ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. From the initial chart review of patients from the adult hydrocephalus clinic from January 2003 through December 2014 (n = 624), we selected patients who (a) completed a high-volume lumbar puncture or lumbar drain that resulted in a significant clinical improvement (ie, improvement in functional ambulation performance score, and clinician [J.G.] One theory is that the condition is an obstructive type of communicating hydrocephalus due to reduced CSF resorption. All clinical evaluations performed after shunt were performed on average 10 months after surgery (range, 6–18 months). Predicting the results of cerebrospinal fluid shunting. There are several limitations to this study that need to be considered when interpreting the data. Each ADNI MR imaging examination had to pass screening for blurring, ghosting, and flow artifacts; image homogeneity; signal-to-noise ratio; susceptibility artifacts; and gray-white cerebrospinal fluid contrast. N.M. and H.R. Hayhow B, Begic F, Evans A et-al. Ringstad G, Emblem KE, Geier O, Alperin N, Eide PK. This study compared the accuracy of traditional measures of NPH, namely CA and EI, with segmentation metrics for diagnosis. MRS has not been shown to have any added value for differentiating idiopathic NPH from other types of dementia, nor does it help in patient selection for VP shunting 22. Finally, Table 4 demonstrates that as we progressively excluded cases with the largest ventricular volumes, the diagnostic accuracy of the volumetric model remained above 90%. Radiology. 1996;198(2):523-529. Periventricular hypodensity (on CT) or high T2-FLAIR signal (on MRI) is supportive of changes in brain water content seen in NPH, but these findings can also be seen with microvascular ischemic changes or demyelination 2,25. 2008;29 (1): 1-3. 30. It is thought to have been initially described by Colombian neurosurgeon Salomón Hakim and R D Adams in 1965, although it may actually have been described earlier under a different name by McHugh 4,6,7. We also showed that the predictive model on the basis of combined CA and EI measures demonstrated comparable accuracy to our previously proposed model, which was based on ventricular and gray matter volumes (11) in the distinction between NPH and non-NPH. NPH is different than other types of hydrocephalus in that it develops slowly over time. Check for errors and try again. Demographics of the three patient groups are listed in Table 1. Symptoms may be relieved by ventricular shunting. Note.—Data in parentheses are numerator and denominator. Normal pressure hydrocephalus: significance of MRI in a potentially treatable dementia. We excluded participants who did not demonstrate this positive response to shunt to minimize confounding of comorbid neurodegenerative disorders. ; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; agrees to ensure any questions related to the work are appropriately resolved, all authors; literature research, N.M., H.P., A.M.F., B.A.A., A.L., B.E.D., C.S., Y.S., O.G., H.R., A.E.G. The drainage of CSF is blocked gradually, and the excess fluid builds up slowly. Ventricular volume differences across the three groups were statistically significant (F = 93.7; P < .0001). Extensive demographics, family history, and medical history are available for all ADNI participants. 19 (7): 1277-84. Thus, our proposed prediction model on the basis of CA and EI may serve as a screening tool to help the radiologist identify patients with possible NPH and recommend further volumetric assessment. From the Dept of Radiology, Brigham and Women’s Hospital, Boston, Mass (N.M.); Riverside Regional Medical Center, Newport News, Va (H.P. We also plan to analyze volumetric measures of patients presumed to have NPH who did not respond to high-volume lumbar puncture or spinal drain procedures to identify imaging features that may predict response to cerebrospinal fluid removal. Table 2 Results from Two Types of Multivariate Logistic Regression Models to Distinguish NPH from Non-NPH Patients. Scand. Adachi M, Kawanami T, Ohshima F et-al. One of the outcomes of the logistic regression model is the estimated probability of NPH for each patient. 52 (11): 775-809. ■ 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. 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. The model that used CA and EI demonstrated 89.6%–93.4% accuracy and average area under the curve of 0.96 in differentiating patients with NPH from patients without NPH (ie, Alzheimer disease and healthy control). Normal pressure hydrocephalus (NPH) is an abnormal buildup of cerebrospinal fluid (CSF) in the brain's ventricles, or cavities. Analysis of variance was used to compare mean values of individual variables across study groups. (2009) ISBN:3211855785. 35. Unfortunately, the diagnostic sensitivity and specificity of EI and CA are controversial (10,12,17–19), and therefore their role has remained limited. Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. MRI is the best modality to image anatomical changes and can further support the diagnosis with CSF flow studies and magnetic resonance spectroscopy. We then computed the model’s accuracy, sensitivity, and specificity. For patients from ADNI, we used T1-weighted MPRAGE sequences performed with a 3-T imager (2300/2.98/853; flip angle, 9°; 256 × 256 × 192 matrix; nonisotropic 1.0 × 1.0 × 1.2 mm voxels; and bandwidth, 240 Hz/pixel) and a 1.5-T imager (2400/3.5/1000; flip angle, 8°; 192 × 192 × 160 matrix; 1.2 × 1.2 × 1.25 mm voxels; and bandwidth, 180 Hz/pixel). 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). (2010) Cerebrospinal fluid research. The regression model that used volumetric predictors of gray matter and white matter was 94.3% accurate. 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). and N.M., with 1 and 2 years of experience, respectively) and one neuroradiologist (A.G., with 45 years of experience). 2008;118 (1): 48-53. ICCs showed very good interobserver agreement for CA (ICC, 0.92; 95% confidence interval: 0.89, 0.95) and good agreement for EI (ICC, 0.81; 95% confidence interval: 0.73, 0.87). Data collection and sharing for ADNI supported by National Institutes of Health (U01 AG024904), including the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through contributions from Alzheimer’s Association; Alzheimer’s Drug Discovery Foundation; BioClinica; Biogen Idec; Bristol-Myers Squibb; Eisai; Elan Pharmaceuticals; Eli Lilly and Company; F. Hoffmann-La Roche and its affiliated company Genentech; GE Healthcare; Innogenetics; IXICO; Janssen Alzheimer Immunotherapy Research and Development; Johnson and Johnson Pharmaceutical Research and Development; Medpace; Merck; Meso Scale Diagnostics; NeuroRx Research; Novartis Pharmaceuticals Corporation; Pfizer; Piramal Imaging; Servier; Synarc; and Takeda Pharmaceutical Company. Nuclear medicine is less important in diagnosing NPH. 22. Imaging appearances are nonspecific. Diagnosis of idiopathic normal pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort study, Diagnosing idiopathic normal-pressure hydrocephalus, The differential diagnosis of Alzheimer’s disease. The Canadian Institutes of Health Research provided funds to support ADNI clinical sites in Canada. There is, however, a well-established correlation between higher flow velocities and the favorable outcome after ventriculoperitoneal (VP) shunting; hence, quantitative (rather than qualitative) methods have been developed which can be useful not only in patient selection for shunting but also in diagnosis and predicting prognosis 12-15. 29. 27. Relative to mean value, the bias was 4.20% for gray matter, −7.4% for white matter, 4.8% for ventricle, and 3.2% for hippocampus. Normal pressure hydrocephalus (NPH) is a type of hydrocephalus that usually occurs in older adults. Unlike the model based on the volumetric measures, the model based on CA and EI performs poorly in classifying both patients with AD and HC volunteers. ■ The range for discrimination between patients with NPH and patients who do not have NPH on the basis of combination of CA and EI is 89.6%–93.4% depending on the reader, and it is comparable to 94.3% accuracy of volumetric assessment. Because this disorder is potentially treatable, research focused on improving diagnosis through noninvasive imaging techniques (8,9). ); Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY (B.E.D. Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population. 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. 2006;78(4):395-398. Bradley WG, Scalzo D, Queralt J, et al. Mori E, Ishikawa M, Kato T, Kazui H, Miyake H, Miyajima M, Nakajima M, Hashimoto M, Kuriyama N, Tokuda T, Ishii K, Kaijima M, Hirata Y, Saito M, Arai H. Guidelines for management of idiopathic normal pressure hydrocephalus: second edition. Similar to Alzheimer disease (AD), the prevalence of NPH increases with age, reaching about 6% in those over 80 (3). MRI features are in favor of normal pressure hydrocephalus "NPH" and supported by patient aqueduct showing accentuated CSF flow void signal within its lumen. We assessed the systematic bias and the discrepancy for gray matter, white matter, ventricular, and hippocampal volumes. Gait disorders are the initial manifestations; other symptoms appear as the disease progresses (2). Ventricular volumes in NPH are on average well above 100 mL (4–6). 36 (9): 1623-30. This task greatly benefits from volumetric segmentation. 277 (1-2): 54-7. There is a general agreement that NPH is complex and underdiagnosed, and a detailed characterization of its severity is lacking (2). Hurley RA, Bradley WG, Latifi HT et-al. These cutoffs were obtained by combining the measurements from three observers and systematically varying the cutoff levels to maximize diagnostic accuracy. Author contributions: Guarantors of integrity of entire study, N.M., B.A.A., A.L., A.E.G. 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). Normal pressure hydrocephalus (NPH) happens when too much fluid builds up in a person’s brain without increasing pressure in their brain tissue. Curr Neurol Neurosci Rep. 2008;8 (5): 371-6. Table 2 shows the results of multivariate binary logistic regression models constructed for each reader separately to diagnose NPH (ie, a positive finding). Virhammar J, Laurell K, Cesarini KG, Larsson EM. For comparisons between the ADNI and the local MPRAGE, eight patients (for whom informed consent was obtained) from the adult hydrocephalus clinic scheduled for diagnostic MR imaging during September 2016 were chosen at random and imaged twice, first by using ADNIMPRAGE protocol and then by using the local MPRAGE protocol on the same 1.5-T imager (Avanto; Siemens) in consecutive examinations. American journal of neuroradiology. Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging. Part of the data used in preparation of this article was obtained from the ADNI database (adni.loni.usc.edu). Hakim and Adams [(1)][1] are generally credited with the initial description of NPH, although it may ■ Segmentation metrics may be used as a secondary tool after CA and EI in equivocal cases for more resource intensive but more accurate distinction of NPH from AD or HC. 10.4 Imaging 10.4.1 Modalities 10.4.1.1 Computed Tomography Figure 1: By using MPRAGE sequences, a coronal plane was obtained at the level of the posterior commissure from each observer’s best approximation (blue and red lines, left), with plane oriented 90° to anterior-posterior commissure line. AUC = area under the curve, GM = gray matter volume, VNT = ventricular volume. The structures involved in this study are part of fundamental neuroanatomy expected during medical school training. Enter your email address below and we will send you the reset instructions. ); 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. Several signs of normal pressure hydrocephalus: narrow callosal angle of 74 degrees; coronal T2: periventricular edema (green arrows) sagittal T1: wide cerebral aqueduct (red arrow) and normal floor of the 3rd ventricle (green arrow) axial T2: increased flow void in the aqueduct (green arrow) axial T2: narrow parasagittal CSF fissures (green arrows) (2014) AJNR. Scollato A, Tenenbaum R, Bahl G et-al. Average gray matter volume in AD was significantly lower than in NPH or HC volunteers (Tukey honest significant difference test, P < .01). Normal-pressure hydrocephalus (NPH), also called malresorptive hydrocephalus, is form of communicating hydrocephalus in which excess cerebrospinal fluid (CSF) occurs in the ventricles, and with normal or slightly elevated cerebrospinal fluid pressure. The number of patients with normal-pressure hydrocephalus will increase considerably in the next few decades as a result of demographic trends. Relative to mean value, the bias was 1.0% for gray matter, −0.4% for white matter, 0% for ventricle, and 1.3% for hippocampus. In our patients, functional ambulation performance was determined by using the GaitRite system (CIR Systems, Havertown, Pa) (21). Diagnosing idiopathic normal-pressure hydrocephalus. AJNR. The classic triad consists of the following: 1. Normal-pressure hydrocephalus remains a controversial entity with often ambiguous imaging findings. Differences in the hippocampus across the three groups were significant (F = 28.49; P < .0001). Normal pressure hydrocephalus: new concepts on etiology and diagnosis. Sjaastad O, Skalpe IO, Engeset A. A German epidemiologic study found that normal-pressure hydrocephalus had a prevalence of 0.41% (4:982 individuals) in the over-65 age group. 25. Ishii K, Kanda T, Harada A, Miyamoto N, Kawaguchi T, Shimada K, Ohkawa S, Uemura T, Yoshikawa T, Mori E. Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus. 13. Observations on cerebrospinal fluid hydrodynamics. Images of control patients (both HC patients and patients with AD from ADNI) were acquired with a variety of 1.5-T and 3-T MR imaging systems that used the same T1-weighted MPRAGE sequence. Radiology. The reformatted images were directly provided to the observers. More infrastructure and may take several hours to generate, but we corrected the bias caused by this technical.. 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Do physicians know about normal pressure hydrocephalus ( iNPH ) with Intracranial pressure Scores in idiopathic normal pressure:...