Clinical Proof of the Importance of Compliance for Hydrocephalus Pathophysiology
Recently decreased compliance is discussed as an initially disturbed CSF hydrodynamic parameter in hydrocephalus.
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Abstract Introduction Recently decreased compliance is discussed as an initially disturbed CSF hydrodynamic parameter in hydrocephalus. Materials and Methods In 180 patients with suspected chronic hydrocephalus we performed a dynamic infusion test, which was not used for shunt indication. Shunt indication was based on long-term ICP monitoring. Follow-up was 4.6 ± 1.8 years. Statistics: Spearman-, Kruskal–Wallis-, Wilcoxen-U-test. Results Resistance to outflow (Rout) and Pressure Volume Index (PVI) alone provide positive predictive values (PPV) and sensitivity, which might be sufficient in daily practice, while negative predictive values (NPV) and specificity are weak. With an intelligent combined algorithm of Rout and PVI at a critical value of ROF of 13 mm Hg/ml × min and 30 ml, a clearly improved outcome prediction is possible. Conclusion These clinical results support recent opinions concerning the meaning of Compliance and Rout in hydrocephalus patho-physiology. Keywords Hydrocephalus • shunt • outcome • normal pressure hydrocephalus • iNPH • resistance to outflow • Rout • Compliance • PVI • CSF hydrodynamics
Introduction Since the introduction of tests to measure cerebrospinal fluid (CSF) hydrodynamics (e.g. Resistance to outflow (Rout), Compliance (C) and Pressure Volume Index (PVI)) in the past M. Kiefer () Department of Neurosurgery, Saarland University Medical School, Kirrberger Street, Building: 90.1, Homburg-Saar 66421, Germany e-mail: [email protected] R. Eymann Department of Neurosurgery, Medical School, Saarland University, Kirrberger Street, Building 90, Homburg-Saar, Saarland 66421, Germany
decades, the value of hydrodynamics for the outcome prediction of potential shunt candidates, especially when suffering from idiopathic normal pressure hydrocephalus (i-NPH), has been controversially discussed (6–9, 11, 15, 19, 20). In communicating hydrocephalus with defective CSF absorption, as supposed underlying pathology, only Rout and not Compliance or PVI has been studied routinely in the past. Some milestone contributions with modern flow-sensitive techniques of magnetic resonance imaging (MRI) have proposed a quite different hydrocephalus pathophysiology, with decreased compliance as the initial disturbed hydrodynamic parameter, interpreting Rout elevation solely as an epiphenomenon (1–3, 12). Against the background of this convincing, revolutionary new understanding of hydrocephalus, a clarification of the value of compliance or PVI for shunt indication was lacking. In this prospective study we aimed to perform a comparative analysis of the value of all available hydrodynamic parameters for selecting shunt responders.
Materials and Methods Patients, Indication Policy, Follow-Up and Documentation In a total of 180 patients with suspected chronic hydrocephalus, intracranial pressure (ICP) was measured for 48 hours using an intraventricular Spiegelberg III probe connected to a personal computer with specific software for ICP analysis (14). Furthermore, directly after the Spiegelberg III probe
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