Predictors of the disappearance of triad symptoms in patients with idiopathic normal pressure hydrocephalus after shunt surgery.

We identified factors that predict the disappearance of the triad of symptoms (gait disturbance, cognitive impairment and urinary incontinence) of idiopathic normal pressure hydrocephalus (iNPH) following shunt surgery in this study. We classified 71 patients with iNPH into those whose objective symptoms disappeared (disappearance group) or remained (residual group), for each of the triad symptoms 12 months after shunt surgery. Logistic regression analyses were used to identify the predictors of the disappearance of symptoms among 10 variables before shunt surgery (e.g., age, sex, severity of symptoms, Evans index, cerebrospinal fluid (CSF) pressure, CSF stasis on computerized tomographic cisternography, regional cerebral blood flow on single photon emission computed tomography, three kinds of prior diseases). For each of the triad symptoms, mild symptoms before shunt surgery were predictors of the disappearance of the symptom. Young age was also a predictor of the disappearance of gait disturbance. When the analysis was conducted using subscores of the Mini Mental State Examination, a successful visuoconstruction subtest and an absence of hypertension were predictors of the disappearance of cognitive impairment. None of the neuroimaging examinations predicted the disappearance of symptoms after shunt surgery in this study.

Role of computerized tomographic cisternography in idiopathic normal pressure hydrocephalus.

BACKGROUND: We prospectively evaluate the role of computerized tomographic cisternography (CTC) in idiopathic normal pressure hydrocephalus (iNPH). METHODS: The cerebrospinal fluid kinetics of 70 patients who passed the entry criteria for the Study of iNPH on Neurological Improvement (SINPHONI) and underwent insertion of a shunt were studied. RESULTS: Stasis of the contrast medium at the lateral ventricles over 24 h (positive ventricular stasis) was observed in 60 patients and at the Sylvian fissure or parietal sulci over 48 h (positive surface stasis) in 59 patients. Sixty patients showed a good response to shunt insertion. The sensitivities of CTC findings at the lateral ventricles and brain surface for shunt effectiveness were 81.7 and 86.7%, respectively; however, the specificities were 20 and 0%. Among the 60 patients who showed a good response to the shunt, 49 had positive surface stasis. Positive ventricular stasis was observed in 52 of the 60 patients, and both findings were observed in 44 patients. Three patients who responded to the shunt had negative stasis in both sites. The 11 patients who had negative surface stasis had significantly lower (p < 0.05) preoperative iNPH grading scale-R scores than the 49 patients with positive surface stasis; these patients were considered to be in an early stage of iNPH. CONCLUSIONS: CTC did not provide additional diagnostic value for predicting the shunt response among patients selected using SINPHONI criteria. We suggest that factors other than disturbances in CSF circulation may be related to the pathogenesis of iNPH.

Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus.

The utility of measuring the corpus callosal angle (CA) for the diagnosis of idiopathic normal pressure hydrocephalus (INPH) was investigated. Three-dimensional magnetic resonance imaging (MRI) was performed in 34 INPH patients, 34 Alzheimer's disease (AD) patients, and 34 normal control (NC) subjects. Measurement of the CA on the coronal MR images of the posterior commissure perpendicular to the anteroposterior commissure plane was performed for all subjects. The CA of the INPH group (mean +/- SD, 66 +/- 14 degrees) was significantly smaller than those of the AD (104 +/- 15 degrees) and NC (112 +/- 11 degrees) groups. When using the threshold of the mean - 2SD value of the NC group (= 90 degrees), an accuracy of 93%, sensitivity of 97%, and specificity of 88% were observed for discrimination of INPH from AD patients. Measuring the CA helps in differentiating INPH patients from AD and normally aged subjects.

Voxel-based analysis of gray matter and CSF space in idiopathic normal pressure hydrocephalus.

AIMS: To investigate regional morphologic changes in idiopathic normal pressure hydrocephalus (INPH) based on diagnosis with INPH Guidelines using voxel-based morphometry. METHOD: Three-dimensional magnetic resonance imaging was performed in 34 INPH patients, who met probable INPH criteria, probable 34 Alzheimer disease patients, and 34 normal control subjects. RESULTS: Statistical parametric mapping was used to conduct voxel-based morphometry analysis of the morphologic data and revealed enlarged ventricles and sylvian fissures and stenotic sulci of high convexity, especially in the precuneus in the INPH group, with decreased gray matter density in the insula, caudate and thalamus. CONCLUSION: In INPH, morphologic change occurs in the frontoparietal high convexity with ventricular dilatations, dilated sylvian fissures and tight sulci in the medial parietal lobes.

Controversy of surgical treatment for severe cerebellar infarction.

Treatment for severe cerebellar infarction has been controversial. Clinical outcomes of patients with external ventricular drainage (EVD) and decompression as the first treatment for the infarction were compared. A total of 25 patients with severe cerebellar infarction were subdivided into two groups to compare outcome of the group (group A) with EVD with that of the group (group B) with decompressive surgery as the first surgery. There was no statistically significant difference in age between group A with 71 +/- 6 years and group B with 61 +/- 15 years. The preoperative status was Glasgow Coma Scale (GCS) score 6 in all the patients in group A. It was GCS score 4 in one patient, GCS score 6 in 9 patients, GCS score 7 in 8 patients, and GCS score 9 in two patients in group B. The preoperative neurologic background was almost the same for both groups. In group A, one patient had a good recovery. However, 3 patients became severely disabled and one patient died. In group B, 10 patients had a good recovery and 6 patients became moderately disabled, although two patients were disabled and two patients died. The outcome was good in one patient of group A and in 16 patients of group B, although it was poor in 4 patients each in both groups. Patients in group B had a significantly better prognosis than those in group A. No clear evidence of surgical indications for EVD or suboccipital decompression from neurologic signs or symptoms and from neuroimaging has been reported. Our results seem to suggest that pre-emptive suboccipital decompression with or without resection of necrosis is warranted in the patients with severe cerebellar infarction.

Cerebral perfusion pattern of idiopathic normal pressure hydrocephalus studied by SPECT and statistical brain mapping.

OBJECTIVES: To investigate the specific pattern of cerebral blood flow (CBF) in subjects with idiopathic normal pressure hydrocephalus (iNPH) using voxel-based analysis. METHODS: N-isopropyl-p-[123I]iodoamphetamine (IMP) single photon emission computed tomography (SPECT) images were performed in 30 iNPH patients, who met probable iNPH criteria, 30 Alzheimer disease (AD) patients and 15 normal control (NC) subjects. Inter-group comparisons between iNPH patients and NC subjects and between AD patients and NC subjects were performed using three-dimensional stereotactic surface projection (3D-SSP) analysis. Individual 3D-SSP images of the iNPH patients were assessed by visual inspection. RESULTS: On the Z-score maps, areas of relative hypoperfusion were recognized around the corpus callosum in all 30 iNPH patients, as well as in the Sylvian fissure regions in 19 of 30 iNPH patients which included artifacts by dilated ventricles and the Sylvian fissures. Ten frontal dominant, eight parietotemporal dominant, and 12 diffuse hypoperfusion types were demonstrated. Inter-group comparison between iNPH and NC subjects showed relative hypoperfusion in the frontal and parietotemporal areas and severe hypoperfusion around the corpus callosum and Sylvian fissure regions, while parietotemporal and posterior cingulate CBF reduction was demonstrated between the AD and NC groups. CONCLUSION: Voxel-based analysis showed a characteristic pattern of regional CBF reduction with frontal dominant or diffuse cerebral hypoperfusion accompanying severe hypoperfusion around the corpus callosum and Sylvian fissures with artifacts.

Usefulness of intravascular ultrasonography for treatment of a ruptured vertebral dissecting aneurysm.

We report successful stent implantation and secondary coil embolization in a wide-necked dissecting aneurysm in the vertebral artery. Intravascular ultrasonography (IVUS) showed the thrombosed pseudolumen clearly and enabled precise determination of the appropriate stent size. After stent implantation, Guglielmi detachable coil embolization was performed. Further experience is necessary to refine the technique, but IVUS may be useful to improve the safety of stent-assisted embolization.

Progress of leukoaraiosis is inhibited by correction of platelet hyper-aggregability.

BACKGROUND: Platelet hyper-aggregability is an important risk factor for leukoaraiosis. In this study we investigated whether aggravation of leukoaraiosis can be controlled by means of long-term correction of platelet hyper-aggregability. METHODS: Twenty-one patients with leukoaraiosis and uncorrected platelet hyper-aggregability were compared with 21 controls matched for age, grade of leukoaraiosis and observation period whose platelet hyper-aggregability was corrected. Platelet aggregability was estimated by an optical analytical method with a nine-stage display using two different concentrations each of adenosine diphosphate (ADP) and collagen (the double ADP method). RESULTS: The mean observation period between two magnetic resonance imaging (MRI) scans for both groups was 4.1 years. In the non-corrected group, moderate to severe aggravation of leukoaraiosis was observed in a large number of patients. In the corrected group, only a small number of patients showed generally mild aggravation of leukoaraiosis. The number of patients showing aggravation of periventricular hyperintensity (PVH) was 7 in 21 in the non-corrected group versus 1 in 21 (p = 0.022) in the corrected group, and for aggravation of deep white-matter hyperintensity, these values were 9 in 21 versus 4 in 21, respectively. Thus, the difference was more significant if the degree of aggravation was taken into account. CONCLUSION: The progress of leukoaraiosis is greatly inhibited by long-term correction of platelet hyper-aggregability.

Comparison of conventional region of interest and statistical mapping method in brain single-photon emission computed tomography for prediction of hyperperfusion after carotid endarterectomy.

OBJECTIVE: Hyperperfusion after carotid endarterectomy (CEA) has been proposed as the main mechanism of intracerebral hemorrhage, which is a disastrous complication. The aim of this study was to compare the predictive value of cerebral blood flow (CBF) abnormalities for hyperperfusion after CEA with the conventional region of interest (ROI) analysis and statistical brain mapping analysis. METHODS: For 46 patients with unilateral carotid stenosis of 70% or more, CBF and cerebral vasoreactivity were investigated with resting and acetazolamide-challenge single-photon emission computed tomography before CEA and 1 day after CEA. Three-dimensional stereotactic surface projection (3-D-SSP) analysis of CBF changes was performed by automatic quantification with a predefined template. RESULTS: Logistic regression analysis demonstrated CBF reduction (z-score) to be the only significant variable for postoperative hyperperfusion on 3-D-SSP with thalamic normalization but no significant variable with the ROI method. Receiver operating characteristic (ROC) analysis demonstrated significant improvement in the predictive value of CBF reduction (z-score) on 3-D-SSP (area under the ROC curve = 0.93) in comparison with the ROI method (area under the ROC curve = 0.78) (P = 0.049). According to the optimal cutoff values provided by ROC analysis, patients were categorized into two groups: Type I (CBF decrease < 20%, n = 23) and Type II (CBF decrease > or = 20%, n = 23) on ROI analysis and Type A (z-score < or = 2, n = 40) and Type B (z-score > 2, n = 6) on 3-D-SSP. There was a significant difference in incidence of hyperperfusion between Type A (1 of 40) and Type B (5 of 6) on 3-D-SSP (P = 0.00003) but not between Type I (1 of 23) and Type II (5 of 23) on ROI analysis. Cerebral vasoreactivity did not show significant value in the prediction of hyperperfusion with either the ROI or the 3-D-SSP method. CONCLUSION: Objective assessment of CBF status, especially baseline CBF reduction (z-score), with automatic quantification by 3-D-SSP with normalization had a higher diagnostic value than conventional ROI analysis to identify patients at risk for hyperperfusion after CEA.

Knife blade penetrating stab wound to the brain--case report--.

A 28-year-old man attempted to kill himself with a knife stab into the parietal area. Neuroimaging showed no vascular impairment except slow venous flow around the knife due to tamponading. After obtaining informed consent, the knife was removed through a craniotomy without new brain injury. Postoperative neurological findings showed no deficit. Follow-up angiography revealed no vascular impairment. No infection occurred. Brain stab wounds cause numerous complications, such as intracranial hemorrhage, injury of important vessels, and infections. Minimal blade movement during removal and precautions to prevent massive hemorrhage are essential.

Expanded polytetrafluoroethylene membrane for prevention of adhesions in patients undergoing external decompression and subsequent cranioplasty.

Cranioplasty performed after external decompression for brain swelling may be difficult because of the development of adhesions between the temporal muscle and the dura. Membranes composed of expanded polytetrafluoroethylene (ePTFE) were inserted at external decompression to prevent such adhesions. The ePTFE membranes were placed suturelessly between the temporal muscle and the dura, covering the proximal portion of the temporal muscle at the sphenoidal ridge and the dural suture line. In addition, part of the membrane was placed directly below the skin incision to allow easy visualization at subsequent cranioplasty in 10 patients. Cranioplasty was performed 38 to 126 days (mean 63.9 days) after external decompression. No adhesions were observed, either between the ePTFE membranes and the dura, or between the membranes and the temporal muscle. No temporal muscle and dural injuries occurred during cranioplasty, and no patient showed signs of infection. Mean operating time was 71.0 minutes and mean blood loss was 75.2 ml. Sutureless insertion of ePTFE membranes at external decompression increases the ease and safety of subsequent cranioplasty, decreases operating time and blood loss, and avoids injury to the temporal muscle and dura.

Prediction of hyperperfusion after carotid endarterectomy by brain SPECT analysis with semiquantitative statistical mapping method.

BACKGROUND AND PURPOSE: Hyperperfusion syndrome is a rare but disastrous complication after carotid endarterectomy (CEA). The aim of this study was to investigate the relationship between preoperative cerebral blood flow (CBF) abnormalities and postoperative hyperperfusion through the use of statistical brain mapping analysis. METHODS: For 41 patients with unilateral carotid stenosis >or=70%, CBF and cerebral vasoreactivity (CVR) were investigated with resting and acetazolamide-challenge single photon emission CT before CEA. CBF 1 day after CEA was also measured. Three-dimensional stereotactic surface projection (3D-SSP) analysis of CBF changes was performed by use of a control database of 20 subjects. RESULTS: Patients with reduced CVR (CVR <10%, n=15) were categorized into 2 groups based on the severity of CBF reduction relative to the control database by 3D-SSP analysis without normalization: type I (ipsilateral CBF decrease <20%, n=8) and type II (ipsilateral CBF decrease >or=20%, n=7). With thalamic normalization, the patients were also categorized into 2 groups: type A (ipsilateral Z score 2, n=5). Severe CBF reduction (>or=20% or Z score >2) was significantly associated with postoperative hyperperfusion (CBF increase >or=100%). However, 3D-SSP with thalamic normalization (Z score) demonstrated a higher predictive value (80%) and specificity (91%) for hyperperfusion than 3D-SSP without normalization (percent reduction) (57% and 73%, respectively). No patients with normal CVR (CVR >or=10%, n=26) demonstrated postoperative hyperperfusion. CONCLUSIONS: Objective evaluation of abnormalities of CBF and CVR with 3D-SSP could identify patients at risk for postoperative hyperperfusion.

Direct surgical removal of the dural arteriovenous fistulas involving transverse-sigmoid sinuses.

We investigated the operative methods and the angiographical classification in eight patients with dural arteriovenous fistulas involving transverse-sigmoid sinuses. There were two men and six women with a mean age of 68.3 (range 61-73) years. The initial symptoms were focal neurological deficits (aphasia, hemiparesis, hemianopsia) because of intracranial haematoma in four patients, dementia in two, headache in one and pulsatile tinnitus in one. Preoperatively, transarterial coil embolisaton was performed in four patients and transvenous coil embolisation in three. Finally total removal was performed in all patients. In all patients angiogram showed the presence of sinus occlusion diagnosed in the late venous phase and retrograde flow from the sinuses to the cortical veins. According to Borden's classification, three patients were classified as Type II-C (or C'), four patients as Type III-D and one patient as Type E. The volume of blood loss did not change either with or without preoperative transarterial coil embolisation. There was no new procedure-related morbidity. The presence of sinus occlusion diagnosed in the late venous phase and retrograde flow from the sinuses to the cortical veins indicate that total removal is possible.