CSF Tap Research Articles

Predictive Ability of Frontal Assessment Battery for Cognitive Improvement After Shunt Surgery in Individuals With Idiopathic Normal Pressure Hydrocephalus.

The predictive ability of the Frontal Assessment Battery (FAB) for postoperative cognitive improvement in idiopathic normal pressure hydrocephalus (iNPH) is unstudied. To compare the predictive ability of the FAB and the Mini-Mental State Examination (MMSE) for postoperative cognitive improvement in individuals with iNPH after shunt surgery. We retrospectively reviewed the medical records of individuals with iNPH who had shunt surgery between January 2016 and October 2018. Individuals had completed the tap test and clinical evaluations (FAB, MMSE, Timed Up and Go [TUG]) both before and 24-48 hours after CSF tapping and after surgery. We excluded individuals without complete clinical evaluations and those with shunt surgery performed >6 months after CSF tapping. Factors associated with postoperative FAB and MMSE improvement as per the 2011 iNPH guidelines were extracted using univariate and multivariate logistic regression analyses. Independent variables were baseline FAB and MMSE scores, FAB and MMSE score changes and TUG amelioration rate after CSF tapping, Evans index, age, and days from CSF tapping to surgery and from surgery to postoperative assessment. The mean number of days from CSF tapping to surgery and from surgery to postoperative assessment were 77.5 (SD = 36.0) and 42.0 (SD = 14.5), respectively. Logistic regression analyses showed significant associations in the univariate analyses of postoperative FAB improvement with baseline FAB scores ( P = 0.043) and with FAB score changes after CSF tapping ( P = 0.047). The FAB may help predict postoperative cognitive improvement after shunt surgery better than the MMSE.

A Case of Road Traffic Accident with History of Right Distal Femur Fracture Compound Grade 3b Posted for External Fixation under (TIVA) Total Intravenous Anaesthesia using Supraglottic Airway Device IGEL after Dry CSF tap on SAB (Subarchnoid Block): (Case Study)

A Case of Road Traffic Accident with History of Right Distal Femur Fracture Compound Grade 3b Posted for External Fixation under (TIVA) Total Intravenous Anaesthesia using Supraglottic Airway Device IGEL after Dry CSF tap on SAB (Subarchnoid Block): (Case Study)

Sustained Effect 1 Month After CSF Tap Test in Normal Pressure Hydrocephalus

AbstractBackgroundThe response to CSF tap test (TT) has been considered an indicator of normal pressure hydrocephalus (NPH) and a predictor of shunt effectiveness. Although the effects of the CSF TT are thought to be transient, the duration of those effects has not been studied in detail.MethodWe performed a retrospective analysis of 32 consecutive patients with NPH who underwent quantitative gait analysis before, immediately after, and 1 month after the CSF TT. Responses to the TT were defined as a 15% or greater improvements in step length or walking speed.ResultImmediately after the CSF TT, 24 of 32 patients showed a response on step length or walking speed. Among the 24 patients with a response immediately after the TT, a sustained response 1 month after the TT was maintained in 16 patients. Furthermore, among the 8 patients without an immediate response, 5 patients showed a delayed response 1 month after TT.ConclusionThe effects of the CSF TT on gait parameters were sustained for 1 month in approximately half of the patients with NPH. Decreased tensile strength of the ventricular wall after the TT might explain the sustained effects.

INPH and parkinsonism: A positive shunt response with a negative tap test.

The aim of this study was to compare clinical and functional performances of idiopathic normal pressure hydrocephalus (INPH) patients with and without parkinsonism at the initial evaluation, 72 h after the cerebrospinal fluid tap test (CSF TT), and 6 months after ventriculoperitoneal shunt (VPS) surgery. This is an observational prospective study on patients with INPH who underwent VPS. Patients were classified into INPH with parkinsonism (INPH-P+) and without parkinsonism (INPH-P-). We used the time up and go (TUG) test, Tinetti Performance-Oriented Mobility Assessment (POMA) test, INPH grading scale (INHPGS), and modified Rankin scale (mRS) at baseline, 72 h after CSF TT, and 6 months after VPS surgery. A total of 64 patients with probable INPH were included, 12 patients with INPH-P+ and 52 controls with INPH-P-. Patients with INPH showed significant improvement in all clinical and neurological parameters after VPS including TUG, Tinetti POMA, INPHGS, and mRS (p < 0.001) with the exception of mRS where there was no significant change 72 h after CSF TT compared to baseline for patients with INPH (p = 0.182). Patients with INPH-P+ performed significantly worse than patients with INPH-P- on Tinetti POMA and mRS at baseline, at 72 h post-CSF TT, and at 6 months post-VPS with INPHGS being worst at 72 h post-CSF TT. There was no difference between patients with INPH-P+ and patients with INPH-P- for TUG at baseline (p = 0.270), at 72 h post-CSF TT (p = 0.487), and at 6 months post-VPS (p = 0.182). Patients with INPH-P+ did not show any change in any of the parameters at 72 h post-CSF TT compared to baseline; however, there was a trend toward improvement on TUG (p = 0.058), Tinetti gait (p = 0.062), and Tinetti total (p = 0.067). INPH-P+ significantly improved in all parameters 6 months post-VPS compared to baseline except for mRS (p = 0.124). Patients with INPH-P- significantly improved in all parameters at 72 h post-CSF TT and at 6 months post-VPS compared to baseline, respectively, except on mRS 72 h after CSF TT (p = 0.299). Patients with INPH and parkinsonism overall do worse than patients without parkinsonism. An unsatisfying response to the CSF tap test in INPH patients with parkinsonism should not be used as an exclusion criterion from VPS surgery since patients with and without parkinsonism showed significant improvement post-VPS.

Studying Effect of Therapeutic CSF Tapping on Outcome of Patients with Idiopathic Intracranial Hypertension through Blink Reflex

Studying Effect of Therapeutic CSF Tapping on Outcome of Patients with Idiopathic Intracranial Hypertension through Blink Reflex

Can parkinsonian gait be a predictor of unresponsiveness to CSF tap test in normal-pressure hydrocephalus?

Can parkinsonian gait be a predictor of unresponsiveness to CSF tap test in normal-pressure hydrocephalus?

The PUMCH Evaluation System of Idiopathic Normal Pressure Hydrocephalus and Clinical Practice

Differentiating idiopathic normal pressure hydrocephalus (iNPH) from other neurodegenerative diseases is challenging. Only a portion of the patients clinically suspected of iNPH would respond to surgical intervention. A cerebrospinal fluid (CSF) tap test is usually used to predict surgery outcomes and hence aid clinical decision-making, but the workup varies. We introduce the CSF tap test conducted at our center and examine its power by analyzing data from a series of iNPH cases that underwent shunt placement. We analyze common features in the past medical history of our patients and investigate whether they are related to the etiology of iNPH. Data from 20 patients who were positive in the tap tests preoperatively and received ventriculoperitoneal shunting (VPS) were retrospectively analyzed. Preoperative and postoperative performance data were analyzed. History of any underlying medical conditions was taken into consideration. Patients with negative tap test results of the same period were also followed up. We performed VPS placement in 20 NPH patients from October 2019 to February 2022. Of these, 90% exhibited improvement in at least 1 of the clinical triad, proving the predictive power of the Peking Union Medical College Hospital test workflow. The underlying conditions like hypertension, diabetes and insufficiency in cerebral blood supply were also found to be associated with the onset of NPH. Our evaluation system is a valid tool for NPH assessment and can guide clinical decision-making. Comorbidities should be taken into consideration as they contribute to the pathogenesis and progression of NPH. Better identification of potential iNPH patients will lower the burden exerted on the family and the aging society.

Accuracy of MRI CSF Flowmetry in the Diagnosis of Normal Pressure Hydrocephalus

BACKGROUND: Normal pressure hydrocephalus (NPH) is one of the few treatable causes of dementia. NPH is diagnosed using the clinical triad of: Gait disturbance, progressive mental deterioration, urinary urgency, or incontinence in association with radiological findings suggestive of NPH, for example, ventriculomegaly, disproportionately enlarged subarachnoid space hydrocephalus, and narrow callosal angles. AIM: The purpose of the present study was to assess the accuracy of MRI cine phase flow studies as a non-invasive modality in the diagnosis, and also for the prediction of improvement of symptoms suggestive of NPH without the need for CSF tapping. METHODS: Twenty-six patients suffering clinically from the triad of NPH, or at least two of them; attending our neurology, psychiatry, and neurosurgery clinics in Cairo University Hospitals, with ages ranging between 50 and 85 years, randomly chosen regarding sex or other comorbidities. All patients underwent a regular MRI in addition to CSF flowmetry studies to correlate the MRI findings that reveal NPH with their known clinical features. Careful clinical assessment was performed to detect severity of symptoms, and patients were classified accordingly, and a disability score was provided. After CSF tapping, patients were reassessed clinically after 6–8 h to detect improvement of symptoms, and the degree of improvement was compared to the result of CSF flow study. RESULTS: CSF flow studies, particularly stroke volume across the aqueduct of Sylvius, provide the highest significance in diagnosing hyperdynamic circulation evident by many radiological studies in cases of NPH. This was also found to be a good prognostic factor which correlates well with the improvement of symptoms following CSF tapping. However, its use to exclude suspicious cases of NPH seems unreliable, that is, not a good negative predictor. Findings of MRI CSF flow studies also show significance in detecting brain atrophic changes, especially peak systolic velocity, which usually accompany or mimic the clinical picture of NPH. CONCLUSION: MRI CSF flow studies are an excellent aid as an adjuvant non-invasive technique in selection of suspicious cases as it shows significance in detecting hyperdynamic circulation, especially high stroke volume results in cases of NPH. Both CSF tapping and CSF flowmetry findings “low stroke volume values” were not found to be a good negative predictor for clinical improvement after shunting.

CSF Biomarkers Predict Gait Outcomes in Idiopathic Normal Pressure Hydrocephalus.

Background and ObjectivesThe assessment of biomarkers in selecting patients with idiopathic normal pressure hydrocephalus (iNPH) for shunt surgery has been limited to small cohort studies and those with limited follow-up. We assessed the potential for CSF biomarkers in predicting immediate response to CSF tap test (TT) and long-term response after shunt surgery.MethodsCSF was obtained from patients with iNPH referred for CSF TT after baseline assessment of cognition and gait. CSF neurofilament light (NfL), β-amyloid 42 (Aβ1–42), β-amyloid 40 (Aβ1–40), total tau (tTau), and phosphorylated tau 181 (pTau181) and leucine-rich alpha-2-glycoprotein-1 (LRG1) were measured by ELISA. The ability of these measures to predict immediate improvement following CSF TT and long-term improvement following shunt surgery was compared by univariate and adjusted multivariate regression.ResultsLower NfL, pTau181, tTau, and Aβ1–40 were individually predictive of long-term improvement in gait outcomes after shunt surgery. A multivariate model of these biomarkers and MRI Evans index, adjusted for age, improved prediction (area under the receiver operating curve 0.76, 95% confidence interval 0.66–0.86). tTau, pTau181, and Aβ1–40 levels were statistically different in those whose gait improved after CSF TT compared with those who did not. Using a multivariate model, combining these markers with Evans index and transependymal flow did not significantly improve prediction of an immediate response to CSF TT.DiscussionA combination of CSF biomarkers can predict improvement following shunt surgery for iNPH. However, these measures only modestly discriminate responders from nonresponders following CSF TT. The findings further suggest that abnormal CSF biomarkers in nonresponders may represent comorbid neurodegenerative pathology or a predegenerative phase that presents with an iNPH phenotype.

A pilot study of multiple time points and multidomain assessment in cerebrospinal fluid tap test for patients with idiopathic normal pressure hydrocephalus

ObjectiveOur study aimed to identify the appropriate evaluation time point and assessment forthe CSF tap test(TT) to predict the shunting responsiveness of patients with idiopathic normal-pressure hydrocephalus (iNPH). MethodsEighty-eight inpatients with clinically possible iNPH who underwent CSF TT at multiple time points (baseline, 8 hours, 24 hours, and 72 hours after CSF TT) at Peking Union Medical College Hospital were recruited. The multidomain assessment included the timed up and go test(TUG), 10-meter walking tests, and a brief executive function battery. Performance in multidomain assessment at the indicated time points were compared. The positive response rate and cumulative positive rate of multidomain assessment at multiple time points were calculated. And their corresponding specificity and sensitivity of predicting shunting response were calculated according to the follow-up results after shunting. ResultsThe multidomain assessment performance except TUG at 8 hours were significantly improved at each time point after CSF TT compared with baseline (P<0.01). Reduction more than 10% in the 10-meter walking time and number of steps at 24 hours showed the highest specificity (both 85.7%) and sensitivity (37.5% and 46.7%, respectively) for predicting shunting response. Additionally, an improvement of more than 20% in the composite z score at 72 hours showed 100% specificity and 80% sensitivity for predicting shunting response. ConclusionMultiple time points and multidomain assessment were helpful to identify more shunting responders. Executive function evaluation might be a candidate tool to increase the effectiveness of CSF TT.

Evaluation of the effect comorbid Parkinson syndrome on normal pressure hydrocephalus assessment

ObjectiveThe primary aim of the study was to assess the effect comorbid Parkinson syndromes have on results of CSF tap test (TT) and shunt outcomes for patients presenting with Normal Pressure Hydrocephalus (NPH). We hypothesized that patients with possible NPH and comorbid Parkinson syndromes with Positive DaT scans will not respond to CSF TT at the same rate as patients without comorbid Parkinson syndromes. Additionally, we followed a small number of patients with positive DaT scans who were shunted to assess long term outcome of comorbid Parkinson syndromes. MethodsMedical records and neurological exams of 251 patients were reviewed. In our analysis 101 patients with no parkinsonian symptoms and no DaT scans were included as a control group, there were 52 patients with DaT scans, 31 patients were positive (DaT-P). Gait measures were assessed before and after CSF TT using the Wilcoxon matched-pairs signed-rank test or paired t-tests were used. To compare the effect of DaT-P and Control, we used an ANCOVA controlling for age, sex, assistive device used, and past medical history effecting gait. ResultsThere was not a significant difference in response between Control and DaT-P group. The Control group improved on timed up and go (TUG) by 14.82%, DualTUG 16.35%, 10-meter Walk Test (10MWT) 18.13%, MiniBEST 15.91%, and 6-minute Walk Test (6MWT) 13.96%, while the DaT-P group improved on TUG by 14.93%, DualTUG 17.24%, 10MWT 22.68%, MiniBEST 18.07%, and 6MWT 16.06%. ConclusionOur findings suggest that patients with possible NPH and suspected comorbid movement disorder, showed similar improvement after diagnostic CSF TT compared to participants with no parkinsonian symptoms present on exam. Data availability statementData relevant to the study will be made available from the corresponding author upon a reasonable request.

Endoscopic third ventriculostomy in post traumatic hydrocephalus- Institutional experience

Introduction: Hydrocephalus is a known sequelae in traumatic brain injury patients. It may occur early or late and presents with dementia, urinary incotinence and difficulty in walking as described by Hakim and Adams. There are two distinct types of normal pressure hydrocephalus one is idiopathic most commonly seen in the elderly age groups and the other is secondary due to a cerebro vascular accident, trauma or surgery. The idiopathic type may not respond to the CSF diversion procedure, but the secondary type which responds to CSF diversion procedure. Our study aims at exploring the option of ETV in these patients not making them shunt dependent. Materials and Methods: The patients with traumatic brain injury admitted in the dept. of neurosurgery between January 2012 and January 2018 were included into the study. Congenital hydrocephalus and secondary hydrocephalus due to spontaneous SAH and tumours were excluded. 14 patients were identified and if there was some improvement in their condition after CSF tap test were planned for endoscopic third ventriculostomy. Results: Out of the 14 patients 2 were females and the remaining 12 were males. 2 did not improve at all. 12 had some improvement out of which 3 had a failure and underwent a v-p shunt. Hence there were 5 failures out of 14 which made 35.7%. Mitchel et al and Michelangelo et al reported 72-75% success rates in their study which is similar to our results. Conclusion: ETV is an option which can be offered to patients with secondary hydrocephalus. The chances of failure though present the procedure is minimally invasive and improves CSF dynamics. Keywords: Secondary hydrocephalus due to trauma, Endoscopic third ventriculostomy, Trauma induced hydrocephalus.

Dynamic functional networks in idiopathic normal pressure hydrocephalus: Alterations and reversibility by CSF tap test.

Idiopathic Normal Pressure Hydrocephalus (iNPH)—the leading cause of reversible dementia in aging—is characterized by ventriculomegaly and gait, cognitive and urinary impairments. Despite its high prevalence estimated at 6% among the elderlies, iNPH remains underdiagnosed and undertreated due to the lack of iNPH‐specific diagnostic markers and limited understanding of pathophysiological mechanisms. INPH diagnosis is also complicated by the frequent occurrence of comorbidities, the most common one being Alzheimer's disease (AD). Here we investigate the resting‐state functional magnetic resonance imaging dynamics of 26 iNPH patients before and after a CSF tap test, and of 48 normal older adults. Alzheimer's pathology was evaluated by CSF biomarkers. We show that the interactions between the default mode, and the executive‐control, salience and attention networks are impaired in iNPH, explain gait and executive disturbances in patients, and are not driven by AD‐pathology. In particular, AD molecular biomarkers are associated with functional changes distinct from iNPH functional alterations. Finally, we demonstrate a partial normalization of brain dynamics 24 hr after a CSF tap test, indicating functional plasticity mechanisms. We conclude that functional changes involving the default mode cross‐network interactions reflect iNPH pathophysiological mechanisms and track treatment response, possibly contributing to iNPH differential diagnosis and better clinical management.

A pilot study on the positive rate of multi‐time point and multiple domain evaluation in cerebrospinal fluid tap test of patients with normal pressure hydrocephalus

AbstractBackgroundThe CSF tap test evaluation vary a lot in different medical center, which result in the wide range of sensitivity. Our study aimed to explore the effect of multi time point and multiple domain evaluation on the determination of CSF tap test results in patients with normal pressure hydrocephalus.MethodA total of 150 outpatients with NPH 2013‐2018 from the Department of Neurology of Peking Union Medical College Hospital were enrolled in this study. All patients underwent detailed neuropsychological (MMSE, MOCA, Trail Making Test , Digital Symbol, Stroop‐c test, Grooved pegboard test) and walking ability (10 meter walking test, 5 meter up and go test), and head MRI examination. Patients who did not complete the four time point’s evaluation of CSF tap test to eliminate severe dementia and various reasons. The positive criteria were that the performance of either time or steps in walking test was 20% higher than the baseline level, or both were 10% higher. In the cognitive test, the score of any test is 20% higher than the baseline as a positive criterion. According to this standard, the positive rates of each evaluation test and three evaluation time points were calculated and compared.ResultThe positive rate of 5 meter up and go test on 8 hours, 24 hours and 72 hours after CSF tap test was 40.6%, 42.0%, 48.9%, the positive rate of 10‐meter walking test was 35.8%, 30.9%, 40.7% respectively; the positive rate of Digital Symbol was 23.8%, 38.1%, 42.9% respectively; the positive rate of Trail Making T test was 38.7%, 45%, 57.9%; the positive rates of Stroop‐c performance were 27.0%, 39.3% and 49.1% respectively; the positive rates of Grooved pegboard test on 8 hours, 24 hours and 72 hours after CSF tap test were 25%, 27.9% and 39.7%.ConclusionThe positive rate of 5 meter up and go test is higher than that of 10 meter walking test, and the positive rate of 24‐hour and 72 hour comprehensive evaluation combined with walk and cognitive evaluation is higher.

The changing of cognitive function and the influence of learning effect on the results before and after the CSF tap test in patients with normal pressure hydrocephalus

AbstractBackgroundThe CSF tap test evaluation needs repetitive test of walking ability and cognition. Our study aimed to explore the changes of cognitive function and the influence of learning effect on the results in CSF tap test when evaluating the patients with normal pressure hydrocephalus (NPH).MethodCSF tap test was carried out in 134 patients with NPH 2013‐2018 in neurology clinic of Peking Union Medical College Hospital. All patients underwent detailed neuropsychological evaluation (MMSE, MOCA, Trail Making test, Digital symbol, Stroop‐c test) and walking ability (10 meter walking test, up and go test), and head MRI examination. Patients who did not complete the four time point evaluations of CSF tap test due to severe dementia or any other reasons were excluded. Nonparametric test was used to test the difference of z‐scores of executive function (including connection test, number sign and shop‐c test) between the baseline and the four time points after CSF tap test. According to the baseline MMSE scores, the subjects were divided into MMSE &gt; = 26 and MMSE &lt; 26 groups. The changes of z‐scores of three executive function tests were observed in the group.ResultCompared with the baseline, the Z‐score of executive function began to improve at 24 hours and 72 hours, and there was a statistically significant difference (P 0.001 and 0.000, respectively). Within the MMSE &gt; = 26 group, there was a significant improvement in executive function at 24 hours and 72 hours compared with baseline (P &lt;0.05). In the group with MMSE &lt; 26, the executive function Z‐score at 72 hours was significantly improved compared with that at baseline (P = 0.000), while the improvement at 8 hours and 24 hours was not significant.ConclusionIt was found that the executive function of CSF was improved with different evaluation points. According to the classification of MMSE scores, it was found that patients with different cognitive states had different characteristics of executive function curve, which could not be explained by learning effect.

P1‐322: APPLICATION OF GROOVED PEGBOARD TEST IN CEREBROSPINAL FLUID TAP TEST OF PATIENTS WITH IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS

Motor impairment in NPH can extend beyond gait to include deficits in upper extremity functions and psychomotor speed. The upper extremity function evaluation will be helpful for the NPH patients who are unable to ambulate (e.g. patients is wheelchair bound) may not be able to comply with the gait evaluation. Our study aimed to explore the role of grooved pegboard test in evaluating cerebrospinal fluid tap test in patients with idiopathic normal pressure hydrocephalus. The patients with possible idiopathic normal pressure hydrocephalus in the outpatient clinic, the department of neurology, Peking Union Medical College Hospital from 2013 to 2017 were enrolled. All patients underwent detailed neuropsychological and walking assessments, as well as head magnetic resonance imaging. Forty-three patients with iNPH were recruited in the study, excluding patients with severe dementia and those who did not complete the four time points evaluation of CSF tap test for various reasons. The correlation between grooved pegboard test performance and other clinical assessment were analyzed. In DTI analysis of white matter, the FA and MD values of 19 regions of interest were measured by ROI method. The correlation between grooved pegboard test performance and the white matter lesions were also analyzed. There was no significant difference in the results of CSF tap test between positive and negative patients. The results of the grooved pegboard test were significantly correlated with patients' walking ability (10 m walking time, 5 m up-go test time), cognitive function (MMSE, MOCA, Trail Making Test A Z score, digital symbol Z score, STROOP-C Test Z score) and functional score (ADL, iNPHGS total score, iNPHGS walking, iNPHGS cognition) (P < 0.05). The time of left grooved pegboard test was significantly correlated with FA value of right periventricular lesions (P=0.017). The performance of the grooved pegboard test was related to lower extremity motor ability and cognitive function. It can be used as an alternative evaluation tool for patients who are unable to ambulate and may not be able to comply with the gait evaluation. This project was supported by grant from CAMS 2016-12M-1-004, National NSFC81550021, 2016YFC1306300, grant XDPB10.

Evaluation of Efficacy of Different Identification Tests to Distinguish Cerebrospinal Fluid from Local Anaesthetic Solution: A Comparative Study

Background: Local anaesthetics (LAs) are used clinically for anaesthesia and analgesia either following surgery or for management of other acute and chronic pain conditions; they only last a few hours. Various methods have been mentioned in the past literature for differentiating the CSF and the local anaesthetic solutions. Hence; we planned the present study to check and compare the efficacy of simple identifications tests to distinguish local anesthetic solutions from CSF. Materials & Methods: We planned the present study to compare the efficacy of simple identifications tests to distinguish local anesthetic solutions from CSF. We involved five experienced anesthetists for the present study. Both the anesthetics were asked to identify 0.1 ml sample of bupivacaine and mock CSF (tap water) by each of four physicochemical characteristics based on criteria: Temperature, pH, Presence of glucose, and Turbidity when mixed with thiopentone. The anesthetics involved in the present study were unaware of the results. All the results were recorded on excel sheet and were analyzed by SPSS software. Results: The two test solutions were identified conveniently together with the four physiochemical tests. However; the anesthetics were not able to identify and differentiate the solutions clearly with individual tests. Conclusion: Anesthetist should be accustomed with different physicochemical methods available for differentiating between CSF and local anaesthetic solution. However; no single test appears to have complete reliability. Therefore, combinations of tests must be used.

Computerized gait analysis with inertial sensor in the management of idiopathic normal pressure hydrocephalus.

Gait disturbance (GD) is usually the first and most prominent symptom observed in idiopathic normal pressure hydrocephalus (iNPH). The reversibility of symptoms is related to early diagnosis and treatment. Nowadays early recognition of patients is challenging because GD in the elderly is frequently neglected, leading to late diagnosis and increased disability. In addition, GD is generally assessed by clinical evaluation since computerized gait analysis methods are rarely available. In the present study, we demonstrate the clinical application of an inertial sensor system for gait analysis in iNPH. The primary aim was to test the sensor performance in quantifying impairment in gait parameters in iNPH. The secondary aim was to detect a range of improvement after CSF subtraction test, which could be considered as predictive of favorable shunt response. We performed a case-control prospective study from March 2012 to May 2014. Inpatients at the Division of Neurology, Department of Clinical and Experimental Sciences, Brescia. We enrolled 79 patients with clinical and radiological findings of iNPH and 300 healthy adults over 70 years old without GD as a control group. We performed gait analysis, CSF Tap Test (TT), and shunt surgery in all patients with a diagnosis of iNPH according to the International Guidelines. According to clinical outcomes, we divided patients in responsive (group A) and non-responsive (group B). We then compared pre-operative gait analysis of group A with the control group, and calculated the percentage of improvement after TT between group A and group B. Shunt surgery was performed in 52 patients. After 3 months, 35 patients (group A: 67.3%) showed a positive response to shunt. We quantified the impaired gait parameters in iNPH and assessed the differences with controls. Improvement of speed, stride length and double support time after TT was predictive of positive shunt response. The proposed inertial sensor system is a reliable and easy-to-use system for early detection of iNPH and may be used in any clinical setting. Identification of a GD pattern for iNPH, especially in rehabilitation, may be useful for recognizing patients who are candidates for surgery, thus avoiding permanent disability.

Change in average peak cerebrospinal fluid velocity at the cerebral aqueduct, before and after lumbar CSF tapping by the use of phase contrast MRI, and its effect on gait improvement in patients with normal pressure hydrocephalus.

To compare the change in peak cerebrospinal (CSF) flow velocity at the cerebral aqueduct in patients with normal pressure hydrocephalus (NPH) before and after CSF tapping with clinical outcome of the patients, i.e., gait improvement. Forty patients with NPH were evaluated before and after CSF tapping on 3 consecutive days at our institution. Gait improvement was compared with the average peak velocity at the cerebral aqueduct. The average peak velocity was also compared before and after lumbar CSF tapping using phase contrast magnetic resonance imaging (PC-MRI). The different flow parameters were compared using paired t-test. The average peak velocity before and after lumbar CSF tapping was 5.8196 ± 1.420 cm/s and 4.1411 ± 1.0638 cm/s, respectively. The peak positive, negative, and average velocity decreased in the post-tap group. In our study, 70% of the patients showed gait improvement, and a comparison of the gait improvement with the change in average peak velocity was statistically significant (P = 0.001). Comparison of the change in peak positive and negative velocity with gait improvement was also statistically significant, with a P value of 0.004 and <0.001, respectively. Rest of the CSF flow parameters were statistically insignificant. PC-MRI is a sensitive method to support the diagnosis of NPH. Different flow parameters were comparable before and after CSF tapping. The parameters which might be useful for assessing clinical improvement include a change in the peak average, as well as positive, and negative velocity.

Transcriptomics of toll like receptor signaling pathway in children with acute bacterial meningitis

Background : The invading bacterial pathogens are recognized by a class of pathogen recognition receptors (PRRs) called Toll Like receptors (TLRs) present on immune cells. PRRs play an important role in elimination of pathogens in early part of the disease but also results in unabated inflammation. There is a sparse literature on TLR transcriptome and their role in mediating immune response in bacterial meningitis. Methods : Children hospitalized with bacterial meningitis (ABM, n=30) and aseptic meningitis (ASM, n=11) were enrolled. Controls (n=15) included the children, where CSF tap didn’t yield any infection on lab investigation. The gene expression profile of forty-two genes of TLR signaling pathway was performed using PCR array platform. Further, these results were validated by estimating secretory cytokines and chemokines in CSF using Luminex platform and western blotting. Results : We observed an increased expression of TLR2 (2 folds),TLR3 (13 folds), TLR8 (3 folds), TLR9 (20 folds), CD180(8 folds), TICAM1 and TIRAP dependent signaling pathway genes including of TNF? (8 folds), IL6 (114 folds), IL12 (64 folds), IL10 (17 folds), CCL4 (18 folds), CCL5 (7 folds) and CXCL8 (31 folds) in children with ABM. The protein expression of TLR signaling genes (TLR3,TNF?,IL-1ÃY, IL-6,IL-8, IL10,IL1ra) was observed to increase in children with ABM in comparison with ASM and controls. Further, we also observed higher CSF levels of IL-1ÃY, IL-6, IL-17, IL1ra, IL-8, MCP-1 & RANTES in children with ABM as compared to ASM and controls. Conclusion : An overall upregulation of TLRs and downstream TLR signaling molecules was observed. This subsequently resulted in increased levels of inflammatory cytokines and chemokines in children with ABM. The study provides an insight to role of TLR signaling in augmentation of immune response in pediatric bacterial meningitis which can be further explored for therapeutic intervention to regulate unabated inflammatory process in bacterial meningitis.