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Comparison of elevated intracranial pressure pulse amplitude and disproportionately enlarged subarachnoid space (DESH) for prediction of surgical results in suspected idiopathic normal pressure hydrocephalus

  • Clinical Article - Neurosurgical Techniques
  • Published:
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Abstract

Background

To compare the prognostic value of pulse amplitude on intracranial pressure (ICP) monitoring and disproportionately enlarged subarachnoid space hydrocephalus (DESH) on magnetic resonance imaging (MRI) for predicting surgical benefit after shunt placement in idiopathic normal pressure hydrocephalus (iNPH).

Method

Patients with suspected iNPH were prospectively recruited from a single centre. All patients received preoperative MRI and ICP monitoring. Patients were classified as shunt responders if they had an improvement of one point or more on the NPH score at 1 year post-surgery. The sensitivity, specificity, Youden index, and positive and negative predictive values of the two diagnostic methods were calculated.

Results

Sixty-four of 89 patients clinically improved at 1 year post-surgery and were classed as shunt responders. Positive DESH findings had a sensitivity of 79.4 % and specificity of 80.8 % for predicting shunt responders. Fifty-five of 89 patients had positive DESH findings: 50 of these responded to VP shunt, giving a positive and negative predictive value of 90.9 % and 61.8 %, respectively. Fifty-seven of 89 patients had high ICP pulse amplitude. High ICP pulse amplitude had a sensitivity of 84.4 %, specificity of 88 %, positive predictive value of 94.7 % and negative predictive value of 61.8 % for predicting shunt responders.

Conclusions

Both positive DESH findings and high ICP pulse amplitude support the diagnosis of iNPH and provide additional diagnostic value for predicting shunt-responsive patients; however, high ICP amplitude was more accurate than positive DESH findings, although it is an invasive test.

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Authors and Affiliations

  1. Neurosurgery Department, Neurociencies Unit, University Hospital Germans Trias i Pujol, Crta de Canyet s/n, 08916, Barcelona, Spain

    Roser Garcia-Armengol, Carlos Botella-Campos, Francisco Javier Goncalves, Belén Menéndez, Pilar Teixidor, Lucia Muñoz-Narbona & Jordi Rimbau

  2. Institut de Diagnòstic per la Imatge (IDI), University Hospital Germans Trias i Pujol, Barcelona, Spain

    Sira Domenech

Authors
  1. Roser Garcia-Armengol
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  2. Sira Domenech
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  3. Carlos Botella-Campos
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  4. Francisco Javier Goncalves
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Corresponding author

Correspondence to Roser Garcia-Armengol.

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Funding

No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Comment

Despite technical and knowledge improving, the surgical outcomes and the clinical indication to shunting for iNPH have not improved in the last decades. After the well-known multi-center prospective study SHINPHONI of 2010, the neurosurgical community is aware that disproportionately expanded Sylvian fissures alongside with tight high convexity and medial subarachnoid spaces in MRI - also known as disproportionately enlarged subarachnoid space hydrocephalus (DESH) -is very useful for the diagnosis of iNPH, and therefore could predict the efficacy of treatment.

In this manuscript, the Authors report a prospective study involving long-term follow-up of 89 patients with iNPH over a mean period of 46 months in order to compare the prognostic value of DESH and pulse amplitude ICP. One year after shunting 71,9 % of patients had a clinical improvement and could be classified as shunt responders. 62,9 were DESH positive. DESH had a sensitivity and specifity of around 80 %, with a positive predict value of 91 % and negative predictive value of 60 % for discriminating shunt responders. If associated with ICP amplitude the accuracy of predicting shunt responses reaches globally the > 90 %.

A very intriguing issue is the theory, that positive DESH findings may be caused by defective CSF absorption as a result of suprasylvian subarachnoidal block. This question is worthy to be clarified by appropriate research.

The topic is of neurosurgical relevance, and the study well conducted. Overall, the data are convincing that DESH may be useful as a first test for identifying iNPH patients who will respond to a shunt.

Alex Alfieri

Francesco Ferri

Neuruppin, Germany

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Garcia-Armengol, R., Domenech, S., Botella-Campos, C. et al. Comparison of elevated intracranial pressure pulse amplitude and disproportionately enlarged subarachnoid space (DESH) for prediction of surgical results in suspected idiopathic normal pressure hydrocephalus. Acta Neurochir 158, 2207–2213 (2016). https://doi.org/10.1007/s00701-016-2858-5

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  • DOI: https://doi.org/10.1007/s00701-016-2858-5

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