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Fractional anisotropy in patients with disproportionately enlarged subarachnoid space hydrocephalus

  • Clinical Article - Neurosurgical Techniques
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Abstract

Background

Disproportionately enlarged subarachnoid space hydrocephalus (DESH) findings on MRI were described as a prognostic factor for responsiveness to the treatment of idiopathic normal pressure hydrocephalus (iNPH). Our premise is that DESH could be associated with compression of the cerebral white matter. Microstructural changes can be identified using diffusion tensor imaging (DTI), specifically fractional anisotropy (FA). The aim of this study is to compare FA in iNPH patients with and without DESH and healthy controls.

Methods

We analysed 1.5-T MRI scans of patients fulfilling the criteria of probable or possible iNPH and positive supplementary tests before and after surgery (ventriculo-peritoneal shunt). FA was measured in the anterior and posterior limb of the internal capsule (PLIC) and in the corpus callosum. Patients were divided into the DESH and non-DESH group. These data were also compared to FA values in the control group.

Results

Twenty-seven patients and 24 healthy controls were enrolled. DESH was present in 15 patients and lacking in 12. Twenty-three iNPH patients were shunt responders (85.2 %), and 4 were non-responders (14.8 %). All patients in the DESH group were shunt responders. In the non-DESH group, eight patients were responders (66.7 %). A significant difference between the DESH and non-DESH group was found in the FA of the PLIC. The mean value of FA in the PLIC was 0.72 in the DESH group and 0.66 in the non-DESH group. After the surgery FA decreased in both groups. In the DESH iNPH group FA PLIC decreased to 0.65 and in the non-DESH iNPH group to 0.60. In the healthy controls, the mean FA in the PLIC was 0.58.

Conclusion

DESH on MRI scans is related to a higher FA in the PLIC with a decrease after the surgery. It reflects a more severe compression of the white matter than in non-DESH patients or healthy volunteers. DESH patients had better outcome than non-DESH patients. This study confirmed the importance of DESH as a supportive sign for iNPH.

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Acknowledgments

This study was supported by grant IGA MZ NT14448-3/2013.

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Authors and Affiliations

  1. Department of Neurosurgery, J.E. Purkyne University, Masaryk Hospital, Usti nad Labem, Czech Republic

    T. Radovnický & M. Sameš

  2. Department of Radiology, Masaryk Hospital, Usti nad Labem, Czech Republic

    D. Adámek & M. Derner

Authors
  1. T. Radovnický
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  2. D. Adámek
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  3. M. Derner
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  4. M. Sameš
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Corresponding author

Correspondence to T. Radovnický.

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Funding

The Ministry of Health of the Czech Republic provided financial support in the form of grant IGA MZ NT14448-3/2013.

The sponsor had no role in the design or conduct of this research.

Conflict of interest

None.

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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Comments

Disproportionately enlarged subarchnoid space hydrocephalus (DESH) was described by the Japanese Society of Normal Pressure Hydrocephalus around 2010. Its guidelines define DESH as iNPH with the specific MRI features of tight high-convexity, the presence of medial subarachnoid spaces and ventriculomegaly. Not all patients presenting with iNPH show the classical picture of DESH. It is reported that the improvement rate after shunting in iNPH patients with DESH is 60 % to 70 %. This raises eyebrows, as a similar figure can be found in many studies in iNPH patients without considering whether they were DESH or non-DESH. On top of this, the fast MRI sequences designed to show pulsatile movement of the CSF (Time-SLIP CSF flow imaging) demonstrate that the CSF moves freely in the subarachnoid spaces below and in the Sylvian fissures; however it does not move in the convexity subarachnoid spaces in patients with DESH. This indicates the presence of flow obstacles in the convexity subarachnoid spaces.

There is no study associating DESH with values of parameters derived from CSF dynamics assessment using the infusion test and/or overnight ICP monitoring. The present finding of an increased fractional anisotropy index in DESH patients versus non-DESH NPH is an original one. However, there is an overlap in FA values in both groups; therefore it is not known how FA may be useful for patient classification. The improvement rate of 100 % versus 66 % should be confirmed in a much larger study than 15:12 patients.

Nevertheless the reported finding may contribute to better understanding of the nature of iNPH.

Marek Czosnyka

Cambridge, UK

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Radovnický, T., Adámek, D., Derner, M. et al. Fractional anisotropy in patients with disproportionately enlarged subarachnoid space hydrocephalus. Acta Neurochir 158, 1495–1500 (2016). https://doi.org/10.1007/s00701-016-2861-x

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  • DOI: https://doi.org/10.1007/s00701-016-2861-x

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