Hanna Israelsson

Brain ventricular size in healthy elderly: comparison between evans index and volume measurement.

BACKGROUNDA precise definition of ventricular enlargement is important in the diagnosis of hydrocephalus as well as in assessing central atrophy. The Evans index (EI), a linear ratio between the maximal frontal horn width and the cranium diameter, has been extensively used as an indirect marker of ventricular volume (VV). With modern imaging techniques, brain volume can be directly measured. OBJECTIVETo determine reference values of intracranial volumes in healthy elderly individuals and to correlate volumes with the EI. METHODSMagnetic resonance imaging (3 T) was performed in 46 healthy white elderly subjects (mean age ± standard deviation, 71 ± 6 years) and in 20 patients (74 ± 7 years) with large ventricles according to visual inspection. VV, relative VV (RVV), and EI were assessed. Ventricular dilation was defined using VV and EI by a value above the 95th percentile range for healthy elderly individuals. RESULTSIn healthy elderly subjects, we found VV = 37 ± 18 mL, RVV = 2.47 ± 1.17%, and EI = 0.281 ± 0.027. Including the patients, there was a strong correlation between EI and VV (R = 0.94) as well as between EI and RVV (R = 0.95). However, because of a wide 95% prediction interval (VV: ±45 mL; RVV: ± 2.54%), EI did not give a sufficiently good estimate of VV and RVV. CONCLUSIONVV (or RVV) and the EI reflect different properties. The exclusive use of EI in clinical studies as a marker of enlarged ventricles should be questioned. We suggest that the definition of dilated ventricles in white elderly individuals be defined as VV >77 mL or RVV >4.96 %. Future studies should compare intracranial volumes with clinical characteristics and prognosis.

Vascular risk factors in INPH: A prospective case-control study (the INPH-CRasH study)

Objective: To assess the complete vascular risk factor (VRF) profile of idiopathic normal pressure hydrocephalus (INPH) using a large sample of representative patients with INPH and population-based controls to determine the extent to which vascular disease influences INPH pathophysiology. Methods: All patients with INPH who underwent shunting in Sweden in 2008–2010 were compared to age- and sex-matched population-based controls. Inclusion criteria were age 60–85 years and no dementia. The 10 most important VRFs and cerebrovascular and peripheral vascular disease were prospectively assessed using blood samples, clinical examinations, and standardized questionnaires. Assessed VRFs were hypertension, hyperlipidemia, diabetes, obesity, psychosocial factors, smoking habits, diet, alcohol intake, cardiac disease, and physical activity. Results: In total, 176 patients with INPH and 368 controls participated. Multivariable logistic regression analysis indicated that hyperlipidemia (odds ratio [OR] 2.380; 95% confidence interval [CI] 1.434–3.950), diabetes (OR 2.169; 95% CI 1.195–3.938), obesity (OR 5.428; 95% CI 2.502–11.772), and psychosocial factors (OR 5.343; 95% CI 3.219–8.868) were independently associated with INPH. Hypertension, physical inactivity, and cerebrovascular and peripheral vascular disease were also overrepresented in INPH. Moderate alcohol intake and physical activity were overrepresented among the controls. The population-attributable risk percentage was 24%. Conclusions: Our findings confirm that patients with INPH have more VRFs and lack the protective factors present in the general population. Almost 25% of cases of INPH may be explained by VRFs. This suggests that INPH may be a subtype of vascular dementia. Targeted interventions against modifiable VRFs are likely to have beneficial effects on INPH.

Symptoms of Depression are Common in Patients With Idiopathic Normal Pressure Hydrocephalus : The INPH-CRasH Study

BACKGROUND If patients with idiopathic normal pressure hydrocephalus (INPH) also have depression, this could have important clinical ramifications in assessment and management of their cognitive function and response to shunting. In many dementias, depression is overrepresented, but the prevalence of depression in shunted patients with INPH is unknown. OBJECTIVE The objective of this case-control study was to assess the prevalence of symptoms of depression in shunted INPH patients compared with population-based controls. METHODS INPH patients consecutively shunted from 2008 to 2010 in Sweden were analyzed. Patients remaining after inclusion (within 60-85 years and not having dementia, ie, mini-mental state examination ≥23) had a standardized visit to their healthcare provider and answered an extensive questionnaire. Age- and sex-matched population-based controls underwent the same procedure. Symptoms of depression were assessed using the Geriatric Depression Scale 15 (suspected depression defined as ≥5 points, suspected severe depression as ≥12 points). This study is part of the INPH-CRasH study. RESULTS One hundred seventy-six INPH patients and 368 controls participated. After adjustment for age, sex, cerebrovascular disease, and systolic and diastolic blood pressure, patients had a higher mean depression score (patients: 4.9 ± 3.7 SD, controls: 1.9 ± 2.3 SD; OR 1.4, 95% CI 1.3-1.6, P < .001), more patients had suspected depression (46% vs 13%, OR 6.4, 95% CI 3.8-10.9, P < .001), and more patients had suspected severe depression (7.3% vs 0.6%, OR 14.4, 95% CI 3.0-68.6, P < .005). CONCLUSION Symptoms of depression are overrepresented in INPH patients compared with the population, despite treatment with a shunt. Screening for depression should be done in the evaluation of INPH patients in order to find and treat a coexisting depression.

Ventriculomegaly and balance disturbances in patients with TIA

Israelsson H, Birgander R, Ambarki K, Eklund A, Malm J. Ventriculomegaly and balance disturbances in patients with TIA. 
Acta Neurol Scand: 2012: 125: 163–170. 
© 2011 John Wiley & Sons A/S.

Trunk sway in idiopathic normal pressure hydrocephalus-Quantitative assessment in clinical practice

BACKGROUND In diagnosis and treatment of patients with idiopathic normal pressure hydrocephalus (iNPH), there is need for clinically applicable, quantitative assessment of balance and gait. Using a body-worn gyroscopic system, the aim of this study was to assess postural stability of iNPH patients in standing, walking and during sensory deprivation before and after cerebrospinal fluid (CSF) drainage and surgery. A comparison was performed between healthy elderly (HE) and patients with various types of hydrocephalus (ventriculomegaly (VM)). METHODS Trunk sway was measured in 31 iNPH patients, 22 VM patients and 58 HE. Measurements were performed at baseline in all subjects, after CSF drainage in both patient groups and after shunt surgery in the iNPH group. RESULTS Preoperatively, the iNPH patients had significantly higher trunk sway compared to HE, specifically for the standing tasks (p<0.001). Compared to VM, iNPH patients had significantly lower sway velocity during gait in three of four cases on firm support (p<0.05). Sway velocity improved after CSF drainage and in forward-backward direction after surgery (p<0.01). Compared to HE both patient groups demonstrated less reliance on visual input to maintain stable posture. CONCLUSIONS INPH patients had reduced postural stability compared to HE, particularly during standing, and for differentiation between iNPH and VM patients sway velocity during gait is a promising parameter. A reversible reduction of visual incorporation during standing was also seen. Thus, the gyroscopic system quantitatively assessed postural deficits in iNPH, making it a potentially useful tool for aiding in future diagnoses, choices of treatment and clinical follow-up.

Cardiovascular risk factors are associated with Idiopathic Normal Pressure Hydrocephalus.

An emerging concept is a possible association between vascular disease/cardiovascular risk factors (CVRF) and idiopathic normal pressure hydrocephalus (INPH). However, the CVRF profile of INPH has not been investigated using a modern epidemiological approach. The objective for this case-control study was to determine the total CVRF profile in a large cohort of shunted INPH-patients, compared to the population.

Is there an over-prescription of psychotropic drugs to patients with Idiopathic Normal Pressure Hydrocephalus?

Over-prescription of psychotropic drugs among elderly and cognitively impaired individuals is a well-known problem. One common side effect to a majority of these drugs is an increased risk to fall. This may be fatal in a population already susceptible for falling, such as INPH patients. The objective of this study was to describe the prevalence of prescribed antidepressants, antipsychotics, anxiolytics, hypnotics, and sedatives in shunted INPH patients compared with the population.