DOCSLIB.ORG

Analysis of ICP Pulsatility and CSF Dynamics the Pulsatility Curve and Effects of Postural Changes, with Implications for Idiopathic Normal Pressure Hydrocephalus

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Analysis of ICP Pulsatility and CSF Dynamics the Pulsatility Curve and Effects of Postural Changes, with Implications for Idiopathic Normal Pressure Hydrocephalus Umeå University Medical Dissertations, New Series No 1613 Analysis of ICP pulsatility and CSF dynamics The pulsatility curve and effects of postural changes, with implications for idiopathic normal pressure hydrocephalus Sara Qvarlander Department of Radiation Sciences and Department of Pharmacology and Clinical Neuroscience, Umeå University Umeå, Sweden, 2013 Responsible publisher under swedish law: the Dean of the Medical Faculty This work is protected by the Swedish Copyright Legislation (Act 1960:729) ISBN: 978-91-7459-762-2 ISSN: 0346-6612 Electronic version available at http://umu.diva-portal.org/ Printed by: Print & Media Umeå, Sweden 2013 “Prediction is very difficult, especially if it's about the future.” Niels Bohr Abstract The volume defined by the rigid cranium is shared by the brain, blood and cerebrospinal fluid (CSF). With every heartbeat the arterial blood volume briefly increases and venous blood and CSF are forced out of the cranium, leading to pulsatility in CSF flow and intracranial pressure (ICP). Altered CSF pulsatility has been linked to idiopathic normal pressure hydrocephalus (INPH), which involves enlarged cerebral ventricles and symptoms of gait/balance disturbance, cognitive decline and urinary incontinence that may be improved by implantation of a shunt. The overall aim of this thesis was to investigate the fluid dynamics of the CSF system, with a focus on pulsatility, and how they relate to INPH pathophysiology and treatment. Mathematical modelling was applied to data from infusion tests, where the ICP response to CSF volume manipulation is measured, to analyse the relationship between mean ICP and ICP pulse amplitude (AMP) before and after shunt surgery in INPH (paper I-II). The observed relationship, designated the pulsatility curve, was found to be constant at low ICP and linear at high ICP, corresponding to a shift from constant to ICP dependent compliance (paper I). Shunt surgery did not affect the pulsatility curve, but shifted baseline ICP and AMP along the curve towards lower values. Patients who improved in gait after surgery had significantly larger AMP reduction than those who did not, while ICP reduction was similar, suggesting that improving patients had baseline ICP in the linear zone of the curve before surgery. Use of this phenomenon for outcome prediction was promising (paper II). The fluid dynamics of an empirically derived pulsatility-based predictive infusion test for INPH was also investigated, with results showing strong influence from compliance (paper III). Clinical ICP data at different body postures was used to evaluate three models describing postural effects on ICP. ICP decreased in upright positions, whereas AMP increased. The model describing the postural effects based on hydrostatic changes in the venous system, including effects of collapse of the jugular veins in the upright position, accurately predicted the measured ICP (paper IV). Cerebral blood flow and CSF flow in the aqueduct and at the cervical level was measured with phase contrast magnetic resonance imaging, and compared between healthy elderly and INPH (paper V). Cerebral blood flow and CSF flow at the cervical level were similar in INPH patients and healthy elderly, whereas aqueductal CSF flow differed significantly. The pulsatility in the aqueduct flow was increased, and there was more variation in the net flow in INPH, but the mean net flow was normal, i.e. directed from the ventricles to the subarachnoid space (paper V). In conclusion, this thesis introduced the concept of pulsatility curve analysis, and provided evidence that pulsatility and compliance are important aspects for successful shunt treatment and outcome prediction in INPH. It was further confirmed that enhanced pulsatility of aqueduct CSF flow was the most distinct effect of INPH pathophysiology on cerebral blood flow and CSF flow. A new model describing postural and hydrostatic effects on ICP was presented, and the feasibility and potential importance of measuring ICP in the upright position in INPH was demonstrated. Table of Contents Original Papers iii Abbreviations iv Introduction 1 Background 3 CSF circulation 3 Intracranial blood circulation 4 Intracranial pulsatility 5 Idiopathic Normal Pressure Hydrocephalus 6 Mathematical modelling of CSF dynamics 7 Infusion tests 10 Hydrostatic pressure gradients and posture 12 Phase-Contrast Magnetic Resonance Imaging 13 Aims 17 Materials and methods 19 General overview 19 Ethical approval 19 Subjects 19 Infusion test protocols 23 ICP data quality 25 Post processing of ICP data 25 Mathematical modelling and derivations 29 Magnetic Resonance Imaging 38 Post processing of MRI data 39 Statistics 41 Results 43 The pulsatility curve 43 Response to shunt surgery 45 AMPmean – Mean pulse amplitude 47 Postural effects on ICP 49 Cerebral blood flow and CSF flow 51 Discussion 53 Intracranial pulsatility 53 Treatment and outcome prediction in INPH 54 Pathophysiology of INPH 56 Extension of the mathematical model of CSF dynamics 59 Modelling of postural and hydrostatic effects on ICP 60 Future research 62 Conclusion 65 Acknowledgements 67 References 69 i ii Original Papers This thesis is based on the following papers, which are referred to by their Roman numerals in the text: I. Qvarlander S, Malm J, Eklund A. The pulsatility curve – the relationship between mean intracranial pressure and pulsation amplitude. Physiological Measurement 31(11):1517-28, 2010* II. Qvarlander S, Lundkvist B, Koskinen L-O D, Malm J, Eklund A. Pulsatility in CSF dynamics: pathophysiology of idiopathic normal pressure hydrocephalus. Journal of Neurology, Neurosurgery, and Psychiatry 84(7):735-41, 2013* III. Qvarlander S, Malm J, Eklund A. CSF dynamic analysis of a predictive pulsatility-based infusion test for normal pressure hydrocephalus. Medical and Biological Engineering and Computing 2013 Oct 23. [Epub ahead of print]* IV. Qvarlander S, Sundström N, Malm J, Eklund A. Postural effects on intracranial pressure: modeling and clinical evaluation. Journal of Applied Physiology 2013 Sep 19. [Epub ahead of print]* V. Qvarlander S, Ambarki K, Wåhlin A, Jacobsson J, Birgander R, Malm J, Eklund A. Differences in cerebral blood flow and CSF flow between INPH and healthy elderly. In manuscript. * Reprinted with permission. iii Abbreviations ΔV Intracranial arterial volume expansion at systole ρ Density of cerebrospinal fluid/blood (approximated as water) AMP Pulse amplitude of intracranial pressure AMPmean Mean pulse amplitude of intracranial pressure during first 10 minutes of constant flow infusion AMPnorm Normalized pulse amplitude of intracranial pressure AMPr Baseline/resting pulse amplitude of intracranial pressure ANOVA Analysis of variance C Compliance of the cerebrospinal fluid system CBF Cerebral arterial blood flow CFI Constant flow infusion CPI Constant pressure infusion CSF Cerebrospinal fluid Cout Conductance of cerebrospinal fluid outflow (1/Rout) CVP Central venous pressure ECG Electrocardiogram FFT Fast Fourier transform g Gravitational acceleration HIPCSF Hydrostatic indifference point of the cerebrospinal fluid system HIPvein Hydrostatic indifference point of the venous system ICA Internal carotid artery ICP Intracranial pressure ICPnorm Normalized intracranial pressure ICPr Baseline/resting intracranial pressure ICPstart Intracranial pressure at start of external infusion Ia Absorption rate of cerebrospinal fluid If Formation rate of cerebrospinal fluid Iext Rate of external infusion IJV Internal jugular vein INPH Idiopathic normal pressure hydrocephalus k Elastance coefficient of the cerebrospinal fluid system (=1/0.4343PVI) Lheart Distance from auditory canal to the centre of the sternum (as an anatomical reference for the heart) Lheart-HIPvein Distance from the heart to the hydrostatic indifference point of the venous system Lcollapse Distance from top of collapsed venous segment to the auditory canal iv MRI Magnetic resonance imaging NPH Normal pressure hydrocephalus P0 Pressure constant of the mathematical model of the cerebrospinal fluid system PC-MRI Phase contrast magnetic resonance imaging Pd Venous pressure in the dural venous sinus PHIPvein Venous pressure at the venous hydrostatic indifference point PVI Pressure volume index (=1/0.4343k) ROC Receiver operating characteristic ROI Region of interest Rout Resistance to cerebrospinal fluid outflow/absorption (1/Cout) RPPC Relative pulse pressure coefficient, slope of linear relationship between pulse amplitude and mean intracranial pressure SD Standard deviation SV Stroke volume VA Vertebral artery Venc Maximum velocity measured without aliasing in phase contrast magnetic resonance imaging sequence v vi Introduction The adult cranium is rigid, and encloses a fixed volume that is shared by the brain, blood and cerebrospinal fluid (CSF). The Monro-Kelli doctrine postulates that, as these constituents are considered essentially incompressible, the increases in the volume of one of the constituents must be compensated for by reduction in the others (82). The doctrine was defined for slow processes, such as a mass lesion, e.g. an intracranial haemorrhage, but can also be applied to interpret fast, cardiac-related pulsatility. Thus, with every heartbeat, when the intracranial arterial blood volume briefly increases, venous blood and CSF is forced out of the intracranial compartment (53, 54). The intracranial flow of blood and CSF is thus pulsatile, as is the intracranial pressure (ICP). This cardiac-related pulsatility has become the focus of several hypotheses
Load more

Recommended publications
  • Serial Tap Test of Patients with Idiopathic Normal Pressure
    da Rocha et al. Fluids Barriers CNS (2021) 18:22 https://doi.org/10.1186/s12987-021-00254-3 Fluids and Barriers of the CNS RESEARCH Open Access Serial Tap Test of patients with idiopathic normal pressure hydrocephalus: impact on cognitive function and its meaning Samanta Fabrício Blattes da Rocha1* , Pedro André Kowacs1,2, Ricardo Krause Martinez de Souza1, Matheus Kahakura Franco Pedro1, Ricardo Ramina1 and Hélio A. Ghizoni Teive3 Abstract Background: Idiopathic normal pressure hydrocephalus (INPH) is characterized by gait disturbance, urinary incon- tinence and cognitive decline. Symptoms are potentially reversible and treatment is based on cerebrospinal fuid shunting. The tap test (TT) is used to identify patients that will beneft from surgery. This procedure consists of the withdrawal of 20 to 50 mL of cerebrospinal fuid (CSF) through a lumbar puncture (LP) after which the symptoms of the triad are tested. Improvement in the quality and speed of gait are already recognized but cognitive improvement depends on several factors such as tests used, the time elapsed after LP for re-testing, and the number of punctures. Serial punctures may trigger similar conditions as external lumbar drainage (ELD) to the organism. Objective: This study aimed to identify how serial punctures afect cognition to increase the sensitivity of the test and consequently the accuracy of surgical indication. Methods: Sixty-one patients with INPH underwent baseline memory and executive tests repeatedly following the 2-Step Tap Test protocol (2-STT – two procedures of 30 mL lumbar CSF drainage separated by a 24-h interval). The baseline scores of INPH patients were compared with those of 55 healthy controls, and with intragroup post-puncture scores of the 2-STT.
    [Show full text]
  • Quantitative MRI for Rapid and User-Independent Monitoring of Intracranial CSF Volume in Hydrocephalus
    ORIGINAL RESEARCH ADULT BRAIN Quantitative MRI for Rapid and User-Independent Monitoring of Intracranial CSF Volume in Hydrocephalus X J. Virhammar, X M. Warntjes, X K. Laurell, and X E.-M. Larsson ABSTRACT BACKGROUND AND PURPOSE: Quantitative MR imaging allows segmentation of different tissue types and automatic calculation of intracranial volume, CSF volume, and brain parenchymal fraction. Brain parenchymal fraction is calculated as (intracranial volume Ϫ CSF volume) / intracranial volume. The purpose of this study was to evaluate whether the automatic calculation of intracranial CSF volume or brain parenchymal fraction could be used as an objective method to monitor volume changes in the ventricles. MATERIALS AND METHODS: A lumbar puncture with drainage of 40 mL of CSF was performed in 23 patients under evaluation for idiopathic normal pressure hydrocephalus. Quantitative MR imaging was performed twice within 1 hour before the lumbar puncture and was repeated 30 minutes, 4 hours, and 24 hours afterward. For each time point, the volume of the lateral ventricles was manually segmented and total intracranial CSF volume and brain parenchymal fraction were automatically calculated by using Synthetic MR postprocessing. RESULTS: At 30 minutes after the lumbar puncture, the volume of the lateral ventricles decreased by 5.6 Ϯ 1.9 mL (P Ͻ .0001) and the total intracranial CSF volume decreased by 11.3 Ϯ 5.6 mL (P Ͻ .001), while brain parenchymal fraction increased by 0.78% Ϯ 0.41% (P Ͻ .001). Differences were significant for manual segmentation and brain parenchymal fraction even at 4 hours and 24 hours after the lumbar tap.
    [Show full text]
  • The Clinical Effect of Lumbar Puncture in Normal Pressure Hydrocephalus
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.45.1.64 on 1 January 1982. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1982;45:64-69 The clinical effect of lumbar puncture in normal pressure hydrocephalus C WIKKELS0, H ANDERSSON, C BLOMSTRAND, G LINDQVIST From the Department of Neurology and Neurosurgery, Sahlgren Hospital, University of Goteborg, Sweden SUMMARY Owing to all the difficulties involved in selecting patients with normal pressure hydro- cephalus for shunt-operation, a cerebrospinal fluid-tap-test (CSF-TT) is introduced. Psychometric and motor capacities of the patients are measured before and after lumbar puncture and removal of 40-50 ml CSF. Patients fulfilling criteria for normal pressure hydrocephalus were compared to patients with dementia and atrophy shown by computed tomography. Normal pressure hydro- cephaluspatients showed temporary improvement after lumbar puncture. The extent ofthe temporary improvement appeared to be well correlated with the improvement after shunt operation. Accord- ingly, the CSF-TT seems to be of value when selecting those patients who will probably benefit from a shunt operation. The syndrome of normal pressure hydrocephalus is pressure by lumbar puncture caused both subjective Protected by copyright. characterised by gait disturbance, progressive mental and objective temporary improvement in some deterioration and urinary incontinence.' Particularly patients with normal pressure hydrocephalus.10 16 17 noteworthy is the complex gait disturbance with Such patients also improved after CSF-shunting. spastic-ataxia, extrapyramidal components, and However, no details have been given about the commonly dyspraxia of gait.2 In addition, there is in amount of CSF which was drained or to what degree typical cases mental "slowing up" with lack of the CSF pressure was lowered.
    [Show full text]
  • Endoscopic Third Ventriculostomy in Post Traumatic Hydrocephalus- Institutional Experience
    Original Research Article DOI: 10.18231/2455-8451.2018.0015 Endoscopic third ventriculostomy in post traumatic hydrocephalus- Institutional experience Geover J. Lobo1, Madhukar T. Nayak2,* 1Assistant Professor, 2Professor, Dept. of Neurosurgery, Fr. Muller Medical College & Hospital, Mangaluru, Karnataka, India *Corresponding Author: Email: [email protected] Abstract Introduction: Hydrocephalus is a known sequelae in traumatic brain injury patients. It may occur early or late and presents with dementia, urinary incotinence and difficulty in walking as described by Hakim and Adams. There are two distinct types of normal pressure hydrocephalus one is idiopathic most commonly seen in the elderly age groups and the other is secondary due to a cerebro vascular accident, trauma or surgery. The idiopathic type may not respond to the CSF diversion procedure, but the secondary type which responds to CSF diversion procedure. Our study aims at exploring the option of ETV in these patients not making them shunt dependent. Materials and Methods: The patients with traumatic brain injury admitted in the dept. of neurosurgery between January 2012 and January 2018 were included into the study. Congenital hydrocephalus and secondary hydrocephalus due to spontaneous SAH and tumours were excluded. 14 patients were identified and if there was some improvement in their condition after CSF tap test were planned for endoscopic third ventriculostomy. Results: Out of the 14 patients 2 were females and the remaining 12 were males. 2 did not improve at all. 12 had some improvement out of which 3 had a failure and underwent a v-p shunt. Hence there were 5 failures out of 14 which made 35.7%.
    [Show full text]
  • Idiopathic Normal Pressure Hydrocephalus: Diagnostic and Predictive Value of Clinical Testing, Lumbar Drainage, and CSF Dynamics
    CLINICAL ARTICLE J Neurosurg 125:591–597, 2016 Idiopathic normal pressure hydrocephalus: diagnostic and predictive value of clinical testing, lumbar drainage, and CSF dynamics *Cynthia V. Mahr, MD,1 Markus Dengl, MD,1 Ulf Nestler, MD,1 Martin Reiss-Zimmermann, MD,2 Gerrit Eichner, ScD,3 Matthias Preuß, MD,1 and Jürgen Meixensberger, MD 1Departments of 1Neurosurgery and 2Neuroradiology, University Hospital Leipzig; and 3Mathematical Institute, Justus-Liebig University Gießen, Germany OBJECTIVE The aim of the study was to analyze the diagnostic and predictive values of clinical tests, CSF dynamics, and intracranial pulsatility tests, compared with external lumbar drainage (ELD), for shunt response in patients with idio- pathic normal pressure hydrocephalus (iNPH). METHODS Sixty-eight consecutive patients with suspected iNPH were prospectively evaluated. Preoperative assess- ment included clinical tests, overnight intracranial pressure (ICP) monitoring, lumbar infusion test (LIFT), and ELD for 24–72 hours. Simple and multiple linear regression analyses were conducted to identify predictive parameters concern- ing the outcome after shunt therapy. RESULTS Positive response to ELD correctly predicted improvement after CSF diversion in 87.9% of the patients. A Mini–Mental State Examination (MMSE) value below 21 was associated with nonresponse after shunt insertion (specific- ity 93%, sensitivity 67%). Resistance to outflow of CSF (ROut) > 12 mm Hg/ml/min was false negative in 21% of patients. Intracranial pulsatility parameters yielded different results in various parameters (correlation coefficient between pulse amplitude and ICP, slow wave amplitude, and mean ICP) but did not correlate to outcome. In multiple linear regression analysis, a calculation of presurgical MMSE versus the value after ELD, ROut, and ICP amplitude quotient during LIFT was significantly associated with outcome (p = 0.04).
    [Show full text]
  • The Adjustable Shunt Valve in the Treatment of Adult Hydrocephalus Effect on Complications, Intracranial Pressure and Clinical Symptoms
    The adjustable shunt valve in the treatment of adult hydrocephalus Effect on complications, intracranial pressure and clinical symptoms Dan Farahmand Department of Neurosurgery Institute of Neuroscience and Physiology Sahlgrenska Academy at University of Gothenburg Click here to enter text. The adjustable shunt valve in the treatment of adult hydrocephalus Effect on complications, intracranial pressure and clinical symptoms © Dan Farahmand 2014 [email protected] ISBN 978-91-637-5698-6 Printed in Gothenburg, Sweden 2014 by Ineko AB To my beloved wife Johanna and to our wonderful sons Valter and Viktor ABSTRACT Background: Hydrocephalus causes impaired gait, balance, cognition and continence, all of which can be reversed by shunt treatment. Adjustable valves are commonly used in the shunt treatment of hydrocephalus but randomized controlled trials (RCT) are scarce. The aim of the present thesis was to evaluate adjustable valves in the treatment of hydrocephalus. Patients and Methods: In Study I, 450 hydrocephalus patients undergoing primary shunt insertion were followed over 10 years to investigate the short- term perioperative risk factors of shunt surgery. In Study II the relationship between intracranial pressure (ICP) and ICP wave amplitude (AMP), valve settings and body positions were studied in 15 hydrocephalus patients. During the shunt operation an intraparenchymatous ICP-sensor was simultaneously inserted and ICP/AMP analyzed with the shunt ligated and when opened at different opening pressures and body positions. A double- centered RCT was conducted in studies III and IV, including 68 patients with iNPH. The patients received a ventricular shunt and were randomized into two groups; in one group (20-4) the valve was initially set to 20 cm H2O and gradually reduced to 4 cm H2O over the course of the 6 month study period.
    [Show full text]
  • Walking Assessment After Lumbar Puncture in Normal-Pressure Hydrocephalus: a Delayed Improvement Over 3 Days
    CLINICAL ARTICLE J Neurosurg 126:148–157, 2017 Walking assessment after lumbar puncture in normal-pressure hydrocephalus: a delayed improvement over 3 days Roman Schniepp, MD,1,2 Raimund Trabold, MD,3 Alexander Romagna, MD,3 Farhoud Akrami,2 Kristin Hesselbarth,2 Max Wuehr, PhD,2 Aurelia Peraud, MD,3 Thomas Brandt, MD,2,4 Marianne Dieterich, MD,1,2 and Klaus Jahn, MD2,5 1Department of Neurology, 2German Center for Vertigo and Balance Disorders, 3Department of Neurosurgery, 4Institute for Clinical Neuroscience, Ludwig-Maximilians University Munich; and 5Schoen Klinik, Bad Aibling, Bavaria, Germany OBJECTIVE The determination of gait improvement after lumbar puncture (LP) in idiopathic normal-pressure hydro- cephalus (iNPH) is crucial, but the best time for such an assessment is unclear. The authors determined the time course of improvement in walking after LP for single-task and dual-task walking in iNPH. METHODS In patients with iNPH, sequential recordings of gait velocity were obtained prior to LP (time point [TP]0), 1–8 hours after LP (TP1), 24 hours after LP (TP2), 48 hours after LP (TP3), and 72 hours after LP (TP4). Gait analysis was performed using a pressure-sensitive carpet (GAITRite) under 4 conditions: walking at preferred velocity (STPS), walking at maximal velocity (STMS), walking while performing serial 7 subtractions (dual-task walking with serial 7 [DTS7]), and walking while performing verbal fluency tasks (dual-task walking with verbal fluency [DTVF]). RESULTS Twenty-four patients with a mean age of 76.1 ± 7.8 years were included in this study. Objective responder status moderately coincided with the self-estimation of the patients with subjective high false-positive results (83%).
    [Show full text]
  • Biomarkers in Patients with Idiopathic Normal Pressure Hydrocephalus
    Biomarkers in patients with idiopathic normal pressure hydrocephalus Dr Andrew Tarnaris Ptychion Iatrikes, M.R.C.S (Ed) Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, and Department of Neuroinflammation, Institute of Neurology, Queen Square, University College London, London, WC1N 3BG. Supervisors: Mr. Laurence Watkins Mr. Neil Kitchen Thesis submitted for the degree of Doctor of Medicine (MD Res) at the University of London 1 Declaration I hereby declare that the work presented in this thesis is my own. Andrew Tarnaris 2 Abstract Idiopathic normal pressure hydrocephalus (iNPH) is a condition affecting a small percentage of the elderly population; however it is the only known treatable cause of dementia. Surgical cerebrospinal fluid (CSF) diversion is the only known treatment for the condition today. However, such a procedure is not to be offered lightly and any expected benefit has to balance the associated surgical risks. The prognosis of a favourable surgical outcome has been problematic since the conception of the syndrome. None of current prognostic tests reaches 100% sensitivity or specificity and it is felt that there might be a need for a combination of tests, rather than a single one to maximize the chances of selecting the right patients to offer a surgical CSF diversion procedure. Biomarkers are biological substances that may act as surrogate markers of response to a treatment or to characterise a disease’s progression over time. The aim of this study was to identify CSF markers of favourable surgical outcome in patients with iNPH undergoing the insertion of a ventriculoperitoneal shunt (VPS).
    [Show full text]
  • Revised June 2Nd 2014
    Revised March 2018 CURRICULUM VITAE Petra Margarete Klinge, M.D. Ph.D. PERSONAL INFO Current Position Professor of Neurosurgery Alpert Medical School Brown University Attending Neurosurgeon Director, Pediatric Neurosurgery Division Director, Research Center and Clinic for Cerebrospinal Fluid Disorders Department of Neurosurgery Rhode Island Hospital 593 Eddy Street, APC 6 Providence, RI 02903 Phone (401) 793 9123 FAX (401) 444 2788 Email [email protected]; [email protected] EDUCATION 1986 -1988 Medical School Bochum, Germany 1988 - 1993 Medical School Kiel, Germany 1993 M.D. degree, Medical School Kiel 2002 Ph.D. degree Hannover Medical School, Germany POSTGRADUATE HONOURS AND AWARDS 2001 Best Poster Award at the 27th scientific annual meeting of the German Federation of women in medicine 09/2009 Top Abstract Award : Interaventricular implantation of alginate-encapsulated glukagon/like-peptide-1 (GLP-1) producing human mesenchymal stem cells in a double transgenic mouse model of AD. 2nd Annual meeting of the International Society of Hydrocephalus and CSF disorders 02/2014 Brite-Lite Winner 2013, Hasbro Children’s Hospital, RI http://www.hasbrochildrenshospital.org/About/Brite_Lite_Program.html 06/2014 Recognition for Exemplary Teaching in BIOL 3652 IMS II:Brain Sciences Brown University 1 PROFESSIONAL LICENSES AND BOARD CERTIFICATION 1994 German Medical License 2002 German Board Certification and Accreditation as Specialist for Neurosurgery 2008 Rhode Island Medical License (LA 00007, LA 00013 since 7/2014) ACADEMIC APPOINTMENTS
    [Show full text]
  • How Can You Best Diagnose Idiopathic Normal Pressure Hydrocephalus?
    From the CLINICAL INQUIRIES Family Physicians Inquiries Network Daniel Hunter-Smith, MD How can you best diagnose Adventist La Grange Family Medicine Residency, La Grange, idiopathic normal pressure Illinois Cleo Pappas, MLIS, AHIP Library of Health Sciences, hydrocephalus? University of Illinois at Chicago Evidence-based answer Diagnose idiopathic normal pressure controlled trial [RCT] and prospective hydrocephalus (INPH) by clinical history, trials). brain imaging, physical findings, and The cerebrospinal fluid (CSF) opening physiological criteria. pressure should be between 70 and 245 The clinical examination must mm H2o (SOR: B, based on systematic show the characteristic gait disturbance review of small rCT and prospective and either impaired cognition or trials). No single test has sufficient impaired urinary continence (strength sensitivity to rule out the diagnosis of INPH of recommendation [SOR]: B, based on (SOR: B, based on systematic review of systematic review of small randomized small rCT and prospective trials). Clinical commentary Subtle clues help risks. Neuroimaging plays a role, but only FAST TRACK make the diagnosis when the clinical suspicion is high. To diagnose Normal pressure hydrocephalus is primarily Therefore, understanding the subtleties diagnosed clinically. The classic triad of in the character of the gait, the time of idiopathic gait instability, cognitive dysfunction, and onset, the progression of dementia, and the normal pressure urinary incontinence, however, seldom onset of urinary incontinence in relationship
    [Show full text]
  • Hydrocephalus 2013 Abstract Book.Pdf
    HYDROCEPHALUS 2013 ATHENS The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders 29 June - 2 July 2013 Athenaeum InterContinental Athens Hotel Table of Contents 04 Sponsors Acknowledgements 07 Useful Information 10 President’s Message 11 Vice-President’s Message 12 Committees 15 Program Overview 21 Detailed Program 33 Oral Presentations – Oral (O) 63 Poster Presentations – Poster (P) 79 Index 87 Notes EOF Reg. Nr. 5307/20.3.2013 © Copyright 2013, The Organizing Committee of “Hydrocephalus 2013 Athens, the Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders” Publications Management: ARTION Conferences & Events 2 3 Sponsors Acknowledgements The Organizing Committee of “Hydrocephalus 2013 Athens, the Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders” would like to thank the sponsors and exhibitors for their contribution and support to the Meeting. GOLDEN SPONSORS EXHIBITORS COMMUNICATION SPONSOR 4 5 Useful Information Official Language The official language of the Meeting is English. Venue Athenaeum InterContinental Athens Hotel 89-93 Syngrou Avenue Str. GR-11745, Athens, Greece Tel.: +30 210 9206000 www.ichotelsgroup.com Venue Floor Plan Athenaeum InterContinental Athens HYDROCEPHALUS 2013 ATHENS The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders 6 7 Secretariat & Information Desk The Secretariat Desk will be located at the Meeting Venue and will operate: Saturday, 29 June 2013, 08:00 - 18:30 Sunday, 30 June 2013, 08:00 - 17:30
    [Show full text]
  • Endoscopic Third Ventriculostomy in Idiopathic Normal Pressure Hydrocephalus
    Alexandria Journal of Medicine (2013) xxx, xxx–xxx Alexandria University Faculty of Medicine Alexandria Journal of Medicine www.sciencedirect.com Endoscopic third ventriculostomy in idiopathic normal pressure hydrocephalus Mohammed Ahmed Eshra * Department of Neurosurgery, Faculty of Medicine, Alexandria University, Egypt Received 20 June 2013; accepted 20 November 2013 KEYWORDS Abstract Objective: To determine the efficacy of endoscopic fenestration of the third ventricle in CSF; the treatment of idiopathic normal pressure hydrocephalus. Idiopathic normal pressure Methods: 16 patients with idiopathic normal pressure hydrocephalus were treated by endoscopic hydrocephalus; third ventriculostomy. This study lasted three years. All patients were over 50 years old com- Endoscopic third plaining of 2 or more of the famous triad of gait disturbance, urinary incontinence and dementia. ventriculostomy All patients had ventricular dilatation with negative history of infection, brain injury or hemor- rhage. Results: 8 patients showed marked improvement in their clinical conditions, 3 patients showed mild improvement, while 5 patients had no improvement without any deterioration in their preoperative state. Thus the overall improvement after ventriculostomy occurred in 11 patients (68%). Conclusion: Endoscopic third ventriculostomy is as effective as shunt in treating idiopathic normal pressure hydrocephalus. Patients must be treated as early as possible before permanent damages occur. Further studies are needed to clarify more about the pathophysiology, CSF dynamics and new management. ª 2013 Production and hosting by Elsevier B.V. on behalf of Alexandria University Faculty of Medicine. 1. Introduction causes of dementia. First described by Hakim in 1965, NPH describes hydrocephalus in the absence of papilledema and Normal pressure hydrocephalus (NPH) is a clinical syndrome with normal cerebrospinal fluid (CSF) opening pressure on 1 characterized by gait disturbance, bladder incontinence, and lumbar puncture.
    [Show full text]