Abstract

ObjectivesIdiopathic normal pressure hydrocephalus (INPH) is a neurodegenerative disorder characterized by excess cerebrospinal fluid (CSF) in the ventricles, which can be diagnosed by invasive CSF drainage test and treated by shunt placement. Here, we aim to investigate the diagnostic and prognostic power of systematic volumetric analysis based on brain structural MRI for INPH.MethodsWe performed a retrospective study with a cohort of 104 probable INPH patients who underwent CSF drainage tests and another cohort of 41 INPH patients who had shunt placement. High-resolution T1-weighted images of the patients were segmented using an automated pipeline into 283 structures that are grouped into different granularity levels for volumetric analysis. Volumes at multi-granularity levels were used in a recursive feature elimination model to classify CSF drainage responders and non-responders. We then used pre-surgical brain volumes to predict Tinetti and MMSE scores after shunting, based on the least absolute shrinkage and selection operator.ResultsThe classification accuracy of differentiating the CSF drainage responders and non-responders increased as the granularity increased. The highest diagnostic accuracy was achieved at the finest segmentation with a sensitivity/specificity/precision/accuracy of 0.89/0.91/0.84/0.90 and an area under the curve of 0.94. The predicted post-surgical neurological scores showed high correlations with the ground truth, with r = 0.80 for Tinetti and r = 0.88 for MMSE. The anatomical features that played important roles in the diagnostic and prognostic tasks were also illustrated.ConclusionsWe demonstrated that volumetric analysis with fine segmentation could reliably differentiate CSF drainage responders from other INPH-like patients, and it could accurately predict the neurological outcomes after shunting.Key Points• We performed a fully automated segmentation of brain MRI at multiple granularity levels for systematic volumetric analysis of idiopathic normal pressure hydrocephalus (INPH) patients.• We were able to differentiate patients that responded to CSF drainage test with an accuracy of 0.90 and area under the curve of 0.94 in a cohort of 104 probable INPH patients, as well as to predict the post-shunt gait and cognitive scores with a coefficient of 0.80 for Tinetti and 0.88 for MMSE.• Feature analysis showed the inferior lateral ventricle, bilateral hippocampus, and orbital cortex are positive indicators of CSF drainage responders, whereas the posterior deep white matter and parietal subcortical white matter were negative predictors.

Highlights

  • Idiopathic normal pressure hydrocephalus (INPH) is characterized by the clinical triad of dementia, gait dysfunction, and urinary incontinence due to excess cerebrospinal fluid (CSF) buildup in the brain

  • We were able to differentiate patients that responded to CSF drainage test with an accuracy of 0.90 and area under the curve of

  • We aim to evaluate the full potential of volumetric analysis in the diagnosis and prognosis of INPH, using an automatic whole-brain segmentation pipeline [23] that parcellates the brain into 283 structures and allows volumetric analysis at multiple levels of granularity [24]

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Summary

Introduction

Idiopathic normal pressure hydrocephalus (INPH) is characterized by the clinical triad of dementia, gait dysfunction, and urinary incontinence due to excess cerebrospinal fluid (CSF) buildup in the brain. In the absence of any proven medical therapy, surgical placement of a shunt to drain excess CSF is shown to be an effective treatment [1, 2], controversy remains [3]. Diagnosis of INPH, is challenging because its clinical and radiological presentations occur in aging, cerebrovascular disorders, neurodegenerative diseases, and other forms of hydrocephalus [4]. One of the most effective tests is CSF removal by a large volume lumbar puncture (LVLP) or extended CSF drainage by lumbar drainage (ELD) [4]. The feasibility of using non-invasive neuroimaging tools, i.e., MRI, to replace or complement the invasive test has been recently investigated [6,7,8,9]

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