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1.
PLoS One ; 14(5): e0217705, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31141553

RESUMO

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) causing gait impairment, dementia and urinary incontinence among the elderly, is probably under-diagnosed and under-treated. Despite being known since the 1960s, there is still a lack of prospective, population-based studies on the prevalence of iNPH. Such studies are warranted to minimize selection bias and estimate the true prevalence of the disease. METHODS: The prevalence of iNPH was determined in a randomly selected sample of residents, aged 65 years and older, in the Swedish county of Jämtland. Out of 1,000 individuals invited to participate, 673 (67.3%) completed a questionnaire with seven questions on iNPH symptoms. A subgroup, with and without self-reported symptoms, participated in clinical and radiological evaluations and were diagnosed according to international guidelines. Measurement of cerebrospinal fluid opening pressure was not performed as it was considered too invasive. RESULTS: Those who reported at least two symptoms in the questionnaire (n = 117) and 51 randomly selected individuals with 0-1 symptom participated in further examinations. Out of them, 25 individuals received the diagnosis probable iNPH according to American-European guidelines (except for the criterion of CSF opening pressure) corresponding to a prevalence of 3.7%. The prevalence of iNPH was four times higher among those aged 80 years and older (8.9%) than among those aged 65-79 years (2.1%) (p <0.001). The difference in prevalence between men (4.6%) and women (2.9%) was not significant (p = 0.24). When iNPH was diagnosed according to the Japanese guidelines the prevalence was 1.5. CONCLUSIONS: In this prospective, population-based study the prevalence of iNPH was 3.7% among individuals 65 years and older, and more common in the higher age group, 80 years and above. INPH should be increasingly recognized since it is a fairly common condition and an important cause of gait impairment and dementia among the elderly that can be effectively treated by shunt surgery.


Assuntos
Demência/epidemiologia , Marcha/fisiologia , Hidrocefalia de Pressão Normal/epidemiologia , Incontinência Urinária/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Demência/fisiopatologia , Feminino , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Masculino , Prevalência , Estudos Prospectivos , Incontinência Urinária/fisiopatologia
2.
Gait Posture ; 72: 12-15, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31129388

RESUMO

INTRODUCTION: Idiopathic normal pressure hydrocephalus (iNPH) is a syndrome characterized by a triad composed of cognitive alteration, urinary incontinence, and gait impairment associated with ventricular enlargement and normal cerebrospinal fluid pressure. Gait impairment is among the earliest symptoms; however, the reliability of the evaluation is not well-established and no consensus has been reaching regarding variables that should be analyzed and which parameters should be considered to accurately assess post-intervention improvement. RESEARCH QUESTION: Are the degree of repeatability, standard error of measurement, and minimum detectable change considered to detect changes in gait variables in iNPH patients? METHODS: A total of 84 iNPH patients with a mean age of 77.1 (±6.4) years were analyzed. Gait deviation index (GDI), speed, cadence, cycle time, stride length, single support, and first and second double support were chosen as the variables to be analyzed. Statistical analysis was performed by an independent evaluator, with gait repeatability assessed by the intraclass correlation coefficient (ICC) and the standard error of measure (SEM). RESULTS: ICC values were 0.76-0.85 with excellent repeatability, while SEM demonstrated that the variables with best repeatability were the GDI (mean, 4.94; 95% confidence interval (CI), 4.63-5.43), representing a 7.65% mean relative error of the measurement (mean, 0.05 m; 95% CI, 0.05-0.06), and stride length (mean 0.05 m; 95% CI, 0.05-0.06), with a 7.69% mean relative error. SIGNIFICANCE: We concluded that GDI and stride length were the variables with the best repeatability and lower variability in the gait of iNPH patients.


Assuntos
Análise da Marcha/métodos , Transtornos Neurológicos da Marcha/fisiopatologia , Hidrocefalia de Pressão Normal/fisiopatologia , Idoso , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Velocidade de Caminhada/fisiologia
3.
Neuroradiology ; 61(6): 659-666, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30915496

RESUMO

PURPOSE: To identify if specific findings on magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow studies can be utilised to identify which patients with idiopathic normal pressure hydrocephalus (iNPH) will have improved gait following a CSF tap test (TT). METHODS: Prospective study of patients undergoing a CSF TT for iNPH. Functional gait was assessed using the timed up and go (TUG) test before and after the CSF TT. MRI CSF flow studies accompanied the CSF TT. The minimum clinically important difference for the TUG (3.63 s) was used as a cutoff value to categorise patients as responders to the CSF TT. RESULTS: Fifty-three patients underwent CSF TT and MRI CSF flow studies. Significant differences were identified between groups for (non-responder vs responder) superior sagittal sinus flow (47.10% vs 40.41%), sagittal sinus stroke volume (274 vs 176.5 µl), sagittal sinus to arterial stroke volume ratio (0.203 vs 0.164), sagittal sinus area (42.2 mm2 vs 36.2 mm2) and circumference (27.7 mm vs 24.95 mm). No differences were present for aqueduct stroke volume, arterial stroke volume or aqueduct net flow. CONCLUSION: A link between gait improvement resulting from CSF drainage and sagittal sinus measurements indicates that the sagittal sinus may play a role in the manifestation of symptoms in iNPH. This may have implications for the diagnosis of iNPH and potentially inform clinical decision making regarding surgical intervention.


Assuntos
Derivações do Líquido Cefalorraquidiano , Transtornos Neurológicos da Marcha/líquido cefalorraquidiano , Transtornos Neurológicos da Marcha/terapia , Hidrocefalia de Pressão Normal/líquido cefalorraquidiano , Hidrocefalia de Pressão Normal/terapia , Imagem por Ressonância Magnética/métodos , Seio Sagital Superior/diagnóstico por imagem , Idoso , Feminino , Transtornos Neurológicos da Marcha/fisiopatologia , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Masculino , Estudos Prospectivos , Resultado do Tratamento
4.
Br J Radiol ; 92(1097): 20180553, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30760003

RESUMO

OBJECTIVE: To clarify the cause of higher water fluctuation of the brain in idiopathic normal pressure hydrocephalus (iNPH), we assessed change in hemodynamic-independent apparent diffusion coefficient during the cardiac cycle (ΔADC) in iNPH. METHODS: Electrocardiographically synchronized single-shot diffusion echo-planer imaging (b = 0, 500, and 1000 s/mm2) was performed in healthy volunteers, atrophic ventricular dilation group, and iNPH group, respectively. The ΔADC (b = 0 and 1000 s/mm2) and maximum ADC (b = 0 and 500 s/mm2) in the cardiac cycles were measured at the frontal white matter in the brain. Then, self-corrected ΔADC was obtained from the ΔADC divided by the maximum ADC (ADCpeak: perfusion-related diffusion) to correct the blood flow effect. RESULTS: The ΔADC after correction was significantly higher in the iNPH group than in the other two groups. However, there was no significant difference in ADCpeak values among the groups. CONCLUSION: Self-corrected ΔADC in iNPH increased because of changes in the biomechanical properties of the brain. Self-corrected ΔADC analysis makes it possible to obtain information on hemodynamically independent water fluctuation as well as perfusion in iNPH. ADVANCES IN KNOWLEDGE: Analysis self-corrected ΔADC provides simultaneously information on biomechanical properties, perfusion, and water fluctuation in iNPH.


Assuntos
Encéfalo/diagnóstico por imagem , Encéfalo/fisiopatologia , Imagem de Difusão por Ressonância Magnética , Hemodinâmica , Hidrocefalia de Pressão Normal/diagnóstico por imagem , Hidrocefalia de Pressão Normal/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Eletrocardiografia , Feminino , Humanos , Masculino
5.
Arch Phys Med Rehabil ; 100(8): 1458-1466, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30731067

RESUMO

OBJECTIVES: To investigate which clinical assessments are suitable for differentiating patients who fall from patients who do not fall in patients with idiopathic normal pressure hydrocephalus (iNPH). DESIGN: Prospective observational study. SETTING: Osaka Medical College Hospital. PARTICIPANTS: Patients with a cerebrospinal fluid tap test (TT) result meeting the diagnosis criteria for iNPH (N=68). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were assessed before the TT based on the following: timed Up and Go (TUG), 10-meter walk test (10MWT), Functional Gait Assessment (FGA), Berg Balance Scale (BBS), isometric quadriceps strength (QS), and a history of falls within the past 6 months. RESULTS: The full area under the curve (AUC) of the receiver operating characteristic curves and 95% confidence interval were found to be 0.651 (95% confidence interval, 0.503-0.775) for the TUG, 0.692 (95% confidence interval, 0.540-0.812) for the 10MWT, 0.869 (95% confidence interval, 0.761-0.933) for the FGA, and 0.796 (95% confidence interval, 0.663-0.886) for the BBS; except for QS, they all were identified as statistically significant predictive variables. In the TUG<20 seconds group (n=47), the FGA (AUC 0.849 [95% confidence interval, 0.698-0.932]) and BBS (AUC 0.734 [95% confidence interval, 0.550-0.862]) were found to be statistically significant predictive variables; however, the other assessments were not. In the TUG<15 seconds group (n=34), the FGA was found to be the only statistically significant predictive variable (AUC 0.842 [95% confidence interval, 0.640-0.942]), whereas the other assessments were not. The AUC of the FGA was statistically significantly greater than those of the other assessments. CONCLUSIONS: Our findings indicate that patients with iNPH who fall experience falls due to dynamic balance dysfunction during gait rather than lower limb muscle strength. The FGA may be more suitable than other assessments for differentiating patients who fall from patients who do not fall in patients with mild iNPH.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Avaliação da Deficiência , Transtornos Neurológicos da Marcha/fisiopatologia , Hidrocefalia de Pressão Normal/fisiopatologia , Equilíbrio Postural/fisiologia , Idoso , Feminino , Humanos , Hidrocefalia de Pressão Normal/líquido cefalorraquidiano , Masculino , Força Muscular/fisiologia , Estudos Prospectivos , Fatores de Risco
6.
Fluids Barriers CNS ; 16(1): 2, 2019 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-30665428

RESUMO

BACKGROUND: This study investigated cerebrospinal fluid (CSF) hydrodynamics using cine phase-contrast MRI in the cerebral aqueduct and the prepontine cistern between three distinct groups: pre-shunt normal pressure hydrocephalus (NPH) patients, post-shunt NPH patients, and controls. We hypothesized that the hyperdynamic flow of CSF through the cerebral aqueduct seen in NPH patients was due to a reduction in cisternal CSF volume buffering. Both hydrodynamic (velocity, flow, stroke volume) and peak flow latency (PFL) parameters were investigated. METHODS: Scans were conducted on 30 pre-treatment patients ranging in age from 58 to 88 years along with an additional 12 controls. Twelve patients also received scans following either ventriculoatrial (VA) or ventriculoperitoneal (VP) shunt treatment (9 VP, 3 VA), ranging in age from 74 to 89 years with a mean follow up time of 6 months. RESULTS: Significant differences in area, velocity, flow, and stroke volume for the cerebral aqueduct were found between the pre-treatment NPH group and the healthy controls. Shunting caused a significant decrease in both caudal and cranial mean flow and stroke volume in the cerebral aqueduct. No significant changes were found in the prepontine cistern between the pre-treatment group and healthy controls. For the PFL, no significant differences were seen in the cerebral aqueduct between any of the three groups; however, the prepontine cistern PFL was significantly decreased in the pre-treatment NPH group when compared to the control group. CONCLUSIONS: Although several studies have quantified the changes in aqueductal flow between hydrocephalic groups and controls, few studies have investigated prepontine cistern flow. Our study was the first to investigate both regions in the same patients for NPH pre- and post- treatment. Following shunt treatment, the aqueductal CSF metrics decreased toward control values, while the prepontine cistern metrics trended up (not significantly) from the normal values established in this study. The opposing trend of the two locations suggests a redistribution of CSF pulsatility in NPH patients. Furthermore, the significantly decreased latency of the prepontine cisternal CSF flow suggests additional evidence for CSF pulsatility dysfunction.


Assuntos
Aqueduto do Mesencéfalo/fisiopatologia , Derivações do Líquido Cefalorraquidiano , Líquido Cefalorraquidiano , Hidrocefalia de Pressão Normal/fisiopatologia , Hidrocefalia de Pressão Normal/cirurgia , Hidrodinâmica , Idoso , Idoso de 80 Anos ou mais , Aqueduto do Mesencéfalo/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Hidrocefalia de Pressão Normal/diagnóstico por imagem , Processamento de Imagem Assistida por Computador , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Reconhecimento Automatizado de Padrão , Resultado do Tratamento
8.
Neuroimage Clin ; 21: 101605, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30497983

RESUMO

OBJECTIVE: Create an automated classifier for imaging characteristics of disproportionately enlarged subarachnoid space hydrocephalus (DESH), a neuroimaging phenotype of idiopathic normal pressure hydrocephalus (iNPH). METHODS: 1597 patients from the Mayo Clinic Study of Aging (MCSA) were reviewed for imaging characteristics of DESH. One core feature of DESH, the presence of tightened sulci in the high-convexities (THC), was used as a surrogate for the presence of DESH as the expert clinician-defined criterion on which the classifier was trained. Anatomical MRI scans were automatically segmented for cerebrospinal fluid (CSF) and overlaid with an atlas of 123 named sulcal regions. The volume of CSF in each sulcal region was summed and normalized to total intracranial volume. Area under the receiver operating characteristic curve (AUROC) values were computed for each region individually, and these values determined feature selection for the machine learning model. Due to class imbalance in the data (72 selected scans out of 1597 total scans) adaptive synthetic sampling (a technique which generates synthetic examples based on the original data points) was used to balance the data. A support vector machine model was then trained on the regions selected. RESULTS: Using the automated classification model, we were able to classify scans for tightened sulci in the high convexities, as defined by the expert clinician, with an AUROC of about 0.99 (false negative ≈ 2%, false positive ≈ 5%). Ventricular volumes were among the classifier's most discriminative features but are not specific for DESH. The inclusion of regions outside the ventricles allowed specificity from atrophic neurodegenerative diseases that are also accompanied by ventricular enlargement. CONCLUSION: Automated detection of tight high convexity, a key imaging feature of DESH, is possible by using support vector machine models with selected sulcal CSF volumes as features.


Assuntos
Encéfalo/fisiopatologia , Hidrocefalia de Pressão Normal/fisiopatologia , Aprendizado de Máquina , Espaço Subaracnóideo/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Curva ROC , Sensibilidade e Especificidade , Máquina de Vetores de Suporte
10.
Int J Geriatr Psychiatry ; 34(3): 453-462, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30474244

RESUMO

OBJECTIVES: Apathy is prevalent in patients with idiopathic normal pressure hydrocephalus (iNPH), a treatable disorder resulting from ventricular enlargement. We assessed the relationship between apathy and regional cerebral blood flow (rCBF) in patients with iNPH. METHODS: Before lumbo-peritoneal shunt surgery (LPS), 56 iNPH patients were evaluated on apathy and dysphoria subscales of the Neuropsychiatric inventory (NPI), and were divided into two groups according to NPI apathy score: 15 without apathy (iNPH-APA) and 41 with apathy (iNPH+APA). Among iNPH+APA, 29 patients were evaluated for apathy and dysphoria 3 months after LPS, and were divided into two groups on the basis of the change in NPI apathy score: 13 with improvement (iNPH+ImpAPA) and 16 without improvement in apathy (iNPH-ImpAPA). N-isopropyl-p-iodoamphetamine single photon emission computed tomography using the autoradiography method was performed before and after LPS, and rCBF was calculated in 22 regions of interest in the frontal cortex, basal ganglia, and limbic system. RESULTS: In iNPH+APA, rCBF in the right caudate nuclei before LPS was significantly lower than that in iNPH-APA (P = 0.004; two-sample t test). Between iNPH-ImpAPA and iNPH+ImpAPA, a significant group-by-shunt interaction was observed for rCBF in only the right caudate nuclei (F1, 28  = 11.75, P = 0.002; two-way repeated-measures analysis of variance), with increased rCBF in iNPH+ImpAPA but not in iNPH-ImpAPA. The significant group-by-shunt interaction persisted if change in NPI dysphoria scores was used as a covariate (F1, 27  = 8.33, P = 0.008). CONCLUSIONS: Our findings suggest that right caudate dysfunction might cause apathy in iNPH patients.


Assuntos
Apatia , Circulação Cerebrovascular , Hidrocefalia de Pressão Normal/fisiopatologia , Hidrocefalia de Pressão Normal/psicologia , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada de Emissão de Fóton Único/métodos
11.
J Clin Neurosci ; 61: 10-13, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30409528

RESUMO

Idiopathic Normal Pressure Hydrocephalus (iNPH) is a frequent neuropsychiatric entity. Clinically it is characterised by Hakim's triad: Dementia, gait disturbance and urinary incontinence. While its symptomatology is typical, the etiology and thereby physiopathology of iNPH still remain enigmatic. This review summarizes and synthesizes different etiologic conceptions and physiopathologic aspects of iNPH. A research of literature via the PubMed/MEDLINE and the Cochrane database was conducted. Only English language articles clearly outlining a reasonable concept of physiopathology were included. Most authors advocate that iNPH is a result of chronically altered cerebrospinal fluid (CSF) dynamics, i.e. deranged CSF production, kinetics and reabsorption. In addition, there are vascular, metabolo-neurodegenerative and hereditary factors. Neuroinflammation does not seem to play a significant role in the etiology of iNPH. All in all, iNPH seems to combine several pathogenetic factors leading to a self-reinforcing vicious circle. The majority of studies hint at CSF disturbances on grounds of altered hemodynamics.


Assuntos
Hidrocefalia de Pressão Normal/líquido cefalorraquidiano , Hidrocefalia de Pressão Normal/etiologia , Hidrocefalia de Pressão Normal/fisiopatologia , Feminino , Humanos , Masculino
12.
Clin EEG Neurosci ; 50(3): 210-218, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30417664

RESUMO

Idiopathic normal pressure hydrocephalus (iNPH) is a neuropsychiatric disease characterized by gait disturbance, cognitive dysfunction, and urinary incontinence that affects a large population of elderly people. These symptoms, especially gait disturbance, can potentially be improved by cerebrospinal fluid (CSF) drainage, which is more effective if performed at an early stage of the disease. However, the neurophysiological mechanisms of these symptoms and their recovery by CSF drainage are poorly understood. In this study, using exact low-resolution brain electromagnetic tomography-independent component analysis (eLORETA-ICA) with electroencephalography (EEG) data, we assessed activities of five EEG resting-state networks (EEG-RSNs) in 58 iNPH patients before and after drainage of CSF by lumbar puncture (CSF tapping). In addition, we assessed correlations of changes in these five EEG-RSNs activities with CSF tapping-induced changes in iNPH symptoms. The results reveal that compared with 80 healthy controls, iNPH patients had significantly decreased activities in the occipital alpha rhythm, visual perception network, and self-referential network before CSF tapping. Furthermore, CSF tapping-induced changes in occipital alpha activity correlated with changes in postural sway and frontal lobe function. Changes in visual perception network activity correlated with changes in gait speed. In addition, changes in memory perception network activity correlated with changes in Parkinsonian gait features. These results indicate a recruitment of cognitive networks in gait control, and involvement of the occipital alpha activity in cognitive dysfunction in iNPH patients. Based on these findings, eLORETA-ICA with EEG data can be considered a noninvasive, useful tool for detection of EEG-RSN activities and for understanding the neurophysiological mechanisms underlying this disease.


Assuntos
Encéfalo/fisiopatologia , Eletroencefalografia , Marcha/fisiologia , Hidrocefalia de Pressão Normal/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Eletroencefalografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos dos Movimentos/diagnóstico , Transtornos dos Movimentos/fisiopatologia , Neuroimagem/métodos
13.
J Neurol Sci ; 395: 164-168, 2018 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-30340088

RESUMO

BACKGROUND: Idiopathic normal-pressure hydrocephalus (iNPH) is defined by ventriculomegaly, cognitive decline, urinary incontinence and gait problems. Vascular risk factors (VRF) are associated with iNPH but obstructive sleep apnea (OSA) -a well-known independent VRF- is seldom mentioned. METHODS: We investigated the presence of sleep-disordered breathing in a prospective cohort of 31 consecutive unselected patients with iNPH using sleep questionnaires and nocturnal polysomnography (PSG). RESULTS: We found OSA in 90·3% (28/31) patients with iNPH; all had undiagnosed sleep abnormalities (snoring, awakenings, nocturia) and excessive daytime sleepiness (Epworth scale = 11·4 ±â€¯6·4; normal <8). Nocturnal PSG showed moderate-to-severe OSA in 25 patients (80·6%) with mean apnea-hypopnea index (AHI) 31·6 ±â€¯23·6/h; mean respiratory distress index (RDI) 34·5/h; and, mean SaO2 desaturation at nadir, 82·2 ±â€¯7·5%. The observed OSA prevalence is statistically significant: 90·3%, 95%CI 74·3-97·5; p = 0·000007. Other VRF included overweight body-mass index (BMI >25- < 30 kg/m2) in 59%, hyperhomocysteinemia 57%, hypertension 43%, hyperlipidemia 39%, diabetes 32%, smoking 21%, coronary disease 18%, and previous stroke 10%. CONCLUSION: Abnormal sleep breathing is frequently associated with iNPH. Validation in larger series is required but we suggest including sleep evaluation in patients suspected of iNPH.


Assuntos
Hidrocefalia de Pressão Normal/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Idoso , Feminino , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Masculino , Polissonografia , Prevalência , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/fisiopatologia
14.
Sci Rep ; 8(1): 13639, 2018 09 11.
Artigo em Inglês | MEDLINE | ID: mdl-30206302

RESUMO

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by reversible neurological symptoms due to an impairment in cerebrospinal fluid (CSF) clearance. In these patients, cognitive functions are severely impaired, with a scenario similar to Alzheimer's disease (AD), making the differential diagnosis difficult and highlighting the need of new markers. We analyzed the composition of sphingolipids (SLs) in serum, by combining a single phase extraction with a high-performance thin-layer chromatography (HPTLC) primuline-profiling, and, in CSF, by MALDI profiling and LC-MS. Ceramides and sphingomyelins (SMs) were similar in serum of iNPH and AD patients compared to healthy controls, whereas, in CSF, MALDI profiling indicated that: 1) SM C24:1 is significantly decreased in AD compared to iNPH patients and controls (Kruskal-Wallis p-value < 0.00001); 2) phosphatidylcholine (PC) 36:2 is increased in iNPH patients (p-value < 0.001). LC-MS identified an increasing trend of Cer C24:0 and of a set of SMs in patients with AD, a significant decrease of sphingosine-1-phosphate (S1P) (t-test p-value 0.0325) and an increase of glucosylceramide (GlcCer) C24:0 (p-value 0.0037) in AD compared to iNPH patients. In conclusion CSF PC 36:2, SM C24:1, S1P, and GlcCer can contribute to improve the differential diagnosis of patients with iNPH or AD and foster preventive therapeutic strategies in the early phase of the disease.


Assuntos
Doença de Alzheimer/líquido cefalorraquidiano , Disfunção Cognitiva/líquido cefalorraquidiano , Hidrocefalia de Pressão Normal/líquido cefalorraquidiano , Esfingomielinas/líquido cefalorraquidiano , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/sangue , Doença de Alzheimer/fisiopatologia , Biomarcadores/sangue , Biomarcadores/líquido cefalorraquidiano , Ceramidas/sangue , Ceramidas/líquido cefalorraquidiano , Disfunção Cognitiva/sangue , Disfunção Cognitiva/fisiopatologia , Diagnóstico Diferencial , Feminino , Humanos , Hidrocefalia de Pressão Normal/sangue , Hidrocefalia de Pressão Normal/fisiopatologia , Masculino , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Esfingomielinas/sangue
15.
Clin Neurol Neurosurg ; 174: 75-79, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30218879

RESUMO

OBJECTIVES: Distal obstruction is a common cause of shunt failure and need for revision in patients undergoing ventriculoperitoneal shunting (VPS) for idiopathic normal pressure hydrocephalus (iNPH). PATIENTS AND METHODS: Records of patients with iNPH treated with VPS between 2001 and 2017 were reviewed. Patients undergoing initial shunt placement at our institution were included for analysis and the incidence of revision surgery due to distal obstruction was noted. Risk factors for distal obstruction were identified using a stepwise Cox proportional hazards model. RESULTS: There were 341 patients included for analysis. Assistance from a general surgeon in placement of the peritoneal catheter was provided in 54 patients (15.8%). Shunt revision was necessary in 69 patients (20.2%), with 17 patients (5.0%) found to have a distal malfunction. On univariate analysis, increasing age was associated with reduced risk of distal malfunction (Unit RR 0.92, 95% CI 0.89-0.96; p < 0.001). BMI ≥ 38.9 (RR 6.60, 95% CI 1.84-19.00), prior abdominal surgery (RR 2.95, 95% CI 1.11-7.70; p = 0.032), and fixed-setting valve (RR 6.24, 95% CI 1.27-112.72; p = 0.020) were associated with increased likelihood of distal malfunction. General surgery involvement had no effect on distal malfunction rates (OR 1.30, 95% CI 0.25-3.21; p = 0.693). On multivariate analysis, increasing age (Unit RR 0.92, 95% CI 0.89-0.95; p < 0.001) and prior abdominal surgery (RR 3.30, 95% CI 1.23-8.71; p = 0.019) were independently associated with decreased and increased risk of distal obstruction, respectively. CONCLUSIONS: We identify multiple factors associated with distal shunt obstruction, and found that general surgery assistance was not protective against distal malfunction. These data may aid in the risk-stratification of patients undergoing VPS for iNPH.


Assuntos
Hidrocefalia de Pressão Normal/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Derivação Ventriculoperitoneal/efeitos adversos , Idoso , Estudos de Coortes , Feminino , Seguimentos , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Derivação Ventriculoperitoneal/tendências
16.
Neuroimage Clin ; 20: 731-741, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30238917

RESUMO

The aim of the present study was to examine cerebrospinal fluid (CSF) volumetric net flow rate and direction at the cranio-cervical junction (CCJ) and cerebral aqueduct in individuals with idiopathic normal pressure hydrocephalus (iNPH) using cardiac-gated phase-contrast magnetic resonance imaging (PC-MRI). An in-depth, pixel-by-pixel analysis of regions of interest from the CCJ and cerebral aqueduct, respectively, was done in 26 iNPH individuals, and in 4 healthy subjects for validation purposes. Results from patients were compared with over-night measurements of static and pulsatile intracranial pressure (ICP). In iNPH, CSF net flow at CCJ was cranially directed in 17/22 as well as in 4/4 healthy subjects. Estimated daily CSF volumetric net flow rate at CCJ was 6.9 ±â€¯9.9 L/24 h in iNPH patients and 4.5 ±â€¯5.0 L/24 h in healthy individuals. Within the cerebral aqueduct, the CSF net flow was antegrade in 7/21 iNPH patients and in 4/4 healthy subjects, while it was retrograde (i.e. towards ventricles) in 14/21 iNPH patients. Estimated daily CSF volumetric net flow rate in cerebral aqueduct was 1.1 ±â€¯2.2 L/24 h in iNPH while 295 ±â€¯53 mL/24 h in healthy individuals. Magnitude of cranially directed CSF net flow in cerebral aqueduct was highest in iNPH individuals with signs of impaired intracranial compliance. The study results indicate CSF flow volumes and direction that are profoundly different from previously assumed. We hypothesize that spinal CSF formation may serve to buffer increased demand for CSF flow through the glymphatic system during sleep and during deep inspiration to compensate for venous outflow.


Assuntos
Ventrículos Cerebrais/fisiopatologia , Hidrocefalia de Pressão Normal/líquido cefalorraquidiano , Hidrocefalia de Pressão Normal/fisiopatologia , Adulto , Idoso , Aqueduto do Mesencéfalo/diagnóstico por imagem , Aqueduto do Mesencéfalo/fisiopatologia , Ventrículos Cerebrais/diagnóstico por imagem , Feminino , Humanos , Hidrocefalia de Pressão Normal/diagnóstico por imagem , Processamento de Imagem Assistida por Computador/métodos , Imagem por Ressonância Magnética , Masculino , Canal Vertebral/diagnóstico por imagem , Canal Vertebral/fisiopatologia
17.
Neurología (Barc., Ed. impr.) ; 33(7): 449-458, sept. 2018. ilus
Artigo em Espanhol | IBECS | ID: ibc-175953

RESUMO

Introducción: Desde la descripción hace 5 décadas de la hidrocefalia crónica del adulto idiopática (HCAi), su fisiopatología ha sido considerada básicamente relacionada con el efecto que la dilatación ventricular ejerce sobre las estructuras adyacentes al sistema ventricular. Sin embargo, las alteraciones en el flujo sanguíneo cerebral (FSC) y, sobre todo, la reducción en el recambio licuoral parecen emerger como componentes fisiopatológicos principales de esta enfermedad. Desarrollo: En la HCAi se observa una compresión del tracto piramidal, de los circuitos cortico-subcorticales fronto-estriatales y fronto-reticulares, y de las fibras profundas del fascículo longitudinal superior. En el cuerpo calloso se objetiva un descenso en el número de fibras comisurales, que son reemplazadas por gliosis. El FSC se encuentra alterado, con un patrón de última pradera en la región subcortical adyacente a los ventrículos, correspondiente a la intersección entre las arterias subependimarias y las arterias perforantes dependientes de los grandes troncos arteriales de la circulación anterior. El recambio diario del LCR se ve disminuido en un 75%, lo que conlleva una reducción del aclaramiento de neurotóxicos y la interrupción de las señalizaciones neuroendocrinas y paracrinas que ocurren a través del LCR. Conclusiones: La HCAi emerge como una entidad nosológica compleja, en la que los efectos de la microangiopatía subcortical y la disminución del recambio de LCR desempeñan un papel fundamental. Esta base fisiopatológica aleja la HCAi del concepto clásico de hidrocefalia y la acerca al perfil de otras enfermedades neurodegenerativas, como la enfermedad de Alzheimer o la enfermedad de Binswanger


Introduction: Since its description five decades ago, the pathophysiology of idiopathic chronic adult hydrocephalus (iCAH) has been traditionally related to the effect that ventricular dilatation exerts on the structures surrounding the ventricular system. However, altered cerebral blood flow, especially a reduction in the CSF turnover rate, are starting to be considered the main pathophysiological elements of this disease. Development: Compression of the pyramidal tract, the frontostriatal and frontoreticular circuits, and the paraventricular fibres of the superior longitudinal fasciculus have all been reported in iCAH. At the level of the corpus callosum, gliosis replaces a number of commissural tracts. Cerebral blood flow is also altered, showing a periventricular watershed region limited by the subependymal arteries and the perforating branches of the major arteries of the anterior cerebral circulation. The CSF turnover rate is decreased by 75%, leading to the reduced clearance of neurotoxins and the interruption of neuroendocrine and paracrine signalling in the CSF. Conclusions: iCAH presents as a complex nosological entity, in which the effects of subcortical microangiopathy and reduced CSF turnover play a key role. According to its pathophysiology, it is simpler to think of iCAH more as a neurodegenerative disease, such as Alzheimer disease or Binswanger disease than as the classical concept of hydrocephalus


Assuntos
Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Doenças Neurodegenerativas/fisiopatologia , Ventrículos Cerebrais/fisiopatologia , Pressão do Líquido Cefalorraquidiano/fisiologia , Circulação Cerebrovascular/fisiologia , Doença Crônica , Hidrocefalia de Pressão Normal/diagnóstico , Hidrocefalia de Pressão Normal/líquido cefalorraquidiano , Doenças Neurodegenerativas/líquido cefalorraquidiano , Doenças Neurodegenerativas/diagnóstico
18.
J Neurol Sci ; 393: 105-109, 2018 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-30153569

RESUMO

Normal pressure hydrocephalus (NPH) is generally treated with ventriculoperitoneal shunts (VPS), with improved symptoms in the majority of patients. We performed a retrospective chart review study in order to describe patterns of, and risk factors for, delayed symptom progression after initially successful VPS placement. 69 consecutive patients underwent VPS placement for NPH, and were followed for a minimum of 12 months postoperatively. 55 patients (80%) had objective improvement in their NPH symptoms after surgery. Of these, 27 patients (49%) developed delayed deterioration of at least one of their NPH symptoms, at a mean of 28.3 months postoperatively (range, 3-77). 1 of the 27 patients was found to have shunt malfunction; 19 had specific clinical or imaging evidence of shunt function. 6/19 patients had transient improvement in their symptoms (lasting 30 days or more) after adjustment of their programmable shunt valves (32%), although symptoms in all of these patients later worsened. During a mean follow up period of 44.4 months (range, 15-87), 12 patients (44%) received other neurological diagnoses felt to at least partially explain their symptoms. Increased patient age was associated with likelihood of delayed symptom progression. We conclude that delayed symptom progression is common after VPS placement for NPH, including after initial symptom improvement; that symptom progression can often be temporarily palliated by shunt valve pressure adjustment; and that older patients are more likely to experience delayed symptom progression. We suggest that patients and their families be counselled accordingly before surgery.


Assuntos
Hidrocefalia de Pressão Normal/cirurgia , Derivação Ventriculoperitoneal , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Feminino , Seguimentos , Humanos , Hidrocefalia de Pressão Normal/epidemiologia , Hidrocefalia de Pressão Normal/fisiopatologia , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
19.
J Neurol Sci ; 391: 54-60, 2018 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-30103972

RESUMO

INTRODUCTION: Idiopathic Normal Pressure Hydrocephlaus (iNPH) is, despite a vastly improved knowledge of the disorder since its first description still underdiagnosed and undertreated. Because of this, there is a need for further large studies describing the typical symptomatology and reversibility of symptoms in iNPH, which was the aim of this study. METHODS: In all, 429 patients (mean age 71 years) were included. Detailed pre- and postoperative examinations of symptoms and signs were analyzed. A composite outcome measure was constructed. RESULTS: Sixty-eight % improved after surgery. Preoperatively, 72% exhibited symptoms from three or four of the assessed domains (gait, balance, neuropsychology and continence) while 41% had symptoms from all four domains. Ninety % had gait disturbances, of which 75% had broad-based gait, 65% shuffling gait and 30% freezing of gait. These disturbances coexisted in most patients preoperatively, but were more likely to appear as isolated findings after surgery. Impaired balance was seen in 53% and retropulsion in 46%. MMSE <25 was seen in 53% and impaired continence in 86%. Improvements were seen in all symptom domains postoperatively. CONCLUSIONS: The iNPH phenotype is characterized by a disturbance in at least 3/4 symptom domains in most patients, with improvements in all domains after shunt surgery. Most patients present with a broad-based and shuffling gait as well as paratonia. Present symptoms in all domains and a shuffling gait at the time of diagnosis seem to predict a favorable postoperative outcome, whereas symptom severity does not.


Assuntos
Hidrocefalia de Pressão Normal/diagnóstico , Hidrocefalia de Pressão Normal/cirurgia , Idoso , Cognição , Feminino , Marcha , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Hidrocefalia de Pressão Normal/psicologia , Masculino , Fenótipo , Equilíbrio Postural , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Incontinência Urinária
20.
World Neurosurg ; 119: e46-e52, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29981467

RESUMO

OBJECTIVE: The counseling of patients with idiopathic normal pressure hydrocephalus (iNPH) is difficult; there is variability in the diagnostic criteria, and a definitive diagnosis can be made only postoperatively. A patient's clinical response to shunting is also difficult to predict. This study examines the subjective experience of patients treated for iNPH, to identify the challenges patients face and to improve patient outcomes and satisfaction. METHODS: We reviewed a consecutive series of patients diagnosed with iNPH who underwent ventriculoperitoneal shunt surgery between January 2012 and March 2016 at our institution. Semistructured telephone interviews were conducted with 31 patients. Interviews were analyzed using the principles of grounded theory. RESULTS: Thirty-one patients who underwent shunt surgery for iNPH were interviewed to reach saturation of themes. Seven themes were identified: 1) long preoperative course causes morbidity; 2) the decision to have shunt surgery is easy to make; 3) patients primarily desire to gain independence; 4) patients show variable levels of anxiety; 5) comorbid conditions interfere with postoperative assessment; 6) patients stand by their decision to have shunt surgery; and 7) outside information is used before surgery. CONCLUSIONS: Patients often present to the neurosurgeon frustrated and desperate after a long preoperative course. It is important to acknowledge the uncertainty regarding diagnosis and response to shunting when counseling patients. Comorbid conditions interfere with the ability to assess progression of iNPH and the effectiveness of the shunt. Patient caregivers play a large role in decision making and clinical course and should be included when counseling patients.


Assuntos
Ansiedade/etiologia , Cuidadores/psicologia , Derivações do Líquido Cefalorraquidiano/métodos , Hidrocefalia de Pressão Normal/psicologia , Hidrocefalia de Pressão Normal/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Hidrocefalia de Pressão Normal/fisiopatologia , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Retrospectivos , Resultado do Tratamento
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