Ishcsf letter march-july 2012 text

What’s new in Hydrocephalus? March to July 2012!

For this letter we conducted a PubMed literature search on “hydrocephalus” and noted that the
total number of publications was 25 001. The number for the period of March to July 2012
was approximately 225. As stated before we have no ambition to be comprehensive or to
make a critical review of what is published, the goal is to illustrate that there are significant
research contributions in the hydrocephalus field by acknowledging a few of these articles.
We also encourage you as members to make us aware of the articles you publish.
Anders Eklund
Secretary/Treasurer ISHCSF
Normal Pressure Hydrocephalus
A new iNPH scale was designed and presented (Hellström et al., 2012). The scale covers the
domains of gait, balance, neuropsychology and continence and they found that it
discriminates well between levels of severity and was reliable and valid. The authors
recommend that the scale should be used in future studies on iNPH. The scale was also used
in the presentation of the one-year outcome in the European multicenter study on iNPH
(Klinge et al., 2012). The results with 84% improving from shunting support shunt surgery in
patients presenting with symptoms and signs and MRI findings suggestive of iNPH.
Solana et al in Barcelona studied cognitive disturbances and neuropsychological changes in a
sample of 185 iNPH patients. Analysis showed that cognitive impairment occurs in practically
all patients and that the most affected domains are memory, executive functions, attention,
and psychomotor speed. Shunting improved especially psychomotor speed, verbal memory,
and general cognition. The study also stressed the importance of treating patients in the early
stages of the disease (Solana et al., 2012).
A paper from Seoul presented positive results from an evaluation of the efficacy of
Solifenacin in the treatment of overactive bladder symptoms in iNPH patients(Chung et al.,
Using a SenseWear armband a group in Linköping made actigraphic recordings and evaluated
physical activity in iNPH patients before and after shunt surgery. Although the patients
improved in the gait tests the actigraphy parameters indicated that they did not use their
improved capacity in their daily life. (Lundin et al., 2012)
Two published papers have investigated the change in ventricular volume with respect to
TAP-test or external lumbar drainage test (Lenfeldt et al., 2012; Singer et al., 2012). Both
found a small but significant decrease in ventricular volume. Other findings was a spatially
distributed increase in the global brain volume following CSF removal (Singer et al., 2012)
and that improvement neither correlated with ventricular reduction or CSF removal volume
(Lenfeldt et al., 2012).
A pituitary endocrine evaluation of 16 NPH patients revealed pituitary dysfunction in five patients and that two improved in testosterone levels from NPH surgical correction. The authors recommend that pituitary screening should be considered in all NPH patients. (Moin et al., 2012) In the search of a prognostic CSF biomarker for iNPH, a group from Tokyo has identified that soluble amyloid precursor protein α (sAPPα) had a sensitivity of 67% and a specificity of 83% for MMSE > 25 after surgery and concluded that sAPPα can be a suitable biomarker for the diagnosis and prognosis of iNPH (Miyajima et al., 2012). Idiopathic intracranial hypertension
In a MRI study on twenty-seven astronauts it was found that exposure to microgravity can
result in a spectrum of intraorbital and intracranial findings similar to those in idiopathic
intracranial hypertension.(Kramer et al., 2012)
Pediatric and Obstructive Hydrocephalus.
In a paper from Malaga presenting a series of 58 ETV procedures the authors investigated the
relationship between the ETVSuccess Score and the postsurgical success rate. They
concluded that the success of ETV could have been predicted by ETVSS and that the
predictability could help establish stricter surgical selection criteria (García et al., 2012). On
the same topic; in certain cases when standard ETV might not be technically possible an
alternative through the lamina terminalis by a transventricular, transforaminal approach with
flexible neuroendoscopy has been presented (Rangel-Castilla et al., 2012). The authors
showed that the procedure was feasible with a low incidence of complications.
A study with focus on ETV in infants younger than 1 year old concluded that the effectiveness of ETV is not actually age-related, but etiology-related, with high success rate for aqueductal stenosis the (90 %) and lower for the treatment of Chiari II-related hydrocephalus (Costa Val et al., 2012). In a study on African infants with congenital aqueductal stenosis, long-term outcome for endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization was investigated. It was concluded that the combined approach was significantly superior to ETV alone for infants younger than 1 year of age. (Warf et al., 2012) In a phase-contrast MRI study comparing CSF flow after ETV and endoscopic aqueductoplasty (EAP) in patients presenting with aqueductal stenosis it was found that CSF flow through ventriculostomies is significantly higher than aqueductal CSF flow after EAP. The authors concluded that this could be one factor to explain why the reclosure rate of aqueducts after EAP is higher than the reclosure rate of the ventriculostoma. (Schroeder et al., 2012) From Denmark there is a contribution with an impressive investigation of familial aggregation of primary congenital hydrocephalus in an unselected nationwide population (Munch et al., 2012). This study, that was based on 1928683 live-born children out of which 2194 had the diagnosis, found strong evidence of familial aggregation, supporting the existence of a genetic component to the etiology. Experimental Hydrocephalus
Del Bigio et al investigated hypoxic and oxidative damage in the brains of rats with kaolin
induced hydrocephalus and found evidence of hypoxia in periventricular capillaries. They
concluded that hypoxia contributes to brain changes in young rodents with hydrocephalus
(Del Bigio et al., 2012). A paper from Xiamen investigated reactive gliosis and
neuroinflammation of hydrocephalic rats of different severity at both cellular and molecular
levels. Results indicate that gliosis and inflammation continue to rise dramatically in
experimental hydrocephalus and can be regarded as the main factors of hydrocephalus (Xu et
al., 2012). In another study intracranial biomechanics of hydrocephalus in rats was
investigated by force-controlled indentations. It was found that very small forces applied
exogenously or endogenously cause progressive intracranial deformation (Shulyakov et al.,
2012). The authors link this to that a small increase in CSF pulsatility can readily explain
enlargement of the cerebral ventricles in hydrocephalus. Abnormal osmotic gradients as a
potential component of hydrocephalus motivated an investigation of relationship between
manipulated CSF osmolarity and ventricle volume in the normal rat brain. The results showed
that hyperosmolar CSF was sufficient to produce a proportional degree of
hydrocephalus.(Krishnamurthy et al., 2012)
In a study from Copenhagen the translational aspects from hydrocephalic rat to hydrocephalic
human brain was investigated by direct comparison of AQP4 expression between those
species. The study emphasizes the relevance and use of models in hydrocephalus research but
also state that caution should be taken when interpreting data from experimental studies and
underscores the importance of translational studies (Skjolding et al., 2012).
A fine review over the current knowledge on the pathophysiology of congenital and neonatal
hydrocephalus was recently presented. (McAllister, 2012)
The Certas shunt was introduced last year and we now presented an in-vitro evaluation
(Eklund et al., 2012). The most interesting feature of the new shunt was the “Virtual Off”
setting with an opening pressure nearly 500 mmH2O that may reduce the need for surgery in
the treatment of subdural hygromas and hematomas. Related to overdrainage, a positive study on the effectiveness of a gravitational valve in the treatment of symptomatic overdrainage in children was recently presented.(Weinzierl et al., 2012) Another alternative could be to use lumboperitoneal shunts with horizontal–vertical valves. It was shown to be safe and effective alternative to ventriculoperitoneal shunting for iNPH, resulting in significant symptomatic improvement with a low risk of overdrainage (Bloch and McDermott, 2012). Bayston and colleagues investigated in vitro the ability of linezolid or vancomycin against biofilms of bacteria in ventriculoperitoneal shunts. The results suggest that both linezolid and vancomycin might be effective against staphylococcal shunt infections without shunt removal.(Bayston et al., 2012) A retrospective study that evaluated CSF reinfection after using ETV during removal of infected CSF shunts found that ETV can be considered a potent alternative or at least an adjunct to ventriculoperitoneal shunts reinsertion (Shimizu et al., 2012). CSF Dynamics and Measurement techniques
Santamarta and colleagues proposed a method based on central tendency measure (CTM) to
quantify and characterize the changes in the ICP waveform. CTM was evaluated using NPH
infusion studies and was showed to be closely correlated with pulsatility and to be a suitable
approach (Santamarta et al., 2012).
In an attempt to measure ICP non-invasively a group in Kaunas have developed a technique
based on simultaneous Doppler ultrasound of the flow in intracranial and extracranial
segments of ophthalmic artery while controlling the external pressure on the tissues
surrounding the eyeball. The method was evaluated against invasive lumbar measurements
and they concluded that the method was precise and accurate (Ragauskas et al., 2012).
Another method for non-invasive measurement of ICP has also bin presented and evaluated
with promising results (Kashif et al., 2012). It uses routinely obtainable time-synchronized
measurements of peripheral arterial blood pressure and blood flow velocity in the middle
cerebral artery. Data are analyzed with a dynamic model and an estimation algorithm.
The pressure pulsatility is potentially an importance component of the pathophysiology of
NPH. In a study from Umeå we investigated the agreement between intracranial pressure
amplitude and lumbar pressure amplitude. We found that the lumbar amplitudes were slightly
attenuated but that lumbar measurements is an alternative to ICP recording (Behrens et al.,
Bayston R, Ullas G, Ashraf W. The action of linezolid or vancomycin on biofilms in ventriculoperitoneal shunts in vitro. Antimicrob Agents Chemother 2012 Behrens A, Lenfeldt N, Qvarlander S, Koskinen LO, Malm J, Eklund A. Are intracranial pressure wave amplitudes measurable through lumbar puncture? Acta Neurol. Scand. 2012 Bloch O, McDermott MW. Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus. J Clin Neurosci 2012; 19: 1107–1111. Chung JH, Lee JY, Kang DH, Ha U-S, Lee SH, Ham WS, et al. Efficacy and safety of solifenacin to treat overactive bladder symptoms in patients with idiopathic normal pressure hydrocephalus: An open-label, multicenter, prospective study. Neurourol Urodyn 2012 Costa Val JA, Scaldaferri PM, Furtado LM, de Souza Baptista G. Third ventriculostomy in infants younger than 1 year old. Childs Nerv Syst 2012; 28: 1233–1235. Del Bigio MR, Khan OH, da Silva Lopes L, Juliet PAR. Cerebral white matter oxidation and nitrosylation in young rodents with kaolin-induced hydrocephalus. J. Neuropathol. Exp. Neurol. 2012; 71: 274–288. Eklund A, Koskinen L-OD, Williams MA, Luciano MG, Dombrowski SM, Malm J. Hydrodynamics of the Certas™ programmable valve for the treatment of hydrocephalus. Fluids Barriers CNS 2012; 9: 12. García LG, López BR, Botella GI, Páez MD, da Rosa SP, Rius F, et al. Endoscopic Third Ventriculostomy Success Score (ETVSS) predicting success in a series of 50 pediatric patients. Are the outcomes of our patients predictable? Childs Nerv Syst 2012; 28: 1157–1162. Hellström P, Klinge P, Tans J, Wikkelso C. A new scale for assessment of severity and outcome in iNPH. Acta Neurol. Scand. 2012 Kashif FM, Verghese GC, Novak V, Czosnyka M, Heldt T. Model-based noninvasive estimation of intracranial pressure from cerebral blood flow velocity and arterial pressure. Sci Transl Med 2012; 4: 129ra44. Klinge P, Hellström P, Tans J, Wikkelso C, On behalf of the European iNPH Multicentre Study Group. One-year outcome in the European multicentre study on iNPH. Acta Neurol. Scand. 2012 Kramer LA, Sargsyan AE, Hasan KM, Polk JD, Hamilton DR. Orbital and Intracranial Effects of Microgravity: Findings at 3-T MR Imaging. Radiology 2012 Krishnamurthy S, Li J, Schultz L, Jenrow KA. Increased CSF osmolarity reversibly induces hydrocephalus in the normal rat brain. Fluids Barriers CNS 2012; 9: 13. Lenfeldt N, Hansson W, Larsson A, Birgander R, Eklund A, Malm J. Three-day CSF drainage barely reduces ventricular size in normal pressure hydrocephalus. Neurology 2012; 79: 237–242. Lundin F, Ulander M, Svanborg E, Wikkelso C, Leijon G. How active are patients with idiopathic normal pressure hydrocephalus and does activity improve after shunt surgery? A controlled actigraphic study. Clin Neurol Neurosurg 2012 McAllister JP. Pathophysiology of congenital and neonatal hydrocephalus. Semin Fetal Neonatal Med 2012 Miyajima M, Nakajima M, Ogino I, Miyata H, Motoi Y, Arai H. Soluble amyloid precursor protein α in the cerebrospinal fluid as a diagnostic and prognostic biomarker for idiopathic normal pressure hydrocephalus. Eur. J. Neurol. 2012 Moin T, Bergsneider M, Vespa P, Heaney AP. Pituitary Function in Patients with Normal Pressure Hydrocephalus before and after Neurosurgical Correction. J Clin Endocrinol Metab 2012 Munch TN, Rostgaard K, Rasmussen M-LH, Wohlfahrt J, Juhler M, Melbye M. Familial aggregation of congenital hydrocephalus in a nationwide cohort. Brain 2012 Ragauskas A, Matijosaitis V, Zakelis R, Petrikonis K, Rastenyte D, Piper I, et al. Clinical assessment of noninvasive intracranial pressure absolute value measurement method. Neurology 2012; 78: 1684–1691. Rangel-Castilla L, Hwang SW, Jea A, Torres-Corzo J. Efficacy and Safety of Endoscopic Transventricular Lamina Terminalis Fenestration for Hydrocephalus. Neurosurgery 2012 Santamarta D, Abásolo D, Martínez-Madrigal M, Hornero R. Characterisation of the intracranial pressure waveform during infusion studies by means of central tendency measure. Acta Neurochir (Wien) 2012 Schroeder C, Fleck S, Gaab MR, Schweim KH, Schroeder HWS. Why does endoscopic aqueductoplasty fail so frequently? Analysis of cerebrospinal fluid flow after endoscopic third ventriculostomy and aqueductoplasty using cine phase-contrast magnetic resonance imaging. J. Neurosurg. 2012; 117: 141–149. Shimizu T, Luciano MG, Fukuhara T. Role of endoscopic third ventriculostomy at infected cerebrospinal fluid shunt removal. J Neurosurg Pediatr 2012; 9: 320–326. Shulyakov AV, Buist RJ, Del Bigio MR. Intracranial Biomechanics of Acute Experimental Hydrocephalus in Live Rats. Neurosurgery 2012 Singer OC, Melber J, Hattingen E, Jurcoane A, Keil F, Neumann-Haefelin T, et al. MR volumetric changes after diagnostic CSF removal in normal pressure hydrocephalus. J Neurol 2012 Skjolding AD, Holst AV, Broholm H, Laursen H, Juhler M. Differences in distribution and regulation of astrocytic aquaporin-4 in human and rat hydrocephalic brain. Neuropathol. Appl. Neurobiol. 2012 Solana E, Sahuquillo J, Junqué C, Quintana M, Poca MA. Cognitive Disturbances and Neuropsychological Changes after Surgical Treatment in a Cohort of 185 Patients with Idiopathic Normal Pressure Hydrocephalus. Arch Clin Neuropsychol 2012 Warf BC, Tracy S, Mugamba J. Long-term outcome for endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization for congenital aqueductal stenosis in African infants. J Neurosurg Pediatr 2012 Weinzierl MR, Hans F-J, Stoffel M, Oertel MF, Korinth MC. Experience with a gravitational valve in the management of symptomatic overdrainage in children with shunts. J Neurosurg Pediatr 2012; 9: 468–472. Xu H, Zhang SL, Tan GW, Zhu HW, Huang CQ, Zhang FF, et al. Reactive gliosis and neuroinflammation in rats with communicating hydrocephalus. Neuroscience 2012; 218: 317–325.


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