臺灣博碩士論文加值系統

背景及目的 : 常壓性水腦症是少數可逆或可治療的失智症之一，目前最有效的治療方法為腦室腹腔分流手術，腦脊髓液穿刺測驗( CSF tap test ) 被認為是預測手術預後準確率最高的測驗之一。本研究的目的在於探討(1)原發性及次發性常壓性水腦症患者在腦脊髓液穿刺測驗表現的異同。(2)分析常見的血管性危險因子或共病症包含高血壓、糖尿病、高膽固醇血症、缺血性心臟病、鬱血性心衰竭、心房纖維顫動、缺血性腦中風及腦部白質病變對於原發性常壓性水腦症患者在腦脊髓液穿刺測驗表現的影響。(3)原發性常壓性水腦症患者在腦脊髓液穿刺測驗前後認知功能改變的程度與內容。(4)原發性常壓性水腦症患者在腦脊髓液穿刺測驗後整體及分項認知功能變化與步態變化的相關性。

方法: 本研究屬回溯性質之研究，從自2006年1月至2009年4月在本院神經科病房進行常壓性水腦症臨床路徑的住院病患收案，根據Norman Relkin等學者在2005年發表於neurosurgery之INPH guideline所提出之診斷準則，總計收案原發性常壓性水腦症患者50人，次發性常壓性水腦症患者9人。這些病患皆進行腰椎穿刺並移除30 ml 之腦脊髓液 ( 即腦脊髓液穿刺測驗 ) 。我們在病患腦脊髓液穿刺測驗前後各進行一次快速行走測試 ( Rapid gait test ) 及認知能力篩選工具(cognitive ability screening instrument, CASI ) 評估。其中快速行走測試時間縮短大於10% 以上或認知能力篩選工具總分進步大於1標準差(1SD)以上者或者定義為腦脊髓液穿刺測驗反應者(CSF tap test responders )。

結果: 本研究結果顯示(1)原發性及次發性常壓性水腦症患者中分別有74.0 % 及 66.7% 是腦脊髓液穿刺測驗反應者，無顯著差異( p= 0.6487 )。(2)腦脊髓液穿刺測驗反應者與不反應者在各項常見的血管性危險因子或共病症之比例及程度皆無顯著差異。(3)原發性常壓性水腦症患者在腰椎穿刺前之認知能力篩選工具總分低於臨界值( cut-off values) 者有72%， 其中各分項認知功能異常比例最高者依次為近期記憶、定向感及語言流暢度；各分項認知功能異常的程度以定向感為最差，其次為近期記憶，再次之者為語言流暢度。原發性常壓性水腦症患者在腦脊髓液穿刺測驗後認知能力篩選工具的總分進步大於1常模標準差(依據年齡及教育程度) 者有40%，以分項認知功能而言，進步大於1標準差之病患比例前四高者依序為注意力、語言流暢度、抽象思考及構圖能力，若以進步之幅度(單位:各分項之常模標準差) 比較，前四高者依序為注意力、遠期記憶、語言流暢度及抽象思考。(4)原發性常壓性水腦症患者之專注力及語言流暢度不論在腦脊髓液穿刺測驗之前或之後都和快速行走測試之結果呈低度至中度負相關。其中對腰椎穿刺測驗步態及認知功能皆反應者，在定向感及抽象思考等認知功能及整體認知能力篩選工具總分的改變量和快速行走測試的改變量呈中度正相關。


結論: 本研究結論暗示腦脊髓液穿刺測驗反應之結果不因原發性或次發性常壓性水腦症而有所差異；血管性危險因子或共病症之有無及程度並不影響原發性常壓性水腦症患者在腦脊髓液穿刺測驗的表現。此外，原發性常壓性水腦症患者之神經心理學表現異常比例最高者依次為近期記憶、定向感及語言流暢度，若以異常程度而言則為定向感、近期記憶及語言流暢度。原發性常壓性水腦症患者在腦脊髓液穿刺測驗後在整體認知功能及注意力、語言流暢度及抽象思考等分項有顯著進步。原發性常壓性水腦症患者專注力及語言流暢度和步態障礙相關且腰椎穿刺測驗步態及認知功能皆反應者在認知功能的進步，尤其是定向感及抽象思考和步態的進步相關。本研究結果支持原發性常壓性水腦症之主要功能缺損在於額葉及皮質下之系統。

Background and Purpose: Normal pressure hydrocephalus is one of the few causes of dementia that is potentially reversible or treatable. Timely diagnosis and placement of a ventriculoperitoneal shunt can lead to significant improvement. The cerebrospinal fluid (CSF) tap test remains one of the most reliable methods to predict the response of shunting. The aim of the study is to investigate (1) whether the rate of positive CSF tap test responders differ between the patients with idiopathic normal pressure hydrocephalus ( INPH ) and secondary normal pressure hydrocephalus (SNPH ) . (2) the impact of vascular comorbidities on the CSF tap test in patients with INPH. (3) which individual domain of cognition improve after CSF tap test (4) the association between changes of gait and cognition.

Methods: We retrospectively enrolled consecutive patients admitted for work-up for normal pressure hydrocephalus from Jan 2006 to April 2009 in Department of Neurology, Kaohsiung Medical University Hospital. The criteria of diagnosis of INPH and SNPH was based on the INPH guideline by Norman Relkin et al. published in neurosurgery in 2005. The studied subjects consisted of 50 patients with INPH and 9 patients with SNPH. We performed lumbar puncture and removed 30 ml of CSF. Rapid gait test and cognitive ability screening instrument ( CASI ) were assessed before and after CSF tap test. We defined CSF tap responders as the patients who improved either in gait or cognition after CSF tap test. The improvement of rapid gait test should be more than 10% and that of CASI should be more than one standard deviation (1 SD) for the patient’s age and education level.

Results: We found that (1) the rate of CSF tap test responders was not significantly different between the patients with INPH and SNPH. (2) the rate of CSF tap test responders was not related to the presence or severity of vascular comorbidities in the patients with INPH. The vascular comorbidities being analyzed included hypertension, diabetes, hypercholesterolemia, ischemic heart disease, congestive heart failure, atrial fibrillation, ischemic stroke and while matter changes. (3) 72% of patients with INPH had total score of CASI below cut-off values for the patient’s age and education level. Regarding the percentage of patients with impairment in individual cognitive domain, the highest were recent memory, orientation and verbal fluency. Regarding the severity of impairment defined by the units of SD in the individual cognitive domain, the most significant deficits were seen in orientation, recent memory and verbal fluency. 40% of patient with INPH got improvement by more than 1SD of total score of CASI after CSF tap test. Regarding the percentage of patients with improvement by more than 1SD of the individual cognitive domain, the highest were attention, verbal fluency, abstract and construction. Regarding the degree of improvement defined by the units of SD in the individual cognitive domain, the most significant change was seen in attention, remote memory, verbal fluency and abstract. (4) there was a slightly negative correlation between scores of concentration and verbal fluency and rapid gait test. The correlation was observed both before and after CSF tap test in patients with INPH. Besides, the moderate correlation between improvement of orientation and abstract and that of rapid gait test was seen in the subset of CSF tap test responders who improved in both cognition and gait.


Conclusions: The study suggested that the etiologies of normal pressure hydrocephalus did not affect the results of CSF tap test and the impact of vascular comorbidities on CSF tap test in patients with INPH was not significant. The neuropsychological deficits of the patients with INPH were mostly seen in recent memory, orientation and verbal fluency. The patients with INPH improved in overall cognition after CSF tap test. The most significant change was seen in attention, verbal fluency and abstract regarding both percentage of patients with improvement and the degree of improvement. Besides, the association between concentration and verbal fluency and gait disturbance was observed in patients with INPH and the improvement of gait was correlated with that of orientation and verbal fluency in the subset of CSF tap test responders who improved both in cognition and gait. Our results support that the major defect in INPH is in frontal-subcortical system.

目錄
中文摘要 II
英文摘要 VI
正文
第一章 緒論
第一節 研究背景 1
第二節 研究目的 2

第二章 文獻探討
第一節 常壓性水腦症之診斷準則 3
第二節 腦脊髓液穿刺測驗對常壓性水腦症診斷之
重要性 9
第三節 血管性危險因子或共病症對原發性常壓性水腦
症患者預後之影響 12
第四節 原發性常壓性水腦症患者之神經心理學表現
及和步態障礙之相關性 15

第三章 研究方法
第一節 研究設計 17
第二節 研究對象 17
第三節 研究工具 20
第四節 研究流程 26
第五節 資料分析 27
第四章 研究結果
第一節 常壓性水腦症患者之基本人口學統計，血管共
病症資料，臨床特徵及腰椎穿刺測驗結果 28
第二節 比較原發性常壓性水腦症患者中腰椎穿刺測驗
反應者與不反應者之之基本人口學統計，血管
共病症資料，臨床特徵及腰椎穿刺測驗結果33
第三節 原發性常壓性水腦症患者之認知能力篩選工具
在腰椎測驗前後之表現 41
第四節 原發性常壓性水腦症患者之認知功能和步態障礙
之相關性 43
第五章 討論與建議
第一節 比較原發性常壓性水腦症和次發性常壓性水腦症
患者腰椎穿刺測驗反應 44
第二節 比較原發性常壓性水腦症患者中腰椎穿刺測驗
反應者與不反應者之血管性危險因子及共病症45
第三節 原發性常壓性水腦症患者之神經心理學表現
及和步態障礙之相關性 46
第四節 結論 49
第五節 研究限制 49
第六節 研究貢獻與未來發展 52

圖表目錄
圖2-1-1 原發性常壓性水腦症患者之連續顱內壓監測 5
圖3-4-1 研究流程圖 26
表2-1-1 常壓性水腦症之預後測試 11
表4-1-1 常壓性水腦症患者之基本人口學統計及血管共病症資料 54
表4-1-2 常壓性水腦症患者之臨床特徵 55
表4-1-2 常壓性水腦症患者之臨床特徵 (續) 56
表4-1-3 常壓性水腦症患者之腰椎穿刺測驗結果 57
表4-2-1 比較原發性常壓性水腦症患者中腰椎穿刺測驗反應者
與不反應者之基本人口學統計及血管共病症資料 58
表4-2-2 比較原發性常壓性水腦症患者中腰椎穿刺測驗反應者
與不反應者之臨床特徵 59
表4-2-3 比較原發性常壓性水腦症患者中腰椎穿刺測驗反應者與
不反應者之腰椎穿刺測驗結果 60
表4-3-1 原發性常壓性水腦症患者之腰椎穿刺前之神經心
理學表現 62
表4-3-2 原發性常壓性水腦症患者之認知能力篩選工具
在腰椎穿刺測驗前後表現 62
表4-4-1 原發性常壓性水腦症患者在腰椎穿刺前後之認知能力篩選
工具和快速行走測試之相關性 63
表4-4-2 原發性常壓性水腦症患者中腰椎穿刺測驗反應者
(步態及認知功能皆反應)之認知能力篩選工具和快速
行走測試進步之相關性64
附件
附件1 原發性常壓性水腦症之診斷準則 (歐美版) 65
附件2 原發性常壓性水腦症之診斷準則 (日本版) 68
附件3 Evan’s index 計算方法 69
附件4 同意臨床試驗證明書 70
附件5 ARWMC (Age-Related White Matter Changes )71
scale
參考文獻 73

參考文獻

1.Petersen R, Mokri, B, Laws, ER Jr. Surgical treatment of idiopathic hydrocephalus in elderly patients. Neurology. 1985;35:307-311
2.Clarfield AM. The reversible dementias: Do they reverse? Ann Intern Med. 1988;109:476-486
3.Beck JC, Benson DF, Scheibel AB, Spar JE, Rubenstein LZ. Dementia in the elderly: The silent epidemic. Ann Intern Med. 1982;97:231-241
4.Vanneste J. Diagnosis and management of normal-pressure hydrocephalus. J Neurol 2000;247:5-14
5.Adams R, Fisher, CM, Hakim, S, et al. . Symptomatic occult hydrocephalus with "Normal" Cerebrospinal-fluid pressure. A treatable syndrome. N Engl J Med. 1965;273:117-126
6.Graffradford N. Normal pressure hydrocephalus. Neurologic Clinics. 2007;25:809-832
7.Bergsneider M, Miller C, Vespa PM, Hu X. Surgical management of adult hydrocephalus. Neurosurgery. 2008;62 Suppl 2:643-659; discussion 659-660
8.Mori K. Management of idiopathic normal-pressure hydrocephalus: A multi-institutional study conducted in Japan. Journal of Neurosurgery. 2001;95:970-973
9.Malm J, Eklund, A. . Idiopathic normal pressure hydrocephalus. Practical Neurology. 2006;6:14-27
10.Wikkelso C, Andersson, H, Blomstrand, C, et al. . Normal pressure hydrocephalus. Predictive value of the cerebrospinal fluid tap-test. Acta Neurol Scand. 1986;73:566-573
11.Krauss JK RJ, Vach W, et al. Vascular risk factors and arteriosclerotic disease in idiopathic normal-pressure hydrocephalus of the elderly. Stroke. 1996;27:24–29
12.Vanneste J, Augustijn, P, Dirven, C, et al. . Shunting normal-pressure hydrocephalus: Do the benefits outweigh the risks? A multicenter study and literature review. Neurology. 1992;42:54-59
13.Hakim S AR. The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neurol Sci. 1965;2:307-327
14.Boon A, Tans, JT, Delwel, EJ, et al. Dutch normal-pressure hydrocephalus study: Prediction of outcome after shunting by resistance to outflow of cerebrospinal fluid. J Neurosurg. 1997;87:687-693
15.Pujari S, Kharkar, S, Metellus, P, et al. . Normal pressure hydrocephalus: Long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008;79:1282-1286
16.Sudarsky L, Simon, S. . Gait disorder in late-life hydrocephalus. Arch Neurol 1987;44:263-267
17.Williams MA TG, de Lateur B, et al. Objective assessment of gait in normal-pressure hydrocephalus. Am J Phys Med Rehabil. 2008;87:39-45
18.Relkin N MA, Klinge P, et al. Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005;57:S4-S16
19.Bugalho P GJ. Gait disturbance in normal pressure hydrocephalus: A clinical study. Parkinsonism Relat Disord. 2007;13:434–437
20.Stolze H, Kuhtz-Buschbeck, JP, Drucke, H, et al. . Comparative analysis of the gait disorder of normal pressure hydrocephalus and Parkinson''s disease. J Neurol Neurosurg Psychiatry. 2001;70:289-297
21.Hellstrom P EM, Archer T, et al. The neuropsychology of patients with clinically diagnosed idiopathic normal pressure hydrocephalus. Neurosurgery. 2007;61:1219–1226
22.Sakakibara R, Kanda T, Sekido T, Uchiyama T, Awa Y, Ito T, Liu Z, Yamamoto T, Yamanishi T, Yuasa T, Shirai K, Hattori T. Mechanism of bladder dysfunction in idiopathic normal pressure hydrocephalus. Neurourology and Urodynamics. 2008;27:507-510
23.Krauss JK, Droste DW, Bohus M, Regel JP, Scheremet R, Riemann D, Seeger W. The relation of intracranial pressure B-waves to different sleep stages in patients with suspected normal pressure hydrocephalus. Acta Neurochirurgica. 1995;136:195-203
24.Graff-Radford N, Godersky, JC, Jones, MP. . Variables predicting surgical outcome in symptomatic hydrocephalus in the elderly. Neurology. 1989;39:1601-1604
25.Kristensen B, Malm, J, Fagerland, M, et al. Regional cerebral blood flow, white matter abnormalities, and cerebrospinal fluid hydrodynamics in patients with idiopathic adult hydrocephalus syndrome. J Neurol Neurosurg Psychiatry. 1996;60:282-288
26.Bech-Azeddine R HP, Juhler M, et al. Idiopathic normal-pressure hydrocephalus: Clinical comorbidity correlated with cerebral biopsy findings and outcome of cerebrospinal fluid shunting. J Neurol Neurosurg Psychiatry. 2007;78:157–161
27.Golomb J WJ, Miller DC, et al. Alzheimer’s disease comorbidity in normal pressure hydrocephalus: Prevalence and shunt response. J Neurol Neurosurg Psychiatry. 2000;68:778–781
28.Savolainen S, Paljarvi, L, Vapalahti, M. Prevalence of Alzheimer''s disease in patients investigated for presumed normal pressure hydrocephalus: A clinical and neuropathological study. Acta Neurochir (Wien) 1999;141:849-853
29.Ishikawa M, Hashimoto M, Kuwana N, Mori E, Miyake H, Wachi A, Takeuchi T, Kazui H, Koyama H. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurologia Medico-Chirurgica. 2008;48 Suppl:S1-23
30.JA V. Diagnosis and management of normal-pressure hydrocephalus. J Neurol. 2000;247:5–14
31.Thomsen A, Borgesen, SE, Bruhn, P, Gjerris, F. Prognosis of dementia in normal-pressure hydrocephalus after a shunt operation. Ann Neurol. 1986;20:304-310
32.Black P. Idiopathic normal-pressure hydrocephalus. Results of shunting in 62 patients. J Neurosurg. 1980;52:371-377
33.O'' Hayon BB, Drake JM, Ossip MG, Tuli S, Clarke M. Frontal and occipital horn ratio: A linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Pediatric Neurosurgery. 1998;29:245-249
34.Ishikawa M. Clinical guidelines for idiopathic normal pressure hydrocephalus. Neurologia Medico-Chirurgica. 2004;44:222-223
35.Kitagaki H, Mori E, Ishii K, Yamaji S, Hirono N, Imamura T. CSF spaces in idiopathic normal pressure hydrocephalus: Morphology and volumetry. American Journal of Neuroradiology. 1998;19:1277–1284
36.Sasaki M HS, Yuasa T, et al. Narrow CSF space at high convexity and high midline areas in idiopathic normal pressure hydrocephalus detected by axial and coronal MRI. Neuroradiology. 2008;50:117-122
37.Sand T, Bovim G, Grimse R, Myhr G, Helde G, Cappelen J. Idiopathic normal pressure hydrocephalus: The CSF tap-test may predict the clinical response to shunting. Acta Neurologica Scandinavica. 1994;89:311-316
38.Stolze H, Kuhtz-Buschbeck, JP, Drucke, H, et al. Gait analysis in idiopathic normal pressure hydrocephalus--which parameters respond to the CSF tap test? Clin Neurophysiol. 2000;111:1678-1686
39.Marmarou A BM, Klinge P, et al. The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Neurosurgery. 2005;57:S17-S28
40.Walchenbach R GE, Thomeer RT, et al. The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry. 2002;72:503-506
41.Solana E, Poca MA, Sahuquillo J, Benejam B, Junqué C, Dronavalli M. Cognitive and motor improvement after retesting in normal-pressure hydrocephalus: A real change or merely a learning effect? Journal of Neurosurgery. 2009 May
42.Akai K, Uchigasaki S, Tanaka U, Komatsu A. Normal pressure hydrocephalus. Neuropathological study. Acta Pathologica Japonica. 1987;37:97-110
43.Bech R, Waldemar, G, Gjerris, F, et al. Shunting effects in patients with idiopathic normal pressure hydrocephalus; correlation with cerebral and leptomeningeal biopsy findings. Acta Neurochir (Wien) 1999;141:633-639
44.Casmiro M, D''Alessandro R, Cacciatore FM, Daidone R, Calbucci F, Lugaresi E. Risk factors for the syndrome of ventricular enlargement with gait apraxia (idiopathic normal pressure hydrocephalus): A case-control study. Journal of Neurology, Neurosurgery, and Psychiatry. 1989;52:847–852
45.Graff-Radford N, Godersky, JC. . Idiopathic normal pressure hydrocephalus and systemic hypertension. Neurology. 1987;37:868-871
46.Ritter S, Dinh, TT. . Progressive postnatal dilation of brain ventricles in spontaneously hypertensive rats. Brain Res. 1986;370:327-332
47.Krauss J, Regel, JP, Vach, W, et al. . White matter lesions in patients with idiopathic normal pressure hydrocephalus and in an age-matched control group: A comparative study. Neurosurgery. 1997;40:491-496
48.Tullberg M, Hultin, L, Ekholm, S, et al. . White matter changes in normal pressure hydrocephalus and binswanger disease: Specificity, predictive value and correlations to axonal degeneration and demyelination. Acta Neurol Scand. 2002;105:417-426
49.Waldemar G, Schmidt JF, Delecluse F, Andersen AR, Gjerris F, Paulson OB. High resolution spect with [99mTc]-d,l-HMPAO in normal pressure hydrocephalus before and after shunt operation. J Neurol Neurosurg Psychiatry. 1993;56:655-664
50.Bradley WJ, Whittemore, AR, Watanabe, AS, et al. Association of deep white matter infarction with chronic communicating hydrocephalus: Implications regarding the possible origin of normal-pressure hydrocephalus. AJNR Am J Neuroradiol 1991;12:31-39
51.Owler BK, Momjian S, Czosnyka Z, Czosnyka M, Péna A, Harris NG, Smielewski P, Fryer T, Donovan T, Coles J, others. Normal pressure hydrocephalus and cerebral blood flow: a PET study of baseline values. Journal of Cerebral Blood Flow & Metabolism. 2004;24:17–23
52.Bradley W. Normal pressure hydrocephalus: New concepts on etiology and diagnosis. AJNR Am J Neuroradiol 2000;21:1586-1590
53.George AE. Chronic communicating hydrocephalus and periventricular white matter disease: A debate with regard to cause and effect. AJNR American Journal of Neuroradiology. 1991;12:42-44
54.Boon A, Tans, JT, Delwel, EJ, et al. Dutch normal-pressure hydrocephalus study: The role of cerebrovascular disease. J Neurosurg. 1999;90:221
55.Spagnoli D IL, Bello L, et al. Impact of cerebrovascular disease on the surgical treatment of idiopathic normal pressure hydrocephalus. Neurosurgery. 2006;59:545-552
56.Krauss J, Droste, DW, Vach, W, et al. Cerebrospinal fluid shunting in idiopathic normal-pressure hydrocephalus of the elderly: Effect of periventricular and deep white matter lesions. Neurosurgery. 1996;39:292-299
57.Bugalho P AL. Normal-pressure hydrocephalus: White matter lesions correlate negatively with gait improvement after lumbar puncture. Clin Neurol Neurosurg 2007;109:774-778
58.Tullberg M, Jensen C, Ekholm S, Wikkelso C. Normal pressure hydrocephalus: Vascular white matter changes on mr images must not exclude patients from shunt surgery. American Journal of Neuroradiology. 2001;22:1665–1673
59.Owler B, Pickard, JD. . Normal pressure hydrocephalus and cerebral blood flow: A review. Acta Neurol Scand. 2001;104:325-342
60.Sasaki H IK, Kono AK, et al. Cerebral perfusion pattern of idiopathic normal pressure hydrocephalus studied by SPECT and statistical brain mapping. Ann Nucl Med. 2007;21:39-45
61.Klinge PM BD, Samii A, et al. Correlates of local cerebral blood flow (CBF) in normal pressure hydrocephalus patients before and after shunting-a retrospective analysis of [15O]H2O PET-CBF studies in 65 patients. Clin Neurol Neurosurg 2008; 10: 369-375
62.Thomas G, McGirt MJ, Woodworth G, Heidler J, Rigamonti D, Hillis AE, Williams MA. Baseline neuropsychological profile and cognitive response to cerebrospinal fluid shunting for idiopathic normal pressure hydrocephalus. Dementia and Geriatric Cognitive Disorders. 2005;20:163-168
63.Ogino A, Kazui H, Miyoshi N, Hashimoto M, Ohkawa S, Tokunaga H, Ikejiri Y, Takeda M. Cognitive impairment in patients with idiopathic normal pressure hydrocephalus. Dementia and Geriatric Cognitive Disorders. 2006;21:113-119
64.Iddon JL PJ, Cross JJ, et al. Specific patterns of cognitive impairment in patients with idiopathic normal pressure hydrocephalus and Alzheimer''s disease: A pilot study. J Neurol Neurosurg Psychiatry. 1999;67:723–732
65.Lenfeldt N, Larsson, A, Nyberg, L, et al. . Idiopathic normal pressure hydrocephalus: Increased supplementary motor activity accounts for improvement after csf drainage. Brain Res. 2008;131:2904-2912
66.Deblieck C, Pesenti G, Scifo P, Fazio F, Bricolo E, Lo Russo G, Scialfa G, Cossu M, Bottini G, Paulesu E. Preserved functional competence of perilesional areas in drug-resistant epilepsy with lesion in supplementary motor cortex: f MRI and neuropsychological observations. NeuroImage. 2003;20:2225-2234
67.Kazui H, Kitagaki H, Mori E. Cortical activation during retrieval of arithmetical facts and actual calculation: A functional magnetic resonance imaging study. Psychiatry and Clinical Neurosciences. 2000;54:479-485
68.Della Sala S, Francescani A, Spinnler H. Gait apraxia after bilateral supplementary motor area lesion. J Neurol Neurosurg Psychiatry. 2002;72:77-85
69.Miyoshi N, Kazui, H, Ogino, A, et al. . Association between cognitive impairment and gait disturbance in patients with idiopathic normal pressure hydrocephalus. Dement Geriatr Cogn Disord. 2005;20:71-7670.
70. Nakayama T OY, Yoshikawa E, et al. Striatal D2 receptor availability after shunting in idiopathic normal pressure hydrocephalus. J Nucl Med. 2007;48:1981–1986
71.Ishii K, Kanda T, Harada A, Miyamoto N, Kawaguchi T, Shimada K, Ohkawa S, Uemura T, Yoshikawa T, Mori E. Clinical impact of the callosal angle in the diagnosis of idiopathic normal pressure hydrocephalus. European Radiology. 2008;18:2678–2683
72.Teng EL, Hasegawa K, Homma A, Imai Y, Larson E, Graves A, Sugimoto K, Yamaguchi T, Sasaki H, Chiu D. The cognitive abilities screening instrument (CASI): A practical test for cross-cultural epidemiological studies of dementia. International Psychogeriatrics / IPA. 1994;6:45-58
73.Morris JC. The clinical dementia rating (CDR): Current version and scoring rules. Neurology. 1993;43:2412-2414
74Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The neuropsychiatric inventory: Comprehensive assessment of psychopathology in dementia. Neurology. 1994;44:2308-2314
75.Knopman DS, DeKosky ST, Cummings JL, Chui H, Corey-Bloom J, Relkin N, Small GW, Miller B, Stevens JC. Practice parameter: Diagnosis of dementia (an evidence-based review): Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2001;56:1143-1153
76.Gill TM, Williams CS, Tinetti ME. Assessing risk for the onset of functional dependence among older adults: The role of physical performance. Journal of the American Geriatrics Society. 1995;43:603-609
77.Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. British medical bulletin. 2005;71:45–59
78.Wahlund LO, Barkhof F, Fazekas F, Bronge L, Augustin M, Sjogren M, Wallin A, Ader H, Leys D, Pantoni L, others. A new rating scale for age-related white matter changes applicable to MRI and CT. Stroke 2001;32: 318-1322
79.Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 1975;12:189-198
80.Liu CK LR, Lai CL. A normative study of chinese version
of the cognitive abilities screening instrument [abstract]. Bull
Taiwan Neurol Soc. 1998;23:49
81.Lindqvist G, Andersson H, Bilting M, Blomstrand C, Malmgren H, Wikkelsø C. Normal pressure hydrocephalus: Psychiatric findings before and after shunt operation classified in a new diagnostic system for organic psychiatry. Acta Psychiatrica Scandinavica Supplementum. 1993;373:18-32
82.Black P, Ojemann, RG, Tzouras, A. . CSF shunts for dementia, incontinence, and gait disturbance. Clin Neurosurg. 1985;32:632-651
83.Tullberg M, Jensen, C, Ekholm, S, Wikkelso, C. . Normal pressure hydrocephalus: Vascular white matter changes on MR images must not exclude patients from shunt surgery. AJNR Am J Neuroradiol. 2001;22:1665-1673
84.Schlosser R, Hutchinson M, Joseffer S, Rusinek H, Saarimaki A, Stevenson J, Dewey SL, Brodie JD. Functional magnetic resonance imaging of human brain activity in a verbal fluency task. British Medical Journal. 1998;64:492–498
85Cummings JL. Subcortical dementia. Neuropsychology, neuropsychiatry, and pathophysiology. The British Journal of Psychiatry. 1986;149:682-697
86.Cummings JL. Frontal-subcortical circuits and human behavior. Arch Neurol. 1993;50:873-880
87.Moretti J-L, Sergent A, Louarn F, Rancurel G, Percq M, Flavigny R, Degos J-D, Caron J-P, Poncin Lafitte M, Bardy A, Vigneron N. Cortical perfusion assessment with 123i-isopropyl amphetamine (123I-IAMP) in normal pressure hydrocepha lus (NPH). European Journal of Nuclear Medicine and Molecular Imaging. 1988;14:73-79
88.Momjian S OB, Czosnyka Z, et al. Pattern of white matter regional cerebral blood flow and autoregulation in normal pressure hydrocephalus. Brain. 2004;127:965-972
89.Miyoshi N, Kazui H, Ogino A, Ishikawa M, Miyake H, Tokunaga H, Ikejiri Y, Takeda M. Association between cognitive impairment and gait disturbance in patients with idiopathic normal pressure hydrocephalus. Dementia and Geriatric Cognitive Disorders. 2005;20:71-76
90.Dumarey NE, Massager N, Laureys S, Goldman S. Voxel-based assessment of spinal tap test-induced regional cerebral blood flow changes in normal pressure hydrocephalus. Nuclear Medicine Communications. 2005;26:757-763
91.Kubo Y KH, Yoshida T, et al. Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus. Dement Geriatr Cogn Disord. 2008;25:37–45
92.Podsiadlo D, Richardson S. The timed "Up & go": A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society. 1991;39:142-148
93.Hellström P, Edsbagge M, Archer T, Tisell M, Tullberg M, Wikkelsø C. The neuropsychology of patients with clinically diagnosed idiopathic normal pressure hydrocephalus. Neurosurgery. 2007;61(6):1219-26; discussion 1227-8.
94.Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: Diagnosis and treatment. Current Neurology and Neuroscience Reports. 2008;8:371-376