İdiopatik Normal Basınçlı Hidrosefali Hastalarında Kraniyal MR Bulguları

Öz

Amaç: Bu makalenin amacı, normal basınçlı hidrosefalide az bilinen veya göz ardı edilen kraniyal MRG bulgularının vurgulanmasıdır. Gereç ve Yöntemler: 2014-2017 yılları arasında, nöroloji tarafından idiopatik normal basınçlı hidrosefali tanısı konmuş hastalardan; yapılan boşaltıcı lomber ponksiyonda pozitif sonuç elde edilip ventriküloperitoneal şant takılan 9 hasta, boşaltıcı lomber ponksiyonda anlamlı klinik düzelme elde edilememesi üzerine şant takılmasından vazgeçilen 3 hasta ve boşaltıcı lombar ponksiyonu kabul etmeyen 4 hastanın preoperatif kraniyal MRI bulguları retrospektif olarak incelendi. Bulgular: İdiopatik normal basınçlı hidrosefali tanısı konan 8 erkek, 8 kadın toplam 16 hastaincelendi. Ortalama yaş 73,6 olarak saptandı. Hastaların %68,75’inde çok belirgin serebral atrofi, %100’ünde temporal hornlarda genişleme, %75’inde silvian fissürde genişleme vardı. Korpus kallozum incelmesi %100, ventrikül çatısında dalgalanma bulging %68,75 oranında saptandı. Ortalama kallozal açı 83,4 derece, şant takılıp fayda gören hastalarda ise 71,6 dereceydi. Evans indeksi ortalama 0.4, 3.ventrikül ortalama çapı 1,49 cm, aquaduct çapı ortalama 2,66 mm olarak ölçüldü. Periventriküler hiperintensite %81,25, beyaz cevher hiperintensitesi %62,5 oranında saptandı. Singulat sulkus bulgusu %37,5, mezensefalon bulgusu %81,25, hidrosefaliyle orantısız subaraknoid alan genişlemesi %81,25 oranında saptandı. Sonuç: Literatürde farklı görüşler olmakla birlikte; preoperatif MR’da 40-90 derecelik kallozal açı, temporal hornların dilatasyonu, hidrosefaliyle orantısız genişlemiş bazal subaraknoid alanlar, periventriküler hiperintensite ve boşaltıcı lombar ponksiyondan fayda görülmesi, şanttan faydalanım açısından pozitif belirteçtir

Anahtar Kelimeler

• İdiopatik normal basınçlı hidrosefali, ventriküloperitoneal şant, kraniyal MRG

Hydrocephalus Cranial MRI Findings in Idiopathic Normal Pressure

Abstract

Objective: The aim of this article is to emphasize the findings of minimally known or ignored cranial MRI in normal pressure hydrocephalus. Material and Methods: We retrospectively evaluated the preoperative cranial MRI findings of 9 patients where a ventriculoperitoneal shunt was inserted after a positive result withthe lumbar tap test performed by the author, 3 patients where it was decided not to place a shunt as there was no significant clinical improvement on the lumbar tap test performed by the author, and 4 patients who did not accept a lumbar tap test, among our patients diagnosed with idiopathic normal pressure hydrocephalusby the Neurology Department between 2014 and 2017. Results: A total of 16 patients consisting of 8 males and 8 females with a diagnosis of normal pressure hydrocephalus were evaluated. The mean age was 73.6 years. Marked cerebral atrophy was found in 68.75% of the patients, temporal horn dilatation in 100% and Sylvian fissure dilatation in 75%. Corpus callosum thinning was found at a rate of 100% and ventricular roof bulging at 68.75%. The mean callosal angle was 83.4 degrees, decreasing to 71.6 degrees in patients who had benefited from a shunt. The mean Evans index was 0.4, mean 3rd ventricle diameter 1.49 cm, and the mean aqueduct diameter 2.66 mm. Periventricular hyperintensity was present in 81.25% and white matter hyperintensity in 62.5%. A cingulate sulcus finding was observed in 37.5%, a mesencephalon finding in 81.25%, and disproportionate subarachnoid area enlargement in 81.25%. Conclusion: Despite the various views in the literature a 40-90 degree preoperative callosal angle, dilated temporal horns, disproportionately enlarged basal subarachnoid areas, periventricular hyperintensity and benefit from lumbar puncture drainage are positive indicators of benefiting from a shunt

Keywords

• Idiopathic normal pressure hydrocephalus, ventriculoperitoneal shunt, cranial magnetic resonance imaging

Kaynakça

1. Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: Diagnosis and treatment. Curr Neurol Neurosci Rep 2008; 8(5):371-6.
2. Graff-Radford NR. (2017). Normal pressure hydrocephalus. In: Uptodate, DeKosky ST, Eichler AF(Eds). Available from: pressure hydrocephalus?search= normal %20pressure %20hydrocephalus&source=search_result&sel (Accessed on January 15,2018.)
3. Andrén K, Wikkelsö C, Sundström N, Agerskov S, Israelsson H, Laurell K, Hellström P, Tullberg M. Long‐ term effects of complications and vascular comorbidityin idiopathic normal pressure hydrocephalus: A quality registry study. J Neurol 2018; 265(1)178-86.
4. Tanaka N, Yamaguchi S, Ishikawa H, Ishii H, Meguro K. Prevalence of possible idiopathic normal-pressure hydrocephalus in Japan: The Osaki-Tajiri project. Neuroepidemiology 2009; 32(3):171-5.
5. Özdöl Ç, Belen D. İdiopatik normal basınçlı hidrosefali. Türk Nöroşirürji Dergisi 2009; 19(2):97-104.
6. Williams MA, Malm J. Diagnosis and treatment of idiopathic normal pressure hydrocephalus. Continuum (Minneap Minn) 2016; 22:579-99.
7. Krefft TA, Graff-Radford NR, Lucas JA, Mortimer JA. Normal pressure hydrocephalus and large head size. Alzheimer Dis Assoc Disord 2004; 18(1):35-7.
8. Kuriyama N, Tokuda T, Miyamoto J, Takayasu N, Kondo M, Nakagawa M. Retrograde jugular flow associated with idiopathic normal pressure hydrocephalus. Ann Neurol 2008; 64(2):217-21.

9. Savolainen S, Hurskainen H, Paljärvi L, Alafuzoff I, Vapalahti M. Five-year outcome of normal pressure hydrocephalus with or without a shunt: Predictive value of the clinical signs, neuropsychological evaluation and infusion test.Acta Neurochir (Wien) 2002; 144(6):515-23.
10. Hamilton R, Patel S, Lee EB, Jackson EM, Lopinto J, Arnold SE, Clark CM, Basil A, Shaw LM, Xie SX, Grady MS, Trojanowski JQ. Lack of shunt response in suspected idiopathic normal pressure hydrocephalus with Alzheimer disease pathology. Ann Neurol 2010; 68(4):535-40.
11. Allali G, Laidet M, Armand S, Assal F. Brain comorbidities in normal pressure hydrocephalus. Eur J Neurol 2017; 25(3)542-8.
12. Krauss JK, Regel JP, Vach W, Droste DW, Borremans JJ, Mergner T. Vascular risk factors and arteriosclerotic disease in idiopathic normal-pressure hydrocephalus of the elderly. Stroke 1996; 27(1):24-9.
13. Bech RA, Waldemar G, Gjerris F, Klinken L, Juhler M. Shunting effects in patients with idiopathic normal pressure hydrocephalus; Correlation with cerebral and leptomeningeal biopsy findings. Acta Neurochir (Wien). 1999; 141(6):633-9.
14. Virhammar J, Laurell K, Cesarini KG, Larsson EM. Preoperative prognostic value of MRI findings in 108 patients with idiopathic normal pressure hydrocephalus. AJNR Am J Neuroradiol 2014; 35(12):2311-8.
15. Ishii K, Kanda T, Harada A, Miyamoto N, Kawaguchi T,Shimada K, Ohkawa S, Uemura T, Yoshikawa T, Mori E. Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus. Eur Radiol 2008; 18:2678-83.
16. Tullberg M, Jensen C, Ekholm S, Wikkelsİ C. Normal pressure hydrocephalus: Vascular white matter changes on MR images must not exclude patients from shunt surgery. AJNR Am J Neuroradiol 2001; 22:1665-73.
17. Mullaguri N, Battineni A, Newey CR, Nattanmai P. White matter changes in corpus callosum in a patient with idiopathic normal pressure hydrocephalus. J Neurosci Rural Pract 2017; 8(4):657-9.
18. Badía MC, Bueno A, Láinez JM. Corpus callosal signal changes in patient with obstructive hydrocephalus after ventriculoperitoneal shunting. Neurologia 2005; 20:692- 3.
19. Constantinescu CS, McConachie NS, White BD. Corpus callosum changes following shunting for hydrocephalus: Case report and review of the literature. Clin Neurol Neurosurg 2005; 107:351-4.
20. Jack CR Jr, Petersen RC, O’Brien PC, Tangalos EG. MR-based hippocampal volumetry in the diagnosis of Alzheimer’s disease. Neurology 1992; 42(1):183-8.
21. Hebb AO, Cusimano MD. Idiopathic normal pressure hydrocephalus: A systematic review of diagnosis and outcome. Neurosurgery 2001; 49(5):1166-84; discussion 1184-6.
22. Adachi M, Kawanami T, Ohshima F, Kato T. Upper midbrain profile sign and cingulate sulcus sign: MRI findings on sagittal images in idiopathic normal-pressure hydrocephalus, Alzheimer’s disease, and progressive supranuclear palsy.Radiat Med 2006; 24(8):568-72.
23. Momjian S, Owler BK, Czosnyka Z, Czosnyka M, Pena A, Pickard JD. Pattern of white matter regional cerebral blood flow and autoregulation in normal pressure hydrocephalus. Brain 2004; 127:965-72.
24. Li X, Miyajima M, Jiang C, Ara H. Expression of TGF- betas and TGF-beta type II receptor in cerebrospinal fluid of patients with idiopathic normal pressure hydrocephalus. Neurosci Lett 2007; 413:141-4.
25. Tarkowski E, Tullberg M, Fredman P, Wikkelsö C. Normal pressure hydrocephalus triggers intrathecal production of TNF-alpha. Neurobiol Aging 2003; 24:707- 14.