Usefulness of the convexity apparent hyperperfusion sign in 123I-iodoamphetamine brain perfusion SPECT for the diagnosis of idiopathic normal pressure hydrocephalus

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OBJECTIVE

The gold standard for the diagnosis of idiopathic normal pressure hydrocephalus (iNPH) is the CSF removal test. For elderly patients, however, a less invasive diagnostic method is required. On MRI, high-convexity tightness was reported to be an important finding for the diagnosis of iNPH. On SPECT, patients with iNPH often show hyperperfusion of the high-convexity area. The authors tested 2 hypotheses regarding the SPECT finding: 1) it is relative hyperperfusion reflecting the increased gray matter density of the convexity, and 2) it is useful for the diagnosis of iNPH. The authors termed the SPECT finding the convexity apparent hyperperfusion (CAPPAH) sign.

METHODS

Two clinical studies were conducted. In study 1, SPECT was performed for 20 patients suspected of having iNPH, and regional cerebral blood flow (rCBF) of the high-convexity area was examined using quantitative analysis. Clinical differences between patients with the CAPPAH sign (CAP) and those without it (NCAP) were also compared. In study 2, the CAPPAH sign was retrospectively assessed in 30 patients with iNPH and 19 healthy controls using SPECT images and 3D stereotactic surface projection.

RESULTS

In study 1, rCBF of the high-convexity area of the CAP group was calculated as 35.2–43.7 ml/min/100 g, which is not higher than normal values of rCBF determined by SPECT. The NCAP group showed lower cognitive function and weaker responses to the removal of CSF than the CAP group. In study 2, the CAPPAH sign was positive only in patients with iNPH (24/30) and not in controls (sensitivity 80%, specificity 100%). The coincidence rate between tight high convexity on MRI and the CAPPAH sign was very high (28/30).

CONCLUSIONS

Patients with iNPH showed hyperperfusion of the high-convexity area on SPECT; however, the presence of the CAPPAH sign did not indicate real hyperperfusion of rCBF in the high-convexity area. The authors speculated that patients with iNPH without the CAPPAH sign, despite showing tight high convexity on MRI, might have comorbidities such as Alzheimer’s disease.

ABBREVIATIONS 123I-IMP = 123I-iodoamphetamine; ARG = autoradiography; CAP = patients with the CAPPAH sign; CAPPAH = convexity apparent hyperperfusion; CBF = cerebral blood flow; DESH = disproportionately enlarged subarachnoid space hydrocephalus; FAB = Frontal Assessment Battery; iNPH = idiopathic normal pressure hydrocephalus; iNPHGS = iNPH Grading Scale; MMSE = Mini–Mental State Examination; NCAP = patients without the CAPPAH sign; rCBF = regional CBF; ROI = region of interest; SEE = stereotactic extraction estimation; SSP = stereotactic surface projection; TMT-A = Trail Making Test A; TUG = Timed Up and Go.

Article Information

Correspondence Masaki Kondo: Kyoto Prefectural University of Medicine, Kyoto, Japan. maskondo@koto.kpu-m.ac.jp.

INCLUDE WHEN CITING Published online March 16, 2018; DOI: 10.3171/2017.9.JNS171100.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A representative case with indistinct DESH and distinct CAPPAH signs. Coronal FLAIR MR image (A) and axial and sagittal CBF SPECT images (B) of an 81-year-old woman suffering from gait disturbance and urinary incontinence. In the MR images, the DESH finding is indistinct because the subarachnoid spaces in the high-convexity area are narrow but the sulci can still be seen. In contrast, the CBF SPECT images show distinct hyperperfusion in the high-convexity area (the CAPPAH sign). Axial and sagittal CBF SPECT images (C) of a 69-year-old man with no neurological symptoms or cognitive deficits are also shown.

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    Definition of the CAPPAH sign using axial and coronal CBF SPECT images in patients with iNPH. In coronal slices, the relative CBF of the high-convexity area and medial parietal lobe is increased. On axial slices, the relative CBF of the high-convexity area is increased in a circular (A) or linear (B) pattern along the superior sagittal sinus.

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    Three regions regarded as the high-convexity area at the gyrus level. In our study, the 3 areas of the paracentral lobule (green), superior parietal lobule (blue), and precuneus (red), the Talairach Daemon Level 3 regions used in the SEE method, are defined as the high-convexity area.

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    Definition of the CAPPAH sign using 3D-SSP images. On 3D-SSP images in a patient with iNPH, the high-convexity area is represented in red, which means that the relative CBF is increased. CBL = cerebellum as reference regions; GLB = global brain regions as reference regions; INF = inferior view; LT.LAT = left lateral view; LT.MED = left medial view; PNS = pons as reference regions; POST = posterior view; RT.LAT = right lateral view; RT.MED = right medial view; SUP = superior view; THL = thalamus as reference regions.

References

1

Adams RDFisher CMHakim SOjemann RGSweet WH: Symptomatic occult hydrocephalus with “normal” cerebrospinal-fluid pressure. A treatable syndrome. N Engl J Med 273:1171261965

2

Cabral DBeach TGVedders LSue LIJacobson SMyers K: Frequency of Alzheimer’s disease pathology at autopsy in patients with clinical normal pressure hydrocephalus. Alzheimers Dement 7:5095132011

3

Hamilton RPatel SLee EBJackson EMLopinto JArnold SE: Lack of shunt response in suspected idiopathic normal pressure hydrocephalus with Alzheimer disease pathology. Ann Neurol 68:5355402010

4

Hashimoto MIshikawa MMori EKuwana N: Diagnosis of idiopathic normal pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort study. Cerebrospinal Fluid Res 7:182010

5

Hebb AOCusimano MD: Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome. Neurosurgery 49:116611862001

6

Iida HAkutsu TEndo KFukuda HInoue TIto H: A multicenter validation of regional cerebral blood flow quantitation using [123I]iodoamphetamine and single photon emission computed tomography. J Cereb Blood Flow Metab 16:7817931996

7

Iida HItoh HBloomfield PMMunaka MHigano SMurakami M: A method to quantitate cerebral blood flow using a rotating gamma camera and iodine-123 iodoamphetamine with one blood sampling. Eur J Nucl Med 21:107210841994

8

Iida HKanno IMiura SMurakami MTakahashi KUemura K: Error analysis of a quantitative cerebral blood flow measurement using H215O autoradiography and positron emission tomography, with respect to the dispersion of the input function. J Cereb Blood Flow Metab 6:5365451986

9

Ishii KHashimoto MHayashida KHashikawa KChang CCNakagawara J: A multicenter brain perfusion SPECT study evaluating idiopathic normal-pressure hydrocephalus on neurological improvement. Dement Geriatr Cogn Disord 32:1102011

10

Ishii KKawaguchi TShimada KOhkawa SMiyamoto NKanda T: Voxel-based analysis of gray matter and CSF space in idiopathic normal pressure hydrocephalus. Dement Geriatr Cogn Disord 25:3293352008

11

Ishikawa M: Clinical guidelines for idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 44:2222232004

12

Kazui HMiyajima MMori EIshikawa M: Lumboperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (SINPHONI-2): an open-label randomised trial. Lancet Neurol 14:5855942015

13

Kitagaki HMori EIshii KYamaji SHirono NImamura T: CSF spaces in idiopathic normal pressure hydrocephalus: morphology and volumetry. AJNR Am J Neuroradiol 19:127712841998

14

Kobayashi STateno MUtsumi KTakahashi AMorii HSaito T: Two-layer appearance on brain perfusion SPECT in idiopathic normal pressure hydrocephalus: a qualitative analysis by using easy Z-score imaging system, eZIS. Dement Geriatr Cogn Disord 28:3303372009

15

Kristensen BMalm JFagerland MHietala SOJohansson BEkstedt J: Regional cerebral blood flow, white matter abnormalities, and cerebrospinal fluid hydrodynamics in patients with idiopathic adult hydrocephalus syndrome. J Neurol Neurosurg Psychiatry 60:2822881996

16

Kubo YKazui HYoshida TKito YKimura NTokunaga H: Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus. Dement Geriatr Cogn Disord 25:37452008

17

Marmarou ABergsneider MKlinge PRelkin NBlack PM: The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery 57 (3 Suppl):S17S28 ii–v2005

18

Mataró MPoca MASalgado-Pineda PCastell-Conesa JSahuquillo JDíez-Castro MJ: Postsurgical cerebral perfusion changes in idiopathic normal pressure hydrocephalus: a statistical parametric mapping study of SPECT images. J Nucl Med 44:188418892003

19

Matsuda H: Cerebral blood flow and metabolic abnormalities in Alzheimer’s disease. Ann Nucl Med 15:85922001

20

Minoshima SKoeppe RAFrey KAKuhl DE: Anatomic standardization: linear scaling and nonlinear warping of functional brain images. J Nucl Med 35:152815371994

21

Mizumura SKumita SCho KIshihara MNakajo HToba M: Development of quantitative analysis method for stereotactic brain image: assessment of reduced accumulation in extent and severity using anatomical segmentation. Ann Nucl Med 17:2892952003

22

Mori EIshikawa MKato TKazui HMiyake HMiyajima M: Guidelines for management of idiopathic normal pressure hydrocephalus: second edition. Neurol Med Chir (Tokyo) 52:7758092012

23

Relkin NMarmarou AKlinge PBergsneider MBlack PM: Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 57 (3 Suppl):S4S16ii–v 2005

24

Sasaki HIshii KKono AKMiyamoto NFukuda TShimada K: Cerebral perfusion pattern of idiopathic normal pressure hydrocephalus studied by SPECT and statistical brain mapping. Ann Nucl Med 21:39452007

25

Sato THanyu HHirao KShimizu SKanetaka HIwamoto T: Deep gray matter hyperperfusion with occipital hypoperfusion in dementia with Lewy bodies. Eur J Neurol 14:129913012007

26

Takaya MKazui HTokunaga HYoshida TKito YWada T: Global cerebral hypoperfusion in preclinical stage of idiopathic normal pressure hydrocephalus. J Neurol Sci 298:35412010

27

Takeuchi TGoto HIzaki KTamura STomii MSasanuma J: Pathophysiology of cerebral circulatory disorders in idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 47:2993062007

28

Talairach JTournoux PRayport M: Co-Planar Stereotaxic Atlas of the Human Brain: 3-Dimensional Proportional System: An Approach to Cerebral Imaging. Rayport M, trans. Stuttgart: Thieme1988

29

Tedeschi EHasselbalch SGWaldemar GJuhler MHøgh PHolm S: Heterogeneous cerebral glucose metabolism in normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 59:6086151995

30

Woodworth GFMcGirt MJWilliams MARigamonti D: Cerebrospinal fluid drainage and dynamics in the diagnosis of normal pressure hydrocephalus. Neurosurgery 64:9199262009

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