Diffusion Tensor Imaging Reveals Supplementary Lesions to Frontal White Matter in Idiopathic Normal Pressure Hydrocephalus

Neurosurgery 68:1586–1593, 2011 DOI: 10.1227/NEU.0b013e31820f3401

Idiopathic normal-pressure hydrocephalus (INPH) is associated with white matter lesions, but the extent and severity of the lesions do not cohere with symptoms or improvement after shunting, implying the presence of further, yet undisclosed, injuries to white matter in INPH.

OBJECTIVE: To apply diffusion tensor imaging (DTI) to explore white matter lesions in patients with INPH before and after drainage of cerebrospinal fluid (CSF).

METHODS: Eighteen patients and 10 controls were included. DTI was performed in a 1.5T MRI scanner before and after 3-day drainage of 400 mL of CSF. Regions of interest included corpus callosum, capsula interna, frontal and lateral periventricular white matter, and centrum semiovale. White matter integrity was quantified by assessing fractional anisotropies (FA) and apparent diffusion coefficients (ADC), comparing them between patients and controls and between patients before and after drainage. The significance level corresponded to .05 (Bonferroni corrected).

RESULTS: Decreased FA in patients was found in 3 regions (P < .002, P < .001, and P < .001) in anterior frontal white matter, whereas elevated ADC was found in genu corpus callosum (P < .001) and areas of centrum semiovale associated with the precentral gyri (P < .002). Diffusion patterns in these areas did not change after drainage.

CONCLUSION: DTI reveals subtle injuries—interpreted as axonal loss and gliosis—to anterior frontal white matter where high-order motor systems between frontal cortex and basal ganglia travel, further supporting the notion that motor symptoms in INPH are caused by a chronic ischemia to the neuronal systems involved in the planning processes of movements.