Focal dilation and paradoxical collapse of cortical fissures and sulci in patients with normal-pressure hydrocephalus

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Object. The authors describe a subgroup of patients with shunt-proven normal-pressure hydrocephalus (NPH) who presented with focal fissural and sulcal dilation on imaging studies. The specific radiological features and methods of differentiating this condition from cortical atrophy are delineated.

Methods. Normal-pressure hydrocephalus has been described as dilation of the ventricles that is out of proportion to the sulci. Sulcal dilation has been taken as evidence of cortical atrophy and has even been used as a criterion to exclude patients from undergoing a shunting procedure. The authors describe five cases of patients with shunt-proven NPH who presented with focal dilation of cortical fissures and sulci. In three of the cases, there was a paradoxical decrease in the size of the dilated fissures and sulci that paralleled the decrease in the size of the lateral ventricles following successful shunting.

Conclusions. This study demonstrates that focal fissural and sulcal dilation may represent reservoirs of cerebrospinal fluid analogous to the ventricular system. Patients should not be denied a shunting procedure solely on the basis of focally dilated fissures of sulci.

Article Information

Address reprint requests to: Andrei I. Holodny, M.D., Department of Radiology, UMDNJ—New Jersey Medical School, University Hospital C-320, 150 Bergen Street, Newark, New Jersey 07103–2714. email: holodnai@umdnj.edu.

© AANS, except where prohibited by US copyright law.

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    Case 1. Axial CT scans obtained through the bodies of the lateral ventricles (left) and the third ventricle (center) and a paramidline sagittal T1-weighted MR image (right) (TR 600 msec, TE 15 msec) demonstrating marked dilation of the lateral ventricles. The third ventricle is severely dilated and rounded. The fourth ventricle is also dilated. Evaluation of the sulci demonstrates marked dilation of the following sulci: the sylvian fissures bilaterally, the central sulci bilaterally, the anterior aspect of the interhemispheric fissure, the left parietooccipital fissure, and the left calcarine fissure. In addition, there is marked focal dilation of the sulcus cinguli on the right side, the precentral sulcus on the left side, and the frontal sulci bilaterally. There is also dilation of the suprasellar and quadrigeminal plate cisterns. The remaining sulci are compressed. The sagittal MR image demonstrates thinning and upward bowing of the corpus callosum. More caudal images demonstrated a moderate dilation of the temporal horns of the lateral ventricles; however, there is no evidence of dilation of the choroidal and parahippocampal fissures, hippocampal atrophy, or cerebellar or brainstem abnormalities.

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    Case 2. Upper Left and Right: Axial T1-weighted MR images obtained in a 68-year-old man with NPH demonstrating enlarged lateral ventricles, including the temporal horns, as well as moderately distended sylvian fissures. Several months after successful shunt placement, the patient returned with recurrent symptoms. Lower Left: Computerized tomography scan demonstrating evidence of shunt failure with distention of the lateral ventricles. Sylvian fissure dilation was also present. Lower Right: Computerized tomography scan obtained after shunt revision demonstrating a decrease in the size of the lateral ventricles as well as a decrease in the size of the sylvian fissures.

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    Case 3. Upper Left and Right: Computerized tomography scans obtained before shunt placement in a 77-year-old man with clinical NPH. There is moderate dilation of the ventricular system including the lateral ventricles and the third ventricle. There is also dilation of the sylvian fissures. The image obtained near the vertex (upper right) shows a CSF pocket within the distended central sulcus. Lower Left and Right: Computerized tomography scans obtained in the same patient after shunt placement demonstrating a considerable decrease in the size of the lateral ventricles and the third ventricle. The sylvian fissures have also decreased in size. The image obtained near the vertex demonstrates that the distended central sulcus has collapsed. The distended sylvian fissures as well as the sulcus along the high convexity appear to have been functioning as CSF reservoirs in this patient with NPH.

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    Case 4. Left: Axial CT scan obtained before shunt placement in an 85-year-old woman with the clinical triad of NPH demonstrating dilation of the lateral ventricles and the sylvian fissures. In addition, there was focal dilation of the interhemispheric fissure and a number of sulci over the frontal lobes. The patient's symptoms were relieved following placement of an intraventricular shunt. Right: Computerized tomography scan obtained after shunt placement demonstrating a decrease in the size of the lateral ventricles, the sylvian fissures, the interhemispheric fissure, and the sulci over the frontal lobes.

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    Case 5. Sagittal T1-weighted MR images demonstrating marked distention of the lateral ventricles in a 75-year-old man with clinical NPH. In addition there is a large pocket of CSF in a left frontal sulcus as well as a pocket of CSF within the interhemispheric fissure located anterior to the genu of the corpus callosum. These pockets of CSF may act as reservoirs analogous to the accumulation of CSF in the ventricles.

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