Clinical Trial Based Rationale for the Successful Use of DOAC in the Treatment of Cerebral Venous Sinus Thrombosis (CVST): A Case Report.

In cerebral venous sinus thrombosis (CVST), venous sinus occlusion increases venous pressure and disrupts venous return, resulting in progression to venous infarction and venous hemorrhage, with poor neurologic outcome. Therefore, early recanalization of the major venous sinus is critical. Anticoagulant therapy with continuous intravenous infusion of heparin and subsequent oral anticoagulant administration is the recommended first line of treatment for CVST. Some large clinical trials for venous thromboembolism (VTE) have shown that direct oral anticoagulant (DOAC) is non-inferior to the standard therapy with heparin or warfarin and causes less bleeding. In contrast, there are only a few reports on CVST treatment with DOAC such as Dabigatran, Rivaroxaban and Edoxaban describing good efficacy and safety. And there is one randomized clinical trial on DOAC treatment for CVST after acute phase. We report a successfully treated case of CVST in acute phase with progressive neurologic symptoms that achieved early recanalization of the obstructed sinus by an early switch from continuous intravenous infusion of heparin to oral Edoxaban.

Stroke Systems of Care During the COVID-19 Epidemic in Kobe City.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems' ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. METHODS: This was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. RESULTS: During the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. CONCLUSION: Kobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

Successful Reperfusion with Endovascular Therapy Has Beneficial Effects on Long-Term Outcome Beyond 90 Days.

BACKGROUND AND PURPOSE: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. METHODS: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. RESULTS: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23-5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18-0.62; p < 0.01), independent of the 90-day mRS score. CONCLUSIONS: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

Total serum protein reference value as a clinical diagnostic index of equine proliferative enteropathy.

Equine proliferative enteropathy (EPE) caused by Lawsonia intracellularis is characterized by hypoproteinemia. There are currently no reliable reports that provide a reference value for the total serum protein (TP) concentration to clinically diagnose EPE. The objective of this study was to statistically determine the reference value. Feces and sera of 99 foals with EPE-like clinical signs and of 35 healthy foals were obtained. The samples were used for specific-gene detection of L. intracellularis, TP measurement, and specific-antibody detection against L. intracellularis. Based on these results, the optimal reference value for the TP concentration as a clinical diagnostic index of EPE was found to be ≤ 4.8 g/dl. This clinical diagnostic index will provide an effective approach for diagnosing EPE.

YAMATO Study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy).

BACKGROUND AND PURPOSE: We investigated whether administration of edaravone, a free radical scavenger, before or during tissue-type plasminogen activator (tPA) can enhance early recanalization in a major arterial occlusion. METHODS: The YAMATO study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy) is an investigator-initiated, multicenter (17 hospitals in Japan), prospective, randomized, and open-label study. Patients with stroke secondary to occlusion of the M1 or M2 portion of the middle cerebral artery and within 4.5 hours of the onset were studied. The subjects were randomly allocated to the early group (intravenous edaravone [30 mg] was started before or during tPA) and the late group (edaravone was started after tPA and the assessment of early recanalization). RESULTS: One-hundred sixty-five patients (96 men; median age [interquartile range], of 78 [69-85] years) were randomized 1:1 to either the early group (82 patients) or the late group (83 patients). Primary outcome, defined as an early recanalization 1.5 hour after tPA, was observed in 53% of the early group and in 53% of the late group (P=1.000). About secondary outcomes, the rate of significant recanalization of ≥50% was not different between the 2 groups (28% versus 34%; P=0.393). The symptomatic intracerebral hemorrhage has occurred in 4 patients (5%) in the early group and in 2 patients (2%) in the late group (P=0.443). The favorable outcome (modified Rankin Scale score of 0-2) at 3 months was also similar between the groups (53% versus 57%; P=0.738). CONCLUSIONS: The timing of edaravone infusion does not affect the rate of early recanalization, symptomatic intracerebral hemorrhage, or favorable outcome after tPA therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/ctr/index-j.htm. Unique identifier: UMIN000006330.

Reevaluation of Pholiota squarrosa lectin-reactive haptoglobin as a pancreatic cancer biomarker using an improved ELISA system.

An increase in Lewis- and core-type fucosylation of haptoglobin has been reported in patients with pancreatic cancer (PC), suggesting that fucosylated haptoglobin is a candidate PC biomarker. Previously, we developed a Pholiota squarrosa lectin antibody enzyme-linked immunosorbent assay (PhoSL-ELISA) system for the detection of core-fucosylated haptoglobin. However, with this methodology, positive results were only obtained for some patients with PC, demonstrating the need for a more sensitive detection system. In the current study, we developed an improved PhoSL-ELISA system with higher sensitivity to detect core-fucosylated haptoglobin using high-concentration urea as a denaturing agent with lectin to facilitate detection. We then reevaluated the performance of PhoSL reactive-core-fucosylated haptoglobin (PhoSL-HP) as a PC biomarker using the improved PhoSL-ELISA system. PhoSL-HP levels in the sera of patients with PC were significantly higher than those in healthy volunteers, with an area under the curve (AUC) value of 0.753. Furthermore, the AUC value of CA19-9 improved from 0.793 to 0.907 when combined with PhoSL-HP. Additionally, several CA19-9-negative cases among the patients with PC were diagnosed as positive for PhoSL-HP. In conclusion, PhoSL-HP detection using our improved ELISA system might allow PhoSL-HP to serve as a potential biomarker for PC and thus might be useful to complement the detection of CA19-9 in PC diagnosis.

Utility of relative ADC ratio in patient selection for endovascular revascularization of large vessel occlusion.

PURPOSE: The relative apparent diffusion coefficient (ADC) ratio on magnetic resonance imaging (MRI) can be used to evaluate the degree of ischemia. Here, we assessed the predictability of ischemic reversibility and the risk of hemorrhagic transformation using the relative ADC ratio. METHODS: This single-center retrospective study analyzed 56 patients with acute occlusion of the internal carotid artery (ICA) or the middle cerebral artery (M1) with endovascular revascularization. Diffusion-weighted imaging (DWI) lesions were classified as reversible lesions, final infarct lesions, and hemorrhagic or non-hemorrhagic regions. The relative ADC ratio was calculated in each DWI lesion and was defined as the ratio of ADC pixel values within affected territory to ADC pixel values in contralateral normal brain regions. RESULTS: The average relative ADC ratio was 0.890±0.045 in reversible DWI lesion and 0.640±0.041 in final infarct DWI lesion (P<0.001). In 4 cases with hemorrhagic transformation, hemorrhagic transformation regions were 0.557±0.049 and non-hemorrhagic transformation regions were 0.762±0.042 (P<0.001). In addition, percentage DWI improvement was inversely correlated with DWI lesion volume at the time of hospitalization (r=-0.840) and onset-to-reperfusion time (r=-0.765), but no correlation was noted with patient age (r=-0.043) or the first NIHSS score (r=-0.277). CONCLUSIONS: The relative ADC ratio may be useful for predicting DWI reversibility and post-reperfusion hemorrhagic transformation, even in patients with an unknown time of onset.

Ultrasonography and C-reactive protein can predict the outcomes of voiding cystography after the first urinary tract infection.

AIM: This study evaluated whether sex, clinical variables, laboratory variables or ultrasonography predicted the presence of vesicoureteric reflux during the first episode of urinary tract infection in paediatric patients. We also aimed to define the criteria that indicated the need for voiding cystography testing. METHODS: We used voiding cystography to investigate 200 patients who experienced their first urinary tract infection at our institution between 2004 and 2013 and retrospectively analysed the data by reviewing their medical records. RESULTS: Sex (p = 0.001), peak blood C-reactive protein levels (p < 0.001), the duration of fever after antibiotic administration (p = 0.007) and the ultrasonography findings grade (p < 0.001) were significantly different between patients with and without vesicoureteric reflux. Grade IV-V ultrasonography findings and C-reactive protein levels of ≥80 mg/L predicted vesicoureteric reflux with a sensitivity, specificity and odds ratio of 47.8%, 87.8% and 6.59 (95% confidence interval = 3.26-13.33), respectively (p < 0.001). CONCLUSION: Voiding cystography should be performed for patients with C-reactive protein levels of ≥80 mg/L and grade IV-V ultrasonography findings, but is not necessary in patients with C-reactive protein levels of <80 mg/L and grade I-III ultrasonography findings.

"Loop-like formation" in the cortical venous reflux of dural arteriovenous fistula with intracranial hemorrhage.

BACKGROUND AND PURPOSE: Cortical venous reflux (CVR) in dural arteriovenous fistulas (AVFs) is a well-known risk factor for intracranial hemorrhage. However, the impact of the angiographic characteristics of CVR on the risk of intracranial hemorrhage remains unclear. This study retrospectively reviewed the angioarchitectural features of CVR to assess their influence on the risk of intracranial hemorrhage in dural AVFs. PATIENTS AND METHODS: We retrospectively evaluated 68 consecutive patients with dural AVFs treated at our hospital between September 2001 and February 2010. In all cases, the angioarchitectural features of CVR were analyzed using cerebral angiography with a special focus on the venous drainage pattern of dural AVFs. "Loop-like formation" was defined as at least one CVR forming a curvature and connection adjacent to the original arteriovenous shunt point. RESULTS: Ten dural AVF patients (14.7%) presented with intracranial hemorrhage. All ten dural AVFs with intracranial hemorrhage showed CVR with a "loop-like formation" on angiography. This association was found to be statistically significant (P<0.0001). CONCLUSION: "Loop-like formation" in CVR may be a risk factor for intracranial hemorrhage resulting from dural AVF. This angioarchitectural feature of venous drainage may be a useful prognostic indicator, and hence should be a point of focus during treatment decisions.

Endovascular Treatment May Be Effective in Preventing Recurrence of Ischemic Stroke in Vertebral Artery Stump Syndrome: A Case Series.

Vertebral artery stump syndrome (VASS) is a rare condition that can cause posterior circulation ischemic stroke due to occlusion of the ipsilateral vertebral artery (VA) orifice, resulting in blood flow stagnation and embolus formation. Although there is no established treatment for this condition, we observed 3 cases of VASS out of 326 acute ischemic stroke cases at a single institution from April 2021 to October 2022. Despite the best possible antithrombotic treatment, all 3 patients had recurrent ischemic strokes. One patient underwent drug-eluting stenting of the VA orifice to relieve occlusive flow. The other 2 patients received coil embolization, which resulted in the disappearance of their culprit collateral flow. None of the patients had recurrent ischemic strokes after endovascular intervention. Based on our observations, stenting and coil embolization are effective methods for preventing future recurrences of VASS.

[Cluster-like headache cause by cavernous sinus dural arteriovenous fistula, cured by transvenous embolization: a case report].

We report a unique case of cavernous sinus(CS)-dural arteriovenous fistula(dAVF)with cluster headache-like ophthalmalgia without chemosis and exophthalmos, that was successfully treated by transvenous embolization. A 25-year-old man presented with severe right cluster headache-like ophthalmalgia and could not get complete relief of symptoms by medical treatment. MRI showed a hyper-intensity signal in the right cavernous sinus and cerebral angiography revealed Barrow type D cavernous sinus dural arteriovenous fistula, which is thought to be the cause of ophthalmalgia. Percutaneous transvenous embolization of the anterior part of the right CS and superior ophthalmic vein was performed and complete obliteration of dAVF was obtained followed by complete cure of cluster headache-like ophthalmalgia. We can detect neither the recurrence of dAVF on MRI nor any clinical symptom after 23 months of the treatment. This is the first clinical presentation of cluster headache-like ophthalmalgia caused by CS dAVF and it emphasizes the unique and important potential relationship between them.

Incidence and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Registry-based Descriptive Trial in Kobe City.

The current study aims to evaluate the incidence and results of aneurysmal subarachnoid hemorrhage (aSAH) throughout Kobe City. Based on a multicenter retrospective registry-based descriptive trial involving all 13 primary stroke centers in Kobe City, patients with aSAH treated between October 2017 and September 2019 were studied. A total of 334 patients were included, with an estimated age-adjusted incidence of 11.12 per 100,000 person-years. Curative treatment was given to 94% of patients, with endovascular treatment (51%) preferred over surgical treatment (43%). Of the patients, 12% were treated by shunt surgery for sequential hydrocephalus with a worse outcome at 30 days or discharge (14% vs. 46%, odds ratio (OR): 0.19, 95% confidence interval (CI): 0.088-0.39, p-value <0.001). As for vasospasm and delayed cerebral ischemia, most patients were given intravenous fasudil infusion (73%), with endovascular treatment for vasospasm in 24 cases (7.2%). The fasudil group had more good outcomes (42% vs. 30%, OR: 1.64, 95% CI: 0.95-2.87, p-value = 0.075) and significantly less death (3.3% vs. 35%, OR: 0.064, 95% CI: 0.024-0.15, p-value <0.001) at 30 days or discharge. Mortality rose from 12% at 30 days or discharge to 17% at 1 year, but neurological function distribution improved over time (modified Rankin Scale 0-2 was 39% at 30 days or discharge, 53% at 60 days, and 63% at 1 year). Our retrospective registered trial presented various statistics on aSAH, summarizing the current treatment status and prognosis.

[A case of A3-A3 bypass and proximal clipping for a ruptured left A1 dissecting aneurysm].

A 58-year-old woman was admitted to our hospital with sudden onset of headache. CT and angiogram revealed subarachnoid hemorrhage due to a dissecting aneurysm at the left A1 segment. ACoA was not identified. We performed proximal clipping with A3-A3 bypass for preventing the recurrence of the hemorrhage and for reducing ischemia in the territory of the left ACA. After the operation, CT revealed the infarctions in the corpus callosum, the left medial frontal lobe and the genu of the internal capsule. But the postoperative angiogram demonstrated no aneurysm and the opacification of the recurrent artery of Heubner and the part of perforating branches. A3-A3 bypass was patent. The patient experienced a good recovery without recurrence of bleeding.

Fatal Hemorrhage Immediately after Transvenous Embolization of Transverse-sigmoid Sinus Dural Arteriovenous Fistulas: A Case Report.

Objective: We report a case of intracerebral hemorrhage following emergency transvenous embolization for an acute symptomatic non-hemorrhagic dural arteriovenous fistula (dAVF). Case Presentation: An 83-year-old woman demonstrated gait disorder and disturbance of consciousness. A transverse-sigmoid dAVF with retrograde deep venous drainage was detected on DSA. The left sigmoid sinus-jugular vein and the sinus confluence were occluded and the dAVF drains via the straight sinus (SS), medial superior cerebral veins and deep veins to the superior sagittal sinus (SSS). The dAVF was emergently treated by sinus packing of the transverse-sigmoid sinus with coils with contralateral approach via the occluded sinus confluence. Although the dAVF was markedly regressed, massive cerebral hemorrhage developed in the left parietal lobe immediately after embolization. Conclusion: Although early treatment is required for dAVFs with aggressive symptoms, precious evaluation of their hemodynamics, particularly for drainage pattern, is mandatory to avoid a serious complication.

Clinical predictors of transient ischemic attack, stroke, or death within 30 days of carotid artery stent placement with distal balloon protection.

PURPOSE: Carotid artery stent placement has been accepted as an effective alternative to carotid endarterectomy (CEA), especially in patients at high risk in the setting of CEA. The purpose of this study was to determine potential clinical risk factors for the development of postprocedural neurologic deficits after carotid artery stent placement. MATERIALS AND METHODS: The clinical characteristics of 58 patients (49 men, nine women; 41 at high risk with CEA, 17 at low risk; median age, 70 years) who underwent carotid artery stent placement with distal balloon protection for 65 hemispheres/arteries (31 asymptomatic lesions and 34 symptomatic lesions) and the combined 30-day complication rates (transient ischemic attack [TIA], minor stroke, major stroke, or death) were analyzed. RESULTS: Six patients (9.0%) experienced a TIA and one patient (1.5%) had a major stroke (1.5%) within 30 days of the procedure. There were no deaths, so the overall 30-day combined stroke and death rate was 1.5%. The chi(2) test revealed that advanced age (>75 years) was a significant clinical predictor of 30-day combined neurologic complications and major adverse effects (P < .01). In addition, a symptomatic lesion was marginally associated with the 30-day incidence of neurologic ischemia on the ipsilateral side (P = .049). CONCLUSIONS: Our data suggest that carotid artery stent placement with distal balloon protection can be performed with similar periprocedural complication rates as CEA. CEA should be the first-line treatment in the management of patients older than 75 years of age.

Intentional Herniation Technique with the Neuroform EZ Stent System for Preservation of Aneurysmal Neck Branch: A Case Report.

Endovascular treatment of bifurcation aneurysms is difficult and complicated because arterial branches may arise from the aneurysmal neck. We treat these cases with complex techniques such as Y or T stenting. In this report, we deployed one Neuroform EZ stent using the intentional herniation technique for the preservation of arterial branches. A 78-year-old female presented with two unruptured aneurysms. One was an 8 mm aneurysm located at the bifurcation of the internal carotid artery and the posterior communicating artery (PcomA). The other was an 11 mm aneurysm located at the cavernous segment of the internal carotid artery. A 4.5x20 mm Neuroform EZ stent was placed across the aneurysm neck. The delivery wire and microcatheter were pushed during deployment, similar to braided stents. High resolution cone beam computed tomography (CT) after stenting revealed the stent strut to be vertically aligned near the aneurysmal sac, and the PcomA orifice was preserved. We performed coil embolization easily and achieved acceptable obliteration. Our intentional herniation technique may be useful in some cases. Open cell stents have some advantages depending on the method of deployment.

Remarkable effects of cabergoline in a patient with huge prolactinoma resistant to high-dose bromocriptine: case report.

BACKGROUND: Cabergoline (CAB) has been proposed as the first-line treatment in the management of prolactin (PRL)-secreting tumors (prolactinoma [PRLoma]), including those resistant to standard dopamine agonist (DAA) therapy. The authors report remarkable effects of CAB in a case of huge PRLoma that had been resistant to a long-term, high-dose treatment with bromocriptine (BRC). CASE DESCRIPTION: A 28-year-old man was originally presented with oculomotor paresis when he was 9 years old. After 2 partial resections, he was treated with a maximum 60-mg/d dose of BRC for 18 years. Nonetheless, the tumor grew up to more than 8 cm in diameter, serum PRL increased over 60000 ng/mL, and his visual acuity deteriorated. Cabergoline normalized serum PRL level, shrank the tumor mass remarkably, and caused marked improvement of visual acuity. CONCLUSION: Prolactin normalization and significant tumor shrinkage could be achieved with CAB even in extremely BRC-resistant PRLomas. Surgical resection should be reserved only for patients who are resistant to cabergoline or who require urgent decompression in such emergency as massive intratumoral hemorrhage.

Therapeutic strategy for pineal parenchymal tumor of intermediate differentiation (PPTID): case report of PPTID with malignant transformation to pineocytoma with leptomeningeal dissemination 6 years after surgery.

Pineal parenchymal tumor of intermediate differentiation (PPTID) is rare. The WHO first classified PPTID in 2000 as a pineal parenchymal tumor (PPT) with an intermediate prognosis between pineocytoma (PC) and pineoblastoma (PB). It is considered an intermediate-grade tumor and divided into WHO grade II or III.The number of available reports about PPTID is presently limited, and the appropriate management for this tumor has not yet been determined.The authors report a rare case of PC in a 63-year-old woman who presented with lower-extremity weakness and gait disturbance. A pineal mass lesion was detected on MRI. A diagnosis of PC was established after microsurgical gross-total tumor resection, and the patient received no adjuvant therapy after surgery. Two years after surgery, a partial recurrence was recognized and Gamma Knife radiosurgery was performed. Fours years later, the patient developed diffuse leptomeningeal dissemination. She was successfully treated with craniospinal irradiation. Leptomeningeal dissemination may develop 6 years after the initial diagnosis of PC. A histopathological study of the recurrent tumor revealed a malignant change from PC to PPTID.The present case shows the importance of long-term follow-up of patients with PPTs following resection and the efficacy of craniospinal irradiation in the treatment of leptomeningeal dissemination.

Utility of MRI-based disproportionately enlarged subarachnoid space hydrocephalus scoring for predicting prognosis after surgery for idiopathic normal pressure hydrocephalus: clinical research.

OBJECTIVE The presence of disproportionately enlarged subarachnoid space hydrocephalus (DESH) on brain imaging is a recognized finding of idiopathic normal pressure hydrocephalus (iNPH), but the features of DESH can vary across patients. The aim of this study was to evaluate the utility of MRI-based DESH scoring for predicting prognosis after surgery. METHODS In this single-center, retrospective cohort study, the DESH score was determined by consensus between a group of neurosurgeons, neurologists, and a neuroradiologist based on the preoperative MRI findings of the patients with suspected iNPH. The DESH score was composed of the following 5 items, each scored from 0 to 2 (maximum score 10 points): ventriculomegaly, dilated sylvian fissures, tight high convexity, acute callosal angle, and focal sulcal dilation. The association between the DESH score and improvement of the scores on the modified Rankin Scale (mRS), iNPH Grading Scale (iNPHGS), Mini-Mental State Examination (MMSE), Trail Making Test-A (TMT-A), and Timed 3-Meter Up and Go Test (TUG-t) was examined. The primary end point was improvement in the mRS score at 1 year after surgery, and the secondary outcome measures were the iNPHGS, MMSE, TMT-A, and TUG-t scores at 1 year after surgery. Improvement was determined as improvement of 1 or more levels on mRS, ≥ 1 point on iNPHGS, ≥ 3 points on MMSE, a decrease of > 30% on TMT-A, and a decrease of > 10% on TUG-t. RESULTS The mean DESH score for the 50 patients (mean age 77.6 ± 5.9 years) reviewed in this study was 5.58 ± 2.01. The mean rate of change in the mRS score was -0.50 ± 0.93, indicating an inverse correlation between the DESH score and rate of change in the mRS score (r = -0.749). Patients who showed no improvement in mRS score tended to have a low DESH score as well as low preoperative MMSE and TMT-A scores. There were no differences in the areas of deep white matter hyperintensity and periventricular hyperintensity on the images between patients with and without an improved mRS score (15.6% vs 16.7%, respectively; p = 1.000). The DESH score did differ significantly between patients with and without improved scores on the iNPHGS (6.39 ± 1.76 vs 4.26 ± 1.69, respectively; p < 0.001), MMSE (6.63 ± 1.82 vs 5.09 ± 1.93; p = 0.010), TMT-A (6.32 ± 1.97 seconds vs 5.13 ± 1.93 seconds; p = 0.042), and TUG-t (6.48 ± 1.81 seconds vs 4.33 ± 1.59 seconds; p < 0.001). CONCLUSIONS MRI-based DESH scoring is useful for the prediction of neurological improvement and prognosis after surgery for iNPH.