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Associations of intracranial pressure with brain biopsy, radiological findings, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus

  • Clinical Article - Neurosurgical Anatomy
  • Published:
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Abstract

Background

It remains unclear how intracranial pressure (ICP) measures are associated with brain biopsies and radiological markers. Here, we aim to investigate associations between ICP and radiological findings, brain biopsies, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus (iNPH).

Method

In this study, we retrospectively analyzed data from 73 patients admitted with suspected iNPH to Kuopio University Hospital. Of these patients, 71% underwent shunt surgery. The NPH registry included data on clinical and radiological examinations, 24-h intraventricular pressure monitoring, and frontal cortical biopsy.

Results

The mean ICP and mean ICP pulse wave amplitude were not associated with the shunt response. Aggregations of Alzheimer’s disease (AD)-related proteins (amyloid-β, hyperphosphorylated tau) in frontal cortical biopsies were associated with a poor shunt response (P = 0.014). High mean ICP was associated with Evans’ index (EI; P = 0.025), disproportional sylvian and suprasylvian subarachnoid spaces (P = 0.014), and focally dilated sulci (P = 0.047). Interestingly, a high pulse wave amplitude was associated with AD-related biopsy findings (P = 0.032), but the mean ICP was not associated with the brain biopsy. The ICP was not associated with medial temporal lobe atrophy, temporal horn widths, or white matter changes. ICP B waves were associated with less atrophy of the medial temporal lobe (P = 0.018) and more severe disproportionality between the sylvian and suprasylvian subarachnoid spaces (P = 0.001).

Conclusions

The EI and disproportional sylvian and suprasylvian subarachnoid spaces were associated with mean ICP. Disproportionality was also associated with ICP B waves. These associations, although rather weak, with elevated ICP in 24-h measurements, support their value in iNPH diagnostics and suggest that these radiological markers are potentially related to the pathogenesis of iNPH. Interestingly, our results suggested that elevated pulse wave amplitude might be associated with brain amyloid accumulation.

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Abbreviations

Aβ:

Amyloid beta

AD:

Alzheimer’s disease

CSF:

Cerebrospinal fluid

CT:

Computed tomography

EI:

Evans’ index

HPτ:

Hyperphosphorylated tau

ICP:

Intracranial pressure

iNPH:

Idiopathic normal pressure hydrocephalus

KUH:

Kuopio University Hospital

MMSE:

Mini-Mental State Examination

MRI:

Magnetic resonance imaging

NPH:

Normal pressure hydrocephalus

SA:

Subarachnoid

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Acknowledgments

The authors thank Marita Voutilainen, RN, for maintenance of the KUH NPH register and biostatistician Tuomas Selander for statistical assistance.

Author information

Authors and Affiliations

  1. Neurosurgery of NeuroCenter, Kuopio University Hospital and University of Eastern Finland, P.O. Box 100, 70029, Kuopio, Finland

    Maria Kojoukhova, Krista-Irina Vanha, Matti Timonen, Juha E. Jääskeläinen & Ville Leinonen

  2. Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland

    Anne M. Koivisto & Ossi Nerg

  3. Neurology of NeuroCenter, Kuopio University Hospital, Kuopio, Finland

    Anne M. Koivisto & Ossi Nerg

  4. Department of Pathology, Kuopio University Hospital, Kuopio, Finland

    Jaana Rummukainen & Tuomas Rauramaa

  5. Institute of Clinical Medicine-Pathology, University of Eastern Finland, Kuopio, Finland

    Tuomas Rauramaa

  6. Department of Radiology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland

    Ritva Vanninen & Anna Sutela

Authors
  1. Maria Kojoukhova
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  2. Krista-Irina Vanha
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  4. Anne M. Koivisto
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  9. Juha E. Jääskeläinen
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Corresponding author

Correspondence to Maria Kojoukhova.

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Funding

The Fund of Mauri and Sirkka Wiljasalo, KUH VTR Fund, and The Finnish Medical Foundation provided financial support in the form of grant funding. The sponsors had no role in the design or conduct of this research.

Conflicts of interest

All authors certify that they have no affiliations with or involvement in any organization 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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Comments

Kojoukhova and colleagues have retrospective analyzed 73 patients with suspected idiopathic normal pressure hydrocephalus to find potential associations of intracranial pressure with brain biopsy, radiological findings, and shunt surgery outcome.

As the authors point out, in idiopathic normal pressure hydrocephalus the pathophysiology is still not completely understood, and a multifactorial disease seems to be highly probable.

Thus, the present article comparing ICP data with neuropatholocical, neuroradiological and clinical post-shunt-surgery results could be highly relevant. The limitations of the present article—most importantly the retrospective design of the study, relatively small number of patients, and lack of standardized, objective criteria to assess shunt response—have been adequately discussed.

Marcus Reinges

Giessen, Germany

Anna Sutela and Ville Leinonen shared last authorship

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Kojoukhova, M., Vanha, KI., Timonen, M. et al. Associations of intracranial pressure with brain biopsy, radiological findings, and shunt surgery outcome in patients with suspected idiopathic normal pressure hydrocephalus. Acta Neurochir 159, 51–61 (2017). https://doi.org/10.1007/s00701-016-3025-8

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