**Author details**

susceptibility artifact, particularly on T2 weighted images, making the torn ligament appear "normal" (uniform, hypointense, "dark" signal with uniform thickness) [35]. With proper MRI sequences, such as "Proton Density" thin section data sets, the "gray" intermediate signal indicative of ligamentous disruption can be contrasted by a background of adjacent

Standard T1 W and T2 W CCJ MRI protocols with 5- to 7-mm-thick slices are insufficient to demonstrate such membrane/ligament lesions [37]. Sections 2–3 mm thick give adequate spatial resolution with an adequate signal-to-noise ratio. The low membrane/ligament signal afforded by proton density (PD)-weighted images provide better delineation from both CSF and adjacent soft tissues compared to the standard T1- and T2-weighted sequences that typi-

On T1-weighted images, ligaments are not as well defined because a damaged ligament and the surrounding edema/inflammation and adjacent CSF will all be 'gray', or intermediate in T1 signal [15]. However, with the PD sequence (especially with fat suppression) the edema/ inflammation and CSF become hyperintense (increased in PD signal) while depicting intact ligaments as relatively hypointense (lower) signal. The reason PD-weighted images are not routinely used to replace the standard T1-weighted images (on current C-spine protocols) is

In hyperflexion trauma, all posterior cervical ligaments and membranes are subjected to strain forces. When the atlanto-occipital membrane is stretched beyond its elastic limit, these forces are transmitted to the adjacent dura mater. The rupture of the latter indicates a sprained/

The complex nature of the structure and function of the craniocervical junction makes it especially vulnerable to injury and deformation. Forces acting upon the head and cervical spine as occurs in head/neck trauma, may occur in complex patterns [40]. Accordingly, it is important to ensure that complex injuries are properly evaluated and are not overlooked as complex

The authors would like to acknowledge Dr. Michael Flanagan's numerous contributions to the literature and his seminal writings on the anatomy of the craniocervical junction and the role of cerebrospinal fluid in brain function and health. https://uprightdoctor.wordpress.com/

Special thanks to Ron Tribell and Axis Medical Illustrations for the illustrations at **Figures 1**,

injury scenarios are plausible when trauma occurs to the craniocervical junction [41].

"brighter" CSF (versus intermediate signal with T1 weighting) [36].

cally comprise standard cervical MRI studies [38].

that PD can "miss" medullary space lesions [39].

**4. Kinematic imaging of the craniocervical junction**

injured membrane.

36 Hydrocephalus: Water on the Brain

**Acknowledgements**

about-dr-michael-flanaga/

**3**, **7** and **8**.


### **References**


[12] Tubbs RS, Hallock JD, Radcliff V, et al. Ligaments of the craniocervical junction. Journal of Neurosurgery. Spine. 2011;**14**:697-709

[27] Rogers SJ, Whitehead D. Chiari-1 Malformation. Factsheets for Docs-on-the-go

atic patients. Neurosurgery. 1999 May;**44**(5):1005-1017

Journal of Roentgenology. 2011;**196**:421-425

study. Spine. 2008;**33**(18):2012-2016

**59**(1-2):123-142

2007;**7**:601-609

1995;**36**:425-428

[28] Milhorat TH, Chou MW, Trinidad EM, Kula RW, Mandell M, Wolpert C, Speer MC. Chiari I malformation redefined: Clinical and radiographic findings for 364 symptom-

Craniocervical Junction Syndrome: Anatomy of the Craniocervical and Atlantoaxial Junctions…

http://dx.doi.org/10.5772/intechopen.72890

39

[29] William B. Simultaneous cerebral and spinal fluid pressure recordings. 2. Cere brospinal dissociation with lesions at the foramen magnum. Acta Neurochirurgica. 1981;

[30] Williams HA. Unifying hypothesis for hydrocephalus, Chiari malformation, Syringomyelia, anencephaly and Spina bifida. Cerebrospinal Fluid Research. 2008

[31] Kwong Y, Rao N, Latief K. Craniometric measurements in the assessment of Craniovertebral settling: Are they still relevant in the age of cross-sectional imaging? American

[32] Milhorat TH, Bolognese PA, Nishikawa M, McDonnell NB, Francomano CA. Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and Chiari malformation type I in patients with hereditary disorders of connective tissue. Journal of Neurosurgery. Spine.

[33] Myran R, Kvistad KA, Nygaard OP, Andresen H, Folvik M, Zwart JA. Magnetic resonance imaging assessment of the alar ligaments in whiplash injuries. A case-control

[34] Borchgrevink GE, Smevik O, Nordby A, et al. MR imaging and radiography of patients with cervical hyperextension-flexion injuries after car accidents. Acta Radiologica.

[35] Ronnen H, de Korte PJ, Brink PRG, et al. Acute whiplash injury: Is there a role for MR

[36] Krakenes J, Kaale BR, Rorvik J, et al. MRI assessment of normal ligamentous structures

[37] Krakenes J, Kaale BR. MRI assessment of craniovertebral ligaments and membranes

[38] Pfirrmann CWA, Binkert CA, Zanetti M, et al. MR morphology of alar ligaments and occipitoatlantoaxial joints: Study in 50 asymptomatic subjects. Radiology. 2001;**218**:133-137 [39] Roy S, Hol PK, Laerum LT, et al. Pitfalls of magnetic resonance imaging of alar ligament.

[40] Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine

[41] Swartz EE, Floyd RT, Cendoma M. Cervical spine functional anatomy and the biomechanics of injury due to compressive loading. Journal of Athletic Training. 2005;**40**(3):155-161

imaging? A prospective study of 100 patients. Radiology. 1996;**201**:93-96

in the craniovertebral junction. Neuroradiology. 2001;**43**:1089-1097

after whiplash trauma. Spine. 2006;**31**:2820-2826

injuries. The Journal of Trauma. 1993;**34**:342-346

Neuroradiology. 2004;**46**:392-398


[27] Rogers SJ, Whitehead D. Chiari-1 Malformation. Factsheets for Docs-on-the-go

[12] Tubbs RS, Hallock JD, Radcliff V, et al. Ligaments of the craniocervical junction. Journal

[13] Panjabi M, Dvorak J, Crisco J III, Oda T, Hilibrand A, Grob D. Flexion, extension, and lateral bending of the upper cervical spine in response to alar ligament transections.

[14] Krakenes J, Kaale BR, Moen G, Nordli H, Gilhus NE, Rorvik J.MRI of the tectorial and posterior atlanto-occipital membranes in the late stage of whiplash injury. Neuroradiology.

[15] Krakenes J, Kaale BR, Moen G, et al. MRI assessment of the alar ligaments in the late stage of whiplash injury-a study of structural abnormalities and observer agreement.

[16] Tubbs RS1, Salter G, Grabb PA, Oakes WJ. The denticulate ligament: Anatomy and func-

[17] Grostic JD. Dentate ligament-cord distortion hypothesis. Chiropr Res J. 1988;**1**(1):47-55 [18] Freeman MD, Rosa S, Harshfield D, Smith F, Bennett R, Centeno CJ, Kornel E, Nystrom A, Heffez D, Kohles SS. A case-control study of cerebellar tonsillar ectopia (Chiari) and

[19] Ubogu EE, Zaidat OO. Vertebrobasilar dolichoectasia diagnosed by magnetic resonance angiography and risk of stroke and death: A cohort study. Journal of Neurology,

[20] Tomasello F, Alafaci C, Salpietro FM, Longo M. Bulbar compression by an ectatic vertebral artery: A novel neurovascular construct relieved by microsurgical decompression.

[21] Milandre L, Bonnefoi B, Pestre P, Pellissier JF, Grisoli F, Khalil R. Vertebrobasilar arterial dolichoectasia: Complications and prognosis. Revue Neurologique (Paris). 1991;

[22] Chiari Conundrum. JAMA (2009-01-14). Chiari conundrum: Researchers tackle a brain

[23] Rosa S, Baird JW. The Craniocervical Junction: Observations Regarding the Relationship between Misalignment, Obstruction of Cerebrospinal Fluid Flow, Cerebellar Tonsillar Ectopia, and Image-Guided Correction. Basel, Karger: The Craniocervical Syndrome

[24] Upledger J. The Expanding Role of Cerebrospinal Fluid in Health and Disease. Cranio-

[25] Sakka L, Coll G, Chazal J. Anatomy and physiology of cerebrospinal fluid. European

[26] Andeweg J. Intracranial venous pressures, hydrocephalus and effects of cerebrospinal

Annals of Otorhinolaryngology, Head and Neck Diseases. 2011;**128**:309-316

fluid shunts. Child's Nervous System. October 1989;**5**(5):318-323 (2005), 1-4

puzzle for the 21st century. Rebecca Voelker JAMA. 2009;**301**(2):147-149

tional significance. Journal of Neurosurgery. 2001 Apr;**94**(2 Suppl):271-275

head/neck trauma (whiplash). Brain Injury. 2010;**24**(7-8):988-994

Neurosurgery, and Psychiatry. 2004;**75**:22-26

sacrally Speaking Massage Today; March 2002

Neurosurgery. 2005;**56**:117-124

and MRI; 2015. pp. 48-66

**147**:714-722

of Neurosurgery. Spine. 2011;**14**:697-709

Journal of Spinal Disorders. 1991;**4**:157-167

Neuroradiology. 2002;**44**:617-624

2003;**45**:585-591

38 Hydrocephalus: Water on the Brain


**Section 3**

**Clinical and Cognitive Features of NPH**

**Clinical and Cognitive Features of NPH**

**Chapter 4**

**Provisional chapter**

**Clinical and Cognitive Features of Idiopathic Normal**

**Introduction**: Idiopathic normal pressure hydrocephalus (iNPH) is characterized by dilated cerebral ventricles with progressive impaired gait, cognition, and urinary control. Firstly described in 1965 by Hakim and Adam, it remains largely under-diagnosed. The diagnosis is based on clinical and imaging (CT or MRI) investigations; a timely diagnosis and cerebrospinal fluid (CSF) shunt surgery has reported to be beneficial in 60 up to 80%

**Body**: The severity of motor and cognitive disturbances varies widely and it can be difficult to distinguish iNPH from other neurodegenerative disorders. The cognitive and behavioral disturbances have been commonly described as "fronto-subcortical dysfunction". However, this definition is reductive not encompassing the entire cognitive spectrum of iNPH deficits. In our sample we found an impairment in respect to healthy controls in all the neuropsychological tests, but verbal memory. We could also find a positive correlation between the severity of cognition deficit and disease progression,

**Conclusions**: iNPH can be reliably diagnosed with an organized approach. Neurologists play an essential role in the care of patients and a multidisciplinary team can improve this process. An early shunt surgery might contain the progression of the disturbances and

**Keywords:** hydrocephalus, neurodegenerative diseases, cognition, aging and dementia,

**Clinical and Cognitive Features of Idiopathic Normal** 

DOI: 10.5772/intechopen.73273

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Pressure Hydrocephalus**

**Pressure Hydrocephalus**

http://dx.doi.org/10.5772/intechopen.73273

Paolo Vitali

**Abstract**

of the cases.

neurogeriatric

Paolo Vitali

Elena Sinforiani, Claudio Pacchetti, Marta Picascia, Nicolò Gabriele Pozzi, Massimiliano Todisco and

Elena Sinforiani, Claudio Pacchetti, Marta Picascia, Nicolò Gabriele Pozzi, Massimiliano Todisco and

Additional information is available at the end of the chapter

suggesting a common pathological mechanism.

also possibly prevent their development.

Additional information is available at the end of the chapter

**Provisional chapter**
