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 9th km. Thessaloniki - Thermi, Thomas Building, Monday, 1 July 2013, 08:00 - 17:00 P.O. Box. 60705, GR-57001 Thessaloniki, Greece Tuesday, 2 July 2013, 08:00 - 12:30 Meeting Director: Despina Amarantidou Meeting Coordinator: Zoi Pazaiti T +30 2310250928 (direct line), Delegates Management & Hotel Accommodation: +30 2310272275 Anneta Pavloudi F +30 2310272276 Sponsors & Exhibitors: Lina Tsipouridou E [email protected] Publications, Press & Media: Maria Kantziari www.hydrocephalus2013.com Website & e-Marketing: Alexandros Antoniou

Name Badge Τhe Name Badge needs to be worn at the venue as well as to any social venue to get access to the Meeting’s sessions and its events.

Instructions for Oral Presentations • Presentations should be given to the Meeting Secretariat the latest a day before the presentation (preferably upon registration) on a CD, DVD or memory stick. • If personal notebooks need to be used, the Technical Secretariat should be notified the latest a day before the presentation (preferably upon registration).

Certification - Award of Points Attending the “Hydrocephalus 2013 Athens, the Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders” is endorsed by 15 Continuing Medical Education (CME) points. Certificates of Attendance will be issued at the end of the Meeting and will be given to the participants, given they have attended at least 60% of the Meeting hours.

Internet Facilities WI-FI connection is provided at the Meeting premises (at an extra charge in the rooms).

Useful Phones Police* 100 Ambulance* 166 Fire* 199 Emergency phone** 112 Phone book information* 11888

* It refers to a local number and can be used only from a local phone. ** It refers to a European number. After a recorded message in English and Greek, an operator receives the call in English, French or Greek, puts the caller through to the necessary service, and assists with interpretation, if necessary. For any further information please contact the Meeting Secretariat.

8 9 President’s Message Vice-President’s Message

Dear Colleagues, Dear Colleagues and Friends,

Hydrocephalus 2013 Athens, the Fifth Meeting of the International Society for Hydrocephalus It is a great honour for the Hellenic Neurosurgical Society to host “Hydrocephalus 2013 and CSF Disorders (ISHCSF) is taking place on 29 June – 2 July 2013, at the Athenaeum Athens, the Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders” InterContinental Athens Hotel, on the mainland of Greece. On behalf of the Hellenic co-organized with the International Society for Hydrocephalus and Cerebrospinal Fluid Neurosurgical Society and the Department of Neurosurgery at Virginia Commonwealth Disorders. Hydrocephalus remain worldwide an important public health problem of our days, University and ISHCSF, we warmly welcome you to the Meeting. affecting all ages and, particularly, as the average life expectancy has increased.

The first pre-historic settlement was constructed in 3000 BC around the hill of Acropolis We believe that this Meeting provides a cutting edge educational and scientific experience, where the King of Athens, Theseus unified the ten tribes of early Athens into one kingdom. focusing on the latest developments in research and management of hydrocephalus and CSF This process of synoikismos – bringing together in one home – is the theme of this year’s disorders. A vibrant social program provides an opportunity to explore the fascinating city of conference which colleagues from all around the world with wide-ranging research interests Athens and other highlights of Modern and Classical Greece. and expertise in the management of hydrocephalus and CSF disorders will come together in one home, Athens. We focus on both adult and pediatric hydrocephalus through our We welcome you in Athens, in order to join the International Society for Hydrocephalus and attendees, presenters and international faculty. The meeting presents the latest advances Cerebrospinal Fluid Disorders to strengthen its work against hydrocephalus in all parts of the in the basic, clinical and translational sciences as they evolve toward a more complete world. understanding of hydrocephalus and CSF disorders with the overall goal of promoting the best possible care for patients. In addition, we provide unique opportunities to future leaders of the field, who are the young investigators.

Athens. Modern Greek Athínai, Ancient Greek Athēnai is the historic city and capital of Greece Ioannis Patsalas, MD, PhD where the city’s values acquired a universal significance starting from the “Golden Age of Pericles”. The Acropolis of Athens (5th c. B.C), the ancient citadel of the city is surrounded by sacred temples and ancient theatres which are the glories of Classical Greece. At the foot of the Acropolis, we are welcomed by the restored neoclassical homes, pedestrianized streets, shops and restaurants where delicious Greek cuisine which was founded on the Mediterranean flavors of olive oil and fish is served. If you want to relax by the tranquil President of the Hellenic Neurosurgical Society and turquoise waters, then the magnificent Crete and the Aegean Islands should be your next Vice President of Hydrocephalus 2013 Athens, destination. The 2013 Meeting of the International Society of Hydrocephalus and CSF Disorders

We wish you a wonderful stay in Athens.

Best Regards,

Gunes Ayse Aygok, MD, PhD

President of Hydrocephalus 2013 Athens, The 2013 Meeting of the International Society of Hydrocephalus and CSF Disorders

10 11 Committees

Organizing & Scientific Local Organizing Committee Committee

Honorary President President Harold F Young, USA Gunes A. Aygok President Vice President Gunes A. Aygok, USA Ioannis Patsalas Co-President Gen. Secretary Ioannis Patsalas, Greece Panagiotis Selviaridis Members Members Grant Bateman, Australia Alexandros Andreou Ari Blitz, USA Emmanouil Chatzidakis William G. Bradley, USA Nikolaos Foroglou Thomas Brinker, USA Konstantinos Kouzelis Marek Czosnyka, UK George Makrygiannakis Zofia Czosnyka, UK George Orfanides Anders Eklund, Sweden Antonios Vakis Neill Graff-Radford, USA Mark Hamilton, Canada Masatsune Ishikawa, Japan Program Overview Heizel Jones, UK Cemil Kayis, USA Uwe Kehler, Germany Petra Klinge, USA Mark Luciano, USA Jan Malm, Sweden James Pat McAllister, USA Etsuro Mori, Japan Harold Rekate, USA Norman Relkin, USA Daniele Rigamonti, USA Bertil Romner, Denmark Martin Schuhmann, Germany Katsuma Shima, Japan Mattieu Vinchon, France Carsten Wikkelsö, Sweden Michael A. Williams, USA

12 Hydrocephalus2013 Athens The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders

Program Overview (Athenaeum Ballroom II)

Saturday, 29 June 2013

08:00 - 18:30 Registrations 15:00 - 18:00 ISHCSF Board Meeting (Delta Sygma Meeting Room) 20:00 - 22:00 Official Opening Ceremony - Welcome Reception

Sunday, 30 June 2013

08:00 - 08:15 Opening Remarks Gunes A. Aygok, MD, PhD President of the 5th Meeting of International Society for Hydrocephalus and CSF Disorders (ISHCSF) Ioannis Patsalas, MD, PhD Vice President of the 5th Meeting of ISHCSF and President of the Hellenic Neurosurgical Society Michael A. Williams, MD President of ISHCSF

Session I 08:15 - 10:00 Normal Pressure Hydrocephalus Chairs: Uwe Kehler & Masatsune Ishikawa Mathematical modeling is a powerful tool of inductive reasoning Harold Rekate, MD 50 years later: NPH revisited Daniele Rigamonti, MD 2005 NPH practice guidelines revisited: Lessons learned from the European prospective. NPH trial and status of normal pressure. Hydrocephalus management Petra Klinge, MD, PhD Can we decrease over-drainage shunt complications in idiopathic normal pressure hydrocephalus? Neill Graff-Radford, MD

10:00 - 10:30 Coffee Break

15 Hydrocephalus2013 Athens Program overview

Session II Monday, 1 July 2013 10:30 - 12:00 Clinical Diagnosis: The Value of Supplemental Prognostic Tests for the Preoperative Assessment of NPH Task Force Session Chairs: John D. Pickard & Etsuro Mori 08:00 - 09:00 Task Force: Co-Morbidity & Outcome Assessment in Idiopathic Normal Pressure Hydrocephalus Oral Presentations Chairs: Petra Klinge & Anders Eklund Diagnostic challenges of idiopathic normal pressure hydrocephalus 12:00 - 12:30 Lunch and Poster Viewing due to comorbidity Jan Malm, MD 12:30 - 13:00 ISHCSF Membership Meeting Idiopathic normal pressure hydrocephalus: Where do we stand with our understanding of patient outcome? Session III Mark Hamilton, MD 13:00 - 13:50 CSF Dynamics Chairs: Thomas Brinker & Olivier Balédent Session IV Who needs a shunt? Who needs a revision? CSF dynamics perspective 09:00 - 10:00 Neuroimaging Marek Czosnyka, PhD Chairs: Harold Rekate & Eftychia Kapsalaki Low CSF pressure states Imaging of adult hydrocephalus: Toward a consensus for classification Laurence D. Watkins, MD Ari Blitz, MD Predictability of shunt effectiveness on MRI findings in idiopathic normal 13:50 - 14:30 CSF Dynamics: The Value of ICP and CSF Pulse Pressure Analysis pressure hydrocephalus Masatsune Ishikawa, MD, PhD Oral Presentations 10:00 - 10:30 Coffee Break 14:30 - 15:00 Coffee Break Session V Presidential Plenary Session 10:30 - 12:00 Neuroimaging: The Value of Imaging Techniques in Hydrocephalus 15:00 - 16:00 The Visual Impairment / Intracranial Pressure (VIIP) Syndrome Chairs: Mitsuhito Mase & Ari Blitz Chairs: Petra Klinge & Michael A. Williams The Visual Impairment / Intracranial Pressure (VIIP) syndrome Oral Presentations - A new challenge for human space flight Christian Otto, MD 12:00 - 12:30 Lunch and Poster Viewing Earth-based implications of VIIP for research and clinical care in IIH and hydrocephalus Satellite Symposium Michael A. Williams, MD 12:30 - 14:00 INPH: Are we making Progress? Carsten Wikkelsö, MD Expert Panel Session Etsuro Mori, MD, PhD 16:00 - 17:00 Programmable Valves and Siphon Regulatory Devices: Harold Rekate, MD The Clinical and Engineering Aspects Ville Leinonen, MD Chairs: Uwe Kehler & Daniele Rigamonti Daniele Rigamonti, MD Session VI Uwe Kehler, MD 14:00 - 15:30 Surgical Management: Shunt Cemil Kayis, PhD Chairs: Daniele Rigamonti & Damianos Sakas

17:00 - 18:00 Poster Viewing Oral Presentations

15:30 - 16:00 Coffee Break

16 17 Hydrocephalus2013 Athens Program overview

Session VII 16:00 - 17:00 Surgical Management: ETV Chairs: Mark Hamilton & Kostas Fountas

Oral Presentations

17:00 - 18:00 Poster Viewing

21.00 Gala Dinner

Tuesday, 2 July 2013

Session VIII 08:00 - 09:00 Pediatric Hydrocephalus Chairs: J. Gordon McComb & Ioannis Patsalas Magement of congenital hydrocephalus: Reviewing decision dilemmas in prenatal period, treatment options in neonates and infants Nikolaos Foroglou, MD, PhD Critical observations on the role of endoscopic third ventriculostomy in the treatment of hydrocephalus Spyridon Sgouros, MD

Session IX 09:00 - 10:00 Surgical Management: Pediatric Hydrocephalus Detailed Program Chairs: Masaaki Hashimoto & Konstantinos Kouzelis

Oral Presentations

10:00 - 10:30 Coffee Break

Session X 10:30:11:30 The Basic Science of Hydrocephalus Chairs: Zofia Czosnyka & James Pat McAllister

Oral Presentations

11:30 - 12:30 Closing Remarks Gunes A. Aygok, MD, PhD Ioannis Patsalas, MD, PhD Michael A. Williams, MD

18 Hydrocephalus2013 Athens The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders

Detailed Program (Athenaeum Ballroom II)

Saturday, 29 June 2013

08:00 - 18:30 Registrations 15:00 - 18:00 ISHCSF Board Meeting (Delta Sygma Meeting Room) 20:00 - 22:00 Official Opening Ceremony - Welcome Reception

Sunday, 30 June 2013

08:00 - 08:15 Opening Remarks Gunes A. Aygok, MD, PhD President of the 5th Meeting of International Society of Hydrocephalus and CSF Disorders (ISHCSF) Ioannis Patsalas, MD, PhD Vice President of the 5th Meeting of ISHCSF and President of the Hellenic Neurosurgical Society Michael A. Williams, MD President of ISHCSF

Session I 08:15 - 10:00 Normal Pressure Hydrocephalus Chairs: Uwe Kehler & Masatsune Ishikawa Mathematical modeling is a powerful tool of inductive reasoning Harold Rekate, MD 50 years later: NPH revisited Daniele Rigamonti, MD 2005 NPH practice guidelines revisited: Lessons learned from the European prospective. NPH trial and status of normal pressure. Hydrocephalus management Petra Klinge, MD, PhD Can we decrease over-drainage shunt complications in idiopathic normal pressure hydrocephalus? Neill Graff-Radford, MD

10:00 - 10:30 Coffee Break

21 Hydrocephalus2013 Athens DETAILED Program

Session II (2) Department of Public Health and Clinical Medicine, Umeå University Hospital, Sweden 10:30 - 12:00 Clinical Diagnosis: The Value of Supplemental Prognostic Tests (3) Institute of Neuroscience and Physiology, The Sahlgrenska Academy, for the Preoperative Assessment of NPH University of Gothenburg, Sweden Chairs: John D. Pickard & Etsuro Mori (4) Department of Neuroscience, Neurology, Uppsala University Hospital, Sweden (5) Department of Neurosurgery, Lund University Hospital, Sweden Oral Presentations (6) Department of Clinical and Experimental Medicine (IKE), Division of Neuroscience, O01. EVIDENCE FOR A RAPID, SUBSTANTIAL AND SUSTAINED INCREASE IN HOSPITAL Linköping University, Sweden 7 INPATIENT SERVICES FOR HYDROCEPHALUS IN THE ELDERLY IN THE US, 2002-2009 ( ) Department of Radiation Sciences, Umeå University, Sweden J. Ney1, M.A. Williams2 O09. A NOVEL CASE OF FAMILIAL IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS 1,2 1 1,2 1,2 (1) Comparative Effectiveness, Cost and Outcomes Research Center, E. Liouta , F. Liakos , D. Sakas , G. Stranjalis 1 University of Washington, Seattle, USA ( ) The Petros Kokkalis Center for Neurosurgery Research, Athens, Greece 2 (2) Adult Hydrocephalus Center, The Sandra and Malcolm Berman Brain & Spine Institute, ( ) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece Baltimore, USA O02. PRE- AND POST-OPERATIVE GAIT AND BALANCE ANALYSIS IN PATIENTS 12:00 - 12:30 Lunch and Poster Viewing WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS N. Darras1, M. Tziomaki1, E. Liouta2, F. Liakos2, C. Koutsarnakis2, G. Stranjalis2 12:30 - 13:00 ISHCSF Membership Meeting (1) ELEPAP Gait & Motion Analysis Center, Athens, Greece (2) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece Session III O03. PRE- AND POST-OPERATIVE GAIT ANALYSIS OF: 13:00 - 13:50 CSF Dynamics A) DBS-STN AND B) IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS PATIENTS Chairs: Thomas Brinker & Olivier Balédent N. Darras1, E. Liouta2, F. Liakos2, C. Koutsarnakis2, P. Stathis2, D. Sakas2, G. Stranjalis2 Who needs a shunt? Who needs a revision? CSF dynamics perspective (1) ELEPAP Gait & Motion Analysis Center, Athens, Greece Marek Czosnyka, PhD 2 ( ) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece Low CSF pressure states O04. VERBAL FLUENCY AND FINGER TAPPING IMPROVEMENT AFTER LUMBAR TAP TEST Laurence D. Watkins, MD PREDICTS GAIT OUTCOME IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS (ΙNPH) 1,2 1 1,2 1,2 1,2 E. Liouta , F. Liakos , S. Gkatzonis , D. Sakas , G. Stranjalis 13:50 - 14:30 CSF Dynamics: The Value of ICP and CSF Pulse Pressure Analysis (1) The Petros Kokkalis Center for Neurosurgery Research, Athens, Greece (2) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece O05. BRAIN’S CRITICAL CLOSING PRESSURE DURING INFUSION TESTS Oral Presentations O10. 200 LONGITUDINAL ICP ANALYSES AT QUEEN SQUARE G.V. Varsos, Z. Czosnyka, M. Czosnyka, J.D. Pickard J.D. Shand Smith1,2, S. Thompson1, A.K. Toma1, A. Khan1, N.D. Kitchen1,2, L.D. Watkins1,2 Department of Clinical Neurosciences, University of Cambridge, UK (1) Victor Horsley Department of Neurosurgery, National Hospital for Neurology O06. THE EXTENDED LUMBAR DRAINAGE TEST ALONE PREDICTS SHUNT REPONSE IN and Neurosurgery, Queen Square, London, UK IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS: THE DEMISE OF THE DIAGNOSTIC (2) Department of Brain Repair and Rehabilitation, Institute of Neurology, CONSTANT RATE LUMBAR INFUSION TEST University College London, UK L. Nicolae, W.G.B. Singleton, R. Sivakumaran, R.J. Edwards O11. THE INTRACRANIAL PULSE PRESSURE AMPLITUDE AND COGNITIVE IMPROVEMENT Department of Neurosurgery, Frenchay Hospital, Bristol, UK AFTER CSF TAP TEST IN ΙNPH O07. IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS: A. Behrens1,2, S. Qvarlander3, A. Eklund3, J. Malm1 PATOPHYSIOLOGY AND DIAGNOSIS BY CSF BIOMARKERS (1) Department of Clinical Neuroscience, Umeå University, Sweden A. Jeppsson1, H. Zetterberg2,3, K. Blennow2, C. Wikkelsö1 (2) Blekinge Centre of Competence, Karlskrona, Sweden (1) Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, (3) Department of Radiation Sciences, Umeå University, Sweden The Sahlgrenska Academy, University of Gothenburg, Sweden O12. CSF PULSE PRESSURE IS CORRELATED WITH A MARKER OF VASCULAR DISORDER (2) Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, E.A. Schmidt1, E. Caussé2 Institute of Neuroscience and Physiology, The Sahlgrenska Academy, (1) Department of Neurosurgery, Toulouse, France University of Gothenburg, Sweden (2) Department of Biochemistry, Toulouse, France (3) UCL Institute of Neurology, Queen Square, London, UK O13. POST TRAUMATIC NON-ACUTE HYDROCEPHALUS: PROFILE OF CSF DYNAMICS O08. COMORBIDITY AND RISK FACTORS ASSOCIATED WITH HYDROCEPHALUS Z. Czosnyka, M. Czosnyka, J.D. Pickard H. Israelsson1, B. Carlberg2, C. Wikkelsö3, K. Laurell1,4, B. Kahlon5, G. Leijon6, A. Eklund7, J. Malm1 Academic Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK (1) Department of Pharmacology and Clinical Neuroscience, Umeå University Hospital, Sweden

22 23 Hydrocephalus2013 Athens DETAILED Program

14:30 - 15:00 Coffee Break 10:00 - 10:30 Coffee Break

Presidential Plenary Session Session V 15:00 - 16:00 The Visual Impairment / Intracranial Pressure (VIIP) Syndrome 10:30 - 12:00 Neuroimaging: The Value of Imaging Techniques in Hydrocephalus Chairs: Petra Klinge & Michael A. Williams Chairs: Mitsuhito Mase & Ari Blitz The Visual Impairment / Intracranial Pressure (VIIP) syndrome - A new challenge for human space flight Oral Presentations Christian Otto, MD O14. MRI TIME-SPATIAL LABELING INVERSION PULSE (TIME-SLIP) FINDINGS TO SUPPORT Earth-based implications of VIIP for research and clinical care in IIH POSSIBLE CEREBROSPINAL FLUID (CSF) OLFACTORY DRAINAGE IN HUMANS and hydrocephalus S. Yamada1, M. Miyazaki2, C. Ouyang2, R. Anderson2, W.G. Bradley3, J.G. McComb4 Michael A. Williams, MD (1) Department of Neurosurgery, Oiso Hospital, Tokai University, Kanagawa, Japan (2) Toshiba Medical Research Institute, Vernon Hills, Illinois, USA Expert Panel Session (3) Department of Radiology, University of California, San Diego, USA 16:00 - 17:00 Programmable Valves and Siphon Regulatory Devices: (4) Division of Neurosurgery, Children’s Hospital of Los Angeles, USA The Clinical and Engineering Aspects Department of Neurological Surgery, Keck School of Medicine, University of Southern Chairs: Uwe Kehler & Daniele Rigamonti California, Los Angeles, USA Daniele Rigamonti, MD O15. MR IMAGING OF CSF AND BLOOD FLOW IN HYDROCEPHALUS Uwe Kehler, MD O. Balédent1, C. Gondry-Jouet2, C. Capel3, S.E. Sankari4, A. Fichten2, R. Bouzerar1 Cemil Kayis, PhD (1) Image Processing, University Hospital, Amiens, France (2) Department of Radiology, University Hospital, Amiens, France 17:00 - 18:00 Poster Viewing (3) Department of Neurosurgery, University Hospital, Amiens, France (4) Department of Neurology, University Hospital, Brussels, Belgium O16. CSF FLOW MEASUREMENTS WITH PC-MRI IN HYDROCEPHALUS DEPEND ON MRI CONSTRUCTORS S.E. Sankari1, I. Bogdan2, N. Michoux2, C. Grandin2, T. Duprez2 (1) Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium 2 Monday, 1 July 2013 ( ) Department of Neuroradiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium O17. PREDICTABILITY OF SHUNT EFFECTIVENESS ON MRI FINDINGS IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS Task Force Session M. Ishikawa 08:00 - 09:00 Task Force: Co-Morbidity & Outcome Assessment in Idiopathic Normal Normal Pressure Hydrocephalus Center, Otowa Hospital, Kyoto, Japan Pressure Hydrocephalus O18. WATER MOLECULAR FLUCTUATION IN VENTRICULES Chairs: Petra Klinge & Anders Eklund AND BRAIN TISSUE IN NORMAL PRESSURE HYDROCEPHALUS Diagnostic challenges of idiopathic normal pressure hydrocephalus M. Mase1, T. Miyati2, N. Ohno2, H. Kan3, H. Kasai3, K. Yamada1 due to comorbidity (1) Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Jan Malm, MD Japan Idiopathic normal pressure hydrocephalus: Where do we stand with (2) Faculty of Health Science, Institute of Medical, Pharmaceutical and Health Sciences, our understanding of patient outcome? Kanazawa University, Japan Mark Hamilton, MD (3) Department of Radiology, Nagoya City University Hospital, Japan O19. DISPROPORTIONATELY ENLARGED SUB-ARACHNOID-SPACE HYDROCEPHALUS Session IV (DESH) IS NOT ASSOCIATED WITH SHUNT-REPONSIVE IDIOPATHIC NORMAL PRESSURE 09:00 - 10:00 Neuroimaging HYDROCEPHALUS (ΙNPH) Chairs: Harold Rekate & Eftychia Kapsalaki L. Nicolae1, W.G.B. Singleton1, R. Sivakumaran1, A. Mortimer2, R.J. Edwards1 Imaging of adult hydrocephalus: Toward a consensus for classification (1) Department of Neurosurgery, Frenchay Hospital, Bristol, UK Ari Blitz, MD (2) Department of Neuroradiology, Frenchay Hospital, Bristol, UK Predictability of shunt effectiveness on MRI findings in idiopathic normal O20. Evaluation of Cerebral Atrophy in INPH via CSF Infusion Test pressure hydrocephalus G. Aygok, D. Hidlay, C. Kayis Masatsune Ishikawa, MD, PhD Department of Neurosurgery, Medical College of Virginia Commonwealth University, USA

24 25 Hydrocephalus2013 Athens DETAILED Program

O21. POSITRON EMISSION TOMOGRAPHY WITH [18F]FLUTEMETAMOL AND [11C]PIB FOR Oral Presentations DETECTION OF CEREBRAL CORTICAL AMYLOID IN NORMAL PRESSURE HYDROCEPHALUS 023. INTRACRANIAL PRESSURE DYNAMICS AT DIFFERENT OPENING PRESSURES PATIENTS AND BODY POSITIONS IN SHUNT TREATMENT OF COMMUNICATING HYDROCEPHALUS V. Leinonen1, J.O. Rinne2,3, K.A. Virtanen2, O. Eskola2, J. Rummukainen4, J. Huttunen1, D. Farahmand1, S. Qvarlander2, J. Malm3, C. Wikkelsö1, A. Eklund2,3, M. Tisell1 M. von und zu Fraunberg1, O. Nerg5, A.M. Koivisto5, J. Rinne1, J.E. Jääskeläinen1, C. Buckley6, (1) Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, A. Smith6, P.A. Jones6, P. Sherwin7, G. Farrar6, R. McLain8, M. Kailajärvi9, K. Heurling10, The Sahlgrenska Academy, University of Gothenburg, Sweden I.D. Grachev7 (2) Centre for Biomedical Engineering and Physics, Department of Radiation Sciences, (1) Department of Neurosurgery, KUH NeuroCenter, Kuopio University Hospital and Umeå University, Sweden Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland (3) Department of Clinical Neuroscience, Umeå University, Sweden (2) Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland O24. CHANGES OF INTRA-ABDOMINAL PRESSURE AND THE IMPACT ON VALVE (3) Department of Neurology, Turku University Hospital, Turku, Finland SELECTION FOR VENTRICULOPERITONEAL SHUNTS (4) Department of Pathology, Kuopio University Hospital, Kuopio, Finland U. Kehler, Y. Chehade (5) Department of Neurology, KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany and Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, O25. FINAL REPORT OF JAPAN SHUNT REGISTRY (JSR): Kuopio, Finland ESPECIALLY ON SHUNT ROUTE AND PRESSURE SETTING OF PROGRAMMABLE VALVE (6) Medical Diagnostics, GE Healthcare, Amersham, UK M. Hashimoto1, M. Miyajima2, H. Arai2, H. Origasa3, I. Date4, M. Matumae5, JSR Group (7) Medical Diagnostics, GE Healthcare, Princeton, NJ, USA (1) Department of Neurosurgery, Noto General Hospital, Japan (8) PFP Statistical Consulting, LLC, Livonia, MI, USA (2) Department of Neurosurgery, Juntendo University, Tokyo, Japan (9) Medical Diagnostics, GE Healthcare, Turku, Finland (3) Department of Biostatistics and Clinical Epidemiology, University of Toyama, Japan (10) Medical Diagnostics, GE Healthcare, Uppsala, Sweden (4) Department of Neurosurgery, Okayama University, Japan O22. CEREBRAL PERFUSION MEASURED BY DSC MRI IS REDUCED (5) Department of Neurosurgery, Tokai University, Kanagawa, Japan IN PATIENTS WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS O26. SURGICAL TREATMENT OF NORMAL PRESSURE HYDROCEPHALUS D. Ziegelitz1, G. Starck2,3, D. Kristiansen4, M. Jakobsson4, M. Hultenmo2,3, I.K. Mikkelsen5, WITH THE USE OF THE PROGRAMMABLE VALVES OF SHUNT SYSTEM P. Hellström4, M. Tullberg4, C. Wikkelsö4 M. Legzdain, G. Gavrilov, D. Svistov Departments of (1) Neuroradiology and (2) Radiation Physics at the Institute of Clinical Department of Neurosurgery, Military Medical Academy, Saint-Petersburg, Russia Sciences, (4) Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and O27. INDICATIONS FOR VALVE-PRESSURE ADJUSTMENTS OF GRAVITATIONAL ASSISTED Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden VALVES IN PATIENTS WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS (3) Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, L. Gölz, J. Lemcke, U. Meier Sweden Department of Neurosurgery, Unfallkrankenhaus Berlin, Germany (5) Center of Functionally Integrative Neuroscience, Århus University Hospital, Denmark O28. SOCIAL IMPACT OF SHUNT SURGERY IN PATIENTS DIAGNOSED WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS 12:00 - 12:30 Lunch and Poster Viewing J. Petersen, C. Wikkelsö, P. Hellström, Å. Lundgren-Nilsson Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Satellite Symposium The Sahlgrenska Academy, University of Gothenburg, Sweden 12:30 - 14:00 INPH: Are we making Progress? O29. Cognitive and functional improvement after shunt placement. Carsten Wikkelsö, MD Five year outcome analysis in 49 patients suffered idiopathic normal Etsuro Mori, MD, PhD pressure hydrocephalus Harold Rekate, MD S. Sfikas, K. Kasapas, D. Katsianis, V. Valadakis, G. Orfanides Ville Leinonen, MD Department of Neurosurgery, “G. Gennimatas” General Hospital of Athens, Greece O30. INTRACRANIAL HYPERTENSION CAUSED BY DURAL AVF INVOLVING SSS Session VI WITHOUT VENTRICULOMEGALY 14:00 - 15:30 Surgical Management: Shunt N. Aihara, M. Mase, K. Yamada Chairs: Daniele Rigamonti & Damianos Sakas Department of Neurosurgery, Nagoya City University Medical School, Japan

15:30 - 16:00 Coffee Break

26 27 Hydrocephalus2013 Athens DETAILED Program

Session VII Tuesday, 2 July 2013 16:00 - 17:00 Surgical Management: ETV Chairs: Mark Hamilton & Kostas Fountas Session VIII 08:00 - 09:00 Pediatric Hydrocephalus Oral Presentations Chairs: J. Gordon McComb & Ioannis Patsalas O31. ETV VERSUS VENTRICULAR TAP TEST Magement of congenital hydrocephalus: Reviewing decision dilemmas B.D. Elder, C.R. Goodwin, T.A. Kosztowski, J. Pindrik, D. Moran, I. Jusue-Torres, J. Hoffberger, in prenatal period, treatment options in neonates and infants D. Rigamonti Nikolaos Foroglou, MD, PhD Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, USA Critical observations on the role of endoscopic third ventriculostomy O32. VENTRICULAR AND CORTICAL SUBARACHNOID SPACE DIMENSIONS IN ADULT in the treatment of hydrocephalus HYDROCEPHALUS BEFORE AND AFTER ENDOSCOPIC THIRD VENTRICULOSTOMY IN Spyridon Sgouros, MD CORRELATION TO THE CLINICAL OUTCOME N. Paidakakos1, M. Sklavounou1, M. Krommida2, N. Gkekas1, P.E. Valkimadi2, K. Kouzounias1, Session IX D.D. Mitsikostas2, D. Bouramas1 09:00 - 10:00 Surgical Management: Pediatric Hydrocephalus (1) Department of Neurosurgery, Athens Naval Hospital, Greece Chairs: Masaaki Hashimoto & Konstantinos Kouzelis (2) Department of Neurology, Athens Naval Hospital, Greece O33. NEUROPSYCHOLOGICAL OUTCOME AFTER ENDOSCOPIC THIRD VENTRICULOSTOMY FOR OBSTRUCTIVE HYDROCEPHALUS Oral Presentations M. Hamilton, B. Brooks, L. Partlo, W. Hader O36. ENDOSCOPIC THIRD VENTRICULOSTOMY IN CHILDREN: Department of Clinical Neurosciences, University of Calgary, Canada ANALYSIS OF PROGNOSTIC FACTORS O34. ENDOSCOPIC APPEARANCES OF RARE CAUSES OF OBSTRUCTIVE HYDROCEPHALUS R.S. de Oliveira, L.L. Furlanetti, M. Volpon, H.R. Machado K. Barkas, A. Bartoli, G. Samandouras Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Brazil Queen Square, London, UK O37. RESULTS OF ENDOSCOPIC TREATMENT IN CHILDREN O35. PROGNOSTIC VALUE OF BODY MASS INDEX IN GENDER IN THE PREDICTION UNDER 2 YEARS WITH HYDROCEPHALUS OF HYDROCEPHALUS AFTER SURGERY IN CHIARI I MALFORMATION A. Sufianov, G. Sufianova, Y. Yakimov, R. Sufianov F.S. Almotairi, M. Tisell Federal State Budget Institution “Federal Centre of Neurosurgery”, Department of Neurosurgery, Sahlgrenska IC, University of Gothenburg, Sweden Department of Health of Russia, Tyumen, Russia O38. NEUROENDOSCOPIC TREATMENT OF HYDROCEPHALUS IN THE FIRST YEAR OF LIFE 17:00 - 18:00 Poster Viewing A.H.G.B. Da Cunha Hospital da Restauracao, Recife, Brazil 21.00 Gala Dinner O39. Blood and CSF flows in pediatric hydrocephalus as precocious shunt placement decision tool C. Capel1,2, C. Gondry-Jouet1,3, A. Fichten1,2, J. Peltier1,2, O. Balédent1 (1) BioFlow Image, Hospital University Center Nord, Amiens, France (2) Department of Neurosurgery, Hospital University Center Nord, Amiens, France (3) Department of Radiology, Hospital University Center Nord, Amiens, France O40. CEREBROSPINAL FLUID HYDROTHORAX, AN UNUSUAL COMPLICATION OF VENTRICULOPERITONEAL SHUNT E.A. Elgamal1, F.S. Almotairi1, A.M. Abdullah2, M.A.M. Salih2 (1) Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia (2) Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia

10:00 - 10:30 Coffee Break

Session X 10:30:11:30 The Basic Science of Hydrocephalus Chairs: Zofia Czosnyka & James Pat McAllister

28 29 Hydrocephalus2013 Athens DETAILED Program

Oral Presentations O41. ABERRANT ACTIVATION OF WNT/Β-CATENIN SIGNAL IN RATS WITH COMMUNICATING HYDROCEPHALUS H. Xu, Z.X. Wang, S.L. Zhang, G.W. Tan, H.W. Zhu, F. Liu Department of Neurosurgery, First Affiliate Hospital of Xiamen University, China O42. LEUCINE-RICH Α2-GLYCOPROTEIN (LRG) IS A NOVEL BIOMARKER OF NEURODEGENERATIVE DISEASE IN HUMAN CEREBROSPINAL FLUID AND CAUSES NEURODEGENERATION IN MOUSE CEREBRAL CORTEX M. Miyajima1, M. Nakajima1, I. Ogino1, H. Arai1, Y. Motoi2, N. Tada3 (1) Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo, Japan (2) Department of Neurology, Juntendo University Graduate School of Medicine, Tokyo, Japan (3) Laboratory of Genome Research, Research Institute for Diseases of Old Age, Juntendo University Graduate School of Medicine, Tokyo, Japan O43. MONOAMINE NEUROTRANSMITTER METABOLITES CONCENTRATION AS A MARKER OF CEREBROSPINAL FLUID (CSF) VOLUME CHANGES J. Marakovic1, D. Chudy1, M. Klarica2, D. Oreskovic3 (1) Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia (2) Department of Pharmacology and Croatian Institute for Brain Research, School of Medicine, University of Zagreb, Croatia (3) Department of Molecular Biology, Ruder Boskovic Institute, Zagreb, Croatia O44. HYDROCEPHALIC CEREBROSPINAL FLUID IS A FRIENDLY HOST FOR NEURAL STEM CELL TRANSPLANTATION J.P. McAllister1, C. González2, M.C. Jara2, K. Vío2, R. González2, M. Guerra2, E. Ortega3, J. Jaque3, S. Rodríguez2, P. Salazar2, C.E. Johanson4, E.M. Rodríguez2 (1) Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, USA Oral Presentations - Oral (O) (2) Instituto de Anatomía, Histología y Patología, Universidad Austral de Chile, Valdivia, Chile (3) Instituto de Neurociencias Clínicas, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile (4) Department of Neurosurgery, Alpert Medical School, Brown University, Providence, Rhode Island, USA O45. NEURAL STEM AND PROGENITOR CELLS COLLECTED FROM THE HYDROCEPHALIC CSF FORM NEUROSPHERES THAT EXHIBIT THE SAME JUNCTION PATHOLOGY AS THE DISRUPTED VENTRICULAR ZONE M. Guerra1, N. Lichtin1, M.C. Jara1, R. González1, K. Vío1, C. González1, E. Ortega2, J. Jaque2, S. Rodríguez1, A. Ortloff3, P. Salazar1, C.E. Johanson5, E.M. Rodríguez1, J.P. McAllister4 (1) Instituto de Anatomía, Histología y Patología, Universidad Austral de Chile, Valdivia, Chile (2) Instituto de Neurociencias Clínicas, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile (3) Escuela de Medicina Veterinaria, Universidad Católica de Temuco, Chile (4) Department of Neurosurgery, Alpert Medical School, Brown University, Providence, Rhode Island, USA (5) Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, USA

11:30 - 12:30 Closing Remarks Gunes A. Aygok, MD, PhD Ioannis Patsalas, MD, PhD Michael A. Williams, MD 30 Hydrocephalus2013 Athens The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders

Oral Presentations - Oral (O)

O01. EVIDENCE FOR A RAPID, SUBSTANTIAL AND SUSTAINED INCREASE IN HOSPITAL INPATIENT SERVICES FOR HYDROCEPHALUS IN THE ELDERLY IN THE US, 2002-2009 J. Ney1, M.A. Williams2 (1) Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, USA (2) Adult Hydrocephalus Center, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, USA

OBJECTIVE: To characterize inpatient care trends for hydrocephalus in the elderly in the United States. MATERIAL - METHOD: Retrospective cohort study using the Nationwide Inpatient Sample from 2002-2009, representing 20% of inpatient discharges in nonfederal U.S. hospitals. Inpatient discharge records for patients ≥age 65 listing ICD-9 codes for congenital, obstructive (OH), and communicating hydrocephalus (CH), and NPH (starting in 2007) as primary diagnosis were included. Extracted data included demographics, comorbidities, shunt surgery, in-hospital mortality, hospital charges, and length of stay. Sample-weighted records were totaled for annual national-level inpatient utilization estimates and trends were assessed using generalized linear models and least squares regressions. RESULTS: 78,674 weighted inpatient discharges met inclusion criteria. 77.9% had CH or NPH; 54.8% had primary shunt surgery, and 3.9% had shunt complications, revision, or replacement. From 2002-2009, the number of discharges with any type of hydrocephalus increased 5.6%/year (p<0.001); CH and NPH increased 9.3%/year (81% increase 2002-2009, p<0.001); OH fell 5.5%/ year (p<0.001); and primary shunt surgery rose 3.9%/year (p<0.14). Comorbidities increased from 1.5 to 2.1 for 2002-2009 (p<0.001). Hospital charges increased 3.4%/year (p<0.001) while length of stay declined 2.3%/year (p<0.001). No significant changes in demographics, regional variations, or in-hospital mortality were seen. From 2004-2005 CH rose 57.1% and primary shunt surgery rose 55.5%, the largest 1-year increase, after which the higher CH/NPH discharge volumes and surgery volumes were sustained through 2009. CONCLUSIONS: A rapid, substantial and sustained gain in inpatient diagnosis and treatment of CH and NPH was seen in elderly patients in the US from 2002-2009.

33 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

O02. PRE- AND POST-OPERATIVE GAIT AND BALANCE ANALYSIS IN PATIENTS were improved in walking velocity, the PDP group showed significantly increased stride length WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS and reduced stance phase proportion. Only cadence was found similar in both groups. The N. Darras1, M. Tziomaki1, E. Liouta2, F. Liakos2, C. Koutsarnakis2, G. Stranjalis2 kinematic and kinetic analysis revealed post-surgery improvement in both groups, although (1) ELEPAP Gait & Motion Analysis Center, Athens, Greece the same parameters were again significantly better in the PDP group. (2) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece CONCLUSIONS: PDP and ΙNPHP were found to significantly differ in specific temporospatial, kinematic and kinetic parameters pre- and postoperatively. Further investigation with larger OBJECTIVE: To study kinematic, kinetic and static balance prior to and one month after shunt samples should be employed in order to establish differential diagnostic criteria regarding the placement in Idiopathic Normal Pressure Hydrocephalus (ΙNPH) patients. two groups. MATERIAL - METHOD: Eight consecutive patients were included in the study (age: 71±7.7 years). 3D gait analysis (kinematics, kinetics, temporospatial) and static balance analysis (20 sec - Eyes Open & Eyes Closed test – Center Of Pressure: ellipse area, average velocity and length) O04. VERBAL FLUENCY AND FINGER TAPPING IMPROVEMENT AFTER LUMBAR TAP TEST were performed. Paired t-tests were used to assess differences between pre and post-shunt PREDICTS GAIT OUTCOME IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS (ΙNPH) examination. Pearson’s Correlation analysis was performed to assess the relationship of pre- E. Liouta1,2, F. Liakos1, S. Gkatzonis1,2, D. Sakas1,2, G. Stranjalis1,2 post balance parameters with changes in temporospatial parameters. (1) The Petros Kokkalis Center for Neurosurgery Research, Athens, Greece RESULTS: After the shunt application, a significant improvement in walking velocity was (2) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece observed (p<0.01) with a significant increase in stride length (p<0.01). Improvements were also found in the sagittal plane range of motion (ROM) of the ankle and knee, improved ROM OBJECTIVE: To investigate what cognitive functions improve following Lumbar Tap (LT) test of the foot progression, increased ankle power production at push-off phase(p<0.05) and in Idiopathic Normal Pressure Hydrocephalus (ΙNPH) patients and whether the improvement increased maximum knee flexion in swing (p<0.05). In the static balance analysis, although of these functions is correlated with gait outcomes in two groups: probable ΙNPH and possible a small improvement was recorded, this was not found to be statistically significant. The ΙNPH. correlation analysis did not reveal any relationship between the static balance parameters and MATERIAL - METHOD: Twenty four patients participated in this study. In accordance with the temporospatial performance. clinical guidelines (Marmarou et al., 2005) eleven patients (mean age=70.8 years, 4 female) CONCLUSIONS: Our study showed that walking velocity, in contrast to static balance, improved were classified as probable ΙNPH (group A) and thirteen (mean age=71.9, 3 female) as after shunt placement in ΙNPH patients. Improvements in the ankle and knee motion contributed possible ΙNPH (group B). Frontal functions that are mainly affected in ΙNPH were examined by to increased stride length. Finally, our data indicated improved foot-to-floor clearance post neuropsychological assessment prior to and an hour after removal of 40 ml of cerebrospinal operatively. fluid. Digit span, trail making A, verbal fluency (letter and category), stroop and finger tapping were the tests administered. In addition, a videotaped 10 m walking test was performed pre- and post-LT in order to assess gait. O03. PRE- AND POST-OPERATIVE GAIT ANALYSIS OF: RESULTS: In group A, verbal fluency (letter) test (p<0.05) and finger tapping task (p<0.01) A) DBS-STN AND B) IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS PATIENTS showed a statistically significant improvement an hour after LT. In parallel, gait was significantly N. Darras1, E. Liouta2, F. Liakos2, C. Koutsarnakis2, P. Stathis2, D. Sakas2, G. Stranjalis2 improved (p<0.01).In group B, no statistically significant improvement was observed in verbal (1) ELEPAP Gait & Motion Analysis Center, Athens, Greece fluency and finger tapping (p>0.05). Accordingly, gait did not show statistically significant (2) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece improvement (p>0.05) after LT. CONCLUSIONS: In our knowledge, this is the first study showing that verbal fluency (letter) OBJECTIVE: To examine the kinematic and kinetic pre- and post-operative differences in two test and finger tapping task improve an hour after a single LT and this can predict favorable groups of patients. Group A: DBS-STN-operated for Parkinson’s Disease (PDP) and Group B: gait outcome in ΙNPH but only for patients classified as probable ΙNPH. Further studies Shunt-operated Idiopathic Normal Pressure Hydrocephalus Patients (ΙNPHP). should investigate whether the above neuropsychological tests can predict gait response to MATERIAL - METHOD: 10 PDP (age: 61±5.3 years) and 8 ΙNPHP (age: 71±7.7 years) were included ventriculoperitoneal shunting. in the study. 3D gait analysis was performed to capture kinematic, kinetics and temporospatial parameters. Paired t-tests were used to assess group differences between pre- and postoperative intervention, and t-tests for independent samples to assess the differences of PDPs and ΙNPHPs (Level of confidence a=0.05). RESULTS: The pre-operative temporospatial comparison showed a significantly lower walking velocity for the ΙNPHP group (P>0.05), although the lower cadence and shorter stride length was not statistically significant. The kinematic and kinetic analysis documented a number of significant differences preoperatively between the two groups which included increased range of motion (ROM) of the pelvis and the sagittal plane hip and knee ROM in the PDP group (P>0.01). The post-operative temporospatial comparison showed that although both groups

34 35 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

O05. BRAIN’S CRITICAL CLOSING PRESSURE DURING INFUSION TESTS CONCLUSIONS: R-out does not predict shunt-response in ΙNPH and probably has little diagnostic G.V. Varsos, Z. Czosnyka, M. Czosnyka, J.D. Pickard value. A positive ELD is significantly associated with shunt-response but has a high negative Department of Clinical Neurosciences, University of Cambridge, UK predictive value, suggesting that patients may be inappropriately denied treatment if this is used alone to select surgical candidates. OBJECTIVE: Infusion tests are used for assessing cerebrospinal fluid dynamics in hydrocephalus. Critical Closing Pressure (CrCP) denotes a threshold of arterial blood pressure (ABP) below which small brain vessels collapse, ceasing blood flow. CrCP is the sum of ICP and arterial wall tension O07. IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS: (WT); based on CrCP is a recently introduced mechanism for ischemia, called Collapsing Margin PATOPHYSIOLOGY AND DIAGNOSIS BY CSF BIOMARKERS (CM). Zero CM indicates collapsed vessels. We investigated CrCP during infusion study and its A. Jeppsson1, H. Zetterberg2,3, K. Blennow2, C. Wikkelsö1 correlation to CSF compensatory parameters. (1) Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, MATERIAL - METHOD: We analyzed clinical data from cerebrospinal infusion tests performed The Sahlgrenska Academy, University of Gothenburg, Sweden in 34 non-shunted hydrocephalus patients. CrCP was calculated from the monitored signals of (2) Clinical Neurochemistry Laboratory, Department of Psychiatry and Neurochemistry, ICP, ABP and transcranial Doppler-based blood flow velocity, while WT was estimated as CrCP- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, ICP. The collapsing margin was trended as the difference between mean ABP and CrCP. University of Gothenburg, Sweden RESULTS: CM at baseline was inversely correlated to brain elasticity (R=-0.358; p=0.038) but (3) UCL Institute of Neurology, Queen Square, London, UK not associated with the resistance to CSF outflow. During infusion study ICP increased from 6.67±4.61 to 24.98±10.49 mm Hg (mean ± SD; p<0.001), resulting in CrCP rising by 22.93% OBJECTIVE: This observational study aimed to explore the pathophysiology of idiopathic (p<0.001) and arterial WT decreasing by 22.93% (p=0.005) due to compensating vasodilation. Normal Pressure Hydrocephalus (ΙNPH) and to evaluate the diagnostic and prognostic value of CM showed a tendency to decrease, albeit not significantly (p=0.070) due to rising ABP by CSF biomarkers. 9.12% (p=0.005). CM was significantly different from zero for the whole duration of the test MATERIAL - METHOD: Lumbar CSF of ΙNPH patients and healthy elderly individuals (HI), and (p<0.001). ventricular CSF (VCSF) from the ΙNPH patients per- and 6 months post-surgery were analyzed CONCLUSIONS: Low CM at baseline pressure may be an indicator of an impaired compensatory by enzyme-linked immunosorbent assay (ELISA). We analyzed neurofilament light protein reserve. Increasing CrCP during the infusion does not pose an elevated ischemic risk for the (NFL), myelin basic protein (MBP), a panel of β-amyloid isoforms; Aβ38, Aβ40, and Aβ42, soluble patient as CM does not reach zero or negative values. amyloid precursor protein (sAPP) isoforms sAPPα and sAPPβ, total- and phosphorylated tau protein(T-, and P-tau), and inflammatory markers interleukin 8 (IL-8), interleukin 10 (IL-10) and monocyte chemoattractant protein 1 (MCP1). O06. THE EXTENDED LUMBAR DRAINAGE TEST ALONE PREDICTS SHUNT REPONSE IN RESULTS: NFL was elevated and APP-derived proteins and tau proteins were lower in ΙNPH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS: THE DEMISE OF THE DIAGNOSTIC patients than in HI. Post-surgery, there was an increase of NFL, APP-derived proteins, P-Tau, and CONSTANT RATE LUMBAR INFUSION TEST albumin in VCSF, whereas levels of MBP and T-Tau had decreased. Improved patients did show L. Nicolae, W.G.B. Singleton, R. Sivakumaran, R.J. Edwards a greater increase of APP-derived proteins in VCSF following shunting than did those who did Department of Neurosurgery, Frenchay Hospital, Bristol, UK not improve. CONCLUSIONS: We interpret our data as ΙNPH pathophysiology to be characterized by a

OBJECTIVE: Evidence suggests that the resistance-to-CSF-outflow (R-out) and CSF tap test are reduced periventricular metabolism and axonal degeneration but no major cortical damage. poorly predictive of clinical outcome after shunting in ΙNPH. In our unit we routinely utilise the constant-rate infusion test alongside extended lumbar CSF drainage (ELD) in the diagnostic work-up of these patients. We sought to determine the value of these two tests in predicting shunt-response. MATERIAL - METHOD: Our prospective database of 232 patients undergoing shunt insertion for ΙNPH 2001-12 was analyzed. Both shunt-response and a positive ELD were defined as a 2-point improvement in the mini-mental test and/or 20% improvement in Raftopolous gait score. The results of the ELD and pre-operative R-out were compared with post-operative shunt-response at both 3 and 12 months. RESULTS: Complete data was available for 208 patients. 3 died before follow-up due and 21 were lost or data was missing. Shunt response was seen in 80% and 74% at 3 and 12 months respectively. The R-out was not significantly associated with shunt-response at thresholds of 12, 14 and 18mmHg/ml/min. A positive ELD was significantly associated with a shunt response (p=0.016) and had a positive predictive value of 80% and a negative predictive value of 35%.

Combining R-out and ELD did not improve the predictive value.

36 37 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

O08. COMORBIDITY AND RISK FACTORS ASSOCIATED WITH HYDROCEPHALUS familial pedigree is concerned, their father, deceased at the age of 75, was reported to have H. Israelsson1, B. Carlberg2, C. Wikkelsö3, K. Laurell1,4, B. Kahlon5, G. Leijon6, A. Eklund7, J. Malm1 the Hakim triad whereas their two daughters (42 and 45 years old) complained of urinary (1) Department of Pharmacology and Clinical Neuroscience, Umeå University Hospital, Sweden incontinence. The 42 years old daughter showed empty sella and the 44 years old daughter (2) Department of Public Health and Clinical Medicine, Umeå University Hospital, Sweden showed empty sella as well as cerebral atrophy with slight ventricular enlargement (however (3) Institute of Neuroscience and Physiology, The Sahlgrenska Academy, not exceeding Evan’s index). This familial case of ΙNPH is unique because, in contrast with University of Gothenburg, Sweden previous reports, both probands and descendants presented with incontinence at an early age. (4) Department of Neuroscience, Neurology, Uppsala University Hospital, Sweden By studying this family longitudinally, our understanding of the natural history of this syndrome (5) Department of Neurosurgery, Lund University Hospital, Sweden may be improved, which, in turn, may lead to prophylactic intervention. (6) Department of Clinical and Experimental Medicine (IKE), Division of Neuroscience, Linköping University, Sweden (7) Department of Radiation Sciences, Umeå University, Sweden O10. 200 LONGITUDINAL ICP ANALYSES AT QUEEN SQUARE J.D. Shand Smith1,2, S. Thompson1, A.K. Toma1, A. Khan1, N.D. Kitchen1,2, L.D. Watkins1,2 OBJECTIVE: The risk factor profile amongst ΙNPH-patients is inadequately known. Hypertension (1) Victor Horsley Department of Neurosurgery, National Hospital for Neurology is considered the single most important risk factor for ΙNPH. However, previous studies have and Neurosurgery, Queen Square, London, UK been small with only hospital-based controls. The objective for this large case-control study (2) Department of Brain Repair and Rehabilitation, Institute of Neurology, was to investigate the vascular risk factor profile in shunted ΙNPH-patients, compared to a sex- University College London, UK and age-matched community-based population. MATERIAL - METHOD: Cases were all shunted ΙNPH-patients registered in the Swedish OBJECTIVE: To provide background mathematical and graphical analysis of longitudinal ICP Register of Hydrocephalus 2008-2010 (from 5 out of 6 neurosurgical centers, covering data in key CSF dynamic disorders. approximately 80% of the Swedish population) and remaining after exclusion criteria (inability MATERIAL - METHOD: Using a new tool for mathematically analysing and graphing longitudinal to communicate, pre-operatively mini mental state estimation (MMSE) <23, age<60 and >85). ICP data we retrospectively analyzed the existing data for every patient who underwent ICP Sex- and age-matched community-based controls were chosen from the Swedish population monitoring at the NHNN over the past 6 years. All patients had Spiegelberg ICP bolts with index. Participants completed an extensive questionnaire and had a visit at their nearest health recording via Spiegelberg ICP Lab software which provides a minute by minute value for care center/neurological department for blood samples and measurements. Focus laid on the systolic, diastolic and mean ICP. Conditions investigated were postural headache, idiopathic ten most important risk factors accounting for 90% of cardiac infarction and stroke, as shown intracranial hypertension, hydrocephalus, normal pressure hydrocephalus, pseudomengiocoele in interheart/interstroke. and chiari/syrinx and investigation of shunt malfunction. Criteria investigated were Median RESULTS: 177 cases (mean age 73, 41% women) and 363 controls (mean age 72, 37% women) Systolic, Diastolic and Mean ICP, Median Pulsatility, Peak ICP Trough ICP, Incidence of spike “ICP”, participated (157 patients excluded, 252 contacted controls chose not to participate). The last percentage high ICP, percentage –ve ICP, PIP (pearsons co-efficient of ICP mean vs pulse) and participant was included in September 2012. The database will close in May 2013. The first indirect compliance. In each case for overall, day and night data. ICP was graphically analyzed results, primarily regarding vascular disease, hypertension and medication of hypertension, will - longitudinally for systolic, diastolic and mean ICP, histographically for mean ICP and scatter of be reported in Athens 2013. mean ICP versus ICP pulsatility. CONCLUSIONS: This community-based epidemiological study will describe the risk factor RESULTS: Clear patterns emerge in each condition, providing insights into their nature and profile in ΙNPH-patients. This will help in understanding the pathophysiology and the influence diagnosis. The analysis algorithm has been implemented through Microsoft Excel with the of vascular comorbidity on the disease. intention of sharing it with our colleagues at IHCSF. Our aim is that they try it, make and suggest alterations and that the resultant algorithm would be implemented in an open source software package. O09. A NOVEL CASE OF FAMILIAL IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS E. Liouta1,2, F. Liakos1, D. Sakas1,2, G. Stranjalis1,2 (1) The Petros Kokkalis Center for Neurosurgery Research, Athens, Greece O11. THE INTRACRANIAL PULSE PRESSURE AMPLITUDE AND COGNITIVE IMPROVEMENT (2) Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Greece AFTER CSF TAP TEST IN ΙNPH A. Behrens1,2, S. Qvarlander3, A. Eklund3, J. Malm1 SUMMARY: The familial occurrence of Idiopathic Normal Pressure Hydrocephalus (ΙNPH) is (1) Department of Clinical Neuroscience, Umeå University, Sweden extremely rare. According to the literature four cases of late-onset familial ΙNPH have been (2) Blekinge Centre of Competence, Karlskrona, Sweden reported. In this report we present the fifth known case of familial NPH. Two sisters aged 72 (3) Department of Radiation Sciences, Umeå University, Sweden and 70 years respectively, showed ventriculomegaly and extensive atrophy on MRI. They presented with a long lasting (25 years) incontinence and a two years history of gait difficulties OBJECTIVE: It has been suggested that ΙNPH improvement after shunt surgery is linked to and cognitive decline (although the Mini Mental Status Exam was >24). They both underwent reduction in cardiac related intracranial pressure pulse amplitude. The objective of this study ventriculoperitoneal shunting followed by a significant clinical improvement. As far as the was to investigate how pulse amplitude changes, induced by a large volume CSF tap, relates to cognitive improvement.

38 39 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

MATERIAL - METHOD: The lumbar CSF pressure was recorded in 21 patients in the preoperative O13. POST TRAUMATIC NON-ACUTE HYDROCEPHALUS: PROFILE OF CSF DYNAMICS investigation for ΙNPH. Baseline pressure was assessed (CELDA, Umea, Sweden), followed by an Z. Czosnyka, M. Czosnyka, J.D. Pickard infusion test. The investigation ended with removal of CSF (mean 43.3 mL±9). The difference in Academic Neurosurgery, Addenbrooke’s Hospital, Cambridge, UK lumbar CSF pulse pressure amplitude between baseline and after CSF removal was calculated. The patients were assessed with a short in-house developed computerized neuropsychological OBJECTIVE: To assess and interpret differences in CSF compensatory profiles between post- test battery before and 3 h after the CSF-tap, including Choice reaction test, Stroop congruent and traumatic non-acute hydrocephalus (pTH) and idiopathic normal pressure hydrocephalus (ΙNPH) incongruent colors tests. The tests have previously been validated and limits for improvement and compare them to patients considered as presenting with normal CSF compensation. have been established. Improvement after tap was defined as improvement in ≥50% of the MATERIAL - METHOD: Computerized infusion tests performed in Hydrocephalus Clinic tests. were audited anonymously. Patients with post-traumatic non-acute hydrocephalus (dilated RESULTS: Amplitude reduction was larger among cognitive improvers (-1.2±1 mm Hg n=14) ventricles, atrophic changes, diminished GCS, without open craniotomy; N=33) were compared than among non-improvers (-0.4±0.3 mm Hg n=6 (one extreme value excluded)) (p<0.05, Mann- to patients classified as typical ΙNPH (N=81) and with group of 27 patients with normal CSF Whitney U). The mean ICP reduction between the improvers/non-improvers did not differ. compensation (NORM, N=27). Baseline ICP, pulse amplitude of 1st harmonic of pulse wave CONCLUSIONS: Cognitive improvement after tap test may be associated with larger (peak-to-peak), slope of amplitude-pressure line, resistance to CSF outflow, elasticity and RAP amplitude drop. This observation supports the role of cardiac related ICP pulsations in ΙNPH index were evaluated. pathophysiology and opens up for new predictive tests for shunt surgery. The results need to RESULTS: Baseline ICP was normal and almost the same in all three groups (cumulative 9.7+/- be verified in a larger prospective study. 4.8 mm Hg). Pulse amplitude was significantly greater in ΙNPH than in pTH and NORM (4.5 +/- 3.1 mm Hg; 2.28+/-2.9 mm Hg; 2.0+/- 1.7 mm Hg; p=0.0001). Resistance to CSF outflow was highest in ΙNPH (17.6+/-5.6 mmHg/(ml/min)); medium in pTH (13.4+/-6.1 mmHg/(ml/min)) and O12. CSF PULSE PRESSURE IS CORRELATED WITH A MARKER OF VASCULAR DISORDER normal in NORM group (6.3+/-1.94 mmHg/(ml/min)) (p<0.0001). Slope of amplitude-pressure E.A. Schmidt1, E. Caussé2 line was similar in ΙNPH and NORM group (0.55+/-0.2) and significantly lower (p<0.002) in pTH (1) Department of Neurosurgery, Toulouse, France (0.28+/-0.18). Elasticity was slightly elevated but not different between three groups (cumulative (2) Department of Biochemistry, Toulouse, France 0.25+/-0.15 1/ml). However, RAP index suggested better compensatory reserve in pTH (0.62+/- 0.1) than in ΙNPH (0.82+/-0.11) and NORM (0.84+/-0.12) (p<0.002). OBJECTIVE: Vascular dysfunction plays also an important role in neurodegeneration and CONCLUSIONS: CSF compensation in post-traumatic hydrocephalus is generally worse than in cerebral atrophy. Homocysteine is a recognized independent risk factor in the genesis of norm but better than in ΙNPH. Stratification of results of infusion tests with aetiology and co- vascular disorder and atherosclerotic diseases. The aim of this study is to measure homocysteine morbidity is necessary. and other thiols in the CSF of patients suspected of normal pressure hydrocephalus (NPH). We correlate CSF thiol biochemistry and brain biomechanics. MATERIAL - METHOD: 155 patients (73 females, 82 males, mean age 72) were included. All O14. MRI TIME-SPATIAL LABELING INVERSION PULSE (TIME-SLIP) FINDINGS TO SUPPORT patients were suspected of NPH. CSF hydrodynamic tests were performed via lumbar puncture. POSSIBLE CEREBROSPINAL FLUID (CSF) OLFACTORY DRAINAGE IN HUMANS A lumbar needle was inserted and a 2ml sample of CSF was withdrawn for biochemical S. Yamada1, M. Miyazaki2, C. Ouyang2, R. Anderson2, W.G. Bradley3, J.G. McComb4 analysis. Then infusion test was performed to gauge intracranial pressure (ICP) mean and ICP (1) Department of Neurosurgery, Oiso Hospital, Tokai University, Kanagawa, Japan pulse pressure, resistance to CSF outflow, CSF production rate and brain elastance. Thiols were (2) Toshiba Medical Research Institute, Vernon Hills, Illinois, USA measured in CSF by capillary electrophoresis/laser induced fluorescence detection. (3) Department of Radiology, University of California, San Diego, USA RESULTS: The mean (SD) CSF values were: Homocysteine 0.27(0.36) µmol/L; Cysteine 4.84(1.7) (4) Division of Neurosurgery, Children’s Hospital of Los Angeles, USA µmol/L; Glutathione 0.56(0.6) µmol/L, Cysteinyl-Glycine 2.96(1.12) µmol/L. CSF-Hcy and CSF- Department of Neurological Surgery, Keck School of Medicine, University of Southern Cys were positively correlated with ICP pulse pressure (resp. r=0.20 and r=0.23 p<0.05). CSF- California, Los Angeles, USA thiols were not correlated with other biomechanical parameters. CONCLUSIONS: ICP pulse amplitude is driven by the pulsatility of the brain vessels and by the OBJECTIVE: The traditional concept of CSF circulation is that CSF is produced in the ventricles brain’s elastance. In our large group of patients, we demonstrate that CSF Hcy is correlated by the choroid plexus, exits the 4th ventricle via the foramina of Magendie & Luschka, enters the with ICP pulse pressure but not with elastance. It suggest that brain vessels are stiffer at higher subarachnoid space to drain into the blood stream through the arachnoid granulations at the CSF homocysteine concentration CSF pulse pressure is correlated with a marker of vascular superior sagittal sinus (SSS). Previous animal experiments, including primates, have called this disorder. circulation pathway into question. Until now there has been no way to non-invasively visualize CSF movement in the normal human subject. Using a newly developed modification of arterial spin labeling, time-SLIP, such observations are now possible. MATERIAL - METHOD: Healthy normal volunteers underwent a non-contrast MRI of the head using the time-SLIP technique on a Toshiba 3T scanner. RESULTS: CSF movement was noted at the cranial base, especially in the cribriform plate region

40 41 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O) at inversion times of 1500-4500 msec after pulse labeling CSF in the region of interest. Little clinical and radiological suspicion of ΙNPH were evaluated using the Philips MRI system. Flows such movement was seen over the convexity, particularly near the SSS. were quantified at aqueductal and subarachnoid cervical CSF, and vascular cervical levels. Data CONCLUSIONS: These observations raise the possibility that more or most CSF is draining at were analyzed using a homemade image processing software, and flow curves/parameters the cranial base in preference to the SSS. calculated. Flow measurement agreement between the two constructors was assessed in HV using the Bland-Altman plot method. RESULTS: We showed a significant systematic difference between the measurements with the O15. MR IMAGING OF CSF AND BLOOD FLOW IN HYDROCEPHALUS 2 systems, for all the evaluated levels. This difference was less pronounced for aqueductal CSF O. Balédent1, C. Gondry-Jouet2, C. Capel3, S.E. Sankari4, A. Fichten2, R. Bouzerar1 flows. Among patients with initial suspicion of ΙNPH, 13 had finally another diagnosis retained (1) Image Processing, University Hospital, Amiens, France (vascular or Parkinson dementia…). All of them had aqueductal flow stroke volumes within (2) Department of Radiology, University Hospital, Amiens, France the normal range, as measured using the same MRI system in HV. Among the 9 patients with (3) Department of Neurosurgery, University Hospital, Amiens, France hyperdynamic aqueductal CSF flows, 5 were diagnosed with ΙNPH, and successfully shunted. (4) Department of Neurology, University Hospital, Brussels, Belgium Finally, 4 patients remain with irresolute diagnosis, and additional tests (ICP monitoring) are performed. SUMMARY: Cerebral hydrodynamic knowledge has benefited considerably from the CONCLUSIONS: This study is the first to highlight significant differences in CSF flow introduction of phase-contrast magnetic resonance imaging (PCMRI).Using post-processing measurements according to the MRI constructor. When appropriate local normal database are software (free access www.tidam.fr), key parameters of flow can be easily calculated to investigate collected, CSF parameters provide additional tools for positive and differential diagnosis in the role of CSF and venous blood compartments in response to systolic brain expansion during ΙNPH. cardiac cycle. We have first defined a rapid PCMRI protocol to be used in clinical practice. In five minutes CSF flow is quantified in the cervical subarachnoid spaces, the pontine cistern, the foramen of Magendi and the aqueduct of Sylvius. Blood flow is quantified in the internal O17. PREDICTABILITY OF SHUNT EFFECTIVENESS ON MRI FINDINGS IN IDIOPATHIC carotid and the vertebral arteries, straight and sagital sinus, jugular and epidural veins. This NORMAL PRESSURE HYDROCEPHALUS global PCMRI protocol was first applied in healthy populations of newborn, children, adults and M. Ishikawa aging subjects to quantify the physiological variability of CSF and cerebral blood flow. For the Normal Pressure Hydrocephalus Center, Otowa Hospital, Kyoto, Japan last 10 years, based on these reference values, patients suspected with hydrodynamic troubles were investigated in our hospital. The objective of this presentation is to describe the power OBJECTIVE: Idiopathic normal pressure hydrocephalus (ΙNPH) has become socially important and the limit of such clinical PCMRI protocol. After a brief presentation of our normal results due to rapid increase of the aged population in Japan. Predictability of shunt effectiveness concerning CSF and blood flow interactions in the cranio spinal system we will directly illustrate is indispensable. Japanese guidelines for ΙNPH in 2011 described the diagnostic value of how PCMRI can be used in patients, to show CSF and blood flow alterations. And, finally, how disproportionately enlarged subarachnoid-space hydrocephalus (DESH) on MRI. However, there these results are used by neurosurgeon or neurologist in case of: were some inter-observer differences on MRI findings. For overcoming this, we classified DESH • Sylvius aqueductal stenosis, finding into three major types: DESH, incomplete DESH and non-DESH. DESH fulfilled three • Endoscopic third ventriculostomy, criteria of ventriculomegaly, tight high convexity and enlarged sylvian fissure. Incomplete DESH • Hydrocephalus- alzheimer-atrophy mixed patients, indicated the type fulfilling two of three criteria. It composed of three subtypes of incomplete • Acute subarachnoid hemorrhage patients, DESH-ventriculomegaly (v), incomplete DESH-tight high convexity(c), and incomplete DESH- • Cerebral venous flow alteration as potential cause of hydrocephalus patients. sylvian fissure(s). To investigate the usefulness of this classification, data of 83 suspected ΙNPH patients in our institute were reviewed. MATERIAL - METHOD: All patients had symptoms of NPH and they received the shunt surgery. O16. CSF FLOW MEASUREMENTS WITH PC-MRI IN HYDROCEPHALUS DEPEND Their symptoms and daily activity were evaluated on admission and at discharge. Mean age ON MRI CONSTRUCTORS was 74 years. S.E. Sankari1, I. Bogdan2, N. Michoux2, C. Grandin2, T. Duprez2 RESULTS: Among all, DESH was noted in 66%, incomplete DESH in 29% and non-DESH in 5%. (1) Department of Neurology, Cliniques Universitaires Saint-Luc, Brussels, Belgium Among incomplete DESHs, incomplete DESH-c, incomplete DESH-s and incomplete DESH-v (2) Department of Neuroradiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium were noted in 16%, 13% and 0%, respectively. Shunt effectiveness of DESH, incomplete DESH-s, incomplete DESH-c, incomplete DESH-v and non-DESH was noted in 74.5%, 84.6%, OBJECTIVE: Hyperdynamic aqueductal flows measured with PC-MRI have been suggested as 27.2%, 0% and 33.3%, respectively. In this study, the patients with MR findings of DESH and an additional diagnosis tool for idiopathic normal pressure hydrocephalus (ΙNPH). However, incomplete DESH-s showed high effectiveness. Both had the ventriculomegaly and the tight controversial cut-off and predictive values have been published. Differences among MRI high convexity. constructors have never been investigated. CONCLUSIONS: The ventriculomegaly and the tight high convexity were highly promising MRI MATERIAL - METHOD: We evaluated 16 healthy elderly volunteers (HV) with 2D fast cine PC- findings. MRI sequences, on 2 different 3T (Philips and Siemens) systems. Twenty-two patients with

42 43 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

O18. WATER MOLECULAR FLUCTUATION IN VENTRICULES RESULTS: 232 patients were shunted from 2001-12 on the basis of clinical ΙNPH with AND BRAIN TISSUE IN NORMAL PRESSURE HYDROCEPHALUS ventriculomegaly (Evans index>0.3). Pre-operative imaging was available in 171 patients. 16 M. Mase1, T. Miyati2, N. Ohno2, H. Kan3, H. Kasai3, K. Yamada1 were lost to follow-up. 155 were analyzed for the presence of DESH. A positive shunt-response (1) Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, was seen in 83% and 75% at 3 and 12-months respectively. A response to shunting, at either Japan time point, was not significantly associated with the presence of DESH (p=0.59 and 0.48). The (2) Faculty of Health Science, Institute of Medical, Pharmaceutical and Health Sciences, presence of tight high convexity alone also did not reach statistical significance (p=0.54). The Kanazawa University, Japan negative predictive value of DESH was 22% at 12 months. (3) Department of Radiology, Nagoya City University Hospital, Japan CONCLUSIONS: The presence of DESH is not a predictive feature of shunt responsive ΙNPH. The negative predictive value is such that patients that may improve with shunting will be denied OBJECTIVE: We have reported that patients with idiopathic normal pressure hydrocephalus this treatment if DESH is used to recruit patients for surgery. (ΙNPH) had significantly larger ΔADC (temporal changes of apparent diffusion coefficient) of the brain tissue. In the present study, we analyzed ΔADC changes of intraventricular cerebrospinal fluid (CSF) in ΙNPH. O20. Evaluation of Cerebral Atrophy in INPH via CSF Infusion Test MATERIAL - METHOD: On a 1.5-T MRI, ECG-triggered single-shot diffusion echo planar G. Aygok, D. Hidlay, C. Kayis imaging was used to obtain ADC images. A normalized-ΔADC image was calculated from all Department of Neurosurgery, Medical College of Virginia Commonwealth University, USA cardiac phase ADC images (20 phases) on a pixel-by-pixel basis using the following equation: Normalized-ΔADC = (ADCmax-ADCmin) / (ADCmax+ADCmin), where ADCmax and ADCmin SUMMARY: Cerebral atrophy is observed in some ΙNPH patients with the triad of clinical represent the maximum and minimum ADC during the cardiac cycle, respectively. We assessed symptoms and ventriculomegaly. The presence of ventricular dilatation may be sometimes normalized-ΔADC and ADC values in the three ventricular regions, i.e. the anterior and posterior misinterpreted as a result of brain atrophy and therefore, ΙNPH has been misdiagnosed as horns of the lateral ventricles and the third ventricle, and compared those values among the Alzheimer’s or other neurodegerative diseases. Thus, it is necessary to characterize the ΙNPH ΙNPH (n=14), atrophic ventricular dilatation (atrophic VD group; n=9), and healthy volunteers radiological findings and differentiate those from the neurodegenerative diseases and ischemic (control group; n=8). changes. Pressure-volume index (PVI) is a number that can be obtained using an infusion study RESULTS: Normalized-ΔADC of the third ventricle was significantly higher in ΙNPH than those to test whether brain tissue is softer or tighter compared to a number regarded as normal (25ml). in the control and atrophic VD groups, whereas there were no significant differences for In this study, we report ten patients with radiological findings suggesting from mild to extensive normalized-ΔADC in the other regions among the groups. atrophic behavior, whereas their lower PVIs indicating the contrary. Our results suggest that the CONCLUSIONS: In the present study, we showed regional difference of CSF water fluctuation atrophy-like features may be the CSF extravasation through the brain parenchyma which plays and significantly large ΔADC in the third ventricle of ΙNPH. CSF movement must be changed the major role in the pathophysiology of these ΙNPH patients. by the different intracranial compliance. Large ΔADC in ΙNPH could be explained dueto compensate low compliance in ΙNPH. It may have a clinical role that the strongly affected area was the third ventricle. O21. POSITRON EMISSION TOMOGRAPHY WITH [18F]FLUTEMETAMOL AND [11C]PIB FOR DETECTION OF CEREBRAL CORTICAL AMYLOID IN NORMAL PRESSURE HYDROCEPHALUS PATIENTS O19. DISPROPORTIONATELY ENLARGED SUB-ARACHNOID-SPACE HYDROCEPHALUS V. Leinonen1, J.O. Rinne2,3, K.A. Virtanen2, O. Eskola2, J. Rummukainen4, J. Huttunen1, (DESH) IS NOT ASSOCIATED WITH SHUNT-REPONSIVE IDIOPATHIC NORMAL PRESSURE M. von und zu Fraunberg1, O. Nerg5, A.M. Koivisto5, J. Rinne1, J.E. Jääskeläinen1, C. Buckley6, HYDROCEPHALUS (ΙNPH) A. Smith6, P.A. Jones6, P. Sherwin7, G. Farrar6, R. McLain8, M. Kailajärvi9, K. Heurling10, L. Nicolae1, W.G.B. Singleton1, R. Sivakumaran1, A. Mortimer2, R.J. Edwards1 I.D. Grachev7 (1) Department of Neurosurgery, Frenchay Hospital, Bristol, UK (1) Department of Neurosurgery, KUH NeuroCenter, Kuopio University Hospital and (2) Department of Neuroradiology, Frenchay Hospital, Bristol, UK Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland (2) Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland OBJECTIVE: Disproportionately enlarged subarachnoid-space hydrocephalus (DESH) is a (3) Department of Neurology, Turku University Hospital, Turku, Finland published diagnostic feature of shunt-responsive ΙNPH. We sought to determine whether this (4) Department of Pathology, Kuopio University Hospital, Kuopio, Finland radiological sign is universal in patients with a clinical NPH syndrome and ventriculomegaly (5) Department of Neurology, KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland that responds to shunting. and Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, MATERIAL - METHOD: Retrospective radiological analysis of a prospective ΙNPH database. Kuopio, Finland Multiplanar pre-operative imaging for all patients was analyzed by a neuroradiologist, (6) Medical Diagnostics, GE Healthcare, Amersham, UK blinded to the clinical results, to assess for tight high convexity and sylvian fissure score. The (7) Medical Diagnostics, GE Healthcare, Princeton, NJ, USA presence of DESH was analyzed alongside the clinical response to shunting at 3 and 12 months. (8) PFP Statistical Consulting, LLC, Livonia, MI, USA Shunt-response was defined as a 2-point improvement in the mini-mental test and/or 20% (9) Medical Diagnostics, GE Healthcare, Turku, Finland improvement in Raftopolous gait score. (10) Medical Diagnostics, GE Healthcare, Uppsala, Sweden

44 45 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

OBJECTIVE: To determine the correlation between uptake of the positron emission tomography 023. INTRACRANIAL PRESSURE DYNAMICS AT DIFFERENT OPENING PRESSURES (PET) imaging agent [18F]flutemetamol and amyloid-β measured by immunohistochemical AND BODY POSITIONS IN SHUNT TREATMENT OF COMMUNICATING HYDROCEPHALUS and histochemical staining in a frontal cortical brain biopsy. D. Farahmand1, S. Qvarlander2, J. Malm3, C. Wikkelsö1, A. Eklund2,3, M. Tisell1 MATERIAL - METHOD: Study included 15 patients with possible idiopathic normal pressure (1) Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, hydrocephalus (ΙNPH) and previous right frontal brain biopsy obtained during intracranial The Sahlgrenska Academy, University of Gothenburg, Sweden pressure monitoring. All patients underwent [18F]flutemetamol PET and 7 of these patients also (2) Centre for Biomedical Engineering and Physics, Department of Radiation Sciences, underwent [11C] Pittsburgh compound B (PiB) PET. [18F]Flutemetamol and [11C]PiB uptake was Umeå University, Sweden quantified using standardized uptake value ratio (SUVR) with the cerebellar cortex as a reference (3) Department of Clinical Neuroscience, Umeå University, Sweden region. Tissue amyloid-β was evaluated using the mAb 4G8, Thioflavin-S, and Bielschowsky silver stain. OBJECTIVE: The aim of this, two-center double blind study was to analyze the intracranial RESULTS: [18F]Flutemetamol and [11C]PiB SUVRs correlated with brain biopsy amyloid-β levels pressure (ICP) and pulse amplitude in relation to opening pressure and body position in shunt contralateral (r=0.86, p<0.0001; r=0.96, p=0.0008) and ipsilateral (r=0.82, p=0.0002; r=0.87, treatment of hydrocephalus (HC) patients. p=0.01) to the biopsy site. Association between cortical composite [18F]flutemetamol SUVRs MATERIAL - METHOD: Adult patients diagnosed with communicating HC were operated with and [11C]PIB SUVRs was highly significant (r=0.97, p=0.0003). an adjustable ventriculoperitoneal shunt (Strata®) and a portable intra-parenchymatous ICP- CONCLUSIONS: [18F]flutemetamol detects brain amyloid-β in vivo with moderate to high monitoring device (Raumedic®). Initially the shunt was closed distal to the valve with a dura sensitivity and high specificity representing a valuable new tool to verify the presence or clip ligation. Dura openings were sealed with tissue glue (Tisseel®) to prevent cerebrospinal absence of amyloid-β pathology, especially in patients with possible NPH. fluid leakage. After recording base line ICP over night the patient was positioned supine, sitting and walking respectively during 10 minutes periods while the ICP was recorded. The shunt was then opened in local anaesthesia. The valve was adjusted with 4 hours intervals according to O22. CEREBRAL PERFUSION MEASURED BY DSC MRI IS REDUCED a randomisation pattern with three different valve pressures (Strata® level 0.5; 1.5; 2.5). Before IN PATIENTS WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS each valve adjustment the ICP was recorded in the three different body positions as described D. Ziegelitz1, G. Starck2,3, D. Kristiansen4, M. Jakobsson4, M. Hultenmo2,3, I.K. Mikkelsen5, above. All ICP recordings were coded and randomized and later analyzed using algorithms in P. Hellström4, M. Tullberg4, C. Wikkelsö4 MATLAB® for detection of cardiac related ICP pulsations. Departments of (1) Neuroradiology and (2) Radiation Physics at the Institute of Clinical RESULTS: Twenty patients were included in the study. Five patients were excluded due to Sciences, (4) Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and inability to perform the testing or technical failures. The mean baseline ICP was 12,5 (SD±3,3) Physiology, The Sahlgrenska Academy, University of Gothenburg, Sweden mmHg in the supine position and when the shunt was opened mean ICP was significantly lower (3) Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, (p=0,02). There was a significant decrease of mean ICP comparing supine body position with Sweden sitting and walking activity. The pulse amplitude was also decreased significantly after shunt (5) Center of Functionally Integrative Neuroscience, Århus University Hospital, Denmark opening, but was not altered by different body positions or opening pressures. CONCLUSIONS: This study shows how the ICP and pulse amplitude of HC patients is affected OBJECTIVE: The purpose was to demonstrate a reduced pre-operative cerebral blood flow by shunt surgery, body position, and different opening pressure of the valve. (CBF), correlating with symptoms and signs, in patients with idiopathic normal pressure hydrocephalus (ΙNPH) compared to healthy individuals (HI) by dynamic susceptibility contrast (DSC) MRI perfusion. O24. CHANGES OF INTRA-ABDOMINAL PRESSURE AND THE IMPACT ON VALVE MATERIAL - METHOD: 21 ΙNPH patients and 16 age-matched HI had their perfusion in the SELECTION FOR VENTRICULOPERITONEAL SHUNTS cortical, subcortical and periventricular regions and peri-and para-ventricular profiles estimated U. Kehler, Y. Chehade by multi-slice DSC MRI. Relative CBF (rCBF) was calculated with the occipital cortex as internal Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany reference. Symptoms and signs were assessed by the ΙNPH scale. RESULTS: Periventricular rCBF correlated positively with symptoms and signs pre-operatively OBJECTIVE: Ventriculo-peritoneal shunts (VP-shunts) are most often used in hydrocephalus in ΙNPH patients. Post-operative improvement correlated negatively with pre-operative treatment. The resulting ICP depends on the valve opening pressure, the hydrostatic pressure periventricular and grey matter rCBF. Shunt-responders had higher rCBF values in the basal difference between head and abdomen as well as on the intraabdominal pressure (IAP). However, medial frontal cortex than non-responders. IAP is not exactly known and may change with body position, BMI, chronic constipation and CONCLUSIONS: DSC MRI perfusion is a potentially useful diagnostic tool in ΙNPH and perfusion others. In this study we measured the IAP in different body positions and looked for other based criteria might be possible predictors of shunt response. factors that might influence the IAP. MATERIAL - METHOD: IAP was measured in non-hydrocephalic patients via a bladder catheter in 20 patients in different body positions (prone, supine, laying on left/right side, sitting, standing and bended over). IAP was also related to sex, age and body mass index (BMI). RESULTS: The medium IAP was between 10 and 15 cmH20 in the horizontal position and 20

46 47 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O) to 25 cmH20 in the upright position. In prone position the IAP was 40% higher than in supine O26. SURGICAL TREATMENT OF NORMAL PRESSURE HYDROCEPHALUS position. IAP was highest in standing position with values around 25 cmH20, in sitting position WITH THE USE OF THE PROGRAMMABLE VALVES OF SHUNT SYSTEM values were around 20 cmH20. IAP differed substantially between individuals. Females had M. Legzdain, G. Gavrilov, D. Svistov lower IAP than males. No influence was found depending from (BMI) and age. Department of Neurosurgery, Military Medical Academy, Saint-Petersburg, Russia CONCLUSIONS: IAP changes with body position, but not with BMI. The variability and especially the individual different IAPs make a right valve selection for VP-shunts very difficult, which could OBJECTIVE: The main goal of research is to estimate efficiency of using shunt systems with be overcome at least partially by programmable valves. However, it is not clear if the changes of valve of adjusted pressure in treatment of patients with NPH. IAP are large enough to make the use of programmable valve absolutely necessary. MATERIAL - METHOD: Retrospective analysis of operational treatment results with the use of programmable valve is done. Among 236 patients, 208 people were suffering from ΙNPH. All patients got the following treatment: tap-test, ELD 72 hours, 10 mml per hour, infusion test O25. FINAL REPORT OF JAPAN SHUNT REGISTRY (JSR): (using the standard method of Katzman & Hussey). ESPECIALLY ON SHUNT ROUTE AND PRESSURE SETTING OF PROGRAMMABLE VALVE RESULTS: Patients with the ΙNPH had average liquor pressure 150±45 mmH2O, while in the M. Hashimoto1, M. Miyajima2, H. Arai2, H. Origasa3, I. Date4, M. Matumae5, JSR Group control group has average pressure 122±34 mmH2O. 82.8% of the patients got the implantation (1) Department of Neurosurgery, Noto General Hospital, Japan of programmable valve during the first operation. Pre-designated pressure was 140±20 (2) Department of Neurosurgery, Juntendo University, Tokyo, Japan mmH2O. 1.4 valve adjustment has been done. Even though, the single adjustment was done (3) Department of Biostatistics and Clinical Epidemiology, University of Toyama, Japan for 42.4% of patients. If the implantation of programmable valve was the second operation (4) Department of Neurosurgery, Okayama University, Japan for the patients, readjustment was needed to be provided in 48% of the treatments, for the (5) Department of Neurosurgery, Tokai University, Kanagawa, Japan first-operated patients – 41.2%. Most of the readjustments has been provided during the first 4 months of post-operational period. The level of changes was 35.2 mmH2O. The reasons of OBJECTIVE: Japan Shunt Registry (JSR) for idiopathic normal pressure hydrocephalus (ΙNPH) valve’s reprogramming were: hypodrainage (43.3%), hyperdrainage (31.2%). The rest of the started as prospective multicenter registry for searching present management outlines in situations were scheduled. Results: walking improvement (86%), regression of pelvic organs Japan, Sep. 2009. We reported outline result of JSR in 2012 Kyoto. In this report, we present the dysfunction (43%), regression of cognitive disorders (46%) time course of pressure setting especially on shunt route and the role of anti-siphon device CONCLUSIONS: It is reasonable to use the valves with the adjusted pressure and low pitch of (ASD) as final analysis of JSR. pressure change for the treatment of the NPH because this particular type of patients need MATERIAL - METHOD: JSR was designed to allow comparison of the safety and efficacy of individual adjustment of the valve shunt. various shunt route, types of valve, and setting pressure in programmable valve (PV), baseline clinical data and outcome (mRS, ΙNPH grading scale (GS), adverse event (AE), serious AE. and others, etc.) were collected for 6 months after shunting operation. O27. INDICATIONS FOR VALVE-PRESSURE ADJUSTMENTS OF GRAVITATIONAL ASSISTED RESULTS: In 100 patients, 55 (55%) of was operated by lumbo-peritoneal (LP) shunt and 45% VALVES IN PATIENTS WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS by ventriculo-peritoneal shunt. In shunt system, PV was used in 92%, and ASD was used in L. Gölz, J. Lemcke, U. Meier 85%. Setting pressure of PV in with ASD group (mean±SD: 15.1±3.8/ 13.9±3.2 cmH2O: Initial/6 Department of Neurosurgery, Unfallkrankenhaus Berlin, Germany months) was significantly higher than without ASD group (13.3±4.4/ 11.7±5 cmH2O). Shunt responder rate was observed in 66.7/78.6% (without/with ASD) by mRS. In JSR, strategy of BACKGROUND: Modern ventriculoperitoneal shunts (VPS) are programmable which enables shunting surgery by LP shunt with ASD are recommended in outcome and post-operative clinicians to adjust valve-pressure according to their patients individual needs. management. OBJECTIVE: The aim of this retrospective analysis is to evaluate indications for valve-pressure CONCLUSIONS: These findings as some working hypotheses suggested by the JSR, willbe adjustments in Idiopathic Normal Pressure Hydrocephalus (ΙNPH). expected as an integrated management protocol of ΙNPH for future clinical research. Now, MATERIAL - METHOD: Patients operated between 2004 & 2011 diagnosed with ΙNPH were JSR-II is ongoing. included. Kiefer-Scale was used to classify each patient. Follow-up exams were conducted three, six, and 12 months after shuntimplantation and yearly thereafter. Initial valve-pressure

was 100 or 70 mmH2O. Planned reductions of the valve-pressure to 70 and 50 mmH2O respectively were carried out an reactive adjustments of the valve-pressure to avoid over- and under-drainage were indicated. RESULTS: 52 patients were provided with a Medos-Hakim valve Codman® with a Miethke shunt assistant Aesculap® and 111 patients with a Miethke-proGAV Aesculap®. 180 reductions of the valve- pressure took place (65% reactive, 35% planned). Most patients (89%) needed one or two adjustments of their valve-pressures for optimal results. In 41% an improvement of symptoms was observed. Gait disorder was improved most often after valve-pressure adjustments (32%). 18 times an elevation of valve-pressure was necessary because of headaches, vertigo or the

48 49 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O) development of subdural hygroma. Optimal valve-pressure for most patients was around 50 37 had a dramatic gait improvement. 31 had cognitive improvement, 12 had cognitive decline mmH2O (36%). and 6 developed clinical dementia. CONCLUSIONS: The goal of shunt therapy in ΙNPH should usually be valve-pressure settings CONCLUSIONS: This study demonstrates improvements in both cognitive function (mental between 30-70 mmH2O. Reactive adjustments of the valve-pressure are useful for therapy of tracking speed and sustained attention) and gait, 6 months after surgery. Neuropsychological over- and under-drainage symptoms. Planned reductions of the valve opening pressure are assessment before and after shunt placement provides critical information about recovery in effective even if postoperative results are already satisfactory. ΙNPH and should be incorporated into clinical practice.

O28. SOCIAL IMPACT OF SHUNT SURGERY IN PATIENTS DIAGNOSED O30. INTRACRANIAL HYPERTENSION CAUSED BY DURAL AVF INVOLVING SSS WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS WITHOUT VENTRICULOMEGALY J. Petersen, C. Wikkelsö, P. Hellström, Å. Lundgren-Nilsson N. Aihara, M. Mase, K. Yamada Hydrocephalus Research Unit, Institute of Neuroscience and Physiology, Department of Neurosurgery, Nagoya City University Medical School, Japan The Sahlgrenska Academy, University of Gothenburg, Sweden SUMMARY: It is well known that communicating hydrocephalus in children can be caused by OBJECTIVE: To investigate the impact of shunt surgery on health related quality of life (HRQoL), venous hypertension. For example, in achondroplasia and craniosynostosis, hydrocephalus can individual independence and caregiver burden in ΙNPH patients. be caused by venous outflow obstruction. Venous outflow obstruction in adult is sometimes MATERIAL - METHOD: Thirty-seven patients with ΙNPH were evaluated before and six months induced by dural arteriovenous fistulas (AVF). Shunt flow and venous outflow obstruction in after surgery. Symptoms and signs were assessed by the ΙNPH-scale, HRQoL by EuroQoL 5 dural AVF cause venous hypertension. Conventionally, cerebrospinal fluid (CSF) is absorbed Dimensions (EQ-5D) and independence was evaluated with the Functional Independence through the arachnoid villi or granulation into the venous sinuses. Increased sinus, especially Measure (FIM™). Caregiver burden was evaluated with Caregiver Burden Scale. superior sagittal sinus (SSS), pressure, can impair CSF absorption. Here, we present 3 cases (51y/o RESULTS: Twenty-four (64.9%) of the patients improved clinically and 25(67%) improved their M, 62y/o M, 63y/o M) presenting intracranial hypertension caused by dural AVF. Both intrasinus HRQoL after surgery. The patients rated their HRQoL almost at the same level as found in the and lumbar CSF pressure were estimated in all 3 cases and elevated pressure was confirmed normal population. The change in gait symptoms correlated to change in HRQoL. The patients (CSF pressure: 38, 26, 32 mmHg). However, all 3 cases did not show venticuluomegaly, then, we were less dependent both in physical and cognitive tasks. Improvement of symptoms correlated managed intracranial hypertension by LP shunt. From these findings we conclude that increased to decreased dependency. Caregiver burden was unchanged on group level but decreased sinus pressure actually causes intracranial hypertension but disturbance of CSF absorption due among caregivers to male patients. Impairments in cognition on the ΙNPH-scale correlated with to venous hypertension dose not always cause venticuluomegaly. It may means that CSF can higher caregiver burden. be absorbed by another pathway. CONCLUSIONS: Shunt surgery on ΙNPH patients improves not only symptoms and signs but also HRQoL and the level of independence. O31. ETV VERSUS VENTRICULAR TAP TEST B.D. Elder, C.R. Goodwin, T.A. Kosztowski, J. Pindrik, D. Moran, I. Jusue-Torres, J. Hoffberger, O29. Cognitive and functional improvement after shunt placement. D. Rigamonti Five year outcome analysis in 49 patients suffered idiopathic normal Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, USA pressure hydrocephalus S. Sfikas, K. Kasapas, D. Katsianis, V. Valadakis, G. Orfanides SUMMARY It is not determined if any treatment at all should be offered to patients with Department of Neurosurgery, “G. Gennimatas” General Hospital of Athens, Greece obstructive ventriculomegaly without any overt clinical symptoms. Furthermore, trial CSF drainage to assess for clinical improvement should be performed in this patient population due OBJECTIVE: To elucidate the long-term cognitive condition and functional disability of shunt- to the obstruction. An executive engineer and former astronaut was incidentally found to have responsive ΙNPH patients. hydrocephalus due to aqueductal pathology. The patient had no symptoms in terms of gait, MATERIAL - METHOD: Five year follow-up data of 49 patients diagnosed with ΙNPH by clinical, memory or cognition, but did have some increased urinary urgency over the past 6 months. radiological examination, cerebrospinal fluid pressure and response to the ventriculoperitoneal He underwent neurocognitive testing, with scores well above normal limits. At the time we shunt, were analyzed for signs of dementia and gait impairment. recommended a close follow-up. When he returns, however, we could propose proceed in three 30 patients initially presented a full triad of symptoms, with gait disturbance being the ways. We could continue monitoring. We could place a ventriculostomy catheter for a drainage most frequent followed by deterioration in cognition. 12 had gait and memory problems at trial to assess for any improvement. This could be carried out in two ways: 1) placement of the presentation and 7 had disturbed gait with urinary incontinence. catheter with continuous drainage and monitoring similar to current lumbar drainage trials RESULTS: Mean age at surgery was 71 years for men and 69 years for women. 26 were males and 2) high volume drainage of CSF in the operating room through a ventricular puncture with and 23 females. Three and six month follow-up was available for the majority of the patients and subsequent catheter removal prior to wound closure, with assessment of gait and cognition a year follow-up in half of the patients. 3 patients developed subdural hematomas or hygromas following this ventricular tap test. Alternatively we could proceed directly to an ETV. We are and two shunt obstruction. None of the patients had shunt infection. At the end of follow-up, eager to hear his point of view.

50 51 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

O32. VENTRICULAR AND CORTICAL SUBARACHNOID SPACE DIMENSIONS IN ADULT least one domain prior to surgery. 11/14 patients showed reliable improvement on at least one HYDROCEPHALUS BEFORE AND AFTER ENDOSCOPIC THIRD VENTRICULOSTOMY IN cognitive domain on postoperative testing. The greatest improvement in cognitive function CORRELATION TO THE CLINICAL OUTCOME was seen in verbal and visual memory (58% and 60%). Overall, one quarter to one third of N. Paidakakos1, M. Sklavounou1, M. Krommida2, N. Gkekas1, P.E. Valkimadi2, K. Kouzounias1, patients demonstrated reliable improvement on tests of IQ, attention and concentration, and D.D. Mitsikostas2, D. Bouramas1 executive function. Two patients showed a reliable worsening of executive functioning, both (1) Department of Neurosurgery, Athens Naval Hospital, Greece after uncomplicated ETVs. (2) Department of Neurology, Athens Naval Hospital, Greece CONCLUSIONS: ETV is a safe effective procedure capable of producing reliable objective improvements in cognitive dysfunction related to obstructive hydrocephalus. Patients with OBJECTIVE: This study was designed in an effort to improve the understanding of the alteration cognitive dysfunction alone may benefit from ETV. of cerebrospinal fluid (CSF) hydrodynamics after endoscopic third ventriculostomy (ETV), with a focus on the relative importance of the cortical subarachnoid spaces (CSAS). MATERIAL - METHOD: Twenty five adult patients with hydrocephalus of various etiologies O34. ENDOSCOPIC APPEARANCES OF RARE CAUSES OF OBSTRUCTIVE HYDROCEPHALUS (tumor, aqueductal stenosis, long-standing overt ventriculomegaly, Chiari malformations, K. Barkas, A. Bartoli, G. Samandouras previous intraventricular hemorrhage, and shunt malfunction) who underwent ETV were Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, studied. We investigated the relative distribution of CSF between ventricles and CSAS, before Queen Square, London, UK and after ETV, by magnetic resonance measurements. The correlation to the clinical outcome was also assessed. Successful ETV was defined as improvement/resolution of symptoms with SUMMARY: We report three cases of obstructive hydrocephalus that were caused from rare shunt independence. entities and the diagnosis was made through endoscopic biopsy. The first case is a 52 year old RESULTS: ETV was successful in 16 patients in the first instance, and in another three after a male with metastatic melanoma at the posterior wall of the third ventricle. The second is a 39 second procedure (global success rate 76%). A significant progressive reduction of the ventricular year old female with tumefactive perivascular spaces of the thalamus and midbrain extending dimensions, with concomitant enlargement of the CSAS was found after successful ETV in 84.2% in the third ventricle. Finally the third case is a 36 year old female with known sarcoidosis in (16/19 patients). In two cases of secondary closure of the stoma, brain/CSF morphology tended whom endoscopic biopsy revealed granulomatous tissue in the floor of the fourth ventricle. to shift back to the preoperative status between primary and secondary ETV. To our knowledge this is the first case reported in the literature with endoscopic images of CONCLUSIONS: Commonly, the ratio between ventricular and CSAS dimensions changes after sarcoid in this region. The patients apart from biopsy underwent third ventriculostomy and/or ETV in favor of the latter. Such volume redistributions correlate well with clinical outcome, and CSF diversion. Endoscopy has broadened our horizons in intraoperative anatomical imaging may be used to assess ETV efficacy. CSF volumetry may be useful for diagnosing, prognosticating, and has made biopsy of ventricular lesions easier and safer. The cases we report have extremely and following hydrocephalus, and further research should address this issue. interesting endoscopical images and videos from these rare pathologies.

O33. NEUROPSYCHOLOGICAL OUTCOME AFTER ENDOSCOPIC THIRD VENTRICULOSTOMY O35. PROGNOSTIC VALUE OF BODY MASS INDEX IN GENDER IN THE PREDICTION FOR OBSTRUCTIVE HYDROCEPHALUS OF HYDROCEPHALUS AFTER SURGERY IN CHIARI I MALFORMATION M. Hamilton, B. Brooks, L. Partlo, W. Hader F.S. Almotairi, M. Tisell Department of Clinical Neurosciences, University of Calgary, Canada Department of Neurosurgery, Sahlgrenska IC, University of Gothenburg, Sweden

OBJECTIVE: Cognitive dysfunction is a common complaint at the time of clinical presentation OBJECTIVE: Our aim of this study is to develop a prognostic value of body mass index and of hydrocephalus. Few studies have objectively assessed the response of cognitive dysfunction gender in the prediction of hydrocephalus after craniocervical decompression in chiari I to treatment. The purpose of this study is to determine the effect of endoscopic third malformation. Pre-operative patient factors were not addressed in the literature before. ventriculostomy (ETV) on the neuropsychological outcome in patients presenting with cognitive MATERIAL - METHOD: We undertook a 10-year (2003-2013) retrospective study of all decline secondary to obstructive hydrocephalus. craniocervical decompressions to treat chiari malformation performed at Sahlgrenska IC MATERIAL - METHOD: A retrospective review of patients who underwent ETV and had both University Hospital – Sweden. A total of 53 patients were obtained from the operation database, pre and postoperative neuropsychological testing. Patient demographics and outcome of the and data regarding body mass index, gender and operation dates were registered. Development ETV including complications of the procedure were recorded. Detailed neuropsychological of hydrocephalus and other complications were noted. tests including measures of intelligence, attention and concentration, executive function, visual RESULTS: Of the 53 patients reviewed, 6 patients had hydrocephalus after craniocervical and verbal memory, language functions and fine motor skills was completed. Measures of post decompression, 4 of them received VP shunt and the other 2 were treated conservatively. treatment change were determined utilizing Reliable Change Index (RCI). All the patients who developed hydrocephalus had BMI between 27 and 48, and they were all RESULTS: A total of 13 patients were identified. Etiology of the hydrocephalus was aqueductal females. Hydrocephalus has manifested in a form of headache and CSF leakage in most of the stenosis in 10, tectal glioma in 3 and a posterior fossa cyst in one. The majority of patients patients. (11/13, 85%) demonstrated cognitive dysfunction at the borderline or impairment level in at

52 53 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

CONCLUSIONS: The authors’ data confirm the prognostic value of body mass index and surgery as shunt ligation (n=10), aqueductoplasty and stenting of the aqueduct of the brain gender to detect those patients who are risky to develop postoperative hydrocephalus after (n=9), biopsy and removal of intraventricular tumors (n=5), biopsy hemispheric cysts (n=1), craniocervical decompression. in 10 cases it was necessary to re-ETV. ETV has been clinically and radiographically successful in 64 cases (71.1%) with an average follow-up 51,7±6,2 months (1-150 months). Clinical and radiological inefficient operation revealed an average of 4 months (1-23 months). O36. ENDOSCOPIC THIRD VENTRICULOSTOMY IN CHILDREN: CONCLUSIONS: The use of endoscopic third ventriculostomy in children younger than 2 ANALYSIS OF PROGNOSTIC FACTORS years can achieve a successful outcome in 71.1%. According to the results of our study, the R.S. de Oliveira, L.L. Furlanetti, M. Volpon, H.R. Machado success of endoscopic sinus surgery is no longer dependent on the patient’s age and cause of Division of Pediatric Neurosurgery, Department of Surgery and Anatomy, hydrocephalus. University Hospital of Ribeirão Preto Medical School, University of São Paulo, Brazil

OBJECTIVE: Endoscopic third ventriculostomy (ETV) has particular features and is associated O38. NEUROENDOSCOPIC TREATMENT OF HYDROCEPHALUS IN THE FIRST YEAR OF LIFE with different success rates (SR). The aim was to identify putative factors that could influence A.H.G.B. Da Cunha the outcome of ETV in children. Hospital da Restauracao, Recife, Brazil MATERIAL - METHOD: Clinical data of 114 consecutive patients that underwent ETVs from 2000 to 2010 were reviewed. Data were analyzed with regards to clinical and radiological SR. OBJECTIVE: The management of hydrocephalus in the first year of life is still a challenge for the The actual long-term SR was compared to that predicted by the ETV Success Score (ETVSS) pediatric neurosurgeon. The great vulnerability of newborn compromise the results, regardless model. of the approach of choice. The shunt-implantion is the most common treatment, despite the RESULTS: The study group included 49 males and 65 females with a mean age of 6.17±1.02 complications with serious consequences for the developing nervous system. The endoscopy years (ranging from 11 days to 18 years) at surgery. Tumors and aqueductal stenosis (AS) were has been presented as an alternative to shunts. However, the results in patients under two the most frequent ones observed, each occurring in 33 (29%), followed by malformations in years of age have generated many controversies. The international literature has shown good 24 (21%), cystic lesions in 6 (5%), and other etiologies in 18 (16%). The overall SR at the first results in only 40%, with the best success in aqueduct stenosis cases (70%). The goal of this ETV attempt was 80%, comparable to 74.8% (variance 14.35, 95% CI 69.37-78.22) predicted by presentation is to show the experience of 18 cases endoscopic operated hydrocephalus cases, the ETVSS. SR in patients under 6 months old was 58%, as well as 65% in children between 6 in the first year of life, results and complications. months-one year old, and 86% in children older than one year. AS and hydrocephalus associated MATERIAL - METHOD: We reviewed the literature about neuroendoscopic management to posterior fossa tumors showed 88% and 90% of SR, respectively. Unsatisfactory results were of hydrocephalus in the first year of life and presented our experience of 18 cases operated related to previous intraventricular hemorrhage and infection. The overall complication rate in on between the ages of 32 days and nine months. Six patients were premature infants who this series was 13%. developed hydrocephalus associated with intraventricular hemorrhage (HIV) (Grade III/IV). CONCLUSIONS: Patient’s age and etiology of hydrocephalus were related to SR. Also, the ETVSS Eleven patients presented stenosis of aqueduct (AE) and one more case developed a unilateral was accurate to predict outcome. In long-term follow-up, surgical experience was statistically ventricular hydrocephalus associated with obstruction of the foramen of Monro (OFM). In the pos significant to reduce complications. HIV patients were held brainwashing, coagulation of the choroid plexus and the third ventricle cisternostomy (ETV). Only ETV were used in the aqueductal stenosis and foraminoplasty in the obstruction of foramen of Monro. O37. RESULTS OF ENDOSCOPIC TREATMENT IN CHILDREN RESULTS: The successfully results without any further surgery were 2/5 (40%) in the pos HIV UNDER 2 YEARS WITH HYDROCEPHALUS patients, in 4/11 (40%) in the AE cases and in the endoscopic opening of the foramen of Monro A. Sufianov, G. Sufianova, Y. Yakimov, R. Sufianov as well. The CSF-leakage and infection were the complication in four cases. Federal State Budget Institution “Federal Centre of Neurosurgery”, CONCLUSIONS: Excluding patients with CSF-leakage and infection in the early postoperative Department of Health of Russia, Tyumen, Russia period, the neuroendoscopy was successful in 50% of cases. Because of the high-risk of malfunction and infectious complication related to shunt, primary neuroendoscopic management may be OBJECTIVE: Improved results of surgical treatment of hydrocephalus in children under 2 years considered a treatment of choice to avoid or delay the shunt-implantation. old through the use of endoscopic third ventriculostomy. MATERIAL - METHOD: 90 operations were performed in 85 patients aged 2 years old. The average patient age at the time of surgery was 0,90±0,07 years (3 day-2,00 years). 20,0% of patients on admission had been shunt dysfunction. RESULTS: All patients underwent surgical treatment is easy, with no intraoperative complications, no postoperative mortality. We had a primary ETV in 72 cases and secondary ETV (previously the operated hydrocephalus) in 18 cases. Success in primary and secondary ETV were 61,3% and 65,9%, respectively, without significant differences in the groups. Additionally we performed

54 55 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O)

O39. Blood and CSF flows in pediatric hydrocephalus O41. ABERRANT ACTIVATION OF WNT/Β-CATENIN SIGNAL IN RATS as precocious shunt placement decision tool WITH COMMUNICATING HYDROCEPHALUS C. Capel1,2, C. Gondry-Jouet1,3, A. Fichten1,2, J. Peltier1,2, O. Balédent1 H. Xu, Z.X. Wang, S.L. Zhang, G.W. Tan, H.W. Zhu, F. Liu (1) BioFlow Image, Hospital University Center Nord, Amiens, France Department of Neurosurgery, First Affiliate Hospital of Xiamen University, China (2) Department of Neurosurgery, Hospital University Center Nord, Amiens, France (3) Department of Radiology, Hospital University Center Nord, Amiens, France SUMMARY: Cerebrospinal fluid circulation pathway fibrosis has been implicated in the pathogenesis of communicating hydrocephalus. As aberrant reactivation of Wnt/β-catenin OBJECTIVE: Adults’ hydrocephalus is related to CSF flows disorders. Phase contrast MRI (PC-MRI) signaling pathway is considered as a significant factor to contribute to various chronic fibrosis is the unique tool to measure CSF oscillations in vivo during the cardiac cycle. Nothing is known diseases, we hypothesized that Wnt/β-catenin signaling is activated in hydrocephalus. In this about pediatric CSF flows evolution. The objective of this work was to apply our knowledge paper, we investigated the Wnt/β-catenin pathway in the brain of experimental hydrocephalic of adults’ CSF PCMRI measurements in pediatric hydrocephalus population to point potential rats in terms of protein and gene expression. Therefore twenty five adult SD rats were randomly precocious CSF shunt placement decision. divided into the normal group (n=5), the sham operation group (n=10) and the hydrocephalic MATERIAL - METHOD: 23 children (23,87±21,62 months; [1 – 68]) with normal clinical group (n=10). Hydrocephalic rat models were induced by intraventricular injections of 3% development and no evidence of cerebral dysfunction on MRI were considered as control kaolin, and the ventricular dilatation were examinated by MRI at 2-week postoperation. After population. This control population underwent PC-MRI sequences (ethical agreement) to that, Wnt-1, β-catenin, GSK-3β and Cyclin D-1 were qualified by RT-PCR and Western Blot, while establish reference values of CSF oscillations into the aqueduct and cervical subarachnoid the expression of β-catenin and GSK-3β were localized by Immunohistochemistry. According to spaces and cerebrovascular oscillation. 16 hydrocephalus patients (24,81±25,50 months; [2– the result comparison between the normal group and the sham operation group, the ventricle 90]) with ventricular dilation were also investigated and compared to the control population of hydrocephalic group were obviously enlarged (P<0. 01). The expression of Wnt-1, β-catenin with the same PCMRI protocol. and Cyclin D-1 were increased (P<0. 05) in brain tissue of model group. In contrast, the GSK-3β RESULTS: CSF and vascular flows changed with age function of fontanels closure. Nevertheless expression is decreased (P<0. 05). We demonstrated that the Wnt/β-catenin pathway is activated in front of our preliminary results, hydrocephalus patients’ aqueductal CSF oscillations were in the experimental hydrocephalic rats brain. These results further our understanding of the different between these two groups (23,54±14,07μl in control group; 51,41±49,78μl in patients pathogenesis of hydrocephalus and suggest that regulating Wnt/β-catenin signaling pathway group). In hydrocephalus group, 4 patients presented significant CSF hyperdynamism and three may provide new therapeutic methods for hydrocephalic patients. of these patients had persistent delay of development. We didn’t observe any difference in cervical subarachnoid CSF oscillations and vascular flow. None of them had shunt placement. CONCLUSIONS: Pediatrics hydrocephalus group showed heterogeneous aqueductal CSF O42. LEUCINE-RICH Α2-GLYCOPROTEIN (LRG) IS A NOVEL BIOMARKER oscillations. It reflected existence of multiple kind of hydrocephalus. Do we have to take in OF NEURODEGENERATIVE DISEASE IN HUMAN CEREBROSPINAL FLUID account CSF aqueductal flow alteration as precocious decision of shunt placement? AND CAUSES NEURODEGENERATION IN MOUSE CEREBRAL CORTEX M. Miyajima1, M. Nakajima1, I. Ogino1, H. Arai1, Y. Motoi2, N. Tada3 (1) Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo, O40. CEREBROSPINAL FLUID HYDROTHORAX, AN UNUSUAL COMPLICATION Japan OF VENTRICULOPERITONEAL SHUNT (2) Department of Neurology, Juntendo University Graduate School of Medicine, Tokyo, Japan E.A. Elgamal1, F.S. Almotairi1, A.M. Abdullah2, M.A.M. Salih2 (3) Laboratory of Genome Research, Research Institute for Diseases of Old Age, Juntendo (1) Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia University Graduate School of Medicine, Tokyo, Japan (2) Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia OBJECTIVE: It is often difficult to clinically differentiate between ΙNPH and PSP, particularly SUMMARY: Cerebrospinal fluid (CSF) hydrothorax is a very rare complication following at the early disease stages, and there is no established laboratory test or biomarker that can ventriculoperitoneal (VP) shunt. We report a 14-month-old boy, who was diagnosed to have assist in differential diagnosis in a regular hospital setting. Leucine-rich α2-glycoprotein (LRG) open neural tube defect associated with ventriculomegaly. He underwent VP shunt at the age is a protein induced by inflammation. It contains a leucine-rich repeat (LRR) structure and of 1 mo. He presented with high-grade fever, shortness of breath, tachypnea, wheezy chest, easily binds with other molecules. However, the function of LRG in the brain during aging and and productive cough. Plain chest X-ray and computerized tomography revealed pleural neurodegenerative diseases has not been investigated. effusion with distal catheter of the shunt located in the right pleural cavity. He underwent MATERIAL - METHOD: Here, we measured human LRG (hLRG) concentration in the cerebrospinal externalization of the distal catheter followed by VP shunt revision. In the present case, CSF fluid (CSF) and observed hLRG expression in post-mortem human cerebral cortex. We then hydrothorax resulted from migration of the distal catheter into the pleural cavity. We reviewed generated transgenic (Tg) mice that over-expressed mouse LRG (mLRG) in the brain to examine 17 hitherto reported cases in the literature and the causes that lead to CSF hydrothorax are the effects of mLRG accumulation. discussed. We emphasize the importance of careful and proper placement of the distal catheter RESULTS: The CSF concentration of hLRG increases with age and is significantly higher in during the tunneling procedure to prevent life-threatening complications. patients with Parkinson’s disease with dementia (PDD) and progressive supranuclear palsy (PSP) as compared to that in healthy elderly people, idiopathic normal pressure hydrocephalus (ΙNPH) patients, and individuals with Alzheimer’s disease (AD). With CSF hLRG, ΙNPH patients

56 57 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O) were differentiated with a sensitivity of 68.4%, and specificity of 79.8%. Tg mice exhibited also a brain disorder and that surgery does not resolve most aspects of the disease. Based on the neuronal degeneration and neuronal decline. evidence that the common history of foetal-onset hydrocephalus and abnormal neurogenesis CONCLUSIONS: Accumulation of LRG in the brains of PSP patients is not a primary etiological starts with the disruption of the neural stem (NSCs) and neural precursor (NPCs) cells forming factor, but it is thought to be one of the causes of neurodegeneration. It is anticipated that hLRG the ventricular and the subventricular zones, we sought to explore strategies that might help CSF levels will be a useful biomarker for the differential diagnosis of ΙNPH and PSP. repair such a loss, including intraventricular neural stem cell grafting. MATERIAL - METHOD: NCSs and NPCs from the telencephalon of postnatal day 1 (PN1) and PN7 non-hydrocephalic HTx rats were cultured to obtain neurospheres. After 7 days in vitro O43. MONOAMINE NEUROTRANSMITTER METABOLITES CONCENTRATION (7DIV) they were grown for 2 weeks in a culture medium free of growth factors and containing AS A MARKER OF CEREBROSPINAL FLUID (CSF) VOLUME CHANGES normal (nCSF) or hydrocephalic (hyCSF) CSF. Neurospheres from non-hydrocephalic rats were J. Marakovic1, D. Chudy1, M. Klarica2, D. Oreskovic3 grafted into the lateral ventricle of PN7 hydrocephalic rats. (1) Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia RESULTS: Neurospheres cultured in nCSF and hyCSF disaggregated and differentiated into (2) Department of Pharmacology and Croatian Institute for Brain Research, School of Medicine, neurons and glia; the length of neurites was similar under both conditions. hyCSF+culture University of Zagreb, Croatia medium maintained for 1DIV resulted in small neurospheres. At 2DIV neurospheres differentiated (3) Department of Molecular Biology, Ruder Boskovic Institute, Zagreb, Croatia into cells with long processes. Large neurospheres developed when incubated in pure hyCSF. The grafting of neurospheres into the CSF of hydrocephalic rats is in progress and early results OBJECTIVE: In our previous papers - Marakovic et al. (2010) and Oreskovic and Klarica (2010) are promising. - we demonstrated that changes of blood and CSF osmolarity have strong influence on CSF CONCLUSIONS: The CSF of normal and hydrocephalic animals promotes the differentiation pressure and volume what is in accordance to new proposed hypothesis of CSF physiology. of NSCs/NPCs in neurospheres into neurons and astrocytes, and hyCSF appears as a friendly Thus, acute changes in CSF volume should be reflected on CSF concentration of different CNS medium to host grafted neurospheres. metabolites. METHOD: On anesthetized cats (n=4) we measured the outflow volume of CSF by cisternal free drainage at negative CSF pressure (-10 cm H2O) before and after the intraperitoneal (i.p.) O45. NEURAL STEM AND PROGENITOR CELLS COLLECTED FROM THE HYDROCEPHALIC application of hypo-osmolar substance (distilled water). In samples of CSF collected at different CSF FORM NEUROSPHERES THAT EXHIBIT THE SAME JUNCTION PATHOLOGY AS THE time intervals (30 min) we measured the concentration of 5-hydroxyindoleacetic acid (5-HIIA) DISRUPTED VENTRICULAR ZONE and homovanillic acid (HVA). M. Guerra1, N. Lichtin1, M.C. Jara1, R. González1, K. Vío1, C. González1, E. Ortega2, J. Jaque2, RESULTS: In spite of fact that constant CSF outflow volume is obtained after several minutes S. Rodríguez1, A. Ortloff3, P. Salazar1, C.E. Johanson5, E.M. Rodríguez1, J.P. McAllister4 in our model, the concentrations of 5-HIIA and HVA was gradually increased over time and (1) Instituto de Anatomía, Histología y Patología, Universidad Austral de Chile, Valdivia, Chile become stable after 90 min. After the i.p. application of distilled water the outflow CSF volume (2) Instituto de Neurociencias Clínicas, Facultad de Medicina, Universidad Austral de Chile, significantly increased while concentration of 5-HIIA and HVA significantly decreased during 30 Valdivia, Chile min. (3) Escuela de Medicina Veterinaria, Universidad Católica de Temuco, Chile CONCLUSIONS: Observed results suggest that changes in serum osmolarity change the CSF (4) Department of Neurosurgery, Alpert Medical School, Brown University, Providence, volume and concentrations of neurotransmitters metabolites because of the osmotic arrival of Rhode Island, USA water from CNS blood capillaries into all CSF compartments. (5) Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, USA

O44. HYDROCEPHALIC CEREBROSPINAL FLUID IS A FRIENDLY HOST FOR NEURAL STEM OBJECTIVE: The ventricular zone (VZ) lining the lateral ventricles contains neural stem cells CELL TRANSPLANTATION (NSCs) while the subventricular zone (SVZ) harbors neural precursor cells (NPCs). Evidence J.P. McAllister1, C. González2, M.C. Jara2, K. Vío2, R. González2, M. Guerra2, E. Ortega3, J. Jaque3, obtained from hydrocephalic human foetuses and mutant animals indicates that a cell junction S. Rodríguez2, P. Salazar2, C.E. Johanson4, E.M. Rodríguez2 pathology in NSCs and NPCs leads to disruption of the VZ and SVZ. To determine the fate of the (1) Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, disrupted cells, we analyzed the differentiation of NSCs and NPCs obtained from hydrocephalic Salt Lake City, USA cerebrospinal fluid (hyCSF). (2) Instituto de Anatomía, Histología y Patología, Universidad Austral de Chile, Valdivia, Chile MATERIAL - METHOD: At postnatal day 1 (PN1), cells obtained from the VZ/SVZ of non- (3) Instituto de Neurociencias Clínicas, Facultad de Medicina, Universidad Austral de Chile, hydrocephalic HTx rats or the CSF of hydrocephalic HTx rats at PN1 were cultured for six days Valdivia, Chile (6DIV) and exposed to BrdU on the last day. They were processed for immunofluorescence using (4) Department of Neurosurgery, Alpert Medical School, Brown University, Providence, antibodies for proliferation (BrdU), differentiation (nestin, beta-3-tubulin, GFAP), functional Rhode Island, USA plasma membrane proteins (AQP4, caveolin 1) and adherent junctions (N-cadherin). RESULTS: NSCs and NPCs in the hyCSF proliferated and formed small and large neurospheres OBJECTIVE: It is now understood that hydrocephalus is not only a disorder of CSF dynamics but with distinct immunocytochemical differences that progressively disassembled and formed new

58 59 Hydrocephalus2013 Athens ORAL PRESENTATIONS - ORAL (O) neurospheres. Neurosphere cells showed an abnormal expression of N-cadherin, i.e. junction proteins accumulated in the cytoplasm. In contrast, neurospheres from the non-hydrocephalic rats grew to form compact neurospheres that did not disassemble with N-cadherin located normally at the plasma membrane. CONCLUSIONS: These findings suggest that hyCSF contains NSCs and NPCs that form neurospheres with the same junctional pathology as the hydrocephalic VS/SVZ in vivo. Thus, neurospheres obtained from patients and animal models may be used to investigate the cellular and molecular alterations underlying congenital hydrocephalus.

Poster Presentations - Poster (P)

60 Hydrocephalus2013 Athens The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders Poster Presentations - Poster (P)

P01. TELEMETRIC MONITORING OF THE INTRACRANIAL PRESSURE – FIRST EXPERIENCE T. Radovnicky, P. Vachata, M. Sames Department of Neurosurgery, J.E. Purkyne University, Masaryk Hospital, Usti nad Labem, Czech Republic

SUMMARY: Monitoring of the intracranial pressure is one of the basic diagnostic tools in the neurological and neurosurgical practice. Especially in complex cases of hydrocephalus, monitoring of the intracranial pressure could be the key to the exact diagnosis and treatment. We present three patients in whom a new type of sensor for measuring the intracranial pressure with telemetric data transmission was implanted (endoscopic third ventriculostomy failure, shunt failure and suspected elevated intracranial pressure due to craniosynostosis). The main advantage of this type of sensor is the possibility of long-term monitoring and measurement at home during normal daily activities. According to the authors, this type of sensor has its irreplaceable role in the diagnostic algorithm of hydrocephalus in indicated cases.

P02. CURRENT TESTS FAIL TO IDENTIFY EARLY IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS I. Jusue-Torres, D. Moran, B.D. Elder, J. Pindrik, C.R. Goodwin, T.A. Kosztowski, J. Hoffberger, D. Rigamonti Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, USA

SUMMARY: The syndrome of ΙNPH includes ventriculomegaly with normal intracranial pressure, along with Hakim’s triad of cognitive deficits, gait abnormalities, and urinary incontinence. Gait is typically affected first and has been described as apraxic, magnetic, wide-based and shuffling. Due to increased awareness of ΙNPH and more accessible MRIs, we now see more patients who do not fit the classical description. Two patients, a farmer and a professor, were found to have ventriculomegaly. The farmer reported difficulties when walking, while the professor had more difficulty when running. The farmer underwent a Lumbar Drainage, and standard tests to assess gait and balance problems were completely normal. He went home and only a year later, when retested, demonstrated some imbalance and slowing of gait that improved after a repeated a Lumbar Drainage. The professor, in the absence of any abnormalities at baseline, chose to undergo a tap test followed by a subjective assessment of her running ability. Following the tap test, she was able to run for several days. Based on these results, both patients underwent shunt surgery, and two years postoperatively, the farmer was back to work and the professor was training for a marathon. It is widely accepted that Hakim’s triad is a late development in the progression of ΙNPH. A longer interval from symptom onset to diagnosis leads to a less satisfactory response to treatment. Both of the aforementioned cases support these statements and highlight a big problem: our present tests are inadequate in diagnosing ΙNPH early in its clinical course.

63 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P)

P03. POST LUMBAR PUNCTURE LOG FOR PATIENTS WITH ΙNPH P05. SYRINGOMYELIA AND QUADRIPARESIS J. Hoffberger, J. Wemmer, B.D. Elder, C.R. Goodwin, T.Α. Kosztowski, D. Rigamonti A. Karakouti, D. Koutendakis, D. Arvanitakis Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, USA Neurosurgery Clinic, “Venizeleio-Pananeio” General Hospital, Heraklion Crete, Greece

SUMMARY: We often encounter hydrocephalus patients with mostly subjective symptoms. INTRODUCTION: Syringomyelia with a prevalence estimated to be 8.4 cases per 100,000 Therefore, we must either wait for patients to become more symptomatic or more sensitive people, appears symptoms onset usually in the pediatric population. It constitutes a cavity or a tests need to be developed to enable us to diagnose the patients earlier. We believe it is our cyst within the spinal canal that extends longitudinally and over time destroys the spinal cord. responsibility to try hard to diagnose hydrocephalus at its earliest stage. A very strong positive OBJECTIVE: We are referring to a rare incident of a 15 year-old boy who developed predictor of response to shunting is the response to Lumbar Puncture (LP). We presently syringomyelia, the therapeutic method that was adopted and the patient’s outcome. assess gait and balance pre and post LP (TUG, Tinetti, 10 meters and 6’ walk) to determine if MATERIAL - METHOD: Male 15 years old, who had been surgered for congenital an improvement occurred. This practice, however, has major limitations such as the artificial hydrocephalus and meningomyelocele at 40 days age, attends to the neurosurgery setting of a clinic versus the home environment and the limited time of observation. To correct department with intense headache and refers gradually evolving movement disorder primarily this incongruity, we have created a simple ‘Post Lumbar Puncture Log’ to capture improvement of the lower extremities during the last 2 months and progressive spastic installation of at home. The patients record for 5 consecutive days how he/she scores in 9 different categories: tetraparesis (supported gait). MRI conducted revealed syringomyelia in levels C6 up to C7. balance, shuffling/swaying, standing from sitting, ease on stairs/hills, energy, executive function, Immediately a surgery underwent to drain the tunnel, so to restore the normal flow of alertness/clarity, short-term memory and urinary urgency on a scale of 0-4; (no improvement, cerebrospinal fluid. slight improvement, moderate improvement, significant improvement or not applicable). RESULTS: Ambulatory patient, the 5th postoperative day, without support or walking We believe that a simple tool such as this will help capture the improvement experienced by stick, has been discharged home improved, non-febrile with normal hematologic and a patient and provide a more quantitative measurement, especially if it is validated in large biochemical indicators. Physiotherapy followed the first few months postoperatively. Follow- groups of patients. We are currently working with a statistician to make our log relevant to a up (re) took the 1st and 3rd month postoperatively with radiological neuroimaging and large population and easily analyzed over time. neurological examination, where it was detected fully restored of standing position and gait. DISCUSSION: The relative syringomyelia form, associated with an abnormality of the brain called Arnold-Chiari malformation type II, is the most common cause of syringomyelia, P04. WHY ARE ONLY A FRACTION OF ΙNPH PATIENTS SHUNTED? wherein the anatomical abnormality causes the lower portion of the cerebellum, a projection D. Moran, I. Jusue-Torres, J. Pindrik, B.D. Elder, J. Hoffberger, D. Rigamonti of the normal position of the back head, in sub-occipital area. Some patients with this Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, USA form of the disorder have also hydrocephalus, wherein cerebrospinal fluid accumulates within the skull. A tunnel may then be developed, in the cervical region of the spinal cord. SUMMARY: Poor awareness of idiopathic NPH (ΙNPH) complicates its diagnosis. As such, Because of the relationship that is believed to exist between the brain and spinal cord in this diagnosis is often reached late in the disease course, after several years of symptomatology, kind of syringomyelia, sometimes we refer to it as a syringomyelia communication. since the full triad of gait abnormality, urinary incontinence, and cognitive dysfunction, CONCLUSIONS: Syringomyelia is not always symptomatic or requires in all cases surgery. The represents a late stage of the disease. Once diagnosed, it can reasonably be expected that all exact cause however, remains unknown. patients would receive surgical treatment. However, data from Sweden and Norway suggested that only a fraction of ΙNPH patients are treated surgically. A review of Medicare data confirmed that only 25% of the patients with ΙNPH diagnosis were shunted. Because shunting is an P06. THE CEREBRAL WHITE MATTER LESIONS ASSOCIATED WITH A DEFICIT IN RESPONSE effective method of treatment, it is important to understand the reason for this discrepancy. SUPPRESSION IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS Possible explanations include a patient’s unwillingness to undergo surgery at an advanced age S. Kanno1, M Saito2, T. Kashinoura2, E. Mori2 or a physician’s unwillingness to recommend surgery in the elderly, especially in the setting (1) Department of Neurology, Southmiyagi Medical Center, Shibata, Japan of advanced disease and significant co-morbidities. To improve this situation, we need to (2) Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University, increase awareness about this condition by modernizing nomenclature and diagnostic criteria. Sendai, Japan Furthermore, we need to develop earlier detection methods to identify patients before they present with the full triad, and hence increase the efficacy of surgical intervention. Finally, OBJECTIVE: A deficit of response suppression (the ability to inhibit an incorrect response when improved outcome data needs to be elucidated. also required withhold responses to specific stimuli) is a characteristic feature of cognitive impairment in idiopathic normal pressure hydrocephalus (ΙNPH). The aim of this study was to detect the cerebral white matter lesions associated with a deficit in response suppression in ΙNPH using voxel-based diffusion tensor imaging (DTI). MATERIAL - METHOD: Twenty consecutive ΙNPH patients whose symptoms improved after shunt placement were enrolled. The cerebral white matter integrity was detected by assessing fractional anisotropy (FA). The severity of deficits in response suppression was evaluated using

64 65 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P) the score of the counting-backward test (the first-error score). We investigated the relationship treated with corticosteroid and desmopressin. MRI obtained when he was seventeen years old between the deficits in response suppression and the cerebral white matter involvement using showed triventriculomegaly with AS, which had not been detected at least until he was six a voxel-based multiple regression analysis (preoperative data were used). years old. Endoscopic third ventriculostomy was successfully performed, which improved the RESULTS: The first error scores on the counting-backward test were significantly correlated with headache as well as the MID. The AS in this case was thought to be idiopathic and irrelevant the FA values in the subcortical white matter of the right dorsolateral and medial prefrontal to LINH because LINH is a self-limiting disease that doesn’t affect central nervous system. To cortex and of the right parietal lobe (near the rostral intraparietal sulcus). our best knowledge, this is the first case of developing LIAS in a young adult shown by MRI CONCLUSIONS: A deficit in response suppression in ΙNPH might be associated with the chronologically. dysfunction of the right prefrontal and the right parietal cortexes, which could be caused by the subcortical white matter involvement due to the dilatations of the ventricles and Sylvian fissures. P09. INTO THE VOID OF YOUNG ADULTHOOD – INVESTIGATING THE PATIENT’S PERSPECTIVE A. Brown P07. THICKENED MEMBRANOUS STRUCTURE IN THE PREPONTINE CISTERN Independent, Edinburgh, Scotland IS AN UNDERDIAGNOSED CAUSE OF NORMAL PRESSURE HYDROCEPHALUS T. Baba1, S. Kanno1, O. Iizuka1, M. Iwasaki2, E. Mori1 SUMMARY: The complications of cerebrospinal fluid (CSF) drainage procedures, such as (1) Department of Department of Behavioral Neurology & Cognitive Neuroscience, blockage, infection and over-drainage and the overt consequences of uncontrolled raised Tohoku University Graduate School of Medicine, Sendai, Japan intracranial pressure (on vision, motor function, cognition etc.) are well documented in medical (2) Department of Neurosurgery, Tohoku University Graduate School of Medicine, literature. However, the seemingly minor and more subtle long-term effects and difficulties Sendai, Japan that follow from childhood hydrocephalus often go unrecognized, yet they can present major functional problems for the young adult. The young adult is cut off from all access to treatment or SUMMARY: Normal pressure hydrocephalus (NPH) is considered to be a treatable cause of services in the familiar friendly environment of a children’s hospital, (or ward) with its specialized dementia in the elderly. The diagnosis of NPH is generally made based on the characteristic nurses, physiotherapists, dieticians and so on at the same time as coping with entering further clinical and radiographic findings. However, the pathophysiology of NPH still elusive and it education or employment. Experience has shown that educators and employers have little remains difficult to diagnose atypical cases of NPH. Recently, three-dimensional (3D) Fourier appreciation of such difficulties and moreover frequently confuse hydrocephalus with other transformation constructive interference in steady state (CISS) magnetic resonance imaging neurological conditions. There is a need to bring together the patients’ experiences with the technique has become increasingly used in MR cisternography, because 3D CISS sequence is research of clinicians and scientists in order to provide better information about a medical suited to delineate membranous structures surrounded by cerebrospinal fluid (CSF) with high condition that is very often misunderstood outside the patient’s family and by medical/surgical contrast and high spatial resolution. Using this technique, we found that a part of atypical NPH staff. The author suggests ways of investigating these subtle physical, psychological and patients exhibit thickened membranous structures in the prepontine cistern. In addition, these cognitive consequences of childhood hydrocephalus in the 16-25 year age range and proposes patients showed posterior fossa CSF collection, which mildly compress the inferior vermis. ways of sharing these patient-reported experiences amongst themselves, and with clinicians CSF shunt surgery ameliorated gait disturbance and cognitive impairment in these patients. and educators. Thickened membranous structures in prepontine cistern may be underdiagnosed cause of NPH, and 3D CISS MR imaging is useful to delineating these abnormalities. P10. IS INTERVENTION IN ASYMPTOMATIC HYDROCEPHALUS JUSTIFIABLE? B.D. Elder, C.R. Goodwin, T.A. Kosztowski, D. Moran, I. Jusue-Torres, J. Hoffberger, D. Rigamonti P08. DEVELOPMENT OF LATE-ONSET IDIOPATHIC AQUEDUCTAL Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, USA STENOSIS (LIAS) SHOWN BY MAGNETIC RESONANCE IMAGES – A CASE REPORT D. Kita1, Y. Hayashi1, T. Kitabayashi1, M. Kinoshita1, M. Okajima2, J.-I. Hamada1 SUMMARY: LF is a 26-year-old man with a history of neurogenic bladder and paraplegia (1) Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Japan in the setting of an ischemic myelopathy from spinal muscular atrophy and diabetes. An (2) Department of Pediatrics, Kanazawa University Hospital, Kanazawa, Japan MRI performed after an episode of confusion due to accidental anticholinergic overdose showed ventriculomegaly of the lateral and third ventricles due to aqueductal pathology. He SUMMARY: Adulthood hydrocephalus associated with aqueductal stenosis (AS) can occur is an insurance agent and denies having any problems with memory or multitasking, but is without any particular central nervous system disorders and become symptomatic in relatively wheelchair bound. On examination, his head circumference was 22 inches, cranial nerves were younger ages. Late-onset idiopathic aqueductal stenosis (LIAS) is one of the major terms grossly intact, strength was 0/5 in the lower extremities, and his MMSE was 30/30. Typically, referring such status. Here we report a seventeen-year-old boy case of LIAS and his previous our recommendation in this case would be to follow the patient regularly for progression of magnetic resonance images (MRIs). He became difficult to carry out ordinary high-school life symptoms. However, both the patient and his parents requested to go ahead with surgery because of chronic headache and mild intellectual disability (MID). He had a history of suspected (ETV) for several reasons. They assumed he would eventually need treatment, and presently lymphocytic infundibuloneurohypophysitis (LINH) when he was three years old, which was he was in his best physical shape. Given the difficulty in assessing if gait or continence would

66 67 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P) deteriorate, the only symptom left to monitor would be cognition. Loss of cognitive function MATERIAL - METHOD: Six ΙNPH patients (3 males and 3 females, mean age 73.2±8.6) were was not something the patient was willing to accept. Recommending surgery for a condition enrolled. ORX-A was quantified using a commercially available radioimmunoassay kit. that appears to be asymptomatic is controversial. In hydrocephalus, the lack of symptoms might Neurotransmitter metabolite levels were quantified by high performance liquid chromatography. be real or related to their insidious development rather than their absence. The surgeon facing The Wilcoxon matched pairs test was used for the evaluation of differences between ventricular such a dilemma might not be able to provide an objective recommendation. In such a case, the and lumbar analyte levels. patient’s own tolerance for disability should play a major role in reaching the decision. RESULTS: Ventricular HVA and 5-HIAA CSF levels were higher than lumbar levels [HVA Ventricular/Lumbar (V/L) ratio=2.8±0.91, p=0.002; 5-HIAA V/L=3.03±0.93, p=0.007)] while the opposite difference was found for total protein (V/L=0.50±0.20, p=0.004). No difference in P11. DYNAMIC CHANGE OF CSF FLOW AT LUMBOSACRAL LEVEL MHPG levels was shown (V/L=1.09±0.36, p=0.74). In contrast to HVA and 5-HIAA and similar to K. Kim1, K.D. Kim1, Y Cho1, G.M. Lee1, C. Sohn2 total protein, lumbar ORX-A levels were higher than ventricular levels (ORX-A V/L=0.75±0.17, (1) Department of Rehabilitation Medicine, Seoul National University Hospital, Korea p=0.026). (2) Department of Radiology, Seoul National University Hospital, Korea CONCLUSIONS: The present findings indicating higher lumbar compared to ventricular CSF ORX-A levels may reflect enhanced contributions from the spinal cord. Whether the present SUMMARY: The hydrodynamics of the cerebrospinal fluid (CSF) in the brain can be directly findings can be generalized to other patient groups and/or healthy subjects warrants further inferred from structural change of the ventricles, whereas that in the spinal canal cannot be. As investigation. such, CSF flow at the lumbosacral level has not been a subject of clinical interest and little has been revealed thus far. In this study, we investigated how the CSF flow changes according to the posture using phase contrast magnetic resonance image (3.0T Siemens, German). Velocity P13. POTENTIAL ROLE OF L-PGDS AS A SURROGATE MARKER encoding parameter was optimized after trials and periodicity of CSF flow was normalized per OF FRONTAL LOBE DYSFUNCTION IN NPH cardiac cycle. Phase contrast image in the axial plane was obtained at the L2 and S1 levels N. Nishida1,2, N. Nagata2, H. Toda1, M. Ishikawa3, Y. Urade2, K. Iwasaki1 and phase contrast image in the sagittal plane was also recorded. During the study, lumbar (1) Department of Neurosurgery, Tazuke Kofukai Foundation, Medical Research Institute, flexion was maintained with the hip flexed in supine position and was supported by cushions. Kitano Hospital, Osaka, Japan Ten subjects (25-77 years old, 5 male) participated in this study. In every case, the flow rate (2) Department of Molecular Behavioral Biology, Osaka Bioscience Institute Foundation, at the sacral level was significantly slower than at the lumbar level. During one cycle, steady Osaka, Japa cephalard flow was dominant in the early cycle and phasic caudal flow was dominant in the (3) Department of Neurosurgery and Normal Pressure Hydrocephalus Center, late cycle, either in neutral or in flexion posture. With lumbar flexion, the cephalard flow rate Rakuwakai Otowa Hospital, Kyoto, Japan of the CSF at the L2 level increased marginally compared to with neutral (0.53±0.41 m/s at neutral, 0.94±0.79 ms/s at flexion). The AP diameter of the spinal canal increased insignificantly OBJECTIVE: Normal pressure hydrocephalus (NPH) is a cause of treatable dementia, gait with lumbar flexion. In conclusion, the hydrodynamics of the CSF at lumbosacral level changed disturbance, and urinary incontinence in elderly, yet some part of its etiology is still unknown according to postures. (ie, idiopathic NPH). Lipocalin-type prostaglandin D synthase (L-PGDS) is a major cerebrospinal fluid (CSF) protein produced mainly by arachnoid cells. L-PGDS levels in CSF of NPH patients were reportedly decreased as a consequence of damaged arachnoid cells. L-PGDS is a bi-functional P12. A SIGNIFICANT DIFFERENCE between lumbar and ventricular protein, acting not only as a PGD2-producing enzyme but also as a lipophilic ligand carrier CSF Orexin A levels in IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS and a chaperone preventing amyloid β (Aβ) misfolding aggregation implicated in Alzheimer’s T. Kalamatianos1, K. Margetis1, F. Bourlogiannis2, M. Markianos3, G. Stranjalis1 disease. CSF Aβ decrease was already reported in idiopathic NPH. The aim of this study was to (1) Department of Neurosurgery, Athens University Medical School, Greece confirm the L-PGDS decrease in idiopathic NPH and to clarify its relationship with symptoms. (2) The Petros Kokkalis Center for Neurosurgery Research, Athens, Greece MATERIAL - METHOD: We evaluated 24 patients (Age 75.7±7.8, M 11/F 13) referred for the (3) Department of Neurology, Eginition Hospital, Athens University Medical School, Greece ventriculomegaly with no CSF pathway obstruction, and conducted CSF tap test to determine the shunt indication. NPH symptoms were evaluated before and after tap test, using idiopathic OBJECTIVE: The neuropeptide orexin A (ORX-A) is implicated in the regulation of various NPH grading scale, MMSE, FAB and up and go test. physiological processes, including sleep/wake cycles and reward/motivation. Τhe hypothalamic RESULTS: 12 of 24 patients were diagnosed to have idiopathic NPH, supported by shunt or ORX-A neurons project throughout the brain and spinal cord. In the present study we established tap test response and typical MRI feature (disproportionately enlarged subarachnoid-space and compared ORX-A levels in lumbar and ventricular cerebrospinal fluid (CSF) samples, drawn hydrocephalus; DESH). L-PGDS levels are significantly decreased in DESH patients compared from idiopathic normal pressure hydrocephalus (ΙNPH) patients, during respectively, lumbar to non-DESH patients (13.3±3.3 vs 20.8±6.8 microg/ml, p=0.009). Among clinical profiles, FAB puncture and shunt placement. Ventricular and lumbar CSF levels of total protein and of the significantly correlated with L-PGDS levels in whole patients (Spearman r=-0.59, p=0.005) dopamine, serotonin and norepinephrine metabolites HVA, 5-HIAA and MHPG, were also and DESH patients (Spearman r=-0.68、p=0.02). Moreover, L-PGDS levels showed positive established. correlation with FAB increase after treatment (Spearman r=0.62, p=0.04).

68 69 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P)

CONCLUSIONS: Our data not only support the diagnostic value of L-PGDS as a CSF biomarker, CONCLUSIONS: The authors’ data suggest that PVs have lower rates of revision, infection but also propose the potential role of this protein as a surrogate marker of frontal lobe and subdural hematomas formation and thus, this type of valve is preferred for CSF diversion. dysfunction of NPH. However, there is a need for prospective, case-control studies to confirm these data.

P14. RATIONAL FOR THE GRAVITATION DRIVEN PROGRAMMABLE SHUNT ASSISTANT P16. MIGRATION OF A CYSTOATRIAL SHUNT FRAGMENT INTO THE PULMONARY ARTERY: (PROSA) A CASE REPORT U. Kehler S. Theodoropoulos, N. Paidakakos, E. Rokas, A. Rovlias, E. Konstantinidis Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany Department of Neurosurgery, General Hospital Asklepieio Voulas, Athens, Greece

OBJECTIVE: Since 2008 the gravitation driven programmable shunt assistant (proSA) is SUMMARY: Migration of the distal catheter of a ventriculoatrial (VA) shunt to the pulmonary available. Since then more and more experience is available, however, the rational for using this artery is a rarely encountered complication. We present the unique case of a pulmonary artery new device is necessary to understand and to find the right indications for its use. embolization due to migration of a cystoatrial shunt catheter. A 39-year old female patient MATERIAL - METHOD: Biophysical aspects as well as professional discussions with engineers with a history of middle cranial fossa arachnoid cyst treated elsewhere with a cysto-atrial shunt and neurosurgeons were collected and analyzed. presented with mild chest pain over the last 3 days. Physical and neurological examination, RESULTS: ICP in patients with a ventriculoperitoneal shunt (VP-shunt) depends on the ECG and laboratory tests were normal. Chest x-ray followed by chest CT revealed the catheter’s hydrostatic pressure difference (HPD) between the ventricles and the abdomen, the opening fragment within the left pulmonary artery and the skull x-ray showed the breakage of the distal pressure of the valve system and on the intra-abdominal pressure (IAP). The hydrostatic pressure catheter in the right occipital area. She made an uneventful recovery following removal of difference changes with growing in children, the changing HPD can be equalized by adjusting the catheter by means of percutaneous transfemoral catheterization. Due to the fact that the the proSA. IAP changes with body position, it is lower in females and IAP show a very large patient was neurologically intact and asymptomatic after the catheter’s removal, we assumed range between individuals. This increases the risk of selecting an unsuitable valve. This lack of that the patient was shunt-independent so we did not proceed to shunt revision and released knowledge could be overcome by a programmable device. However, adjusting a differential her with follow-up instructions. Despite of remarkable radiographic findings, our patient had pressure valve has an impact in up-right and horizontal position which is often not wanted. A only minor symptoms with a prominent lack of physical findings. In accordance with previous proSA works only in upright position due to its gravitation driven mechanism and therefore literature reports, this observation emphasizes on the fact that a distal catheter migration to allows the best approach to a physiological ICP in up-right and horizontal position. the pulmonary artery or even the heart may have a long, insidious course which may remain CONCLUSIONS: To deal with the unknown IAP and the changing parameters due to growing clinically unnoticed until severe complications develop. We feel that in this subset of patients a proSA seems to be the most physiological solution in a VP-shunt; however, this has to be a more strict follow-up strategy should be established so that complications such as catheter demonstrated in clinical trials. migration are early detected and treated.

P15. PROGRAMMABLE VERSUS NONPROGRAMMABLE CEREBROSPINAL FLUID SHUNT: P17. Experience of surgical treatment FOR intracranial A 5-YEAR RETROSPECTIVE STUDY OF OUR DEPARTMENT arachnoid cysts in children G. Hadjigeorgiou, A. Zisakis, C. Kelesis, S. Karakalos, V. Varsos G. Letyagin, S. Kim, V. Danilin, A. Sysoeva Department of Neurosurgery, Red Cross Hospital, Athens, Greece Department of Pediatric Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia

OBJECTIVE: Programmable valves (PVs) for shunting CSF have increasingly replaced OBJECTIVE: Intracranial arachnoid cysts remain one of the most important problems in nonprogrammable valves (NPVs) the last years. The aim of this study was to present our 5-year neurosurgery. In this study, the results of surgical treatment of children with arachnoid cysts experience with the use of the PVs versus NPVs in the treatment of hydrocephalus. are represented. The aim of the study is to determine the optimal operative intervention for MATERIAL - METHOD: We collected data for all patients suffering from hydrocephalus of intracranial arachnoid cysts. various causes who underwent CSF shunt implantation between January 1, 2008 and December MATERIAL - METHOD: The study included 8 children ranging in ages from 1 to 12 years 31, 2012. A total of 58 patients were retrieved from our records (30 female and 28 male), with a that underwent surgeries from December 2012 to March 2013. Localization of cysts: cisterna median age of 61.4 yo (range: 28-82 yo). 35 fixed-pressure and 23 programmable valves were ambient (2 cases), Sylvian region (2 cases), hemispheric (3 cases), suprasellar (1 case). Clinical initially implanted. manifestations were performed by increase in the size of the head, vomiting, seizures, cranial RESULTS: The revision rate in patients with fixed-pressure valves was 25,7% (9/35), whereas deformation, and developmental delay. The primary method of treatment in 4 patients (2 the revision rate in the programmable valve subgroup was 17,3% (4/23). The infection rate for hemispheric and 2 Sylvian fissure cysts) was microsurgical fenestration of the cyst wall. The the NPVs and PVs valve subgroups were 8,5% (3/35) and 4,3% (1/23), respectively. Furthermore, other 4 patients underwent endoscopic fenestration. There was no cystoperitoneal shunting subdural hematomas were noticed in 11,4% (4/35) and 8,6% (2/23) of patients with fixed- in the series. pressure valves and adjustable pressure valves, respectively.

70 71 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P)

RESULTS: Clinical and radiological improvement was reported in all cases. There was no MATERIAL - METHOD: From Feb 2007 to Aug 2009, there are 13 cases in aqueduct stenosis morbidity or mortality in the series. No patient needed additional surgery. treated by aqueductoplasty by endoscope with stent placement. Make the patient general CONCLUSIONS: The optimal method of treatment for lateral cysts is a microsurgical fenestration, anesthesia employ Rudolph-Fujinon 3.8mm electronic fiberoptic endoscope. Let lenses as manipulation facilities of endoscopic intervention are limited. In contrast, when midline into ventriculus laterali cerebri, try to expand opening of aqueduct through 2F Foley’s tube cysts accompanied by hydrocephalus, endoscopic cysto-ventriculo-cisternostomy allows to to 4~5mm. Machining the shunt valve into 1cm length of stent, then putting into cerebral minimally invasively and effectively recover CSF circulation. Although catamnesis in this group is aqueduct. less than 3 months, the immediate results suggest that adequately performed cyst fenestration RESULTS: Follow-up time of the 13 patients is 24-36 months, 29 months average. 11 patients eliminates need for cysto-peritoneal shunt implantation. We hope that the follow-up of this get a remission after operation. A 5-months male patient in post hemorrhagic hydrocephalus, group and new cases, will determine indications for the optimal treatment of arachnoid cysts. gets fontanelle tension increased again 2 months later the operation. Endoscope examination indicates that proximal stent membrane obstructed. The 13 patients don’t have any complications. P18. Possibilities of endoscopic 3rd-ventriculostomy CONCLUSIONS: Aqueductoplasty provides the opportunity that get rid of shunt tube depends in treating children hydrocephalus for the patients of obstructive hydrocephalus who can’t get the operation of the ETV, however, G. Letyagin, S. Kim, V. Danilin, A. Sysoeva the single aqueductoplasty may provide a very high rate of re-obstruction. Stent placement Department of Pediatric Neurosurgery, Federal Center of Neurosurgery, Novosibirsk, Russia after aqueduct angioplasty can increase the success rate of operation, but the risks of mid-brain. Employing fiberoptic endoscope to place the stent can decease the injury of complication. OBJECTIVE: Shunting is the most popular method of treating hydrocephalus. This particular method does have some significant disadvantages: complexity of shunt selection, shunt- dependency, shunt dysfunction, peritoneal pseudo-cysts, shunt infection. This could possibly P20. SYRINGOMYELIA WITH COMMUNICATING HYDROCEPHALUS SUCCESSFULLY lead to re-operation. The goal of this study is to observe effectiveness of endoscopic methods TREATED BY THIRD VENTRICULOSTOMY: A CLINICAL AND MRI CASE REPORT of treating hydrocephalus as a primary operation as well as previously shunted children. S. Goutagny1, M.C. Henry-Feugeas2 MATERIAL - METHOD: The observation includes 18 children from 5 months up to 11 years old, (1) Department of Neurosurgery, Hôpitaux Universitaires Paris Nord Val de Seine (Beaujon), which were treated in Federal Center of Neurosurgery from December 2012 till March 2013. 4 Assistance Publique Hôpitaux de Paris, Paris, France patients were previously shunted; 2 patients had hydrocephalus associated with Dandy-Walker (2) Department of Radiology, Hôpitaux Universitaires Paris Nord Val de Seine (Bichat-Claude malformation; 1 patient had occlusion conditioned by suprasellar arachnoid cyst; 1 patient Bernard), Assistance Publique Hôpitaux de Paris, Paris, France with pineal cyst; 1 patient with tumor of quadrigeminal plate. All patients were treated by 3rd- ventriculostomy (cyst-ventriculo-cisternostomy in case of suprasellar arachnoid cyst). Peritoneal OBJECTIVE: To illustrate the clinical, morphological and dynamic effectiveness of endoscopic catheter ligation was done in 2 cases with shunt dysfunction, and 2 cases of removing shunt. third ventriculostomy in a patient presenting a communicating hydrocephalus-associated RESULTS: In all cases clinical improvement was observed, proved by MRI data. In one case, syringomyelia 2 months later after the endoscopy, VP-shunt was placed because of CSF under absorption. MATERIAL - METHOD: A 30-year-old female developed headache associated with cervical pain, Complications and lethality have not been observed in this group. progressive anterograde memory loss and imbalance during the past 2 years. On admission, CONCLUSIONS: Thus 3rd-ventriculostomy is highly effective method of treating hydrocephalus, she presented with hypoesthesia and paresthesia of the left part of the body including the face, which allows lowering percentage of complications and re-operations. Later observation of this and a major gait ataxia. MR assessment used both high-resolution structural sequences and group, which would be replenishing by new data, will allow to estimate long-term effect of CSF and vascular flow sequences. It showed a communicating hydrocephalus with a marked operation and prognosis of further growth of children with hydrocephalus. enlargement of the whole ventricular system, widely opened 4th ventricle outlets and a huge cervical syringomyelia: the severely reduced MR index of cranio-spinal compliance appeared in line with the drastic compression of key subarachnoid spaces for the intracranial dynamics and P19. THE FIBEROPTIC ENDOSCOPE AQUEDUCTOPLASTY AND STENT PLACEMENT with the morphology of the third and fourth ventricles. Despite the communicating nature of FOR TREATMENT OF AQUEDUCT STENOSIS HYDROCEPHALUS the hydrocephalus and based on MRI data, we decided to first perform a third ventriculostomy. J. Zheng, G. Chen, Q. Xiao Thorough evaluation by structural and flow MRI was also performed post-operatively. Department of Neurosurgery, Yuquan Hospital, Tsinghua University, Beijing, China RESULTS: Headache progressively disappeared, ataxia completely resolved in a few days, and sensory disturbances only slightly diminished after 1 year. Follow-up MRI showed a dramatic OBJECTIVE: Endoscopic third ventriculostomy (ETV) has been widely used in treatment collapse of the cervical syrinx, clear improvement of hydrocephalus MR features, including of hydrocephalus caused by aqueduct stenosis. In addition, the fiberoptic endoscope reduced compression of key subarachnoid spaces and improved cranio-spinal communication aqueductoplasty can also be attempted for the patient with difficulty of ETV. We try to use and compliance. fiberoptic endoscope to do aqueductoplasty and stent placement to the patient with difficulty CONCLUSIONS: Third ventriculostomy can improve adult patients presenting syringomyelia of ETV. with communicating hydrocephalus.

72 73 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P)

P21. A NEED FOR ASSESSMENT OF BALANCE IN PATIENTS is related to derangement of CSF flow. To better understand hydrocephalus, we should take WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS in account Bernoulli’s principle and identify the location of E gradients within the brain and K. Kanno1, Y. Sekiguchi2, O. Iizuka1, T. Baba1, S. Kanno1, E. Mori1 the vascular system. Increase in E gradients, e.g. augmentation of pulse waves with pulsating (1) Department of Behavioral Neurology and Cognitive Neuroscience, ventricular balloon, produced experimental hydrocephalus without obstruction of flow. Tohoku University Graduate School of Medicine, Sendai, Japan (2) Department of Physical Medicine & Rehabilitation, Tohoku University Graduate School of Medicine, Sendai, Japan P23. HYDROCEPHALUS AND AUTONOMIC NERVOUS SYSTEM. A REVIEW E.A. Schmidt1, A. Pavy le Traon2, F. Despas3, A. Pathak3, J.M. Senard3 OBJECTIVE: The aim of this study was to elucidate the change of gait and balance disturbances (1) Department of Neurosurgery, Toulouse, France after shunt placement in idiopathic normal pressure hydrocephalus (ΙNPH). (2) Department of Neurology, Toulouse, France MATERIAL - METHOD: Nineteen patients with ΙNPH were enrolled. Gait time and cadence were (3) Department of Clinical Pharmacology, Toulouse, France assessed by the 10-meter walking test (10MW) and Timed up and Go test (TUG). Step height, stride length, and step width were examined by using a three-dimensional motion analyzer. The SUMMARY: The autonomic nervous system (ANS) acts as a control system that affects multiple Berg balance scale (BBS), one leg standing, tandem standing were used as measures for balance. functions in order to maintain systemic homeostasis. The ANS centers are located in the The measurements were repeated before and 2 weeks after shunt placement. We analyzed the lower brainstem that regulate respiration, cardiac function, vasomotor activity and certain associations between the postoperative changes of the gait and balance measurements by reflex actions. Impaired autonomic function is related to many cardiovascular risk factors principal component analysis and regression analysis. and associated with neurodegenerative diseases like Multiple System Atrophy, Lewy body RESULTS: The all parameters of gait and balance were significantly improved after shunt dementia, Parkinson’s and Alzheimer diseases. Cognitive decline, orthostatic hypotension placement. Two factors were obtained on principal component analysis. Factor 1 consisted of and urinary incontinence are in part related to autonomic dysfunction. The overlap between time of 10MW, clearance, stride length, step width, and cadence. Factor 2 was akin to balance normal pressure hydrocephalus (NPH) and other neurodegenerative diseases is well known including one leg and tandem standing. On regression analysis, the improvement of stride in both clinical and pathophysiological aspects. Microvascular alteration, which is common length and cadence explained 54% of improvement of time of 10MW, and the improvement of in NPH, is clearly associated ANS dysfunction. As well, in NPH, urinary incontinence is mainly time of 10MW and step width explained 50% of improvement of time of TUG. due to overactive bladder; a phenomenon mainly driven by or miss-driven by the ANS. Finally CONCLUSIONS: This study suggested that both gait and balance should be separately the demonstration of vasoconstrictory alpha-adrenergic and vasodilatory beta-adrenergic considered in understanding of the change of locomotion disturbance after shunt placement receptors at the level of the choroidal arteries confirms the role of ANS in regulation of cerebral in the ΙNPH patients. As neither 10MW nor TUG reflects balance, assessments of balance should blood volume and cerebrospinal fluid production at the level of the choroid plexus. Apart from be supplemented. acute hydrocephalus with major increase in intracranial pressure, very little is known with respect to the influence of ANS in the pathophysiology of NPH and NPH-related disorders. We performed a systematic literature review in order to identify subtle alteration in ANS regulatory P22. BERNOUILLI’S PRINCIPLE APPLIED TO HYDROCEPHALUS: mechanisms, in a perspective of chronic neurodegenerative disease. In particular we focused NEITHER PRESSURE NOR VELOCITY DRIVE CSF FLOW on the modern pathophysiological and pharmacological aspects of NHP in the light of current E.A. Schmidt1, S. Lorthois2, M. Ros1, P. Swider2 knowledge in ANS. (1) Department of Neurosurgery, Toulouse, France (2) Institute of Fluid Mechanics, Toulouse, France P24. THE INFLUENCE OF REFERENCE PRESSURE ON FLUCTUATIONS OF THE ICP OBJECTIVE: The first law of thermodynamics states that the internal energy (E) of an isolated K. Raman system is constant. Bernoulli’s principle states that total E in a fluid along a streamline is the Feinberg School of Medicine, Northwestern University, Evanston, USA same at all points (i.e. conservation of E). We simply applied Bernoulli’s principle to CSF in hydrocephalus. OBJECTIVE: The Marmarou model has fundamentally influenced the development of MATERIAL - METHOD: Bernoulli’s equation, valid at any point along a streamline, is kinetic E+ mathematical pressure-volume models of CSF dynamics. Though Marmarou assumed the gravitational E + pressure E=constant. If the change in gravitational E is negligible, the sum of reference pressure to be zero, other researchers have argued for non-zero values. Based on kinetic E + potential E remains constant. Thus an increase (rep. decrease) in fluid velocity (i.e. theoretical grounds as well as empirical analysis, there is support for both zero and non-zero kinetic E) occurs with a decrease (resp. increase) in pressure (i.e. potential E). values for the reference pressure in the Marmarou model. A stochastic version of the Marmarou RESULTS: Within a fluid flowing, the highest speed occurs where the pressure is the lowest and model was solved previously for the zero reference pressure case, and a mathematical algorithm vice versa. Hence a fluid can flow from low pressure region to higher pressure region. A fluid was subsequently developed to solve it under non-zero reference pressure. The differences doesn’t flow along a gradient of pressure or velocity, but along a gradient of E. between the predicted paths of the ICP in the two cases remain an unexplored issue. CONCLUSIONS: According to Bernoulli’s principle, CSF is following neither a gradient of pressure MATERIAL - METHOD: The stochastic Marmarou model relating the temporal evolution of ICP nor velocity, but along a gradient of E, from high E region to lower E region. Hydrocephalus in pressure-volume studies to infusions incorporates observed fluctuations in the ICP through a

74 75 Hydrocephalus2013 Athens POSTER PRESENTATIONS - POSTER (P) nonlinear stochastic differential equation (SDE) whose structure is based on physical analogies between CSF dynamics and an electrical circuit. Simulation methods are used to obtain insights into predicted paths of the ICP in the two cases. RESULTS: Under the assumption of zero reference pressure, the stochastic Marmarou model is homogenous; assuming non-zero reference pressure makes it inhomogeneous and mathematically more challenging to solve. Across a range of non-zero values for the reference pressure, solutions are compared to the solution (the ICP trajectory) for the zero reference pressure case. The simulations show that while the paths show structural similarities, the variability of the ICP trajectories is quite different in the two cases. CONCLUSIONS: The choice of reference pressure influences the variability of the predicted ICP path in the stochastic Marmarou pressure volume model. From a clinical perspective, the differences in variability have implications for risk management of the patient. Thus, additional research on resolving the reference pressure controversy is important to the management of hydrocephalus.

P25. LONG-DURATION EXPOSURE TO ZERO GRAVITY; DISC EDEMA, OPTIC NERVE SHEATH DISTENTION AND INCREASED INTRACRANIAL PRESSURE A. Pass1,7, H. Hansen2, H. Killer3, A. Nunez4, E. Bershad5, T. Mader6, R. Gibson7 (1) University Eye Institute, University of Houston, USA (2) Department of Neurology and Psychiatry, University Hospital Hamburg-Eppendorf, Germany (3) Department of Ophthalmology, Kantonsspital Aarau, Switzerland (4) Department of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, USA (5) Department of Neurology, Baylor College of Medicine, Houston, USA (6) Department of Ophthalmology, Alaska Native Medical Center, Anchorage, USA Index (7) Bioastronautics, Wyle, Houston, USA

SUMMARY: It has been described in the literature the observation and assessments of the effects of long-duration (typically 6 months) zero gravity on some International Space Station (ISS) crewmembers. Identified is the presence of optic nerve head edema (unilateral and bilateral), optic nerve sheath distention, globe flattening and mildly increased intracranial pressure (ICP). Also noted are retinal cotton-wool spots, horizontal posterior retinal pole choroidal folds and a hyperopic shift (+0.50D to +1.75D). This constellation of signs and symptoms occur in approximately 40% of the crewmembers with varying degrees of severity. The phenomenon itself is described as the Visual Impairment and Intracranial Pressure (VIIP) Syndrome. The causative factors have been segregated into three main areas; vascular, the brain and the eye. The question is: why is there optic nerve head edema? It has been shown that increasing the ICP results in the distention of the optic nerve sheath, which then creates a cascade of events that includes globe flattening, choroidal folds and a hyperopic shift. A recent publication also demonstrates with ultrasound (ISS inflight and postflight) and postflight magnetic resonance imaging (MRI) that this distention persists after returning to terrestrial gravity but can then re-distend further with another long-duration zero gravity exposure, even without increased ICP (measured postflight). There is currently no capability to measure ICP in-flight aboard the ISS. This poster will discuss the aspects of this paradox between optic nerve compartment syndrome, increased ICP communication with the optic nerve and CSF flow as it is applied to the VIIP syndrome.

76 Hydrocephalus2013 Athens The Fifth Meeting of the International Society for Hydrocephalus and CSF Disorders Index

A.M. Abdullah 29, 56 N. Aihara 27, 51 F.S. Almotairi 28, 29, 53, 56 R. Anderson 25, 41 A. Andreou 12 H. Arai 27, 30, 48, 57 D. Arvanitakis 65 G.A. Aygok 10, 12, 15, 18, 21, 25, 30, 45 T. Baba 66, 74 O. Balédent 16, 23, 25, 29, 42, 56 K. Barkas 28, 53 A. Bartoli 28, 53 G. Bateman 12 A. Behrens 23, 39 E. Bershad 76 K. Blennow 22, 37 A. Blitz 12, 17, 24, 25 I. Bogdan 25, 42 D. Bouramas 28, 52 F. Bourlogiannis 68 R. Bouzerar 25, 42 W.G. Bradley 12, 25, 41 T. Brinker 12, 16, 23 B. Brooks 28, 52 A. Brown 67 C. Buckley 26, 45 C. Capel 25, 29, 42, 56 B. Carlberg 22, 38 E. Caussé 23, 40 E. Chatzidakis 12 Y. Chehade 27, 47 G. Chen 72 Y Cho 68 D. Chudy 30, 58 Z. Czosnyka 12, 18, 22, 23, 29, 36, 41 M. Czosnyka 12, 16, 22, 23, 36, 41 A.H.G.B. Da Cunha 29, 55 V. Danilin 71, 72 N. Darras 22, 34 I. Date 27, 48 F. Despas 75 T. Duprez 25, 42 R.J. Edwards 22, 25, 36, 44 A. Eklund 12, 17, 22, 23, 24, 27, 38, 39, 47 B.D. Elder 28, 51, 63, 64, 67 E.A. Elgamal 29, 56

79 Hydrocephalus2013 Athens INDEX

O. Eskola 26, 45 S. Kanno 65, 66, 74 D. Farahmand 27, 47 K. Kanno 74 G. Farrar 26, 45 E. Kapsalaki 17, 24 A. Fichten 25, 29, 42, 56 S. Karakalos 70 N. Foroglou 12, 18, 29 A. Karakouti 65 K. Fountas 18, 28 H. Kasai 25, 44 L.L. Furlanetti 29, 54 K. Kasapas 27, 50 G. Gavrilov 27, 49 T. Kashinoura 65 R. Gibson 76 D. Katsianis 27, 50 S. Gkatzonis 22, 35 C. Kayis 12, 16, 24, 25, 45 N. Gkekas 28, 52 U. Kehler 12, 15, 16, 21, 24, 27, 47, 70 L. Gölz 27, 49 C. Kelesis 70 C. Gondry-Jouet 25, 29, 42, 56 A. Khan 23, 39 C. González 30, 58, 59 H. Killer 76 R. González 30, 58, 59 K. Kim 68 C.R. Goodwin 28, 51, 63, 64, 67 K.D. Kim 68 S. Goutagny 73 S. Kim 71, 72 I.D. Grachev 26, 45 M. Kinoshita 66 N. Graff-Radford 12, 15, 21 D. Kita 66 C. Grandin 25, 42 T. Kitabayashi 66 JSR Group 27, 48 N.D. Kitchen 23, 39 M. Guerra 30, 58, 59 M. Klarica 30, 58 W. Hader 28, 52 P. Klinge 12, 15, 16, 17, 21, 24 G. Hadjigeorgiou 70 A.M. Koivisto 26, 45 J.-I. Hamada 66 E. Konstantinidis 71 M. Hamilton 12, 17, 18, 24, 28, 52 T.A. Kosztowski 28, 51, 63, 64, 67 H. Hansen 76 D. Koutendakis 65 M. Hashimoto 18, 27, 29, 48 C. Koutsarnakis 22, 34 Y. Hayashi 66 K. Kouzelis 12, 18, 29 P. Hellström 26, 27, 46, 50 K. Kouzounias 28, 52 M.C. Henry-Feugeas 73 D. Kristiansen 26, 46 K. Heurling 26, 45 M. Krommida 28, 52 D. Hidlay 25, 45 K. Laurell 22, 38 J. Hoffberger 28, 51, 63, 64, 67 G.M. Lee 68 M. Hultenmo 26, 46 M. Legzdain 27, 49 J. Huttunen 26, 45 G. Leijon 22, 38 O. Iizuka 66, 74 V. Leinonen 17, 26, 45 M. Ishikawa 12, 15, 17, 21, 24, 25, 43, 69 J. Lemcke 27, 49 H. Israelsson 22, 38 G. Letyagin 71, 72 M. Iwasaki 66 F. Liakos 22, 23, 34, 35, 38 K. Iwasaki 69 N. Lichtin 30, 59 J.E. Jääskeläinen 26, 45 E. Liouta 22, 23, 34, 35, 38 M. Jakobsson 26, 46 F. Liu 30, 57 J. Jaque 30, 58, 59 S. Lorthois 74 M.C. Jara 30, 58, 59 M. Luciano 12 A. Jeppsson 22, 37 Å. Lundgren-Nilsson 27, 50 C.E. Johanson 30, 58, 59 H.R. Machado 29, 54 P.A. Jones 26, 45 T. Mader 76 H. Jones 12 G. Makrygiannakis 12 I. Jusue-Torres 28, 51, 63, 64, 67 J. Malm 12, 17, 22, 23, 24, 27, 38, 39, 47 B. Kahlon 22, 38 J. Marakovic 30, 58 M. Kailajärvi 26, 45 K. Margetis 68 T. Kalamatianos 68 M. Markianos 68 H. Kan 25, 44 M. Mase 17, 25, 27, 44, 51

80 81 Hydrocephalus2013 Athens INDEX

M. Matumae 27, 48 B. Romner 12 J.P. McAllister 12, 18, 29, 30, 58, 59 M. Ros 74 J.G. McComb 18, 25, 29, 41 A. Rovlias 71 R. McLain 26, 45 J. Rummukainen 26, 45 U. Meier 27, 49 M Saito 65 N. Michoux 25, 42 D. Sakas 17, 22, 23, 26, 34, 35, 38 I.K. Mikkelsen 26, 46 P. Salazar 30, 58, 59 D.D. Mitsikostas 28, 52 M.A.M. Salih 29, 56 M. Miyajima 27, 30, 48, 57 G. Samandouras 28, 53 T. Miyati 25, 44 M. Sames 63 M. Miyazaki 25, 41 S.E. Sankari 25, 42 D. Moran 28, 51, 63, 64, 67 E.A. Schmidt 23, 40, 74, 75 E. Mori 12, 16, 17, 22, 26, 65, 66, 74 M. Schuhmann 12 A. Mortimer 25, 44 Y. Sekiguchi 74 Y. Motoi 30, 57 P. Selviaridis 12 N. Nagata 69 J.M. Senard 75 M. Nakajima 30, 57 S. Sfikas 27, 50 O. Nerg 26, 45 S. Sgouros 18, 29 J. Ney 22, 33 J.D. Shand Smith 23, 39 L. Nicolae 22, 25, 36, 44 P. Sherwin 26, 45 N. Nishida 69 K. Shima 12 A. Nunez 76 W.G.B. Singleton 22, 25, 36, 44 I. Ogino 30, 57 R. Sivakumaran 22, 25, 36, 44 N. Ohno 25, 44 M. Sklavounou 28, 52 M. Okajima 66 A. Smith 26, 45 R.S.de Oliveira 29, 54 C. Sohn 68 D. Oreskovic 30, 58 G. Starck 26, 46 G. Orfanides 27, 50 P. Stathis 22, 34 H. Origasa 27, 48 G. Stranjalis 22, 23, 34, 35, 38, 68 E. Ortega 30, 58, 59 A. Sufianov 29, 54 A. Ortloff 30, 59 R. Sufianov 29, 54 C. Otto 16, 24 G. Sufianova 29, 54 C. Ouyang 25, 41 D. Svistov 27, 49 N. Paidakakos 28, 52, 71 P. Swider 74 L. Partlo 28, 52 A. Sysoeva 71, 72 A. Pass 76 N. Tada 30, 57 A. Pathak 75 G.W. Tan 30, 57 I. Patsalas 11, 12, 15, 18, 21, 29, 30 S. Theodoropoulos 71 A. Pavy le Traon 75 S. Thompson 23, 39 J. Peltier 29, 56 M. Tisell 27, 28, 47, 53 J. Petersen 27, 50 H. Toda 69 J.D. Pickard 16, 22, 23, 36, 41 A.K. Toma 23, 39 J. Pindrik 28, 51, 63, 64 M. Tullberg 26, 46 S. Qvarlander 23, 27, 39, 47 M. Tziomaki 22, 34 T. Radovnicky 63 Y. Urade 69 K. Raman 75 P. Vachata 63 H. Rekate 12, 15, 17, 21, 24, 26 A. Vakis 12 N. Relkin 12 V. Valadakis 27, 50 D. Rigamonti 12, 15, 16, 17, 21, 24, 26, 28, 51, 63, 64, 67 P.E. Valkimadi 28, 52 J.O. Rinne 26, 45 G.V. Varsos 22, 36 J. Rinne 26, 45 V. Varsos 70 S. Rodríguez 30, 58, 59 M. Vinchon 12 E.M. Rodríguez 30, 58, 59 K. Vío 30, 58, 59 E. Rokas 71 K.A. Virtanen 26, 45

82 83 Hydrocephalus2013 Athens INDEX

M. Volpon 29, 54 M. von und zu Fraunberg 26, 45 Z.X. Wang 30, 57 L.D. Watkins 16, 23, 39 J. Wemmer 64 C. Wikkelsö 12, 17, 22, 26, 27, 37, 38, 46, 47, 50 M.A. Williams 12, 15, 16, 18, 21, 22, 24, 30, 33 Q. Xiao 72 H. Xu 30, 57 Y. Yakimov 29, 54 S. Yamada 25, 41 K. Yamada 25, 27, 44, 51 H.F. Young 12 H. Zetterberg 22, 37 S.L. Zhang 30, 57 J. Zheng 72 H.W. Zhu 30, 57 D. Ziegelitz 26, 46 A. Zisakis 70

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