Chen Ya-Fang, Wang Yao-Hong, Hsiao Jong-Kai, Lai Dar-Ming, Liao Chun-Chih, Tu Yong-Kwang, Liu Hon-Man
Department of Medical Imaging and Radiology, Hospital and Medical College, National Taiwan University, Taipei, Taiwan.
Surg Neurol. 2008 Dec;70 Suppl 1:S1:69-77; discussion S1:77. doi: 10.1016/j.surneu.2008.08.079.
Regional CBF study has been reported effective in the selection of patient with NPH. However, controversial outcome had been reported. We sought to determine if the combination of rCBF measurement, cerebrovascular reactivity, and regional metabolism were positive predictors of shunt responsiveness in NPH syndrome.
Twenty-eight patients with clinical diagnosis of NPH were enrolled to study their rCBF in CSWM before and after the ACT challenge test, the regional CSWM metabolism by MRSI, and the clinical grading by the CSRIH defined by the Ministry of Health and Welfare of Japan in 1996. All the patients received VP shunting procedure by the same neurosurgical team. The pre- and postoperative clinical conditions were recorded. A patient was considered as "responder" when the patient's CSRIH total score decreased by one or more points. Patients have been followed for a median duration of 40.6 months (range, 28-67 months) with Karnofsky performance scale.
Twenty-three responders had significant improvement after VP shunting in clinical grading; 5 nonresponders were stationary after VP shunting. During the 3 years of follow-up, 5 of the 28 patients died, the other 6 were lost to follow-up (including telephone contact), and 3 had progressive deterioration. The prechallenge rCBF decreased in all the 28 subjects. In the 23 responders, the rCBF after challenge were greater than 20 mL/min per 100 g (P=.008), had a significantly better CRC in the anterior CSWM than the nonresponders (1.40 vs 1.06), and had normal NAA/Cre ratio in the anterior, middle, and posterior CSWM in MRSI study. In those nonresponders, the NAA/Cre ratio was less than 0.8 in at least 2 regions of CSWM, and in 23 patients with symptoms other than ataxia (dementia, incontinence), the NAA/Cre ratio was less than 1.5 at frontal CSWM area. Discharge CSRIH scale was well correlated with CRC (P<.03), the average ACT challenge CBF (P<.005), and the average rCBF (P<.02). There was a statistically significant correlation between discharge CSRIH scale and follow-up performance at 3 months (P=.017), 2 years (P=.018), and 3 years (P=.038).
Measurement of cerebrovascular hemodynamic and regional metabolism can be a good predictor of outcome after shunting in patients with NPH. Magnetic resonance spectroscopic imaging at frontal CSWM has good correlation with clinical symptoms. After VP shunting procedure, the discharge CSRIH scale is a good predictor of long-term outcome of patients with NPH.
据报道，局部脑血流量（CBF）研究在正常压力脑积水（NPH）患者的筛选中有效。然而，也有相互矛盾的结果报道。我们试图确定rCBF测量、脑血管反应性和局部代谢的组合是否为NPH综合征分流反应性的阳性预测指标。
纳入28例临床诊断为NPH的患者，研究其在乙酰唑胺（ACT）激发试验前后脑桥正中矢状位（CSWM）的rCBF、磁共振波谱成像（MRSI）测量的局部CSWM代谢以及日本厚生省1996年定义的CSRIH临床分级。所有患者均由同一神经外科团队进行脑室-腹腔（VP）分流手术。记录术前和术后的临床情况。当患者的CSRIH总分降低1分或更多分时，该患者被视为“有反应者”。采用卡氏功能状态量表对患者进行了中位时间为40.6个月（范围28 - 67个月）的随访。
23例有反应者在VP分流术后临床分级有显著改善；5例无反应者在VP分流术后病情无变化。在3年的随访中，28例患者中有5例死亡，另外6例失访（包括电话联系），3例病情进行性恶化。所有28例受试者激发前的rCBF均降低。在23例有反应者中，激发后的rCBF大于20 mL/（min·100g）（P = 0.008），脑桥正中矢状位前部的脑血管反应性（CRC）明显优于无反应者（1.40对1.06），且在MRSI研究中脑桥正中矢状位前部、中部和后部的N - 乙酰天门冬氨酸/肌酸（NAA/Cre）比值正常。在那些无反应者中，脑桥正中矢状位至少2个区域的NAA/Cre比值小于0.8，在23例有共济失调以外症状（痴呆、尿失禁）的患者中，额叶脑桥正中矢状位区域的NAA/Cre比值小于1.5。出院时的CSRIH量表与CRC（P < 0.03）、平均ACT激发CBF（P < 0.005）和平均rCBF（P < 0.02）密切相关。出院时的CSRIH量表与3个月（P = 0.017）、2年（P = 0.018）和3年（P = 0.038）的随访表现之间存在统计学显著相关性。
脑血管血流动力学和局部代谢测量可为NPH患者分流术后的预后提供良好的预测指标。额叶脑桥正中矢状位的磁共振波谱成像与临床症状密切相关。在VP分流手术后，出院时的CSRIH量表是NPH患者长期预后的良好预测指标。
