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Idiopathic normal pressure hydrocephalus: cerebral perfusion measured with pCASL before and repeatedly after CSF removal
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. Department of Pharmacology and Clinical Neuroscience, Östersund, Umeå University.
Department of Medical Radiation Physics, Lund University.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
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2014 (English)In: Journal of Cerebral Blood Flow and Metabolism, ISSN 0271-678X, E-ISSN 1559-7016, Vol. 34, no 11, 1771-1778 p.Article in journal (Refereed) Published
Abstract [en]

Pseudo-continuous arterial, spin labeling (pCASL) measurements were performed in 20 patients with idiopathic normal pressure hydrocephalus (iNPH) to investigate whether cerebral blood flow (CBF) increases during the first 24 hours after a cerebrospinal fluid tap test (CSF TT). Five pCASL magnetic resonance imaging (MRI) scans were performed. Two scans were performed before removal of 40 mL CSF, and the other three at 30 minutes, 4 hours, and 24 hours, respectively after the CSF TT. Thirteen different regions of interest (ROIs) were manually drawn on coregistered MR images. 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 compared with baseline investigations. The repeatability of CBF measurements at baseline was high, with intraclass correlation coefficients of 0.60 to 0.90 for different ROIs, but the median regional variability was in the range of 5% to 17%. Our results indicate that CBF in white matter close to the lateral ventricles plays a role in the reversibility of symptoms after CSF removal in patients with iNPH.

Place, publisher, year, edition, pages
2014. Vol. 34, no 11, 1771-1778 p.
Keyword [en]
arterial spin labeling, cerebral blood flow, cerebral perfusion, normal pressure hydrocephalus, pCASL, volumetry
National Category
Neurology
Research subject
Neurology; Neurosurgery; Radiology; Neuroscience
Identifiers
URN: urn:nbn:se:uu:diva-222771DOI: 10.1038/jcbfm.2014.138ISI: 000344428800005PubMedID: 25138210OAI: oai:DiVA.org:uu-222771DiVA: diva2:712182
Available from: 2014-04-14 Created: 2014-04-14 Last updated: 2017-12-05Bibliographically 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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