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
2014 (English)In: Journal of Neurosurgery, ISSN 0022-3085, E-ISSN 1933-0693, Vol. 120, no 1, 178-184 p.Article in journal (Refereed) Published
Abstract [en]

Object

Different neuroimaging biomarkers have been studied to find a tool for prediction of response to CSF shunting in idiopathic normal-pressure hydrocephalus (iNPH). The callosal angle (CA) has been described as useful in discriminating iNPH from ventricular dilation secondary to atrophy. However, the usefulness of the CA as a prognostic tool for the selection of shunt candidates among patients with iNPH is unclear. The aim of this study was to compare the CA in shunt responders with that in nonresponders and clarify whether the CA can serve as a predictor of the outcome.

Methods

Preoperative MRI brain scans were evaluated in 109 patients who had undergone shunt surgery for iNPH during 2006-2010. Multiplanar reconstruction was performed interactively to obtain a coronal image through the posterior commissure, perpendicular to the anterior-posterior commissure plane. The CA was measured as the angle between the lateral ventricles on the coronal image. The patients were examined clinically before surgery and at 12 months postoperatively.

Results

Shunt responders had a significantly smaller mean preoperative CA compared with nonresponders: 59° (95% CI 56°-63°) versus 68° (95% CI 61°-75°) (p < 0.05). A CA cutoff value of 63° showed the best prognostic accuracy.

Conclusions

The preoperative CA is smaller in patients whose condition improves after shunt surgery and may be a useful tool in the selection of shunt candidates among patients with iNPH.

Place, publisher, year, edition, pages
http://thejns.org/action/showCoverGallery?journalCode=jns, 2014. Vol. 120, no 1, 178-184 p.
National Category
Medical and Health Sciences Radiology, Nuclear Medicine and Medical Imaging
Identifiers
URN: urn:nbn:se:uu:diva-208803DOI: 10.3171/2013.8.JNS13575ISI: 000329087900027PubMedID: 24074491OAI: oai:DiVA.org:uu-208803DiVA: diva2:654599
Available from: 2013-10-08 Created: 2013-10-08 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Idiopathic Normal Pressure Hydrocephalus: Cerebrospinal Fluid Tap Test and Magnetic Resonance Imaging as Preoperative Prognostic Investigations
Open this publication in new window or tab >>Idiopathic Normal Pressure Hydrocephalus: Cerebrospinal Fluid Tap Test and Magnetic Resonance Imaging as Preoperative Prognostic Investigations
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Idiopathic normal pressure hydrocephalus (iNPH) is a condition with dilated cerebral ventricles but intracranial pressure within normal limits. The symptoms of gait impairment, cognitive decline and urinary incontinence develop gradually. Treatment with shunt insertion results in improvement in eight out of ten patients.

The cerebrospinal fluid tap test (CSF TT) and preoperative magnetic resonance imaging (MRI) are methods used to select patients who may benefit from shunt surgery, but they are performed and interpreted differently in different centers throughout the world. The aim of this thesis was to evaluate the performance of the CSF TT and the underlying mechanisms of improvement in gait function after CSF removal, and to investigate the prognostic value of preoperative MRI scans.

Improvement in gait and changes in cerebral blood flow (CBF) after a CSF TT were investigated in two prospective studies that included 39 and 20 patients, respectively. Gait assessment and perfusion MRI were done before and several times during the first 24 hours after a CSF TT. Perfusion was investigated with pseudo-continuous arterial spin labeling. At the group level, gait function was significantly improved at all investigation times, but only one-third of individual CSF TT responders were improved at all investigation times. In patients with increased CBF in lateral and frontal white matter after the CSF TT, gait function improved more than it did in patients with decreased CBF in these regions. However, in the whole sample, there was no significant increase in CBF after CSF removal.

Preoperative MRI scans were retrospectively evaluated in 109 patients with iNPH who had undergone shunt surgery. The callosal angle was smaller in shunt responders compared with non-responders. The following findings showed the highest association with a positive outcome after shunting: a small callosal angle, wide temporal horns, and occurrence of disproportionally enlarged subarachnoid space hydrocephalus.

In conclusion, CBF in white matter close to the lateral ventricles may play a role in the reversibility of symptoms after CSF removal in patients with iNPH. The CSF TT should be reevaluated if the patient does not initially improve, and preoperative MRI investigations can add prognostic information regarding the selection of shunt candidates.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. 98 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1001
Keyword
normal pressure hydrocephalus, NPH, cerebrospinal fluid disorders, dementia, MRI, CSF tap test, CBF, ASL
National Category
Neurology
Research subject
Neurology; Neurosurgery; Radiology
Identifiers
urn:nbn:se:uu:diva-222779 (URN)978-91-554-8958-8 (ISBN)
Public defence
2014-06-09, Gunnesalen, Akademiska sjukhuset, ing 10, 751 85, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-05-19 Created: 2014-04-14 Last updated: 2014-06-30

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Virhammar, JohanLaurell, KatarinaCesarini, Kristina GiulianaLarsson, Elna-Marie

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