mri of hydrocephalus with thoughts on the etiology of nph and... · mri of hydrocephalus with...
TRANSCRIPT
![Page 1: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/1.jpg)
MRI of Hydrocephalus with Thoughts on the Etiology of NPH
William G. Bradley, MD, PhD, FACRProfessor and Chair
Department of RadiologyUniversity of California, San Diego
![Page 2: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/2.jpg)
Hydrocephalus
• MR findings: Interstitial edema • CSF Flow: Functional (Shuntability)
• Forms: – Obstructive (tumor, inflammation)– Communicating (SAH, meningitis)(NPH)
![Page 3: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/3.jpg)
![Page 4: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/4.jpg)
![Page 5: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/5.jpg)
![Page 6: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/6.jpg)
Colloid Cyst
![Page 7: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/7.jpg)
Communicating Hydrocephalus
![Page 8: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/8.jpg)
![Page 9: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/9.jpg)
![Page 10: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/10.jpg)
Aqueductal Stenosis
![Page 11: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/11.jpg)
No flow void!
![Page 12: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/12.jpg)
Aqueductal Stenosis
• Abnormally small aqueduct• Totally obliterated aqueduct• Membrane formation• Forking with multiple diverticuli
![Page 13: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/13.jpg)
Benign External Hydrocephalus
![Page 14: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/14.jpg)
Benign External Hydrocephalus
![Page 15: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/15.jpg)
Tectal Glioma
How does the CSF get out??
![Page 16: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/16.jpg)
How Does CSF Get Out?
• Through pia?• Via aquaporins?• Via VR spaces? • Via lymphatics?• Solute transport?
![Page 17: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/17.jpg)
Callosal Sulcus
![Page 18: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/18.jpg)
![Page 19: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/19.jpg)
Callosal Sulcus
![Page 20: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/20.jpg)
![Page 21: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/21.jpg)
![Page 22: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/22.jpg)
Normal Pressure Hydrocephalus
• Described by Hakim, Adams, et al (1965)• 50% known cause (SAH, meningitis)• 50% idiopathic (older)• Diagnosis primarily clinical: Gait apraxia,
dementia, incontinence• Radiology: communicating hydrocephalus
![Page 23: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/23.jpg)
Physiologic Tests for NPH• Nuclear cisternography
– Communicating hydrocephalus• Pressure monitoring
– Waterhammer pulse– Plateau waves
• Saline Infusion (outpatient)– If resistance > 4mmHg/ml/min, 82% respond to ELD
• 50 cc Tap test: PPV 73-100%; sensitivity 26-62%• External lumbar drainage (inpatient)
![Page 24: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/24.jpg)
External Lumbar Drainage
• 16 gauge lumbar puncture; catheter drainage• 10 cc/hour for 3 days; gait assessed• Of 151 patients* with iNPH,100 improved with ELD
– Gait only (88%), gait/dementia (84%), triad (59%)• Of responders, 90% improve with VP shunt• Of nonresponders, 22% improve with shunt
*Marmarou A, et al, J. Neurosurg 2005;102:987-997
![Page 25: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/25.jpg)
NPH
![Page 26: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/26.jpg)
![Page 27: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/27.jpg)
NPH
![Page 28: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/28.jpg)
NPH
![Page 29: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/29.jpg)
Atrophy
![Page 30: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/30.jpg)
Gait Disturbance in NPH
Paracentral fibers corticospinal tracts?
Parkinson’s from pressureon substantia nigra?
![Page 31: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/31.jpg)
Enlarged 3rd Ventricle in NPH
![Page 32: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/32.jpg)
Quantification of CSF Flow Void
• Signal loss (dephasing) due to– CSF velocity– Orientation– Gradient strength
• Extent of flow void– More important than magnitude
![Page 33: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/33.jpg)
CSF Flow Void
![Page 34: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/34.jpg)
Proposed Causes of CSF Motion
• Production by choroid plexus (500 ml/day)• Cardiac pulsations
– Choroid plexus (Bering, 1959)– Large arteries– Cerebral hemispheres (phase-contrast MRI)
![Page 35: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/35.jpg)
CSF Flow Void vs. Surgical Response
• 20 patients shunted for presumed NPH (1984)
• All had gait disturbance and dementia• 17/20 had incontinence
![Page 36: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/36.jpg)
NPH vs CSF Flow Void
• Surgical Response graded (1984)– Excellent-good– Fair-poor
• CSF flow graded (1989)– Absent-mild– Moderate-severe
![Page 37: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/37.jpg)
Materials and Methods
• Surgical Response Compared to:• CSF Flow Void on Routine MRI
– 1984– No flow compensation
![Page 38: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/38.jpg)
Normal (1984)
![Page 39: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/39.jpg)
Hyperdynamic flow (1984)
![Page 40: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/40.jpg)
CSF Flow VoidMarked Minimal
8 1
2 9
Good
Poor
Fisher’s Exact Test p< .003
Surgical Response
![Page 41: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/41.jpg)
To shunt or not to shunt
(1984)
Bradley WG, et al, “Marked CSF flow void: an indicator of successful shunting in patients with suspected normal pressure hydrocephalus” Radiology 178:459-466, 1991.
![Page 42: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/42.jpg)
![Page 43: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/43.jpg)
![Page 44: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/44.jpg)
Enlarged Sylvian cisterns in NPH
![Page 45: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/45.jpg)
![Page 46: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/46.jpg)
![Page 47: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/47.jpg)
Association of DWMI and NPH:Clinical
• Some cases of L’etat Lacunaire(Marie, 1901) may have been NPH (Fischer, 1981)
• Coexistence of NPH and Hypertensive Cerebrovascular Disease Noted Previosly (Earnest 1974, Goto 1977, Graff-Radford 1987)
![Page 48: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/48.jpg)
DWMI: Normal vs NPH IncidenceDWMI
3 2 1
32 19 4
15 26 21
NPH(Groups I & II)
NORMAL(Group IV)
X2= 18.44, p < .001
![Page 49: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/49.jpg)
“Multiple deep cerebral infarctions may be the initial pathologic process in some
cases of NPH”
• Earnest, 1974
![Page 50: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/50.jpg)
DWMI
4 5
8 3
Good
Surgical Response
Poor
Fischer’s Exact Test:
Not significant
Marked Minimal
![Page 51: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/51.jpg)
Conclusion
• There is a significantly greater incidence of DWMI in patients with NPH than in age-matched controls.
Bradley WG, et al. “Association of deep white matter infarction with chronic communicating hydrocephalus:implications regarding the possible origin of normal pressure hydrocephalus” AJNR 12:31-39, 1991.
![Page 52: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/52.jpg)
Conclusions
• CSF flow void is useful indicator of favorable response to CSF diversion
• Presence of DWMI is not contraindication to shunting
• NPH and DWMI may be related
![Page 53: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/53.jpg)
CSF Flow Void
![Page 54: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/54.jpg)
CSF Flow Measurement
• CSF flow void on conventional MR images represents average motion during 256 spin echo acquisitions.
• Since CSF motion is due to cardiac pulsations, it is better evaluated using cardiac gated techniques.
![Page 55: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/55.jpg)
Phase ContrastCSF Velocity Imaging
• “Velocity” is speed plus direction• Flow sensitization along craniocaudal axis
– Flow up: shades of black– Flow down: shades of white– No flow: gray– Set aliasing velocity– Quantification of velocity or flow
![Page 56: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/56.jpg)
Qualitative CSF Velocity Imaging
![Page 57: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/57.jpg)
Quantitative CSF Flow Study
• 512x512; 16 cm FOV• .32 mm pixels• 4mm slice angled perpendicular to aqueduct• Velocity-encode in slice direction• Retrospective cardiac-gating (not EKG
triggering)
![Page 58: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/58.jpg)
Quantitative CSF Velocity
Imaging
![Page 59: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/59.jpg)
Quantitative CSF Flow Study
• Through-plane flow-encoding• Venc= 10, 20, 30 cm/sec (NPH)• Venc= 5 cm/sec (shunt malfunction)
![Page 60: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/60.jpg)
Quantitative CSF Velocity Imaging
![Page 61: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/61.jpg)
Communicating Hydrocephalus
![Page 62: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/62.jpg)
CSF Velocity Imaging
Magnitude image Phase contrast image
HS1
c1
![Page 63: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/63.jpg)
Slide 62
HS1 Health Services, 12/26/2003
uc1 bill Bradley, 10/1/2009
![Page 64: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/64.jpg)
Phase Contrast CSF Flow
![Page 65: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/65.jpg)
![Page 66: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/66.jpg)
Quantitative CSF Flow
• GE: Cine PC 40/min/30 degrees• Siemens: Retrospective Cardiac Gating
– Flash 100/10/15 degrees• Both: 18 Cine Frames
![Page 67: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/67.jpg)
Quantitative CSF Velocity
Imaging
ml/sec
cm/sec
![Page 68: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/68.jpg)
Quantitative CSF Velocity Imaging
• Calculates “Aqueductal CSF stroke volume” • Stroke volume: microliters of CSF flowing
back or forth over cardiac cycle• Verified by pulsatile flow phantom using
ultrasound flow meter (Mullin, 1993)
![Page 69: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/69.jpg)
Materials and Methods
• 20 Patients (age 54-85)• Suspected NPH• Routine MRI of Brain• Quantitative CSF Velocity Imaging• VP Shunt• Follow up at 1 month
Bradley WG, et al, “Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging” Radiology 198:523-529, 1996.
![Page 70: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/70.jpg)
Results• Of 20 shunted patients: • 14 had hyperdynamic flow
– (SV>42 microliters; NB: machine specific!)– 13 had a good surgical response– 1 did not (chronic MS)
• 6 had normal or decreased flow – (SV<42 microliters)– 3 had a good surgical response – 3 did not (concomitant atrophy)
BBradley WG, et al, “Normal-pressure hydrocephalus: evaluation with cerebrospinal fluid flow measurements at MR imaging” Radiology 198:523-529, 1996.
![Page 71: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/71.jpg)
NPH
w
![Page 72: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/72.jpg)
NPH (SV = 121 uL)
![Page 73: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/73.jpg)
Results
• Only 7 of 14 (50%) patients with hyperdynamic flow had prominent aqueductal CSF flow void or routine MR images
• Ubiquitous Flow Compensation; FSE
![Page 74: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/74.jpg)
NPH: preshunting• 75-year-old• Gait disorder• Cognitive
impairment – For about 6
months• No tremor• Bilateral
forced grasp
Courtesy of Joseph Masdeu, MD, PhD, NIH
![Page 75: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/75.jpg)
Hydrocephalus: Before and After
• Treated with a ventriculo-peritoneal shunt
Before After
![Page 76: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/76.jpg)
Improved Gait and Cognition After Shunting
![Page 77: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/77.jpg)
78 Year Old Woman with Suspected NPH
![Page 78: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/78.jpg)
CSF Flow Study: No Flow
![Page 79: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/79.jpg)
CISS: Aqueductal Stenosis
![Page 80: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/80.jpg)
Normal Aqueduct: CISS
![Page 81: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/81.jpg)
Aqueductal Stenosis: FIESTA
64 yo womanR/O NPH
![Page 82: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/82.jpg)
What Causes Idiopathic NPH?
• Consider normal bulk flow of water in brain• Consider association of deep white matter
ischemia (DWMI) and NPH
![Page 83: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/83.jpg)
Normal Bulk Flow of Extracellular Brain Water
• Water leaves upstream arterioles under pressure-osmotic gradients (eg, mannitol)
• Normal and excess water resorbed by downstream capillaries and venules
• Vasogenic edema flows centripetally to be absorbed by ventricles
• Interstitial edema flows centrifugally to subarachnoid space via extracellular space
![Page 84: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/84.jpg)
Idiopathic NPH and DWMI• Both diseases of elderly• Significant association now shown by many• CBF reduced in NPH and DWMI • Acetazolamide challenge: no increase in CBF
– Arterioles already maximally dilated (esp WM)• DWMI more extensive than T2 abnormality
– Magnetization transfer ratio decreased– Apparent diffusion coefficient increased– Increased lactate on proton spectroscopy
![Page 85: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/85.jpg)
Possible Etiology of NPH
• Hypothesis: NPH patients have always had large ventricles (“slightly enlarged”)– Decreased CSF resorption (saline infusion test)– Unrecognized benign external hydrocephalus?
• No evidence for previous SAH or meningitis• Significant CSF resorption pathway is via
extracellular space of brain (like tectal gliomas)• Everything fine until “second hit”: DWMI
• Bradley WG, Neurosurgical Clinics of North America 36:661-684;2001
![Page 86: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/86.jpg)
DWMI is “Second Hit” in NPH • No symptoms until DWMI occurs later in life• Resistance to peripheral CSF flow through
extracellular space increases slightly due to DWMI– loss of myelin lipid: more hydrophilic environment– Greater attraction of outflowing CSF to myelin protein
• CSF production continues unabated– Accumulates in ventricles -hydrocephalus worsens– Increased tangential shearing forces – NPH symptoms begin
• Bradley, WG Neurosurgical Clinics of North America 36:661-684;2001
![Page 87: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/87.jpg)
Aqueductal Stenosis in Elderly
• Also rely on extracellular space of brain for CSF drainage
• DWMI is second hit by increasing resistance to CSF outflow
• Sx: headaches plus triad of NPH• ?Mechanism in 30-ish women (Mayo series)
Little JR, et al, Clinical Manifestations of Aqueductal Stenosis in Adults.J Neurosurg. 1975 Nov;43(5):546-52.
![Page 88: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/88.jpg)
![Page 89: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/89.jpg)
Normal SuctionLow ResistanceGood Flow
Normal SuctionHigh ResistanceLow Flow
Normal SuctionLower ResistanceBetter Flow
Normal 4th ventricularOutflow of CSF
Reduced 4th ventricularOutflow of CSF
Increasesd CSF Outflowthrough 4th Ventricle and Extracellular Space
![Page 90: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/90.jpg)
![Page 91: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/91.jpg)
Increasing Resistance to Extracellular CSF Flow vs
Ventricular VolumeRecs vs. Vvent
0
200
400
600
800
1000
1200
0 2 4 6 8 10 12
Recs
Vven
t
![Page 92: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/92.jpg)
Hypotheses
• If NPH patients had benign external hydrocephalus before 1 year of age, their intracranial volumes should still be larger than sex-matched controls
• If they rely on drainage of CSF through the extracellular space of the brain, the ADC should be elevated for a given degree of DWMI
![Page 93: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/93.jpg)
Materials and Methods• Intracranial volumes measured from T2WIs using
workstation (Vital Images)• 22 men with clinical NPH vs 55 controls
– Ave stroke volume: 159 uL (normal: 42 uL)• 29 women with NPH vs 55 controls
– Ave stroke volume: 127 uL
• Bradley WG, et al, “Increased Intracranial Volume: A Clue to the Etiology of • Idiopathic Normal-Pressure Hydrocephalus?” AJNR 25:1479-1484, 2004
![Page 94: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/94.jpg)
Results: Intracranial Volumes
• NPH men (n= 22): 1682 cc • Control men (n=55): 1565 cc• NPH volumes significantly larger (p<.003)
– 117 cc (7.5%)• NPH women (n=29): 1493 cc• Control women (n=55): 1405 cc• NPH volumes significantly larger (p<.002)
– 88 cc (6.5%)
![Page 95: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/95.jpg)
Implication
• Patients with “slightly enlarged ventricles” for no apparent reason should be observed carefully for onset of gait disturbance in later years
• Probable window of opportunity to treat
![Page 96: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/96.jpg)
ADC: NPH vs Controls
• Apparent Diffusion Coefficient (ADC) profile in 10 pixel wide coronal sections through axial slices through upper lateral ventricles
• ADC measurements in centrum semiovale controlled for a given degree of DWMI
![Page 97: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/97.jpg)
ADC Profile: Mid/Posterior Coronal Location
![Page 98: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/98.jpg)
ADC Profile: NPH vs ControlAnterior Coronal Location
Blue: NPHRed: Control
![Page 99: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/99.jpg)
ADC vs NPH vs Control
AVIM: Asymptomatic Ventriculomegaly with features of iNPH on MRI
![Page 100: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/100.jpg)
67 yo man will be shunted for NPH in 19 years; currently
walking 20 miles a day
1982 CT for giant cell arteritis
![Page 101: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/101.jpg)
1985: Still no NPH symptoms
(now age 70)
![Page 102: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/102.jpg)
1991: Pt (now 76) will development NPH in 10 years
![Page 103: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/103.jpg)
Follow up
![Page 104: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/104.jpg)
Testimonial from 86 yo physician with NPH
• Dr Bradley,
• Your optomistic verbal report to me re: the result of my CSF flow study proved accurate. Ventriculo-peritoneal shunt resulted in substantial improvement. Would it be possible for me to receive a written report for my records.
• Thank you.
![Page 105: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/105.jpg)
55 yo r/o Metastatic Melanoma:Future NPH Patient?
![Page 106: MRI of Hydrocephalus with Thoughts on the Etiology of NPH and... · MRI of Hydrocephalus with Thoughts on the Etiology of NPH William G. Bradley, MD, PhD, FACR Professor and Chair](https://reader035.vdocuments.us/reader035/viewer/2022062504/5a7879407f8b9ab8768b8d07/html5/thumbnails/106.jpg)
Conclusions• NPH diagnosed by symptoms, not MRI• MRI used to confirm diagnosis of
shunt-responsive NPH• Asymptomatic patients may have dilated
ventricles and elevated CSF flow: Pre NPH?• Not everyone with benign external
hydrocephalus gets NPH• Keep your extracellular space open