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Pressure and Middle Cerebral Artery Blood Flow Velocity in Patients with Suspected Symptomatic Normal Pressure Hydrocephalus

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Pressure and Middle Cerebral Artery Blood Flow Velocity in Patients with Suspected Symptomatic Normal Pressure Hydrocephalus Jrournal of Neurology, Neurosurgery, and Psychiatry 1993;56:75-79 75 Simultaneous recording of cerebrospinal fluid J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.1.75 on 1 January 1993. Downloaded from pressure and middle cerebral artery blood flow velocity in patients with suspected symptomatic normal pressure hydrocephalus D W Droste, J K Krauss Abstract longer, have a higher amplitude, and appear CSF pressure (intracranial pressure, in plateau-like (therefore also referred to as "pla- one patient lumbar pressure) was mon- teau waves"). Lundberg also described itored continuously for one night in 23 C-waves particularly on the plateaux of the patients with suspected symptomatic nor- A-waves.5 B-waves are found with impaired mal pressure hydrocephalus (NPH) to CSF absorption in NPH and also less fre- identify patients who might benefit from quently in healthy persons,6 whereas A-waves subsequent shunt surgery. In 20 patients may indicate severely impaired CSF absorp- middle cerebral artery (MCA) blood flow tion.'- The origin of these waves is not yet well velocity by means of transcranial Doppler understood. Auer and Sayama observed rhyth- sonography (TCD) and CSF pressure mic pial vessel diameter changes correlating were recorded simultaneously. In three with B-waves.'0 Some authors claim a brain patients transcranial Doppler signals were stem centre is responsible for these oscilla- insufficient. Spontaneous changes in CSF tions." 2 Others stress the coincidence with pressure always paralleled changes in the respiratory and cardiovascular changes. 11-14 TCD signal. Equivalents of B-waves as Transcranial Doppler sonography permits well as intermediate waves (in between B- noninvasive measurement of the blood flow and A-waves), and C-waves could be iden- velocity in the large basal cerebral arteries.'5 tified easily and always appeared in phase. The diameter of these large arteries is assumed The Doppler signal, however, could not be to remain more or less constant.'6 Changes in used to evaluate the absolute changes in cerebral blood flow are caused by constriction CSF pressure. Fast Fourier Transform of or dilatation of the smaller resistance vessels. the Doppler signal was a useful tool to Therefore, changes of cerebral blood flow indicate the relative frequency of B-wave velocity in the large basal arteries correlate equivalents. In five patients the injection with changes of cerebral blood flow. ' In 5 of 10ml saline into the ventricle raised patients Maumer-Huppert et al showed that intracranial pressure considerably, but middle cerebral artery (MCA) blood flow hardly affected the MCA blood flow veloc- velocity and ICP were in phase during ity. Continuous TCD monitoring might be B-waves.6 Goh et al described a decrease in useful as a noninvasive screening proce- ICP with an increase in MCA blood flow http://jnnp.bmj.com/ dure in patients with suspected sympto- velocity and vice versa during A- and B-waves matic NPH before continuous invasive in three hydrocephalic children. In four other CSF pressure measurements are per- children the ICP and TCD signals were in formed. phase.'8 After subarachnoid haemorrhage, the signals took opposite courses. ' After severe (J Neurol Neurosurg Psychiatry 1993;56:75-79) head injury, they were in phase.20 Whether changes in cerebral blood flow/ on October 1, 2021 by guest. Protected copyright. volume are the cause or a consequence of A frequent problem encountered in neurology changes in ICP, there should be a relationship and neurosurgery is determining which between spontaneous ICP oscillations and the patients with suspected normal pressure TCD signal. The following study was designed University of hydrocephalus (NPH) will improve clinically to assess MCA blood flow velocity and CSF Freiburg, Freiburg, after shunt surgery. Positive criteria for the pressure simultaneously in patients with sus- Germany diagnosis of NPH include gait disturbance, pected NPH with special emphasis on the Department of of TCD of Neurology dementia and urinary incontinence, periven- characterisation signal equivalents D W Droste tricular lucency and large ventricles demon- spontaneous CSF pressure oscillations. Department of strated on CT, and clinical improvement after Neurosurgery lumbar puncture. Overnight recording of J K Krauss intracranial pressure (ICP) has become an Correspondence to: established method for selecting patients who Materials and methods Dr Droste, Department of Neurology, Atkinson will respond to shunt surgery. In our institutions patients with suspected Morley's Hospital, Copse Clinical improvement has been correlated NPH who might benefit from shunt surgery Hill, Wimbledon, London SW20 ONE, UK positively with recordings of A-waves or with are routinely submitted to an overnight record- Received 2 December 1991 frequent high amplitude B-wave activity.` ing of ICP. We examined 23 patients (6 men, and in revised form B-waves are spontaneous ICP oscillations with 17 women) with clinical signs of NPH. All 21 April 1992. Accepted 27 May 1992 a wave length of 0O5-2 minutes. A-waves last patients had ventricular enlargement ofvarious 76 Droste, Krauss degrees on a cranial CT scan and all had at ICP was measured via an intraventricular least one of the following symptoms: gait catheter of 2 mm diameter inserted into the J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.1.75 on 1 January 1993. Downloaded from disturbance, dementia, or urinary inconti- frontal horn of the left lateral ventricle through nence. Fourteen patients showed the complete a 2-mm burr hole, 2 cm parasagittal and 2 cm triad of symptoms. In two patients NPH was precoronal, drilled under local anaesthesia. thought to be secondary to meniu ngitis and The intraventricular catheter was secured to subarachnoid haemorrhage, respect:ively. Age the scalp with sutures. In one patient CSF ranged from 55 to 83 years, with the exception pressure was recorded via a lumbar catheter. of one patient who was 24 years old. The mean The transducer (Braun, Germany) was fixed age was 69 years. Informed corisent was over the bregma and connected to an amplifier obtained from the patients or their fiamilies, or (Servomed, Hellige, Germany) and a plotter both. In three elderly women we detected (Recomed, Hellige, Germany). There were no either no transcranial Doppler signalI or only a adverse events such as infection or bleeding. weak one which was not adequate for record- The foramina of Monro were considered to be ing. In the remaining 20 patients an overnight at Ocm CSF. The patients were in a supine (9-18 hours) recording of ICP (in oine patient position with the head flat. lumbar pressure) and MCA blood fli iw velocity For the TCD measurements we used the TC (9-12 hours, either right or left side) was 2000S transcranial Doppler (Eden Medizi- performed simultaneously. nische Elektronik GmbH, Uberlingen, Ger- many) and recorded only the envelope curve (that is, the maximal velocity), not the entire Doppler spectrum, numerically on the hard Fe -Ls. disc (sample rate 41 Hz). The highest middle cerebral artery blood flow velocity was sought at a depth of 45 to 55 mm through the ;,.' temporal window. The side measured was 100 - l 14t ;selected dependent on the quality of the signal and interference due to the catheter and 4.-t- sutures. We used the lowest ultrasound inten- TCD . '. 4t_ .._ sity still able to produce a satisfactory signal ' - Continuous measurement [cm/si '- 1I I' .I (<100 mW/cm2). 4 -!-4 J i [CM/S'l,I.--1 -t was made possible by securing the probe in a I~ 1 _w_1 .1.I. i, 1. head ribbon with adhesive tape. A person sat +{i|t;1__111,Ul'ttil}ljti'1. ,{ -1 V 30 -4t i*i |-ii4fh*4--tlfitl t| [r l l :l.. 1- .i beside the patient for the whole night, checked ,1*i.l;tt - 1' - -.--.-- !.1- -.L-.- I. -i-Xi- for any movement ofthe patient and refastened i, .1 I'. -. II, l-I ! the TCD probe when necessary. The CSF .Pl .-- - - ;-. - -.- -11".60 pressure was recorded throughout the night on I. -: __:. .11. '..I.1I, -". a plotter at a speed of 5 mm/min and inter- 0 .11, L1~ ~' ~ mittently at a higher speed (1 mm/s, 10 mm/s). I ICP t [s] The transcranial Doppler signal was recorded 0 [cm CSF] 5 10 on the hard disc of the TC 2000S and in 15 patients also on the same sheet of paper as the Figure I Simultaneous recording of middle cerebral artery blood flow velocity by CSF pressure using the second channel of the transcranial Doppler (TCD) and intracranial pressure (ICP). Patient 14. plotter. http://jnnp.bmj.com/ The waveforms are not totally parallel. A rhythm of about 3 cardiac cycles of rwavelength is visible in the ICP recording, but not in the TCD recording. There is a sligh,tdelay of In five patients Doppler signals and CSF about O ls between the ICP and TCD signals during one cardiac cycle. pressure were recorded simultaneously during a bolus injection of 10 ml saline via the ventricle catheter. Sixteen patients had ventriculoatrial or ventriculoperitoneal shunting two to four weeks after the CSF pressure / TCD record- on October 1, 2021 by guest. Protected copyright. ing. Results + In all patients the initial baseline intracranial / lumbar pressure was less than 20 cm CSF, : which was consistent with a diagnosis of "Anormal" pressure hydrocephalus. The Dop- pler recording was more susceptible to move- ment artefacts than the pressure registration. However, the artefacts could be reliably identi- fied. In the 15 parallel recordings the course of the Doppler signal was always almost parallel to and in phase with the course of the CSF ICP t I in I pressure. c_rni CS F 1 2 At a speed of 10 mm/s during one cardiac cycle, there was only a delay of about 01 s Figure 2 Patient 18.
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