Cerebral Autoregulation, CSF outflow resistance and outcome following CSF diversion in Normal Pressure Hydrocephalus

Abstract Introduction Normal pressure hydrocephalus (NPH) is not simply the result of a disturbance in cerebrospinal fluid (CSF) circulation, but often includes cardiovascular comorbidity and abnormalities within the cerebral mantle. In this study, we have examined the relationship between the global autoregulation pressure reactivity index (PRx), the profile of disturbed CSF circulation and pressure-volume compensation, and their possible effects on outcome after surgery. Materials and methods We studied a cohort of 131 patients, investigated for possible NPH. Parameters describing CSF compensation and circulation were calculated during the cerebrospinal fluid (CSF) infusion test and PRx was calculated from CSF pressure and arterial pressure recordings. A simple scale was used to mark the patients’ outcome 6 months after surgery (improvement, temporary improvement, and no improvement). Results PRx was negatively correlated with R out (R=−0.18; p=0.044); patients with normal CSF circulation tended to have worse autoregulation. The correlation for patients who were surgically-managed (N=83) was: R=−0.28; p=0.03, and stronger in patients who improved after surgery (N=64; R=−0.36; p=0.03). In patients who did not improve, the correlation was not significantly different from zero (N= 19; R=0.17; p=0.15). There was a trend towards higher values for PRx in non-responders than in responders (PRx =0.16+/− 0.04 vs 0.09 +/−0.02 respectively; p=0.061), associated with higher MAP values (107.2+/−8.2 in non-responders vs 89.5+/−3.5 in responders; p=0.195). The product of MAP* (1+PRx), proposed as a measure of combined arterial hypertension and deranged autoregulation, showed a significant association with outcome (greater value in non-responders; p=0.013). Conclusion Autoregulation proves to associate with cerebrospinal fluid circulation, and appears strongest in shunt responders. Outcome following CSF diversion is possibly most favorable when CSF outflow resistance is increased and global cerebral autoregulation is intact, in combination with arterial normotension.