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Cerebrospinal Fluid Biomarkers in the Evaluation and
Treatment of Normal Pressure Hydrocephalus
by
Tae Sung Lim
Major in Medicine
Department of Medical Sciences
The Graduate School, Ajou University
Cerebrospinal Fluid Biomarkers in the Evaluation and
Treatment of Normal Pressure Hydrocephalus
by
Tae Sung Lim
A Dissertation Submitted to The Graduate School of
Ajou University in Partial Fulfillment of the Requirements for the Degree
of Ph.D. in Medicine
Supervised by
So Young Moon, M.D., Ph.D.
Major in Medicine
Department of Medical Sciences
The Graduate School, Ajou University
August, 2012
ACKNOWLEDGEMENTS
I would like to express my gratitude to all those who gave me the possibility to
complete this thesis. I am greatly grateful to Prof. So Young Moon (Ajou University, Korea)
for encouraging me to finish my experiments and analyses before leaving to St. Louis and
providing me a lot of valuable comments and criticism about this thesis; Prof. In Soo Joo
(Ajou University, Korea) for accepting the chairman of the supervisory committee and
giving me the direction of this thesis and especially, the opportunity to study abroad; Prof.
Sun Ah Park (Soonchunhyang University, Korea) for teaching me the laboratory technique
of ELISA analysis and providing me her valuable samples as normal and disease controls;
Prof. Kyoon Huh (Ajou University, Korea) for giving me inspiration for my thesis and
letting me know the weak points in the connection between part I and II of my thesis; Prof.
Byung Gon Kim (Ajou University, Korea) for letting me use his laboratory facility for my
ELISA analysis and giving me valuable comments to the context of my thesis. I specially
thank Prof. Young Chul Yoon (Chung-Ang University, Korea) for giving me his valuable
sample and Dr. Jun Young Choi for helping me to perform ELISA analyses.
Most of all, I really appreciate the assistance of my wife, Jae Won Hyun and my 3-year
old son, Seungchan Lim to let me study late everyday and go to school for preparation of this
thesis even in weekends.
Jun 29th 2012
Tae Sung Lim from St. Louis
i
- ABSTRACT -
Cerebrospinal Fluid Biomarkers in the Evaluation and Treatment of
Normal Pressure Hydrocephalus
Normal pressure hydrocephalus (NPH) is characterized by slowly progressive gait
disturbance, cognitive impairment and urinary incontinence. It is a well-known potentially
reversible cause of dementia by the shunt operation. However, it is not simple to select
candidates for the shunt operation due to combined pathology and poor general medical
conditions in the aged population and the high complication rate of the procedure. In PART I,
a retrospective study, we reported patients with NPH whose symptomatic response to
repetitive lumbar puncture (LP) was maintained for longer than one year without the need
for the shunt operation and analyzed the predictor for the prolonged symptomatic response to
repetitive LP in patients with NPH. In PART II, a prospective study, we investigated levels
of the β-amyloid 1–42 (Aβ42), total tau protein (T-tau) and tau phosphorylated at position
threonine 181 (P-tau) in cerebrospinal fluid (CSF) of NPH patients and tried to find their
clinical implications in the evaluation and treatment of NPH.
PART I: A retrospective study
Thirty-one NPH patients were retrospectively evaluated. Gait disturbance, urinary
incontinence, and cognitive impairment were semi-quantified. We divided the patients into
ii
three groups (non-responders, temporary responders, and prolonged responders) according to
their responses after LP. We analyzed the characteristics of the groups. Gait disturbance (p=
0.046) and urinary incontinence (p= 0.040) scores and total NPH symptom score (p= 0.007)
immediate after CSF drainage were more significantly improved in prolonged responders
than in temporary responders. On multiple logistic regression analysis, total NPH score
improvement immediate after LP was the only predictor of the prolonged responders (p=
0.038, odds ratio= 9.718). Our study showed that some NPH patients could maintain
favorable courses for at least one year after LP without the shunt operation. Repetitive LP
could be an alternative treatment in selected NPH patients.
PART II: A prospective study
Twenty-five possible NPH patients were prospectively enrolled and their CSF were
collected to analyze levels of Aβ42, T-tau and P-tau using ELISA method. Gait disturbance,
urinary incontinence, and cognitive impairment were semi-quantified and detailed
neuropsychological test was performed. The CSF of 17 Alzheimer’s disease (AD) patients
and 10 normal control subjects were tested to determine a cutoff level of the possible
coexistence of AD pathology in NPH patients. Eight NPH patients were classified into NPH
with lower CSF Aβ42 group and 17 patients were classified into NPH with higher CSF Aβ42
group (cutoff value = 490.13 pg/ml, Aβ42). There was no difference in the NPH grading
score and improvement rate after LP between the two groups. In the evaluation of 18 patients
who underwent the detailed neuropsychological tests (7 with lower CSF Aβ42 and 11 with
high), the NPH with lower CSF Aβ42 group had more deficit in attention (p=0.018),
visuospatial function (p=0.043) and verbal memory (p=0.009). In the evaluation of 10
iii
patients who underwent NP test twice before and after LPs, with lower CSF Aβ42 group
showed less improvement in phonemic categorical naming (p=0.008) and frontal inhibitory
function (p=0.018) after LP compared to NPH with higher CSF Aβ42 group. Our study
suggested that the incidence of Aβ42 pathology in NPH patients was not different from
normal elderly population and the coexistence of Aβ42 pathology in NPH patients might be
a contributing factor for lumbar puncture or shunt unresponsiveness especially in the field of
cognitive dysfunction.
Key words: normal pressure hydrocephalus, lumbar puncture, Alzheimer’s disease,
cerebrospinal fluid, neuropsychological test
iv
TABLE OF CONTENTS
ABSTRACT ··········································································································· ⅰ
TABLE OF CONTENTS ························································································· iv
LIST OF FIGURES ································································································· vi
LIST OF TABLES ·································································································· vii
PART I. Repetitive Lumbar Punctures as Treatment for Normal Pressure
Hydrocephalus: A Retrospective Study
. INTRODUCTIONⅠ ································································································ 2
. MATERIALS AND METHODS Ⅱ ········································································· 4
A. Subjects ··········································································································· 4
B. Evaluation of NPH Symptoms ········································································· 5
C. Classification of Patients ················································································· 6
D. Magnetic Resonance Image ············································································· 7
E. Statistical Analysis ··························································································· 9
F. Representative Cases of Prolonged Responders ·············································· 10
. RESULTS Ⅲ ········································································································· 13
A. Demographic and Clinical Characteristics of the Subject Groups ··················· 13
B. Demographic and Clinical Characteristics of the Subject Subgroups ·············· 15
C. Logistic Regression Analysis ········································································· 17
. DISCUSSION Ⅳ ··································································································· 19
v
PART II. Evaluation of Coexistence of Alzheimer’s Disease Pathology in
Normal Pressure Hydrocephalus using CSF ELISA analyses: A Prospective
Study
Ⅰ. INTRODUCTION ······························································································ 23
Ⅱ. MATERIALS AND METHODS ······································································· 25
A. Subjects ········································································································· 25
B. Evaluation of NPH Symptoms ······································································· 27
C. Sample Collection ························································································· 28
D. ELISA Methods ···························································································· 29
E. Magnetic Resonance Image ··········································································· 31
F. Neuropsychological Tests ·············································································· 33
G. Statistical Analysis ························································································ 34
Ⅲ. RESULTS ········································································································· 35
A. Demographic and Clinical Characteristics of the Subject Groups ··················· 35
B. Classification of NPH Patients According to Response to Lumbar Puncture ··· 38
C. Classification of NPH Patients According to ELISA Results ·························· 40
D. Demographic and Clinical Characteristics of the NPH Patient Subgroups ········ 43
E. Neuropsychological Tests Results ·································································· 45
Ⅳ. DISCUSSION ··································································································· 48
REFERENCES ······································································································· 52
국 요약 ·············································································································· 60
vi
LIST OF FIGURES
PART I. Repetitive Lumbar Punctures as Treatment for Normal Pressure
Hydrocephalus: A Retrospective Study
Fig. 1. Template image for grading white matter hyperintensity ··································· 7
Fig. 2. MRI of three representative prolonged responders ··········································· 12
PART II. Evaluation of Coexistence of Alzheimer’s Disease Pathology in
Normal Pressure Hydrocephalus using CSF ELISA analyses: A Prospective
Study
Fig. 1. Plates of CSF ELISA analyses ·········································································· 30
Fig. 2. Schematic drawing showing linear measures of hippocampal atrophy ············· 32
Fig. 3. Levels of CSF β-amyloid 1–42, total tau protein and tau phosphorylated at position
threonine 181 in the subject groups ································································ 37
Fig. 4. Receiver operating characteristic (ROC) curves for CSF β-amyloid 1–42 in the
control and AD patient groups ·········································································· 41
vii
LIST OF TABLES
PART I. Repetitive Lumbar Punctures as Treatment for Normal Pressure
Hydrocephalus: A Retrospective Study
Table 1. Demographic and clinical characteristics of the subject groups ······················· 14
Table 2. Comparison of demographic and clinical characteristics between temporary
responders and prolonged responders ···························································· 16
Table 3. Logistic regression analysis results for predicting prolonged responder group 18
PART II. Evaluation of Coexistence of Alzheimer’s Disease Pathology in
Normal Pressure Hydrocephalus using CSF ELISA analyses: A Prospective
Study
Table 1. Visual rating of hippocampal atrophy ··························································· 32
Table 2. Demographic and clinical characteristics of the subject groups ······················· 36
Table 3. Demographic and clinical data of the NPH patient subgroups according to
response to lumbar puncture ··········································································· 39
Table 4. Stratificatioin of subject by cut-off level using ROC analysis ······················· 42
Table 5. Demographic and clinical data of the NPH patient subgroups according to CSF
β-amyloid 1–42 level ···················································································· 44
viii
Table 6. Neuropsychological test results of the NPH patient subgroups before CSF
drainage ········································································································ 46
Table 7. Neuropsychological test performance change of the NPH patient subgroups
before and after CSF drainage ········································································· 47
1
PART I.
Repetitive Lumbar Punctures as Treatment for
Normal Pressure Hydrocephalus
: A Retrospective Study
2
I. INTRODUCTION
Normal pressure hydrocephalus (NPH) is characterized by slowly progressive gait
disturbance, cognitive decline, and urinary disturbance. It can be diagnosed by characteristic
clinical features and laboratory findings, especially brain imaging showing enlarged
ventricles with relatively less significant periventricular white matter changes (Adams et al.,
1965). However, in the clinical setting, making an NPH diagnosis is not straightforward. It is
necessary to rule out other possible causes and refer to response to lumbar punctures (LP)
and imaging findings to make a diagnosis and plan for the treatment. Dementia from NPH is
treatable by either a ventriculoperitoneal shunt (VPS) or ventriculo-atrial shunt (VAS). The
response to the shunt operation can be predicted by an LP or external cerebrospinal fluid
drainage prior to the operation (Graff-Radford, 2007). However, it is not simple to select
candidates for the shunt operation due to combined pathology and poor general medical
conditions in the aged population. In addition, according the long-term follow-up studies,
about six to eight percents of patients experience serious and permanent neurological deficits
such as hemiparesis or even death. Various complications such as subdural hematoma,
intracranial hemorrhage, or shunt infection were reported in more than 30% of patients
(Hebb and Cusimano, 2001). These problems underscore the need for other treatment
options.
A few studies reported that patients who underwent an LP once or twice without the
shunt operation showed prolonged symptomatic improvement (Tsakanikas and Relkin, 2007).
However, there have been no studies that evaluated if repetitive LP can be an alternative
treatment to the shunt operation in NPH patients. In this study, we reported patients with
3
NPH whose symptomatic response to repetitive LP was maintained for longer than one year
without the need for a shunt operation and analyzed the predictor for the prolonged
symptomatic response to repetitive LP in patients with NPH.
4
II. MATERIALS AND METHODS
A. Subjects
Among patients who visited the department of neurology at the Ajou Medical Center,
Suwon, Korea from January 2001 to December 2007, we recruited 31 patients who satisfied
with the criteria for NPH and were observed for at least one year after admission treatment.
All patients were fully informed that there were two options of repetitive lumbar punctures
or shunt surgery and agreed to be treated by repetitive lumbar punctures at least for one year.
All patients had had brain MRIs and an LP. The clinical criteria for NPH included following:
(1) insidious onset, age of onset older than 40, disease duration longer than three to six
months, progressive course, and no evidence of other possible diseases that could explain
clinical symptoms and imaging findings, (2) MRI showing ventricular enlargement not
entirely attributable to cerebral cortical atrophy, (3) gait disturbance with or without
cognitive deficit or urinary disturbance, (4) no evidence for the increased intracranial
pressure (70~ 245 mmH2O) (Relkin et al., 2005). After making a diagnosis of NPH, one or
two LPs were performed to drain 30 to 50 ml of the cerebrospinal fluid (CSF).
5
B. Evaluation of NPH Symptoms
An NPH scale modified from Larsson et al. (Larsson et al., 1991) and Krauss et al.
(Krauss et al., 1997) that assessed gait [1 = normal, 2 = walk without any assistive device but
insecure, 3 = walk with cane, 4 = walk with bimanual support(walker), 5 = walk aided by an
assistant, 6 = wheelchair-bounded], urinary disturbance (0 = normal, 1 = sporadic
incontinence or urge phenomena, 2 = frequent incontinence or urge phenomena, and 3 = no
or minimal control of bladder function) and cognitive deficit (0 = normal, 1 = minimal
attention or memory deficits, 2 = considerable attention or memory deficits but oriented to
situational context, and 3 = not or only marginally oriented to situational context) was used
to characterize and grade the clinical syndrome. Patients were evaluated both before and 4 to
6 hours after the LP.
6
C. Classification of Patients
After one-year of observation, patients were grouped into non-responders, temporary
responders, and prolonged responders. Non-responders were patients who showed neither
improvement in any scores nor subjective improvement after the LP. Temporary responders
were patients whose score in any category improved by at least one point or who reported
subjective improvement but whose improvement was not sustained up to three months.
Prolonged responders were patients whose improvement was as above but also was sustained
up to three months.
7
D. Magnetic Resonance Image
The Evans index and white matter hyperintensity were assessed using MRI. The Evans
index was defined as the maximal frontal horn ventricular width divided by the transverse
inner diameter of the skull and signifies ventriculomegaly if it is 0.3 or greater (Relkin et al.,
2005). White matter hyperintensity was evaluated by the method designed by Clinical
research for dementia of South Korea study (CREDOS). Both periventricular (1-3) and deep
(1-3) white matter hyperintensities were assessed using template image (Fig. 1) (Moon et al.,
2011). Each longest-diameter white matter change around the lateral ventricles (capping or
banding on the periventricular areas) or deep in white matter (especially the centrum
semiovale) were evaluated separately. The deep white matter changes were rated as 1 ( < 10
mm), 2 ( ≥ 10 mm, < 25 mm), or 3 ( ≥ 25 mm) and periventricular white matter changes
were rated as 1 ( < 5 mm) or 2 ( ≥ 5 mm, < 10 mm), or 3 ( ≥ 10 mm).
8
Fig. 1 Template image for grading white matter hyperintensity. The deep white matter
changes were rated as 1 ( < 10 mm, A), 2 ( ≥ 10 mm, < 25 mm, B), or 3 ( ≥ 25 mm, C) and
periventricular white matter changes were rated as 1 ( < 5 mm, D) or 2 ( ≥ 5 mm, < 10 mm,
E), or 3 ( ≥ 10 mm, F).
9
E. Statistical Analysis
We compared demographic features, CSF findings, Evans Index, white matter
hyperintensity, medications taken, total and categorized scores for the NPH before and after
the LP, and the amount of the improvement in the scores after the LP between temporary
responders and prolonged responders using the Mann-Whitney test. We also used logistic
regression analysis to search for independent predictors to discriminate between the two
groups. A p value of <0.05 was regarded as statistically significant. The statistical analyses
were performed using commercially available software SPSS 13.0 (SPSS Inc, Chicago, IL,
USA).
10
F. Representative Three Cases of Prolonged Responders
Case 1
A 71-year-old man presented with slowly progressive gait disturbance and frequent falls
that had appeared nine months earlier. In addition, he showed slowly progressive memory
impairment and urinary disturbance such as nocturia and frequency up to 10 times a day. His
gait posture was normal. However, he showed reduction in the overall velocity and the
step/stride length with wide base and ataxia in turning. It took him 13 s to walk 7 meters.
Parkinsonism was not observed. On the Korean Mini-Mental State Examination (K-MMSE),
he scored 18. His total NPH score was 5 with 3 in gait, 1 in cognition, and 1 in urination.
The Evans index was 0.347 and white matter hyperintensity scored 2 in periventricular and 1
in deep white matter (Figure 1A). At six hours after 50 ml of CSF was removed, his 7 m
walking improved to 8 s. His NPH score also improved to 4 due to the improvement of the
gait score from 3 to 2. He was satisfied with his symptomatic improvement, which was
sustained for more than three months up to one year without further LP.
Case 2
A 75-year-old man presented with gait disturbance which had appeared one year prior
to the visit. His gait was characterized by slow velocity, short stride, hesitant initiation, and
ataxia. Parkinsonism was not observed. On the K-MMSE, he scored 25. His NPH score was
6 with 5 in gait, 1 in cognition and 0 in urination. On his brain MRI, his Evans index was
11
0.340 with 2 in the periventricular and 1 in the deep white matter hyperintensity (Fig. 1B).
At six hours after 50 ml of CSF were removed, his NPH score improved to 2 because of
improvement of the gait score from 5 to 2 and cognition score from 1 to 0. His improvement
was sustained up to 3 months. However, his gait started to aggravate with 5 in the gait score
3 months after the LP. He received a second LP removing 50 more ml of CSF, which
resulted in significant improvement in the gait score, dropping it to 2 again. After that time,
he received an LP every three months for one and a half years, allowing him to maintain
independent gait. Finally, he got a VPS with favorable outcome with the NPH score of 2.
Case 3
An 82-year-old man presented with gait disturbance for 6 months. He also noted
frequency and urgency for 3 months. His gait was characterized hesitant initiation, slow
velocity, but normal base. He had trouble walking without assistance. No parkinsonism was
observed. On the K-MMSE, he scored 25. His NPH score was 8 with 5 in gait, 1 in cognition,
and 2 in urination. His Evans index was 0.343 with 1 in the periventricular and 1 in the deep
white matter hyperintensity (Fig. 1C). After 50 ml of CSF removal, his NPH score improved
to 5 because of improvement of the gait score to 3 and urination score to 1. We observed that
for the next three years he sustained his response with a little waxing and waning. His final
NPH score was 5.
12
Fig. 2. MRI of three representative prolonged responders. T2 weighted images show
dilated ventricles with various degrees of periventricular white matter hyperintensities.
13
III. RESULTS
A. Demographic and Clinical Characteristics of the Subject Groups
We recruited 31 patients (21 men and 10 women). The mean age of onset was 72.5 and
the mean disease duration was 453 days. Twenty-two out of 31 patients underwent
cisternography and all of them showed mild to severe communicating hydrocephalus. The
average of Evans index was 0.34 and the mean score of periventricular white matter
hyperintensity was 1.70 and that of deep white matter hyperintensity was 1.67. The mean
value of CSF protein was 38.4 mg/dl and that of CSF glucose was 72.8 mg/dl. The mean
score of NPH score before LP was 5.25 which was improved by 1.45 after LP. According to
the response to LP, the patients were divided into 6 non-responders, 25 responders (12
temporary responders and 13 prolonged responders). We summarized these features in Table
1.
14
Table 1. Demographic and clinical characteristics of the subject groups.
Non- responders
(n=6)
Responders
(n=25)
Total
(n=31)
Sex (Men:Women) 5:1 16:9 21:10
Age (years) 72.8 ± 6.7 73.7 ± 5.8 72.5 ± 5.8
Duration (days) 334 ± 353 481 ± 412 453 ± 400
Evans index 0.34 ± 0.03 0.34 ± 0.02 0.34 ± 0.02
PVWMH 2.00 ± 0.50 1.62 ± 0.88 1.70 ± 0.86
DWMH 1.87 ± 0.87 1.61 ± 0.61 1.67 ± 0.93
CSF protein (mg/dl) 42.3 ± 13.2 37.5 ± 10.9 38.4 ± 11.3
CSF glucose (mg/dl) 68.0 ± 13.7 78.2 ± 21.6 72.8 ± 16.7
Anti-Parkinson drugs (n) 3 13 16
Pre-gait score 2.0 ± 0.00 3.00 ± 1.25 2.80 ± 1.19
Pre-urinary score 1.16 ± 0.40 1.44 ± 0.76 1.38 ± 0.71
Pre-cognition score 0.83 ± 0.40 1.12 ± 0.78 1.06 ± 0.72
Pre-NPH score sum 4.00 ± 0.63 5.56 ± 2.02 5.25 ± 1.93
Post-gait score 2.00 ± 0.00 2.04 ± 0.73 2.03 ± 0.65
Post-urinary score 1.16 ± 0.40 0.88 ± 0.60 0.93 ± 0.57
Post-cognition score 0.83 ± 0.40 0.84 ± 0.47 0.83 ± 0.45
Post-NPH score sum 4.00 ± 0.63 3.76 ± 1.56 3.80 ± 1.42
PVWMH: Periventricular White Matter Hyperintensity; DWMH: Deep White Matter
Hyperintensity; CSF: Cerebrospinal Fluid; NPH: Normal Pressure Hydrocephalus.
15
B. Demographic and Clinical Characteristics of the Subject Subgroups
We statistically compared temporary and prolonged responders using the Mann-
Whitney test. There was no difference in age, sex and duration of illness. Among the
variables tested, the symptom scores before and after LP did not differ between the groups,
while the amount of changes in total NPH scores (p= 0.007), gait score changes (p= 0.046),
and urination score changes (p= 0.040) after LP were significantly different (Table 2).
16
Table 2. Comparison of demographic and clinical characteristics between temporary
responders and prolonged responders.
Temporary
responders
(n=12)
Prolonged
responders
(n=13)
p-value
Sex (Men:Women) M : 8 / F :4 M : 8 / F : 5 0.852
Age (years) 71.6 ± 5.8 73.2 ± 5.9 0.503
Duration (days) 521 ± 458 444 ± 381 0.852
Evans index 0.34 ± 0.02 0.33 ± 0.02 0.650
PVWMH 1.42 ± 0.90 1.81 ± 0.85 0.295
DWMH 1.68 ± 0.96 1.55 ± 0.88 0.728
CSF protein (mg/dl) 36.5 ± 11.4 38.4 ± 10.8 0.689
CSF glucose (mg/dl) 78.2 ± 21.6 70.1 ± 11.8 0.437
Anti-Parkinson drugs (n) 7 6 0.825
Pre-gait score 2.83 ± 1.33 3.15 ± 1.21 0.437
Pre-urinary score 1.33 ± 0.77 1.53 ± 0.77 0.470
Pre-cognition score 1.08 ± 0.79 1.15 ± 0.80 0.810
Pre-NPH score sum 5.25 ± 2.34 5.84 ± 1.72 0.225
Post-gait score 2.25 ± 0.86 1.84 ± 0.55 0.347
Post-urinary score 1.08 ± 0.66 0.69 ± 0.48 0.247
Post-cognition score 0.91 ± 0.51 0.76 ± 0.43 0.611
Post-NPH score sum 4.25 ± 1.86 3.30 ± 1.10 0.270
Gait score improvement 0.58 ± 0.90 1.30 ± 0.94 0.046¶
Urinary score improvement 0.25 ± 0.45 0.84 ± 0.68 0.040¶
Cognition score improvement 0.16 ± 0.38 0.38 ± 0.65 0.538
NPH score improvement 1.00 ± 0.95 2.53 ± 1.50 0.007¶
PVWMH: Periventricular White Matter Hyperintensity; DWMH: Deep White Matter
Hyperintensity; CSF: Cerebrospinal Fluid; NPH: Normal Pressure Hydrocephalus.
¶ p < 0.05.
17
C. Logistic Regression Analysis
To look for predictors to be able to discriminate between temporary and prolonged
responders, we used multiple logistic regression analysis. We categorized several variables
as follows: age of the onset (61-70, 71-80, older than 81), sex (Male, Female), disease
duration (< 1 year, ≥ 1 year), scores for periventricular white matter hyperintensity (< 2, ≥ 2),
and changes in the total NPH scores (< 2, ≥ 2). The analysis showed that the amount of
changes in the total NPH scores was the only independent predictor to discriminate two
groups [Odds ratio, 9.718 (95% confidence interval, 1.128 –83.709), p = 0.038] (Table 3).
18
Table 3. Logistic regression analysis results for predicting prolonged responder group.
B S.E Wald df Sig. OR (95% CI)
Age 1.928 2 0.381
71-80 1.413 1.614 0.766 1 0.382 4.106 (0.173-97.20)
>80 3.096 2.232 1.924 1 0.165 22.101 (0.278-1753)
Female -0.107 1.697 0.004 1 0.950 0.898 (0.032-24.99)
Duration -0.272 1.041 0.068 1 0.794 0.762 (0.099-5.860)
PVWMH 1.818 1.272 2.045 1 0.153 6.162 (0.510-74.47)
NPH improvement 2.274 1.099 4.284 1 0.038* 9.718 (1.128-83.70)
Constant -0.815 1.929 2.130 1 0.144 0.060
PVWMH: Periventricular White Matter Hyperintensity; NPH; Normal Pressure
Hydrocephalus
* p < 0.05
19
IV. DISCUSSION
This study showed that prolonged responders had significantly more improvement in
the total NPH score, gait score, and urination score. In addition, we found that the amount of
the total NPH score change was an independent predictor to discriminate between temporary
and prolonged responders. Although it is impossible to distinguish responses to the LP from
the natural course of the NPH, the patients who showed sustained response with repeated LP
could be evidences for the therapeutic responses. In addition, it is difficult to exclude some
disease responsive to the anti-parkinsonian drugs. However, there was no significant
difference in the drug history among the three groups.
Since Adams et al. first reported on NPH in the 1960s, there have been lots of
controversies surrounding this disease. Even up to now, prospective studies have not come to
a consensus about the disease criteria and pathologic findings (Adams et al., 1965; Graff-
Radford, 2007). The symptomatic triad, gait disturbance, cognitive decline, and urinary
disturbance, are very common complaints in the aged population and can be caused by
various conditions and diseases. Therefore, it is very difficult to avoid false positive or false
negative to make diagnostic criteria (Graff-Radford, 2007). In addition, the ventricle size
increases with age and degenerative diseases such as Alzheimer’s disease are also seen
frequently (Barron et al., 1976; Jack et al., 2004). Therefore, with the current diagnostic
criteria including symptomatic triad and enlarged ventricles, the prevalence of the NPH can
be overestimated. Currently, the main treatment for NPH is a shunt operation. The decision
for the shunt operation is made after one or two LPs. However, long term follow-up studies
20
reported high complication rates and symptomatic aggravation within a few years after the
shunt operation (Pujari et al., 2008). So, in many cases, it is difficult to make diagnoses for
the NPH and make decisions for the treatment. Although a few studies have reported that
patients showed prolonged response to LP, these studies have not been given full attention.
In addition, good response to the LP, which is revealed to be an independent predictor for the
prolonged responders in this study, is also the predictor for favorable outcome of the shunt
operation (Vanneste, 2000). Therefore, repeated LP has not been systematically studied since
the shunt operation was introduced in 1960s.
At an early stage of NPH, patients can compensate for abnormalities in CSF flow
through both reduced production and increased absorption of the CSF due to increased
intracranial pressure (Bateman, 2004). However, as the ventricles get larger, they lose the
elasticity with the even intracranial pressure according to the Laplace’s law. If the ventricles
are slightly shrunken by CSF removal, the elasticity of the ventricles can recover along with
symptomatic improvement for a certain period. It seems that prolonged responders to LP did
not acquire irreversible damage to the brain although patients showed symptoms. However,
if appropriate CSF removal is not done at the threshold, irreversible damage to the cerebrum
occurs and can produce non-responders or temporary responders to the LP.
We should accept that this study has several limitations. This study was retrospective
and could not quantify the severity of each symptom and determine the order of change
accurately. Each symptom was evaluated every 3 months at the outpatient clinic. Therefore,
we could not assess exactly when patients started to worsen. Furthermore, lots of patients
failed to be followed with just one year of observation. Future studies are needed to compare
clinical courses according to the treatment modality (the shunt operation/ repeated LP)
21
among non-responders, temporary responders, and prolonged responders.
In conclusion, this study showed that good responders to the LP should be observed for
at least 3 months to see if their responses are prolonged. If they are prolonged and patients
agree, they can be observed without an immediate shunt operation, especially in cases where
they are not in appropriate condition for the operation or have the possibility of having
several degenerative diseases.
22
PART II.
Evaluation of Coexistence of Alzheimer’s Disease
Pathology in Normal Pressure Hydrocephalus
using CSF ELISA analyses
: A Prospective Study
23
I. INTRODUCTION
Normal pressure hydrocephalus (NPH) is characterized by clinical triad of symptoms
including cognitive impairment, gait difficulty, and urinary incontinence along with
ventricular enlargement in brain imaging (Relkin et al., 2005). It is a potentially reversible
cause of cognitive and motor impairment in older adults using ventriculo-peritoneal (VP)
shunt or ventriculo-atrial (VA) shunt operation. While the treatment with VP shunts are
widely used and encouraging, there exists a high rate of complications and the factors that
predict shunt unresponsiveness remain poorly understood. One potential contributor to shunt
unresponsiveness is the presence of comorbid neurologic conditions that are common in the
aged, such as Alzheimer’s disease (AD) (Hamilton et al., 2010).
NPH and AD have been considered to have definitely different pathomechanism but
these days there have been a number of studies about sharing pathomechanism between the
two diseases (Silverberg et al., 2003). However there is still controversy about the clinical
implication of existence of AD pathology in NPH patients. Some insisted that it was only a
bystander and the rate of coexistence of AD was similar to that of normal population (Bech
et al., 1999; Golomb et al., 2000; Bech-Azeddine et al., 2007) while the others reported the
poor shunt response was possibly due to AD pathology (Hamilton et al., 2010; Patel et al.,
2012). Since the introduction of ELISA method to detect cerebrospinal fluid (CSF)
biomarkers for AD, there have been a lot of studies about the differential role of levels of the
β-amyloid 1–42 (Aβ42), T-tau protein (T-tau) and tau phosphorylated at position threonine
181 (P-tau) in CSF of NPH patients (Agren-Wilsson et al., 2007; Kapaki et al., 2007;
Tarnaris et al., 2009; Leinonen et al., 2011; Tarnaris et al., 2011a). However, there is still
24
conflicting results of the level of each biomarker between the two diseases and the
predictability of outcome in patients who underwent VP shunt.
The aim of this study was to investigate levels of the Aβ42, T-tau and P-tau in CSF of
NPH patients and tried to find their clinical implications in the evaluation and treatment of
NPH.
25
II. MATERIALS AND METHODS
A. Subjects
Among patients who visited the department of neurology at the Ajou Medical Center,
Suwon, Korea from March 2010 to February 2012, we recruited 25 patients who satisfied
with the criteria for possible NPH. All patients had had brain MRIs and an LP. The clinical
criteria for possible NPH included following: (1) Subacute or indeterminate mode of onset,
any age after childhood, non-progressive or not clearly progressive, may follow events, such
as mild head trauma, may coexist with other neurologic, psychiatric, or medical condition
apart from the disease symptoms, (2) MRI showing ventricular enlargement but may be
associated with either cerebral cortical atrophy or structural lesion that may influence
ventricular size (3) Any one symptom from clinical triad (gait disturbance, cognitive deficit
or urinary disturbance) (Relkin et al., 2005). After making a diagnosis of NPH, one or two
LPs were performed to drain 30 to 50 ml of the CSF and 10ml of CSF was collected to
evaluate biomarkers for AD.
The CSF of 17 AD patients and 10 normal control subjects which were collected and
stored previously in two other hospitals (S.C.H. U. H. and C.A. U. H.) were tested to get a
cutoff value of the coexistence of AD pathology. All AD patients met the criteria for
probable AD as proposed by the National Institute of Neurological and Communicative
Diseases and Stroke and Alzheimer’s disease and Related Disorders Association (NINCDS-
ADRDA) (McKhann et al., 1984). All normal control subjects scored in each cognitive
domain test higher than the cutoff value. The cutoff values for each test score were
26
represented as a –1.0 SD below the published norms for their age and education group (Ahn
et al., 2010).
We excluded patients with a history of significant hearing or visual impairment that
could render interview participation difficult, as well as those with a history of other
neurological disorders (e.g., idiopathic Parkinson’s disease, dementia with Lewy bodies, or
active epilepsy), psychiatric illnesses (e.g., schizophrenia, mental retardation, major
depression, or mania), those taking psychotropic medications, and those with a history of
significant alcohol and/or other substance abuse. We obtained informed consent from all
participants after they received a complete written and verbal description of the study. This
study was approved by the hospital's Institutional Review Board.
27
B. Evaluation of NPH symptoms
An NPH scale modified from Larsson et al. (Larsson et al., 1991) and Krauss et al.
(Krauss et al., 1997) that assessed gait [1 = normal, 2 = walk without any assistive device but
insecure, 3 = walk with cane, 4 = walk with bimanual support(walker), 5 = walk aided by an
assistant, 6 = wheelchair-bounded], urinary disturbance (0 = normal, 1 = sporadic
incontinence or urge phenomena, 2 = frequent incontinence or urge phenomena, and 3 = no
or minimal control of bladder function) and cognitive deficit (0 = normal, 1 = minimal
attention or memory deficits, 2 = considerable attention or memory deficits but oriented to
situational context, and 3 = not or only marginally oriented to situational context) was used
to characterize and grade the clinical syndrome. Patients were evaluated both before and 4 to
6 hours after the LP.
28
C. Sample collection
All participants underwent LP in the L3-4 or L4-5 interspace to drain 30~50 ml of CSF
to evaluate response to LP from 10:00 to 12:00. During the procedure, 10 ml of CSF was
collected in polypropylene tubes after discarding the first 3~4ml. Bloody or cloudy samples
were rejected. No serious adverse events were reported. The samples were immediately
centrifuged for 15 minutes at 2000 rpm to remove cells and aliquots were stored in
polypropylene tubes and immediately frozen at −80°C until analysis. They were thawed just
before analysis.
29
D. ELISA Methods
CSF T-tau concentration was determined using a sandwich enzyme-linked
immunosorbent assay ([ELISA] Innotest hTAU-Ag, Innogenetics, Ghent, Belgium)
specifically constructed to measure all tau isoforms irrespective of phosphorylation status, as
previously described (Blennow et al., 1995). P-tau was measured using a sandwich ELISA
method (Innotest Phospho-Tau[181P]), as previously described (Vanmechelen et al., 2000).
Aβ42 levels were determined using a sandwich ELISA (Innotest β-amyloid[1-42]),
specifically constructed to measure amyloid-β containing both the 1st and 42nd amino acids,
as previously described (Andreasen et al., 1999). All biomarker levels were measured in
duplicate according to the manufacturer’s instructions. The CSF samples of NPH patients
were analyzed twice using different aliquot. (Fig. 1).
30
Fig 1. Plates of CSF ELISA analyses used in this study. A: Innotest -amyloid[1-42]; B:
Innotest hTAU-Ag; C: Innotest Phospho-Tau[181P].
31
D. Magnetic Resonance Image
The Evans index and white matter hyperintensity were assessed using MRI. The Evans
index was defined as the maximal frontal horn ventricular width divided by the transverse
inner diameter of the skull and signifies ventriculomegaly if it is 0.3 or greater (Relkin et al.,
2005). White matter hyperintensity was evaluated by the method designed by Clinical
research for dementia of South Korea study (CREDOS). Both periventricular (1-3) and deep
(1-3) white matter hyperintensities were assessed (Moon et al., 2011). Each longest-diameter
white matter change around the lateral ventricles (capping or banding on the periventricular
areas) or deep in white matter (especially the centrum semiovale) were evaluated separately.
The deep white matter changes were rated as 1 ( < 10 mm), 2 ( ≥ 10 mm, < 25 mm), or 3 ( ≥
25 mm) and periventricular white matter changes were rated as 1 ( < 5 mm) or 2 ( ≥ 5 mm, <
10 mm), or 3 ( ≥ 10 mm). Hippocampal arophy was graded by Scheltens’ method (Table 1
and Fig. 2) (Scheltens et al., 1992).
32
Table 1. Visual rating of hippocampal atrophy.
Score Width of choroid
fissure
Width of temporal
horn
Height of
hippocampal
formation
0 Normal Normal Normal
1 ↑ Normal Normal
2 ↑↑ ↑ ↓
3 ↑↑↑ ↑↑ ↓↓
4 ↑↑↑ ↑↑↑ ↓↓↓
↑: increase, ↓: decrease
Fig 2. Schematic drawing showing linear measures of hippocampal atrophy. A: largest
vertical height of hippocampal formation, defined as dentate gyrus, hippocampus proper, and
subiculum together with parahippocampal gyrus; B: largest horizontal width between
hippocampal formation and brainstem; C: largest vertical width of choroid fissure; D: width
of temporal horn.
33
F. Neuropsychological Tests
Neuropsychologists assessed participants' cognitive functioning via the extensive Seoul
Neuropsychological Screening Battery (SNSB) (Ahn et al., 2010) covering five specific
cognitive domains, as follows.
(1) The attention and working memory assessment used the digit span forward and
backward tests.
(2) The language function assessment employed the Korean version of the Boston
Naming Test (K-BNT) (Kim and Na, 1999).
(3) The visuospatial function assessment was the patient's copy score of the Rey
Complex Figure Test (RCFT), neuropsychological assessment in which examinees are asked
to reproduce a complicated line drawing, first by copying and then from memory.
(4) Memory function was divided into verbal and visual memory. We assessed verbal
memory by means of the Seoul Verbal Learning Test (SVLT), the Korean version of the
revised Hopkins Verbal Learning Test (HVLT-R), testing participants on the immediate
recall, delayed recall, and recognition tasks. To assess visual memory, we tested participants
on the RCFT's immediate recall, delayed recall, and recognition tasks.
(5) To assess frontal lobe functioning, we used the contrasting program, go-no go, the
semantic and phonemic aspects of the Controlled Oral Word Association Test (COWAT)
and Stroop test.
34
G. Statistical Analysis
We used chi-square, analysis of variance (ANOVA), and Kruskal-Wallis tests to
compare demographic data of each group and analysis of covariance (ANCOVA) to compare
clinical data adjusted for age, sex and duration of education. Post-hoc analyses with Least
Significant Difference (LSD) method were performed for between-group comparisons.
Intraclass correlation coefficient was calculated to show the test-retest reliability of ELISA.
Receiver operating characteristics (ROC) curve analysis was used to identify the cut-off
levels with the optimal combination of specificity and sensitivity. Mann-Whitney test was
used to compare the scores of neuropsychological tests between the subgroups of NPH
patients, adjusted for age, sex and duration of education. All statistical analyses were
performed using SPSS 13.0 (SPSS Inc, Chicago, IL, USA). Statistical significance was
established using a p-value limit of less than 0.05.
35
III. RESULTS
A. Demographic and Clinical Characteristics of the Subject Groups
Demographic and clinical characteristics and results of statistical analyses are
summarized in Table 2 and plotted in Fig. 3. Age of AD group was significantly older than
control group (p=0.029). The intraclass correlation coefficient of Aβ42, T-tau and P-tau were
0.922, 0.908 and 0.960, respectively. The mean value of the two test results of each analysis
was used for statistical analyses. CSF Aβ42 level of AD group was significantly lower than
NPH group (p=0.013) and control group (p=0.001) after adjustment for age, sex and duration
of education. CSF T-tau and P-tau levels were significantly higher in AD group than NPH
group (p=0.003 and p=0.002, respectively).
36
Table 2. Demographic and clinical characteristics of the subject groups (N=52).
NPH AD Control p1 p2 p3
n (M/F) 25 (12/13) 17 (10/7) 10 (3/7)
Age, yr 73.3±7.0 72.2±10.0 63.0±6.7 0.924 0.029* 0.090
Education, yr 8.5±5.2 6.1±5.6 5.5±5.2 0.469 0.498 0.970
K-MMSE 19.5±6.9 18.3±2.1 24.4±5.5 0.843 0.232 0.157
Aβ42, pg/ml 579.8±182.3 409.2±166.1 691.8±212.7 0.013* 0.241 0.001*
T-tau, pg/ml 131.9±77.6 259.6±161.5 196.9±114.4 0.003* 0.312 0.382
P-tau, pg/ml 27.0±9.6 51.3±28.3 43.0±28.5 0.002* 0.123 0.597
NPH: Normal Pressure Hydrocephalus; AD: Alzheimer’s Disease; M: Male; F: Female;
K-MMSE: Korean version of Mini Mental Status Exam; p1 : p-value between NPH and
AD; p2: p-value between NPH and control; p3: p-value between AD and control
* p < 0.05
37
Fig. 3. Levels of CSF Aβ42 (A), T-tau (b) and P-tau (C) in the subject groups.
38
B. Classification of NPH Patients According to Response to Lumbar Puncture
According to the results of Part I, NPH patients were divided into responder group and
non-responder group. Responder group was determined as patients who showed 2 or more
improvement in NPH scale because it was the only independent predictor for prolonged
responder group. There was no difference in age, sex, duration of education, K-MMSE score,
white matter hyperintensity, hippocampal atrophy and CSF biomarkers for AD (Aβ42, T-tau
and P-tau) between the two groups (Table 3).
39
Table 3. Demographic and clinical data of the NPH patient subgroups according to
response to lumbar puncture (N=25).
Non-responders
(n=16)
Responders
(n=9) p-value
Sex (Men:Women) M : 7 / F : 9 M : 5 / F : 4 0.688
Age (years) 73.8 ± 8.4 72.4 ± 3.9 0.638
Education, yr 8.7 ± 5.1 8.2 ± 5.8 0.833
K-MMSE 20.1 ± 6.9 18.5 ± 7.2 0.600
Aβ42, pg/ml 543.8 ± 157.3 643.7 ± 214.7 0.194
T-tau, pg/ml 133.0 ± 92.0 128.5 ± 46.7 0.874
P-tau, pg/ml 25.5 ± 10.7 29.5 ± 7.2 0.329
Evans ratio 0.35 ± 0.03 0.36 ± 0.02 0.507
DWMH 1.38 ± 0.71 1.89 ± 1.05 0.161
PVWMH 1.81 ± 0.65 2.22 ± 0.83 0.186
Hippocampal atrophy 1.13 ± 0.95 0.89 ± 0.78 0.535
Pre-gait score 1.31 ± 1.13 2.22 ± 1.92 0.148
Pre-urinary score 0.63 ± 0.80 1.56 ± 1.01 0.019
Pre-cognition score 1.31 ± 0.79 1.67 ± 0.70 0.278
Pre-NPH score sum 3.19 ± 2.25 5.44 ± 3.28 0.053
Post-gait score 1.06 ± 1.18 0.89 ± 1.53 0.754
Post-urinary score 0.56 ± 0.81 0.44 ± 1.01 0.753
Post-cognition score 1.31 ± 0.79 1.00 ± 0.86 0.369
Post-NPH score sum 2.94 ± 2.35 2.44 ± 2.96 0.651
Gait score improvement 0.25 ± 0.44 1.33 ± 0.86 < 0.001*
Urinary score improvement 0.06 ± 0.25 1.11 ± 0.78 < 0.001*
Cognition score improvement 0 0.67 ± 0.50 < 0.001*
NPH score improvement 0.25 ± 0.44 3.11 ± 1.16 < 0.001*
NPH: Normal Pressure Hydrocephalus: AD: Alzheimer’s Disease: M: Male: F: Female:
K-MMSE: Korean version of Mini Mental Status Exam: PVWMH: Periventricular
White Matter Hyperintensity: DWMH: Deep White Matter Hyperintensity
40
C. Classification of NPH Patients According to ELISA Results
To determine a cut-off level of the coexistence of AD pathology in NPH patients, ROC
curve analysis was performed. CSF Aβ42 was used because it was the only biomarker which
was significantly different between AD and control group. The area under the curve was
0.876 with p-value of 0.001 (Fig. 4). According to the instruction of previous studies,
sensitivity more than 85% was selected in the determination of cutoff level of 490 pg/ml
which was quite similar to the level of the previous study (482 pg/ml) (Mattsson et al., 2009)
(Table 4).
41
Fig. 4. Receiver operating characteristic (ROC) curve of CSF Aβ42 for discrimination
between the control and AD patient groups.
42
Table 4. Stratification of subject by cut-off level using ROC analysis.
CSF Aβ42,
pg/ml Sensitivity Specificity
134.59 1 0
168.58 1 0.059
202.12 1 0.118
204.35 1 0.176
215.92 0.9 0.176
237.89 0.9 0.235
288.09 0.9 0.294
338.27 0.9 0.353
376.85 0.9 0.412
405.49 0.9 0.471
422.42 0.9 0.529
456.4 0.9 0.588
490.13 0.9 0.647
511.76 0.8 0.647
545.09 0.8 0.706
579.8 0.8 0.765
593.08 0.8 0.824
602.37 0.8 0.882
609.14 0.8 0.941
634.36 0.7 0.941
670.2 0.7 1
690.78 0.6 1
734.44 0.5 1
791.41 0.4 1
813.93 0.3 1
859.97 0.2 1
908.33 0.1 1
913.2 0 1
43
D. Demographic and Clinical Characteristics of the NPH Patient Subgroups
We statistically compared NPH with lower CSF Aβ42 group and NPH with higher CSF
Aβ42 group using the Mann-Whitney test. There was no difference in age, sex and duration
of education. Among the variables tested, hippocampal atrophy grade was significantly
higher in NPH with lower CSF Aβ42 group than NPH with higher CSF Aβ42 group (p=0.02).
There was no difference in the NPH grading score and improvement rate after LP between
the two groups (Table 5).
44
Table 5. Demographic and clinical data of the NPH patient subgroups according to
CSF Aβ42 level (N=25).
NPH with
lower CSF Aβ42
NPH with
higher CSF Aβ42 p-value
n (M/F) 8 (3/5) 17 (9/8) 0.673
Age, yr 76.1±7.3 72.0±6.7 0.187
Education, yr 7.7±5.6 8.7±5.2 0.687
K-MMSE 16.8±6.6 20.8±6.9 0.193
Disease duration, day 724.1±513.6 769.4±520.4 0.857
Aβ42, pg/ml 368.7±72.3 679.1±121.7 <0.001*
T-tau, pg/ml 145.7±103.9 125.3±64.6 0.551
P-tau, pg/ml 28.2±13.8 26.4±7.3 0.682
Evans ratio 0.34±0.02 0.36±0.03 0.277
DWMH 1.6±0.9 1.5±0.8 0.804
PVWMH 2.0±0.7 1.9±0.7 0.856
Hippocampal atrophy 1.6±0.9 0.7±0.6 0.020*
Pre-gait score 2.75±1.48 2.59±1.54 0.807
Pre-urinary score 1.00±1.06 0.94±0.96 0.892
Pre-cognition score 1.50±0.75 1.41±0.79 0.795
Pre-NPH score sum 4.13±2.94 3.94±2.86 0.883
Post-gait score 2.00±1.69 2.00±1.11 1.000
Post-urinary score 0.63±1.06 0.47±0.80 0.689
Post-cognition score 1.38±0.91 1.12±0.78 0.474
Post-NPH score sum 3.00±3.38 2.65±2.14 0.753
Gait score improvement 0.75±0.70 0.59±0.87 0.651
Urinary score improvement 0.38±0.74 0.47±0.71 0.761
Cognition score improvement 0.13±0.35 0.29±0.47 0.377
NPH score improvement 1.25±1.48 1.29±0.68 0.950
NPH: Normal Pressure Hydrocephalus: AD: Alzheimer’s Disease: M: Male: F: Female:
K-MMSE: Korean version of Mini Mental Status Exam: PVWMH: Periventricular
White Matter Hyperintensity: DWMH: Deep White Matter Hyperintensity
45
E. Neuropsychological Tests Results
A total of 18 NPH patients underwent detailed neuropsychological tests as an initial
evaluation before CSF drainage. Seven patients belonged to NPH with lower CSF Aβ42
group and 11 belonged to NPH with higher CSF Aβ42 group. Among the
neuropsychological test scores, the NPH with lower CSF Aβ42 group had lower score in
Digit span forward test (p=0.018), RCFT copy test (p=0.043) and SVLT immediate recall
test (p=0.009) after adjustment for age, sex and duration of education (Table 6)
In a subset analysis of 10 patients who underwent follow-up neuropsychological tests
after CSF drainage, NPH with lower CSF Aβ42 group showed significantly less
improvement in phonemic COWAT (p=0.008) and color reading test in stroop test (p=0.018)
after LP compared to NPH with higher CSF Aβ42 group after adjustment for age, sex and
duration of education. The mean interval between the first and the second
neuropsychological test was 13.2 ± 9.4 days (Table 7).
46
Table 6. Neuropsychological test results of the NPH patient subgroups according to
CSF Aβ42 level before CSF drainage (N=18).
NPH with
lower CSF Aβ42
(n=7)
NPH with
higher CSF Aβ42
(n=11)
p-value
Attention
Digit span forward test 4.7±1.1 6.2±1.4 0.018*
Digit span backward test 2.0±1.5 2.7±1.1 0.271
Language function
K-BNT 25.3±6.6 36.1±14.3 0.157
Visuospatial function
RCFT Copy 12.8±10.7 23.7±12.5 0.043*
Memory function
SVLT immediate recall 6.8±1.9 13.3±3.6 0.009*
SVLT delayed recall 0.1±0.3 1.8±2.0 0.204
SVLT recognition 15.5±2.9 15.9±4.0 0.820
RCFT immediate recall 2.9±4.3 7.9±6.7 0.129
RCFT delayed recall 1.8±2.8 6.6±6.2 0.232
RCFT recognition 16.0±3.3 16.9±3.1 0.480
Frontal function
Contrasting program 15.0±8.3 14.2±9.1 0.691
Go-no go 9.6±10.2 11.0±9.1 0.499
Semantic COWAT 6.3±3.9 8.8±6.1 0.269
Phonemic COWAT 10.0±6.0 14.4±11.4 0.926
Stroop test: color reading 26.0±13.2 44.5±35.9 0.905
NPH: Normal Pressure Hydrocephalus; AD: Alzheimer’s Disease; K-BNT: Korean
version of Boston Naming Test; RCFT: Rey Complex Figure Test; SVLT: Seoul Verbal
Learning Test; COWAT: Controlled Oral Word Association Test.
47
Table 7. Neuropsychological test performance change of the NPH patient subgroups
according to CSF Aβ42 level before and after CSF drainage (N=10).
NPH with
lower CSF Aβ42
(n=5)
NPH with
higher CSF Aβ42
(n=5)
p-value
Attention
Digit span forward test 0.2±1.3 -0.6±0.8 0.131
Digit span backward test 0.0±0.7 -0.2±0.8 0.911
Language function
K-BNT 2.4±6.5 0.6±3.6 0.602
Visuospatial function
RCFT Copy 0.1±4.5 -1.0±2.1 0.577
Memory function
SVLT immediate recall 2.0±3.0 4.2±3.8 0.117
SVLT delayed recall 0.0±0.0 2.0±1.8 0.054
SVLT recognition -1.0±4.1 1.4±2.8 0.602
RCFT immediate recall -0.8±2.5 2.2±3.5 0.245
RCFT delayed recall 0.3±2.3 3.0±3.2 0.245
RCFT recognition -2.6±3.2 2.0±3.0 0.465
Frontal function
Contrasting program -0.2±0.4 0.2±0.4 0.180
Go-no go 3.2±8.9 2.8±6.2 0.451
Semantic COWAT -1.4±3.3 5.4±6.1 0.117
Phonemic COWAT -1.0±1.7 5.4±6.1 0.018*
Stroop test: color reading -4.4±9.5 8.2±8.1 0.008*
NPH: Normal Pressure Hydrocephalus; AD: Alzheimer’s Disease; K-BNT: Korean
version of Boston Naming Test; RCFT: Rey Complex Figure Test; SVLT: Seoul Verbal
Learning Test; COWAT: Controlled Oral Word Association Test.
48
Ⅳ. DISCUSSION
Although there have been a few studies about the coexistence of AD pathology in NPH
patients and its clinical implication, to our best knowledge, this is the first study which
reported the difference in detailed neuropsychological tests before and after CSF drainage
according to CSF biomarkers for AD. The major findings of this study were as follows: (1)
All the three biomarkers for AD diagnosis were significantly different between AD and NPH
groups indicating there was not enough AD pathology compatible to AD in NPH patients
group. (2) There was no difference in CSF biomarkers for AD between responder and non-
responder group. (3) There was no difference in demographic and clinical characteristics
including the response to CSF drainage using NPH grading system between NPH with lower
CSF Aβ42 group and NPH with higher CSF Aβ42 group. (4) Comparison of initial
neuropsychological tests showed deficit in attention, visuospatial function and verbal
memory are more prominent in NPH with lower CSF Aβ42 group than NPH with higher
CSF Aβ42 group. (5) Neuropsychological performance improvement before and after CSF
drainage were significantly less in phonemic categorical naming and frontal inhibitory
function in NPH with lower CSF Aβ42 group than NPH with higher CSF Aβ42 group.
In comparison of Aβ42, T-tau and P-tau between NPH and AD groups, Aβ42 was lower
in AD group than in NPH group and T-tau and P-tau were higher in AD group than in NPH
group. These results correspond well with those of earlier studies which reported various
CSF biomarkers indicating less AD pathology in NPH patients than AD patients group (Lins
et al., 2004; Kapaki et al., 2007; Wilson and Williams, 2010). After determination of cutoff
49
level of AD pathology using ROC analysis of CSF biomarkers in AD and control group, 8
out of 25 NPH patients (32%) were classified as having AD co-pathology. This fits well with
the overall incidence of AD pathology in normal elderly population (Aizenstein et al., 2008).
However some recent studies using ventricular CSF during shunt procedure or external
lumbar drainage (ELD) reported higher T-tau and P-tau level in NPH patients (Tarnaris et al.,
2009; Leinonen et al., 2011; Patel et al., 2012). Elevated T-tau level has been detected in
various diseases causing neuronal injury such as stroke, trauma, hemorrhage and encephalitis
(Hulstaert et al., 1999; Hesse et al., 2001; Paraskevas et al., 2005). Shunt operation and ELD
procedure might result in neuronal injury and elevated T-tau and P-tau level in these studies.
Furthermore, the advanced stage of disease which needed to be treated by shunt operation
might affect this discrepancy.
There was no difference in CSF Aβ42, T-tau and P-tau between non-responder and
responder group. Furthermore, except for the hippocampal atrophy, all the radiological and
clinical symptomatic indicators of NPH patients including response to CSF drainage did not
differ between the two subgroups divided by CSF Aβ42 level. These results are quite similar
to those of previous studies reported that NPH patients benefit equally from shunting
regardless of the presence of AD pathology (Bech et al., 1999; Golomb et al., 2000; Bech-
Azeddine et al., 2007). Recently a study performed to compare CSF biomarkers and
response to ELD showed that none of the biomarker predicted the ELD results (Leinonen et
al., 2011). However there have a few reports that cortical AD pathology and ventricular CSF
biomarker for AD resulted in a less robust response to shunting (Hamilton et al., 2010; Patel
et al., 2012). Further study using simultaneous investigation of AD biomarkers of cortical
pathology and ventricular and lumbar CSF might provide some of these answers.
50
Although there was no difference in general cognitive function between the two
subgroups, the detailed neuropsychological tests revealed more deficits in attention,
visuospatial function and verbal memory in NPH with lower CSF Aβ42 group. These results
suggested that AD pathology impacts an additive AD-related cognitive dysfunction in NPH
patients regardless of underlying cognitive dysfunction caused by NPH (Patel et al., 2012).
Furthermore categorical naming and inhibitory executive dysfunctions in NPH with lower
CSF Aβ42 group, which were considered as NPH-related cognitive dysfunction, were not
improved after lumbar drainage compared to NPH with higher CSF Aβ42 group. The pattern
of improvement in neuropsychological tests in patients with higher CSF Aβ42 was similar to
the result of previous studies which reported improvement of subcortical dysfunction after
shunting but there has been no report about the pattern of improvement after lumbar
puncture (Caltagirone et al., 1982; Tarnaris et al., 2011b; Patel et al., 2012). The difference
between the first and second tests was not the result of learning effect because there was a
report that no learning effect was found in patients with NPH on any of neuropsychological
tests (Solana et al., 2010).
We should accept that this study has several limitations. One limitation of this study is
its relatively small sample size. Another limitation is lack of analysis of long term follow up
data such as shunting history. In addition, normal control subjects were recruited from the
clinic and possibly had cognitive complaint more than those recruited from the cohort.
Subjects with cognitive complaint are known to have more AD pathology than those without
it (Visser et al., 2009). This may affect the lack of difference in T-tau and P-tau between AD
and control groups.
51
In conclusion, our study reported that the incidence of AD pathology in NPH patients
which was demonstrated in the analysis of lumbar CSF ELISA tests was not different from
normal elderly population. However the NPH with lower CSF Aβ42 group showed more
deficits in AD-related cognitive dysfunction such as attention deficit, visuospatial
dysfunction and verbal memory dysfunction. Furthermore NPH with lower CSF Aβ42 group
showed less improvement even in NPH-related cognitive dysfunction such as phonemic
categorical naming and frontal executive function compared to NPH with higher CSF Aβ42
group. These results of the present study suggest that AD co-morbidity in NPH patients
might be a contributing factor for lumbar puncture or shunt unresponsiveness especially in
the field of cognitive dysfunction.
52
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60
- 국 요약 -
상압 증 평가 료에 뇌척 액 생체지 역할
아주 학 학원 학과
임 태
(지도 : 소 )
상압 증 히 진행하는 보행 장애, 인지 장애, 뇨 장애를
특징 하는 질 단락 에 해 있는 매 원인 잘
알 있다. 그러나 노인 자에 는 다른 퇴행 질 인 내과 인
질 이 동 는 경우가 많 며, 단락 자체 높 부작용 인해 에
한 자를 하는 것 쉬운 일이 아니다. 후향 연구인 부분 연구
1에 는 단락 하지 않고 복 인 뇌척 액 액 통해 어도 1 동안
증상 지하는 지속 보인 자들 증 들 보고하고,
지속 군 독립 요인 인자를 찾 한 분 하 다. 향 연구인
부분 연구 2에 는 상압 증 자 뇌척 액에 β-amyloid 1–42 (Aβ42), T-
tau protein (T-tau) and tau phosphorylated at position threonine 181 (P-tau)를 하여
상압 증 자 평가 료에 있어 그 임상 를 견하고자
하 다.
61
부분 연구 1: 후향 연구
31명 상압 증 자들 후향 분 하 다. 보행 장애, 뇨
장애, 인지 장애를 분 하 며 뇌척 액 액 후 에 라 자군
군, 일시 군, 지속 군 나 어 각각 특징에 해 통계
분 시행하 다. 지속 군에 일시 군에 해 뇌척 액 액
후에 보행 장애 (p=0.046) 뇨 장애 (p=0.040), 체 증상
변 (p=0.007)가 하게 높 소견 보 다. 다변량 지스틱 회귀분 에 는
체 증상 항목이 지속 군 일한 요인 인자 (p=0.038, odds
ratio=9.718) 분 었다. 본 논 에 르면 몇몇 상압 증 자들
단락 없이 복 인 뇌척 액 액 통해 어도 1 이상 증상
상태를 지하며 증상 이 클 지속 인 보일 것
상할 있다. 복 인 뇌척 액 액 상압 증 자 단락
체요법 사용 있다.
부분 연구 2: 향 연구
25명 상압 증 자들 향 모집하여 뇌척 액 집하고
상압 증 증상 자 한 신경심리검사를 시행하여 그 결과를
분 하 다. 집 뇌척 액 ELISA 분 통해 Aβ42, T-tau, P-tau를
하 고 상압 증에 알 하이 병 동 여부에 한 값
62
찾 해 17명 알 하이 병 자들과 10명 상 조군 뇌척 액
분 하 다. 8명 상압 증 자들이 알 하이 병 병 군 분 었고
나 지 17명이 알 하이 병 미병 군 분 었다 (cutoff value=490.13 pg/ml,
Aβ42). 군 사이에 상압 증 증상 뇌척 액 액 후
도 차이는 없었다. 신경심리검사를 시행한 18명 자들 분 통하여
알 하이 병 병 군이 알 하이 미병 군에 해 주 집 (p=0.018), 시공간
능 (p=0.043) 언어 억 (p=0.009)에 하를 보이고 있 알
있었다. 뇌척 액 액 후에 시행한 신경심리검사 결과 차이에 한
분 에 는 알 하이 병 병 군에 해 알 하이 병 미병 군에 이름
(p=0.008), 엽 행 능 (p=0.018)에 많 보 다. 본 연구를
통해 상압 증 자들 뇌척 액 상 알 하이 병 병 도는 상
노인 인구집단과 다르지 않았 나 상압 증 자에 알 하이 병
병 뇌척 액 액 또는 단락 에 지 않는 인지 하 연 이 있
알 있었다.
핵심어: 상압 증, 요추 천자, 알 하이 병, 뇌척 액, 신경심리검사