Dr. Frohman and Normal Pressure Hydrocephalus

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Thu Oct 18, 2012 9:14 am

How much of a misnomer is NPH? Do we have a reliable accurate method of measuring CSF pressure? How the pardon-my-expletives do we know what normal CSF pressure is? What if "MS" is caused by intermittent, transient pulses of high ventricular pressure that is relieved both by shunting and by de-stenosis in the jugulars? We need less invasive, less painful and more real-time ways to measure cerebral fluid pressure in the human body. No wonder plethysmography is not taken seriously. This is 2012! Can't somebody get Heisenberg out of the loop? Do our MRI inventors have any ideas?
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Thu Oct 18, 2012 9:39 am

cheerleader wrote:Retrograde jugular flow associated with idiopathic normal pressure hydrocephalus.
http://www.ncbi.nlm.nih.gov/pubmed/18570299

To clarify the relation between the drainage pathway of cerebrospinal fluid and the development of idiopathic normal pressure hydrocephalus (iNPH), we examined flow patterns of internal jugular veins in 20 patients with iNPH and 13 control patients using air-contrast ultrasound venography during the Valsalva maneuver. The iNPH group had a significantly greater frequency of retrograde jugular venous flow (19/20, 95%) than the control group (3/13, 23%) (chi(2) test, p < 0.001). Our results suggest that retrograde jugular venous flow may be associated with the development of iNPH; therefore, the analysis of retrograde jugular venous flow could be a useful element in the diagnosis of iNPH.


yes, this is with Valsalva, where true CCSVI is without Valsalva
----but still an interesting correlation.
cheer


I think that might be premature. Valsalva may muddy the water, but if it induces backward flow, in CCSVI it might only be making things worse than they already are. The point being that just because they used Valsalva to test for NPH, and Zamboni said not to use it in Doppler CCSVI tests doesn't mean that a) it doesn't test just as well for CCSVI retrograde flow and b) the retrograde flow isn't present in the same way in both conditions. We have been shunting hydrocephalus since 1964. Maybe it would also be a good thing for "MS". The shunt my brother had was in his jugular.
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby cheerleader » Thu Oct 18, 2012 10:16 am

Agree--one eye, valsalva may muddy the water, but I wanted to make mention to be clear about differences in CCSVI Syndrome as discovered by Dr. Zamboni.

Here's another paper on hydrocephalus found in MS-- two cases, not just one.

Apparent hydrocephalus and chronic multiple sclerosis: a report of two cases.
O'Brien T, Paine M, Matotek K, Byrne E.
Department of Clinical Neuroscience, St. Vincent's Hospital, Melbourne.
Abstract
Generalised ventricular dilatation with or without cerebral atrophy is common in longstanding multiple sclerosis. This has been widely assumed to be due to periventricular white matter atrophy rather than true communicating hydrocephalus although it can be difficult to distinguish between these on radiological grounds. Here we report 2 chronic MS patients who had progressive dementia, gait disturbance and urinary incontinence and in whom neuroimaging, and in one case CSF infusion studies, suggested hydrocephalus. Both significantly improved following shunting procedures. We suggest that further study is required to investigate whether a significant proportion of patients with chronic MS and dilated ventricles have shunt-responsive hydrocephalus.

http://www.ncbi.nlm.nih.gov/pubmed/7712624

One eye brings up a VERY important point. It is currently not easy to tell the difference between brain atrophy and hydrocephalus on MRI. In both images, the brain appears smaller and the fluid fills in the "empty" space. Nature abhors a vacuum. The only way these docs could guess that this might be NPH was to note the symptoms of NPH, which are 1. gait disturbance 2. progressive dementia 3. urinary incontinence.

And, as I posted in research today back on page 6, CSF markers for NPH look alot like MS, because they have MBP markers, and show demyelination.

MS/CCSVI and NPH share
periventricular white matter lesions
Myelin Basic Protein in CSF
Progressive neurological symptoms
dilated ventricles which signal pseudo atrophy/brain atrophy on MRI
retrograde blood flow in jugular veins

one eye and his brother may be more similar than their docs would think.....

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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Thu Oct 18, 2012 10:47 am

My father had "gait disturbance", and what they called "peripheral neuropathy", which they put down to the effects of his late-onset diabetes, which one prominent neurologist told me is "not auto-immune" (BTW my "MS" came after I was 40). I wonder if Bill and I got it from *his* genes. I wonder if he had "MS". There certainly is a lot of "auto-immunity" in my family. If I didn't know better, I would almost call it self-loathing. But we came from Detroit, and thanks to Henry Ford, most of us ended up with Auto Immunity. My dad drove a Peugeot. After a brief bout of Volkswagens, I have driven mostly Japanese cars. Guess WWII had some effect on me.
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Thu Oct 18, 2012 10:56 am

I'm sure I have lots of "brain atrophy" by now, but my diagnosis was based on an MRI report that said I had an "atrophic" corpus callosum.

I have seen on MRIs that victims of "high pressure" hydrocephalus can have ventricles so expanded that their brains look like they have only grown in a thin layer on the inside of their skulls. Does anyone know if ventricular expansion can cause the corpus callosum to look like it has atrophied?
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby gibbledygook » Thu Oct 18, 2012 12:25 pm

Well it looks like the corpus callosum is right next to the ventriculus tertius. Would that be the 3rd ventricle which is usually the expanded one in MS?!
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Thu Oct 18, 2012 12:50 pm

:!:
further study is required to investigate whether a significant proportion of patients with chronic MS and dilated ventricles have shunt-responsive hydrocephalus


Third ventricle, eh? "Curiouser and curiouser!"

Does anyone who has the ear of somebodies like Dr. Dake or Dr. Hubbard want to pursue this and see if we can get someone who is In The Book interested in these speculations? I might even be able to find them a Suitable Guinea Pig...
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby Cece » Thu Oct 18, 2012 1:12 pm

cheerleader wrote:Retrograde jugular flow associated with idiopathic normal pressure hydrocephalus.
http://www.ncbi.nlm.nih.gov/pubmed/18570299

To clarify the relation between the drainage pathway of cerebrospinal fluid and the development of idiopathic normal pressure hydrocephalus (iNPH), we examined flow patterns of internal jugular veins in 20 patients with iNPH and 13 control patients using air-contrast ultrasound venography during the Valsalva maneuver. The iNPH group had a significantly greater frequency of retrograde jugular venous flow (19/20, 95%) than the control group (3/13, 23%) (chi(2) test, p < 0.001). Our results suggest that retrograde jugular venous flow may be associated with the development of iNPH; therefore, the analysis of retrograde jugular venous flow could be a useful element in the diagnosis of iNPH.


yes, this is with Valsalva, where true CCSVI is without Valsalva----but still an interesting correlation.
cheer

Huh, that is interesting. It's similar to the transient global amnesia group that had deficient jugular valves, with a valsalva event noted shortly before onset of amnesia. Retrograde jugular venous flow for any reason, whether stenosed valves or the condition of excessive retrograde flow upon valsalva, may be not good for our brains.
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby cheerleader » Thu Oct 18, 2012 3:03 pm

You got it, Gibbs---the third ventricle is the one Eliot Frohman mentioned back in '09, the one next to the corpus callosum, and the one implicated in MS and NPH.
NPH is related to corpus collosum abnormalities, one eye----
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077766/

Functional and magnetic resonance imaging correlates of corpus callosum in normal pressure hydrocephalus before and after shunting
Maria Mataró, Mar Matarín, Maria Antonia Poca, Roser Pueyo, Juan Sahuquillo, Maite Barrios, and Carme Junqué
Normal pressure hydrocephalus (NPH) is associated with corpus callosum abnormalities.

Objectives
To study the clinical and neuropsychological effect of callosal thinning in 18 patients with idiopathic NPH and to investigate the postsurgical callosal changes in 14 patients.

Methods
Global corpus callosum size and seven callosal subdivisions were measured. Neuropsychological assessment included an extensive battery assessing memory, psychomotor speed, visuospatial and frontal lobe functioning.
Results
After surgery, patients showed improvements in memory, visuospatial and frontal lobe functions, and psychomotor speed.
Conclusion
The postsurgical corpus callosum increase might be the result of decompression, re‐expansion and increase of interstitial fluid, although it may also be caused by differences in shape due to cerebral reorganisation.


Wanted you to know, the docs are looking into this, especially in relation to CSF disturbances shown on FONAR...CCSVI Alliance has been working to put the researchers together.
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby Rogan » Sun Oct 21, 2012 11:31 am

cheerleader wrote: Now, here's the kicker.....there MAY BE a correlation here with Alzheimer's, Parkinson's, dementia and other diseases of neurodegeneration---these are all diseases where slowed cerebral bloodflow (hypoperfusion) and slowed CSF clearance harm brain tissue.
cheer


Cheerleader, knowing what you do would you suggest to love ones or friends with Parkinson's that they get a Haacke protocol fMRI scan?

I keep hearing on this site little mentions about folks with Parkinson's being helped by PTA (Dr. Arata comes to mind) and other posts.

Just curious about your opinion on this.

Thanks in advance....
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Sun Oct 21, 2012 11:53 am

I can't help thinking there must be a connection with the newly-discovered "glymphatic" clearance system. Didn't someone mention drainage of alzheimers-related molecules by this system?
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby cheerleader » Sun Oct 21, 2012 12:42 pm

Rogan-- I'd recommended either Haacke protocol or Dr. Scott Rosa's FONAR study (which I think is full at this point) CCSVI Alliance has facilitated conversations between these doctors, and they are comparing notes. Please realize that this is all hypothetical at this point, clinical trials are just underway. Haacke was noting venous sinus compression (also indicative of IHH) in people with Parkinson's. We just don't know how venoplasty and/or atlas treatment will work in the long run, and I'd hate to have people getting hopes raised or spending money for venoplasty treatment before more is understood. Please read from the beginning of this thread and see that this discussion was started in '09 to try and figure out restenosis in a gentleman who is now suing Dr. Dake for failed venoplasty. Sometimes early adapters are hurt, and I do NOT want to be suggesting any treatment which is not understood yet. Suffice it to say, something is going on with cerebrospinal fluid stasis, but it's still being elucidated.

One eye--there may very well be a connection with the U of R discovery of the "glymphatic system" and neurodegenerative disease- I believe MS should be added to the list they have here. Yes, this system is thought to clear waste products, like the excess proteins found in Alzheimer's plaques. It also brings nutrients to brain tissue via diffusion.
Waste clearance is of central importance to every organ, and there have been long-standing questions about how the brain gets rid of its waste,” said Maiken Nedergaard, M.D., D.M.Sc., senior author of the paper and co-director of the University’s Center for Translational Neuromedicine. “This work shows that the brain is cleansing itself in a more organized way and on a much larger scale than has been realized previously.
“We’re hopeful that these findings have implications for many conditions that involve the brain, such as traumatic brain injury, Alzheimer’s disease, stroke, and Parkinson’s disease,” she added.

Nedergaard’s team has dubbed the new system “the glymphatic system,” since it acts much like the lymphatic system but is managed by brain cells known as glial cells. The team made the findings in mice, whose brains are remarkably similar to the human brain.

Scientists have known that cerebrospinal fluid or CSF plays an important role cleansing brain tissue, carrying away waste products and carrying nutrients to brain tissue through a process known as diffusion. The newly discovered system circulates CSF to every corner of the brain much more efficiently, through what scientists call bulk flow or convection.

http://www.urmc.rochester.edu/news/stor ... fm?id=3584
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby Rogan » Mon Oct 22, 2012 9:29 am

Cheerleader, thanks for the balanced advice.

Let's hope these amazing doctors and researchers can shed some new light on these horrible degenerative diseases. The drug establishment hasn't led us very far in understanding the disease process for Alzheimer’s or Parkinson's. Do you know why drug company employee's aren't required to take the Hippocratic Oath?

Knowing that the brain is a liquid and not the spongy organ you see in lab jars has always made me think any sort of fluid mechanics dealing with the brain must be very important to a liquid organ.

Anyhow, what is IHH?

And is Dr. Flanagan, the Upright Doc, a part of the CCSVI Alliance's Science Advisory Board?

I have just purchased his book The Downside of Upright Posture. We are so lucky here at TIMS to have his input. From the looks of his website he has been concerned about CSF and blood flow to the brain for quite some time. His thoughts on NPH and Parkinson's are fascinating to say the least.

http://www.upright-health.com/parkinsons.html
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby cheerleader » Mon Oct 22, 2012 10:39 am

Rogan-
oops...meant IIH---idiopathic intracranial hypertension.
Inside the brain are four ventricles. CSF flows through the ventricles by way of channels that connect one ventricle to another. Eventually, the CSF is absorbed into the bloodstream. In order to maintain normal pressure inside the skull the production, flow and absorption of CSF must be kept in balance.

Idiopathic intracranial hypertension or Pseudotumor cerebri In patients suffering from IIH, the pressure inside the brain builds and causes severe, chronic headaches, vision problems and ringing in the ears. Most patients are first evaluated for a brain tumor before their neurologist suspects IIH. It is unknown why this condition occurs. It is mostly identified in young women who are overweight.

http://www.hopkinsmedicine.org/neurolog ... n_iih.html

My husband isn't a gal, and isn't overweight, but he had pulsatile tinnitus (he could hear his blood whoosh in his ear) and headaches, and lost his peripheral vision as a kid due to drusen (fatty deposits on the optic disc) and optic disc pressure. A brain tumor was ruled out when he was a kid, and the docs just said, it's your drusen. He got an MS diagnosis three decades later. Strangely enough, the whooshing and headaches stopped when he had a high stent put in his jugular at Stanford...and endovascular stenting is an accepted procedure for IIH in a stenosed dural sinus.
http://www.ncbi.nlm.nih.gov/pubmed/19877792
http://www.ncbi.nlm.nih.gov/pubmed/18285539
http://www.ajnr.org/content/32/8/1408.full
this is all just hypothesizing. He was never diagnosed with IIH, but it is interesting.

Agree with you about Dr. Flanagan, and have read his book and online site. He's brilliant. The Alliance hasn't announced our scientific board, but we've been working really hard to get these doctors in dialogue with each other.
cheer
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Re: Dr. Frohman and Normal Pressure Hydrocephalus

Postby 1eye » Mon Oct 22, 2012 1:53 pm

All these things seem related. CSF pressure (how is production and absorption accomplished?), arterial pressure, venous pressure. No wonder an ACE inhibitor can have some effect.

What is the "normal" CSF pressure? How is it regulated?

Brains are the only thing not liquid in your head. That's why sometimes they give the appearance of atrophy: brains are compressible, whereas the liquids in your skull, like CSF, arterial, and venous blood, are not. That means, when these fluids are completely surrounded by bone, they have as much give as granite. The other "matter" in your head is softer than granite, and so it compresses and becomes smaller when the liquids exhibit too much pressure. The ventricles might even tear and leak if there is high enough pressure in them. Is there a good non-invasive way to measure instantaneous pressure? Seems to me ultrasound might accomplish this, if pressure affects the propagation of the sound waves. Would have to be a very sensitive and well calibrated instrument.
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