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Aan de slag!Luister! Hoe luister jij naar Gods woorden vandaag? Hoe verbind jij je vandaag met andere christenen, het volk van onze God? Mag God voor jou de enige zijn?Deze overdenking is geschreven door schrijfster Marieke van der Maaten.
Stefan, Laurens en Lars gaan verder! De Tour is inmiddels halverwege, maar vandaag begint het échte werk. Etappe 12 voert de renners naar de iconische Hautacam en dat betekent één ding: spektakel, vuurwerk en misschien wel krakende klassementsmannen. De juiste renners zullen boven komen drijven.De heren blikken terug op de naweeën van etappe 11, denken dat Mathieu nu wel klaar zal zijn, en vragen zich af: hoe komt Pogi uit de val? Aan tafel worden namen genoemd: Alaphilippe, Arensman, Tadej? De heren maken zich op voor dag 13 van deze Villa Tour!En hoe zit het nou met die Live Slow Ride Fast logo's op de weg?Je hoort het allemaal in de Live Slow Ride Fast podcast.
In this two-part episode of the Brain & Life Podcast, co-host Dr. Katy Peters is joined by Elizabeth Ansell, founder and director of #NotJustFatigue. #NotJustFatigue is a nonprofit organization shining a light on myalgic encephalomyelitis/chronic fatigue syndrome, also known as ME/CFS, and educates patients, clinicians, and health organizations about the condition. Elizabeth shares how raising awareness, and furthering research really improves the everyday lives of people living with ME/CFS. Dr. Peters is then joined by Dr. W. Ian Lipkin, who is known internationally for his research and is the John Snow Professor of Epidemiology, Professor of Neurology, and Professor of Pathology and Cell Biology at Columbia University Irving Medical Center, Mailman School of Public Health. Dr. Lipkin discusses what's next in ME/CFS research and what the future could hold. Additional Resources #NotJustFatigue How to Fight Fatigue Understanding the Impact of Invisible Illnesses on Daily Life How Families Are Leading the Charge in Rare Disease Advocacy Other Brain & Life Podcast Episodes on Similar Topics Rare Thoughts on a Rarer Neurologic Condition Shedding Light and Love on a Rare Genetic Condition with Deborah Vauclare Neurofibromatosis Advocacy and Community Building with the Gilbert Family Foundation We want to hear from you! Have a question or want to hear a topic featured on the Brain & Life Podcast? Record a voicemail at 612-928-6206 Email us at BLpodcast@brainandlife.org Social Media: Elizabeth Ansell @notjustfatigue; Dr. W. Ian Lipkin @columbiapublichealth Guests: Hosts: Dr. Daniel Correa @neurodrcorrea; Dr. Katy Peters @KatyPetersMDPhD
In this episode, editor-in-chief Joseph E. Safdieh, MD, FAAN, highlights articles about upadacitinib, a new treatment for giant-cell arteritis; growing evidence linking oral health to a higher risk of neurologic conditions; and why a trial of a new meningitis B vaccine drew a mixed response.
ASML kreeg het hard te verduren op de dag van de kwartaalcijfers. Het bedrijf was niet 100 procent zeker dat het volgend jaar zou groeien, maar de gepresenteerde cijfers waren prima. Toch begrijpt Stan Westerterp (Bond Capital Partners) de reactie van beleggers wel. "Als je geen groei laat zien, dan heb je in de techsector niks te zoeken. Aan de andere kant, misschien legt de nieuwe ceo de lat nu bewust laag, zodat de resultaten laten meevallen", iets wat Stan niet bevalt. Koen Bender (Mercurius Vermogensbeheer) sluit niet uit dat de nieuwe topman bewust met een schone lei wil beginnen. "Maar je gaat mij niet vertellen, met de vraag die er is in de wereld, dat ASML volgens jaar niet gewoon weer groei laat zien." Stan is het daar ook helemaal mee eens. Het sentiment, afgezien van ASML, is helemaal niet slecht. De S&P500, en niet alleen de techsector, laten records zien. Het heeft er alle schijn van dat beleggers het handelstumult met een korrel zout nemen. Dat wordt ook gereflecteerd in bedrijfscijfers, zeker die van Amerikaanse banken, die er nog steeds uitstekend uitzien. Verder in de podcast aandacht voor de bitcoin, en dan met name de blockchain, de definitieve cijfers van TSMC en de Amerikaanse grootbanken. Daarnaast bespreken we de luisteraarsvragen (FlowTraders en Kinepolis) en geven de experts hun tips. Stan tipt drie techbedrijven die niet tot de Magnificent Seven behoren, Koen tipt een bedrijf met de ISIN-code US3377381088. Geniet van de podcast! Let op: alleen het eerste deel is vrij te beluisteren. Wil je de hele podcast (luisteraarsvragen en tips) horen, wordt dan Premium lid van BeursTalk. Dat kost slechts 9,95 per maand, 99 euro voor een heel jaar. Abonneren kan hier!See omnystudio.com/listener for privacy information.
Aan het ontbijtbuffet openen de oogjes zich langzaam onder begeleiding van een paar extra sterke espresso’s. De Casino Night van gisteravond lijkt nog maar een paar uur geleden. “Where are we today? Another Saint, I guess?” Gister was het Saint Thomas, morgen Saint Kitts. “Then today must be Sint Maarten. Wait, what? Are we in France? Or Holland? Or both?” Jawel, het cruiseleven zit vol ingewikkelde vragen. Elke dag een nieuwe droombestemming vereist snel schakelen. Onze drijvende stad meert aan en spuwt ons uit, samen met duizenden anderen. Iedereen waaiert uit. Het eiland heeft tot 16:00 vanmiddag even een tijdelijke bevolkingsgroei van 10 procent, zet alle zeilen bij totdat vanavond de rust wederkeert. En dan, aan het avondbuffet, varend naar het volgende paradijs, buigen alle cruisepassagiers zich over dezelfde vraag? Wat maakte dit eiland uniek? We zijn nooit volledig, wel origineel. Geen experts, maar wel liefhebbers. Hebben we tóch iets verkeerd gezegd of zijn we iets cruciaals vergeten? Volg ons en laat het weten.
Stefan, Laurens en Lars gaan verder! De Tour is inmiddels halverwege, maar vandaag begint het échte werk. Etappe 12 voert de renners naar de iconische Hautacam en dat betekent één ding: spektakel, vuurwerk en misschien wel krakende klassementsmannen. De juiste renners zullen boven komen drijven.De heren blikken terug op de naweeën van etappe 11, denken dat Mathieu nu wel klaar zal zijn, en vragen zich af: hoe komt Pogi uit de val? Aan tafel worden namen genoemd: Alaphilippe, Arensman, Tadej? De heren maken zich op voor dag 13 van deze Villa Tour!En hoe zit het nou met die Live Slow Ride Fast logo's op de weg?Je hoort het allemaal in de Live Slow Ride Fast podcast.
Door de toenemende regeldruk en hoogte van belastingen daalt Nederland op de ranglijst van concurrentievermogen. Aan demissionair minister van Economische Zaken Vincent Karremans de taak om ons weer hoger op de lijst te krijgen. Wat is zijn plan en hoe gaat hij om met de eisen van bedrijven als Tata Steel en ASML in zijn nieuwe functie? Hij bespreekt het met Martijn de Greve. Sven op 1 is een programma van Omroep WNL. Meer van WNL vind je op onze website en sociale media: ► Website: https://www.wnl.tv ► Facebook: https://www.facebook.com/omroepwnl ► Instagram: https://www.instagram.com/omroepwnl ► Twitter: https://www.twitter.com/wnlvandaag ► Steun WNL, word lid: https://www.steunwnl.tv ► Gratis Nieuwsbrief: https://www.wnl.tv/nieuwsbrief
Aan de slag! Open in gedachten Gods boek over jouw leven. Denk er eens over na. Laat Gods licht vallen over jouw zwarte bladzijden. Geniet van alle zegeningen. Maar bovenal, dank Hem voor jouw bestaan. Deze overdenking is geschreven door oud-schrijfster Alina van Rijn.
Tijdens een live nieuwsuitzending in Syrië was te zien hoe een Israëlische aanval op het ministerie van Defensie in Damascus plaatsvond. Het beeld was de live-achtergrond van het nieuwsprogramma. Israël bombardeerde de Syrische hoofdstad als reactie op het geweld van het Syrische regeringsleger tegen de druzen. "Het is een sterk staaltje propaganda van de Israëliërs", meent Paul Römer, oud-directeur radio en tv bij Talpa. "De impact hiervan is mediatechnisch veel groter dan drie bommen die 's nachts vallen. Het is een bewuste, getimede actie geweest." Sarah Sylbing, hoofdredacteur van de VPRO, vond het "vervreemdend" en "heel heftig" om te zien. "Zo'n nieuwsbeeld is heel herkenbaar en vertrouwd." Aan tafel zitten Sarah Sylbing, Paul Römer en Spraakmaker Chris van Dam.
Normal pressure hydrocephalus (NPH) is a pathologic condition whereby excess CSF is retained in and around the brain despite normal intracranial pressure. MRI-safe programmable shunt valves allow for fluid drainage adjustment based on patients' symptoms and radiographic images. Approximately 75% of patients with NPH improve after shunt surgery regardless of shunt type or location. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Kaisorn L. Chaichana, MD, author of the article “Management of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Berkowitz is a Continuum® Audio interviewer and a professor of neurology at the University of California San Francisco in the Department of Neurology in San Francisco, California. Dr. Chaichana is a professor of neurology in the department of neurological surgery at the Mayo Clinic in Jacksonville, Florida. Additional Resources Read the article: Management of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @kchaichanamd Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Kaisorn Chaichana about his article on management of normal pressure hydrocephalus, which he wrote with Dr Jeremy Cutsforth-Gregory. The article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr Chaichana: Yeah, thank you for having me. I'm Kaisorn Chaichana. I'm a neurosurgeon at Mayo Clinic in Jacksonville, Florida. Part of my practice is doing hydrocephalus care, which includes shunts for patients with normal pressure hydrocephalus. Dr Berkowitz: Fantastic. Well, before we get into shunt considerations and NPH specifically, which I know is the focus of your article, I thought it would be a great opportunity for a neurologist to pick a neurosurgeon's brain a bit about shunts. So, to start, can you lay out for us the different types of shunts and shunt procedures, the advantages, disadvantages of each type of shunt, how you think about which shunt procedure should be used for which patient, that type of thing? Dr Chaichana: Yeah. So, there are different types of shunts, and the most common one that is used is called a ventricular peritoneal shunt. So, it has a ventricular catheter, it has a catheter that tunnels underneath the skin and it goes into the peritoneum where the fluid goes from the ventricular system into the peritoneum. Typically, the shunts are in the ventricle because that is the largest fluid-filled space in the brain. Other terminal areas include the atrium, which is really the jugular vein, and those are called ventricular atrial shunts. You can also have ventricular pleural shunts, which end in the pleural space and drain flui into the pleural space. Those are pretty much the most common ventricular shunts. There's also a lumboperitoneal shunt that drains from the lumbar spine, similar to a lumbar drain into the peritoneum. For the lumbar shunts, we don't typically have a lumbar pleural or lumbar atrial shunt just because of the pressure dynamics, because the lumbar spine is below the lung and as well as the atrium. And so, the drainage pattern is very different than ventricular peritoneal which is top to bottom. The most common shunt, why we use the ventricular peritoneal shunt the most, is because it has the most control. So, the peritoneum is set at a standard pressure in the intraabdominal pressure, whereas the ventricular atrial shunt depends on your venous return or venous pressure and your ventricular pleural shunt varies with inspiration and expiration. So, the easiest way for us to control the fluid, the ventricular system is through the ventricular peritoneal shunt. And that's why that's our most common shunt that we use. Dr Berkowitz: Fantastic. So, as you mention in the article, neurologists may be reluctant to offer a shunt to patients with NPH because many patients may not improve, or they improve only transiently; and out of fear of shunt complications. So, of course, as neurologists, we often only hear about a patient's shunt when there is a problem. So, we have this sort of biased view of seeing a lot of shunt malfunction and shunt infection. Of course, we might not see the patient if their shunt is working just fine. How common are these complications in practice, and how do you as a neurosurgeon weigh the risks against the often uncertain or transient benefits of a shunt in a patient with NPH who may be older and multiple medical comorbidities? How do you think about that and talk about it with patients? Dr Chaichana: When you hear about shunt complications, most of the shunt complications you hear about are typically in patients with congenital hydrocephalus. Those patients often require several shunt revisions just from either growing or the shunt stays in for a long time or the ventricular caliber is a lot less than some with normal pressure hydrocephalus. So, we don't really see a lot of complications with normal pressure hydrocephalus. So that shunt placement in these patients is typically pretty safe. The procedure's a relatively short procedure, around 30 minutes to 45 minutes to place a shunt, and we can control the pressure within the shunt setting so that we don't overdrain---which means too much fluid drains from the ventricular system---which can cause things like a subdural, which is probably the most common complication associated with normal pressure hydrocephalus. So, to obviate those risks, what we do is typically insert the shunt and then keep the shunt setting at a high setting. The higher the setting, the less it drains, and then we bring it slowly down based on the patient's symptoms to try to minimize the risk of this over drainage in the subdural hematoma while at the same time benefiting the patient. So, there's a concern for shunt in patients with normal pressure hydrocephalus. The concern or the complication risks are very low. The problem with normal pressure hydrocephalus, though, is that over time these patients benefit less and less from drainage or their disease process takes over. So, I do recommend placing this shunt as soon as possible just so that we can maximize their quality of life for that period of time. Dr Berkowitz: So, if I'm understanding you, then the risk of complication is more sort of due to the mechanical factors in patients with congenital hydrocephalus or sort of outgrowing the shunt, their pressure dynamics may be changing over time. And in your experience, an older patient with NPH, although they may have more medical comorbidities, the procedure itself is relatively quick and low-risk. And the actual complications due to mechanical factors, my understanding, are just much less common because the patient is obviously fully grown and they're getting one sort of procedure at one point in time and tend to need less revision, have less complication. Is that right? Dr Chaichana: Yeah, that's correct. The complication risk for normal hydrocephalus is a lot less than other types of hydrocephalus. Dr Berkowitz: That's helpful to know. While we're talking about some of these complications, let's say we're following a patient in neurology with NPH who has a shunt. What are some of the symptoms and signs of shunt malfunction or shunt infection? And what are the best studies to order to evaluate for these if we're concerned about them? Dr Chaichana: Yeah. So basically, for shunt malfunction, it's basically broken down into two categories. It's either overdrainage or underdrainage. So, underdrainage is where the shunt doesn't function enough. And so basically, they return to their state before the shunt was placed. So that could be worsening gait function, memory function, urinary incontinence are the typical symptoms we look for in patients with normal pressure hydrocephalus and underdrainage, or the shunt is not working. For patients that are having overdrainage, which is draining too much, the classic sign is typically headaches when they stand up. And the reason behind that is when there's overdrainage, there's less cerebrospinal fluid in their ventricular system, which means less intracranial pressure. So that when they stand up, the pressure differential between their head and the ground is more than when they're lying down. And because of that pressure differential, they usually have worsening headaches when standing up or sitting up. The other thing are severe headaches, which would be a sign of a subdural hematoma or focality in their neurological symptoms that could point to a subdural hematoma, such as weakness, numbness, speaking problems, depending on the hemisphere. How we work this up is, regardless if you're concerned about overdrainage or underdrainage, we usually start with a CAT scan or an MRI scan. Typically, we prefer a CAT scan because it's quicker, but the CAT scan will show us if the ventricular caliber is the same and/or the placement of the proximal catheter. So, what we look for when we see that CAT scan or that MRI to see the location of the proximal catheter to make sure it hasn't changed from any previous settings. And then we see the caliber of the ventricles. If the caliber of the ventricles is smaller, that could be a sign of overdrainage. If the caliber of the ventricles are larger, it could be a sign of underdrainage. The other thing we look for are subdural fluid collections or hydromas or subdural hematomas, which would be another sign of lower endocranial pressure, which would be a sign of overdrainage. So those are the biggest signs we look for, for underdrainage and overdrainage. Other things we can look for if we're concerned of the shunt is fractured, we do a shunt X-ray and what a shunt x-ray is is x-rays of the skull, the neck and the abdomen to see the catheter to make sure it's not kinked or fractured. If you're really concerned, you can't tell from the x-ray, another scan to order is a CT of the chest and abdomen and pelvis to look at the location of the catheter to make sure there's no brakes in the catheter, there's no fluid collections on the distal portion of the catheter, which would be a sign of shunt malfunction as well. Other tests that you can do to really exclude shunt malfunction is a shunt patency test, and what that is a nuclear medicine test where radionucleotide is injected into the valve and then the radionucleotide is traced over time or imaged through time to make sure that it's draining appropriately from the valve into the distal catheter into the peritoneum or the distal site. If there's a shunt malfunction that's not drainage, that radioisotope would remain stagnant either in the valve or in the catheter. There's overdrainage, we can't really tell, but there will be a quick drainage of the radioisotope. For shunt infection, we start with an imaging just to make sure there's not a shunt malfunction, and that usually requires cerebrospinal fluid to test. The cerebrospinal fluid can come from the valve itself, or it can come from other areas like the lumbar spine. If the lumbar spine is showing signs of shunt infection, then that usually means the shunt is infected. If the valve is aspirated with- at the bedside with a butterfly needle into the valve and that shows signs of shunt infection, that also could be a sign of infection. Dr Berkowitz: That's very helpful. You mentioned CT and shunt series. One question that often comes up when obtaining neuroimaging in patients with a shunt, who have NPH or otherwise, is whether we need to call you when we're doing an MRI to reprogram the shunt before or after. Is there a way we can know as a neurologists at the bedside or as patients carry a card, like with some devices where we know whether we have to call and bother our neurosurgery colleagues to get this MRI? Or if the radiology techs ask us, is this safe? And is the patient's shunt going to get turned off? How do we go about determining this? Dr Chaichana: Yeah, so unfortunately, a lot of patients don't carry a card. We typically offer a card when we do the shunt, but that card, there's two problems with it. One is it tells the model, but the second thing is it has to be updated any time the shunt is changed to a different setting. Oftentimes patients don't know that shunt setting, and often times they don't know that company brand that they use. There are different types of shunts with different types of settings. If there's ever concern as to what type of shunt they have, an x-ray is usually the best bet to see with a shunt series, or a skull x-ray. A lateral skull x-ray usually looks at the valve, and the valve has certain radio-dense markers that indicate what type of shunt it is. And that way you can call neurosurgery and we can always tell you what the shunt setting is before the MRI is done. Problem with an MRI scan if you do it without a shunt x-ray before is that you don't know the setting before unless the patient really knows or it's in the patient chart, and the MRI can need to change the setting. It doesn't usually turn it off, but it would change the setting, which would change the fluid dynamics within their ventricular system, which could lead to overdrainage or underdrainage. So, any time a patient needs MRI imaging, whether it's even the brain MRI, a spine MRI, or even abdominal MRI, really a shunt x-ray should be done just to see the shunt setting so that it could be returned to that setting after the MRI is done. Dr Berkowitz: So, the only way to know sort of what type of shunt it would be short of the patient knowing or the patient getting care at the same hospital where the shunt was placed and looking it up in the operative reports would be a skull film. That would then tell us what type of shunt is there and then the marking of the setting. And then we would be able to call our colleagues in neurosurgery and say, this patient is getting an MRI this is the setting, this is the type of shunt. And do we need to call you afterwards to come by and reprogram it? Is that right? Dr Chaichana: That's correct, yeah. Dr Berkowitz: Is there anything we would be able to see on there, or it's best we just- best we just call you and clarify? Dr Chaichana: The easiest thing to do is, when you get the skull x-ray, you can Google different types of shunts or search for different shunts, and they'll have markers that show the type of shunt it is as well as the setting that it's at. And just match it up with the picture. Dr Berkowitz: And as long as it's not a programmable shunt, there's no concern about doing the MRI. Is that right? Dr Chaichana: Correct. So, if it's a programmable shunt, even if it's MRI-compatible, we still like to get the setting before and make sure the setting after the MRI is the same. Nonprogrammable shunts can't be changed with MRI scans, and those don't need neurosurgery after the MRI scan, but it should be confirmed before the scan is done. Dr Berkowitz: Very helpful. Okay, so let's turn to NPH specifically. As you know, there's a lot of debate in the literature, some arguing, even, NPH might not even exist, some saying it's underdiagnosed. I think. I don't know if it was last year at our American Academy of Neurology conference or certainly in recent years, there was a pro and con debate of “we are underdiagnosing NPH” versus “we are overdiagnosing NPH.” What's your perspective as a neurosurgeon? What's the perspective in neurosurgery? Is this something we're underdiagnosing, and the times you shunt these patients you see miraculous results? Is this something that we're overdiagnosing, you get a lot of patients sent to that you think maybe won't benefit from a shunt? Or is it just really hard to say and some patients have shunt-responsive noncommunicating hydrocephalus of unclear etiology and either concurrent Parkinson's disease, Alzheimer's, cervical lumbar stenosis, neuropathy, vestibular problems, and all these other issues that play into multifactorial gait to sort of display a certain amount of the percentage of problem in a given patient or take overtime? What's your perspective if you're open to sharing it, or what's the perspective of neurosurgery? Is this debated as it is in neurology or this is just a standard thing you see and patients respond to shunt to some degree in some proportion of the time? And what are the sort of predictors you see in your experience? Dr Chaichana: Yeah, so, for me, I'd say it's too complicated for a neurosurgeon to evaluate. We rely on neurology to tell us whether or not they need a shunt. But I think the problem is, obviously, a part of the workout for at least the ones that I like to do, is that I want them to have a high-volume lumbar puncture with pre- and postgait analysis to see if there's really an objective measure of them improving. If they have an objective measure of improvement---and what's even better is that they have a subjective measure of improvement on top of the objective measure of improvement---then they benefit from a shunt. The problem is, some patients do benefit even though they don't have objective performance increases after a high-volume shunt. And those are the ones that make me the most worrisome to do the shunt, just because I don't like to do a procedure where there's no benefit for the patient. I do see, according to the literature as well, that there's around a 30 to 40%, even 50%, increase in gait function, even in patients that don't have large improvements following the high-volume lumbar puncture. And those are the most challenging patients for us as neurosurgeons because we'll put the shunt in, they say we're no better in terms of their gait, no better in terms of their urinary incontinence. We try to lower their shunt down to a certain setting and we're kind of stuck after that point. The good thing about NPH, though, is that, from the neurosurgery side, the shunt, like I said, is a pretty benign, low-risk procedure. So, we're not putting the patient through a very severe procedure to see if there's any benefit. So, in cases where we try to improve their quality of life in patients that don't have a benefit from high-volume lumbar puncture, we give them the odds of whether or not it's improving and say it might not improve. But because the procedure's minimally invasive, I think it's a good way to see if we can benefit their quality of life. Dr Berkowitz: Yeah, it's a very helpful perspective. Yeah, those are the most challenging cases on our side as well, right. If the patient- we think they may have NPH, or their gait and/or urinary and/or cognitive problems are- at least have a component of NPH that could be reversible, we certainly want to do the large volume lumbar puncture and/or consider a lumbar drain trial, all discussed in other articles and interviews for this issue of Continuum, But the really tough ones, as you said, there is this literature on patients who don't respond to the large-volume lumbar puncture for some reason but still may be shunt responsive. And despite all the imaging predictors and all the other ways we try to think about this, it's hard to know who's going to benefit. I think that's really a helpful perspective from your end that, as you say in the very beginning of your article, right, maybe there's a little bit too much fear of shunting on the neurology side because when we hear about shunts, it's often in the setting of complication. And so, we're not sort of getting the full spectrum of all the patients you shunt and you see who are doing just fine. They might not improve---the question is related to NPH---but at least they're not harmed by the shunt, and we're maybe overbiased and/or seeing a overly representative sample of negative shunt outcomes when they're actually not that common in practice. Is that a fair summary of your perspective? Dr Chaichana: Yeah, that's correct. So, I mean, complications can occur---and anytime you do a surgery, there are risks of complications---but I think they're relatively low for the benefit that we can help their quality of life. And the procedure's pretty short. So, the risk, it mostly outweighs the benefits in cases with normal pressure hydrocephalus. Dr Berkowitz: Very helpful perspective. So, well, thanks so much again. Today I've been interviewing Dr Kaisorn Chaichana about his article on management of normal pressure hydrocephalus, which he wrote with Dr Jeremy Cutsforth-Gregory. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.
Je kunt bij zoiets absurds als het plan van Donald Trump voor wapenleveranties aan Oekraïne vol op het orgel gaan en vragen welk printje in zijn hersenen los zit, of je kunt victorie blazen en net doen alsof je dolblij en dankbaar bent. De weg van de diplomatie, dus, en daarvoor heeft de NAVO gekozen – Mark Rutte voorop. De constructie die Trump heeft bedacht komt neer op een soort parallelle import van wapens. Amerika produceert ze en verkoopt ze aan Europese landen, met een factuur van het Pentagon, en die Europese landen geven de wapens dan aan Oekraïne. Daar zitten batterijen Patriots bij, maar ook munitie en waarschijnlijk raketten voor de lange afstand. Quasi-parallelle importtruc Waarom levert Amerika de wapens niet rechtstreeks, en dan de factuur naar ons? Omdat het beëindigen van Amerikaanse steun aan Oekraïne al tijdens zijn campagne een speerpunt was. Deze quasi-parallelle importtruc valt daarbuiten. Tot verontwaardiging van fanatieke isolationisten als Steve Bannon en Marjorie Taylor Greene die woedend zijn. Geen hulp aan Oekraïne is geen hulp aan Oekraïne, zeggen ze. Amerikaanse wapenindustrie Waarom gaat de factuur naar ons? Omdat Trump zich niet alleen aan zijn belofte houdt geen cent meer aan Oekraïne uit te geven, maar omdat met de nieuwe wapenleveranties een stevige duit naar de Amerikaanse wapenindustrie stroomt. Aan het Oekraïense drama kan je op die manier miljarden verdienen en een hoop banen creëren. En omdat de meeste NAVO-lidstaten akkoord zijn gegaan met Trumps 5-procentsnorm, waaronder ook hulp aan Oekraïne valt, kunnen de Europeanen het volgens hem best betalen. Waarbij hij vergeet dat die verhoging van de defensielasten over een periode van tien jaar wordt ingevoerd, terwijl de aankoop van materieel voor Oekraïne onmiddellijk begint. Dankbaar Eigenlijk moeten we Poetin dankbaar zijn, want door diens weigering op Trumps bestandsvoorstel in te gaan, is Vladimir Vladimirovich plotseling geen inspirerende vriend meer, maar een praatjesmaker die bullshit verkoopt. Dus krijgt die 50 dagen om zich te bedenken en anders komen er nieuwe, draconische sancties, tot misschien wel 500 procent, inclusief voor Russische olieklanten als India en China. Alsof die zich laten intimideren. Kortom, verdien aan je vrienden, en kies die aan de hand van de vraag hoe de pet van je vijand staat. Of zoals Trump het zelf noemt: the art of the deal.See omnystudio.com/listener for privacy information.
In een interview met Nieuwsuur vertelde Caspar Veldkamp, de minister van Buitenlandse Zaken (NSC), over de voortgang van de hulpgoederen richting Gaza. Zo sprak hij over '180 vrachtwagens' die het gebied in zouden zijn gegaan. Maar zijn statements riepen meer vragen op dan antwoorden, stelt journalist Sakina Elkayouhi. "Hij zegt best wel weinig. Hij heeft het over het kibbelen van lidstaten en dat er daardoor geen resultaat behaald is." Bovendien kon Veldkamp niet onderbouwen waar hij het getal van 180 vrachtwagens vandaan haalde. "Wat ik ingewikkeld vind, is dat het Nederlandse standpunt niet wordt uitgelegd", reageert Mireille van Ark, adjunct-hoofdredacteur van RTL Nieuws. Aan tafel zitten Mireille van Ark, Sakina Elkayouhi en Spraakmaker Ineke Sluiter.
Aan de slag!Kijk vandaag eens om je heen naar de dieren die je tegenkomt. Wat zie je van Gods almacht in hen?Deze overdenking is geschreven door schrijfster Corline Hoefnagel.
We lezen u voor uit de geestelijke brief afkomstig uit de abdij Saint-Joseph de Clairval over de Heilige Lodewijk Maria van Montfort. Aan het begin van het vijfentwintigste jaar van zijn pontificaat, op 16 oktober 2002, kondigde Paus Johannes Paulus II een ‘Jaar van de Rozenkrans’ af en gaf de apostolische brief Rosarium Virginis Mariae […]
Aan de slag!Wees vriendelijk voor jezelf en anderen wanneer je het even niet weet. Vraag God in gebed of Hij je de weg wil wijzen wanneer jij het zelf niet meer weet.Deze overdenking is geschreven door schrijfster Suzanne Verschoor.
Digital Brains | Adwise - Een podcast over online marketing, digital en tech
In deze Deep Dive Special gaan we dieper in op het verhaal achter Adwise zelf. Want Adwise bestaat 20 jaar, een bijzondere mijlpaal die we aangrijpen om terug te blikken én vooruit te kijken. Hoe begin je als kleine agency vanuit pure passie? Welke keuzes bepaalden de groei naar een toonaangevend digital agency in binnen- en buitenland? En wat vraagt de toekomst van een bureau dat voorop wil blijven lopen?Aan tafel zit Gijs Westerbeek, CEO en founder van Adwise. Hij deelt openhartig zijn ondernemersreis, de lessen uit twee decennia digital en de ‘Adwise magie' die in al die jaren overeind is gebleven. Een inspirerend gesprek vol inzichten over groei, cultuur, wendbaarheid en leiderschap in een continu veranderende markt.Hosts: Jeroen Roozendaal, Daan Loohuis Gasten: Gijs Westerbeek, CEO van AdwiseShownotes: https://www.adwise.nl/podcast/Volg Adwise ook via:
Deze zomer draait de politiek om de verkiezingsprogramma's voor de verkiezingen van 29 oktober. Met Studio Tegengif duiken we in de belangrijkste ambtelijke adviesrapporten die de financieel-economische basis vormen voor die programma's. We bespreken de kaders waar partijen zich aan zullen moeten houden, en welke opties ambtenaren en denktanks presenteren. Dit is de inhoudelijke vulling waar politieke partijen straks hun ideologische saus overheen gieten. Wat opvalt: in de ambtelijke rapporten klinkt de oproep tot het maken van pijnlijke keuzes steeds luider. Over de dubbele vergrijzing, over veiligheid en defensie, klimaat en stikstof, volkshuisvesting, het complexe belastingstelsel en de vastlopende uitvoering. Gaan politieke partijen hier harde keuzes over maken — of blijven we hangen in vooruitschuif politiek? Aan het eind wagen we een paar voorspellingen: wat gaat er écht gebeuren met deze kennis? Zoals je van Studio Tegengif gewend bent, maken we complexe thema's toegankelijk en bespreekbaar. Deze aflevering werd gemaakt met ondersteuning van Wim Brons van remotepodcast.nl. Een aanrader voor als je op afstand een podcast wil maken met fantastische geluidskwaliteit. Wil je ons steunen? Dat kan: je kunt vriend van de show worden: https://vriendvandeshow.nl/studio-tegengif ***SHOWNOTES*** 18e Studiegroep Begrotingsruimte, ‘De toekomst begint nu' https://www.rijksfinancien.nl/SBR-2025 Ministerie van Financiën, ‘Kamerbrief Rapport 18e Studiegroep Begrotingsruimte' https://www.rijksoverheid.nl/documenten/kamerstukken/2025/07/11/rapport-18e-studiegroep-begrotingsruimte?utm_source=chatgpt.com Centraal Planbureau (CPB), ‘Startnotitie Keuzes in Kaart 2027-2030' https://www.cpb.nl/startnotitie-keuzes-kaart-2027-2030 Centraal Planbureau (CPB), ‘Concept-Macro Economische Verkenning 2026' https://www.cpb.nl/concept-macro-economische-verkenning-2026#docid-161697 Ministerie van Financiën, ‘Belastingplan 2026' https://www.rijksoverheid.nl/documenten/publicaties/2025/04/25/bijlage-1-overzicht-pakket-bp26-voor-fbua NOS, ‘Experts: komende kabinet moet 7 miljard per jaar bezuinigen' https://nos.nl/artikel/2574639-experts-komende-kabinet-moet-7-miljard-per-jaar-bezuinigen Volkskrant, ‘Ambtenaren: Nederland moet van laagbetaald werk af om grip te krijgen op arbeidsmigratie' https://www.volkskrant.nl/politiek/ambtenaren-nederland-moet-van-laagbetaald-werk-af-om-grip-te-krijgen-op-arbeidsmigratie~b0a8ac29/?referrer=https%3A%2F%2Fwww.google.com%2F Volkskrant, ‘Het doorrekenen van een verkiezingsprogramma is nooit allesomvattend, maar kent vele voordelen' https://www.volkskrant.nl/columns-opinie/het-doorrekenen-van-een-verkiezingsprogramma-is-nooit-allesomvattend-maar-kent-vele-voordelen~bc0e171c/
Aan tafel zitten Wendelmoet Boersema, Laurens Vreekamp en Spraakmakers Eefje Cuppen. President Trump komt vandaag met een ‘grote bekendmaking' met betrekking tot Rusland. In elk geval, zo kondigde hij het vorige week aan. Op de Spraakmaker-redactie was wat verwarring of deze bekendmaking niet al te horen was. Trump zegt iets in de trant van 'overdag is Poetin zo'n leuke vent, maar 's avonds gaat hij bombarderen.' Volgens Wendelmoet Boersma, hoofdredacteur van Trouw, is hierbij te zien hoe een zakenman met de politiek botst. "In de zakenwereld is 'een man een man' en volbrengt hij wat hij belooft, maar in de politiek ligt dat toch anders." Boersema vertelt dat de Trouw-redactie aankondigingen van de VS-president altijd onder de loep neemt. "We horen vaak terug van lezers dat ze Trump zat zijn en krijgen meermaals de vraag om minder over hem te rapporteren." Boersema zegt niet te veel aandacht te willen besteden aan Trump. "Maar al dat hij zegt, heeft wel invloed op de wereld, tegen die afweging moet je je constant weten te verhouden. En onder de loep nemen of hij maar iets schreeuwt of daadwerkelijk iets relevants aankondigt." "Bij Trump is alles 'groot'", zegt Laurens Vreekamp, AI-specialist en journalist voor Villamedia. Volgens Vreekamp kan Trump, evenals andere politici, beter gehouden worden aan wat hij wél doet. "Verval als media daarbij niet in de dynamiek, maar spreek politici aan."
Aan de slag! Wat betekent het voor jou om te vertrouwen op God? Denk daar vandaag eens over na. Op welk gebied van je leven kan God nieuwe vrijheid brengen door dat vertrouwen? Deze overdenking is geschreven door oud-schrijfster Lona van den Dries.
Is er eindelijk een lichtpuntje tijdens de Brusselse regeringsvorming? Volgens Georges-Louis Bouchez (MR) wel. Hij lijkt met een idee op de proppen te komen, en daar moet N-VA het aan de Vlaamse kant mee bekopen. Bouchez is on fire! Want ook de band tussen MR en Les Engagés lijkt op losse schroeven te staan. Waarom bijt de MR-voorzitter zo van zich af? Aan tafel: Bart Eeckhout, Stavros Kelepouris, Joline MaenhoutProductie: Laurens Bervoets (hoorstroom) & Dries VermeulenEindredactie: Sam Feys & Rik Boey Wil je reageren? Mail naar podcasts@demorgen.beSee omnystudio.com/listener for privacy information.
Je wilt gezonder leven, meer bewegen of beter eten, dus je maakt een plan. Jij bedenkt wat je lijf nodig heeft, controle aan, doelen stellen... Maar dan lukt het tóch niet zoals je hoopte. In deze aflevering neem ik je mee in de grootste hobbel die ik bij bijna iedereen tegenkom wanneer ze écht willen samenwerken met hun lichaam.Ik vertel je waarom pure controle op je lijf zelden het gewenste resultaat geeft, en hoe het veel krachtiger (én fijner) is om te leren luisteren naar de ware signalen van je lichaam.Na het luisteren van deze aflevering weet je:Waarom het najagen van controle over je lichaam meestal averechts werkt Hoe je de signalen van je lijf écht leert begrijpen (en waarom dat zoveel impact heeft op je gezondheid)Wat het verschil is tussen fysieke controle en innerlijke samenwerking Welke stappen jij vandaag nog kunt zetten om een samenwerking met je lijf te startenVoel jij dat het tijd is om het anders te doen? Zet dan die eerste stap en laat je inspireren door mijn verhaal én neem de uitnodiging aan om in contact te komen met de wijsheid van jouw eigen lichaam!
6 partijen praten over de vorming van een nieuwe Brusselse regering - en deze keer lijkt het 'voor echt'. Heeft Brussel tegen de nationale feestdag eindelijk een bestuursploeg? Aan de top van het tennis domineren Sinner en Alcaraz. Zijn zij de nieuwe Federer en Nadal? En het zoveelste plan om een uitgestorven dier terug te brengen: komt daar ooit iets van, of is het gewoon een PR-stunt?
Krijg je van ChatGPT alleen maar brave, vlakke antwoorden waar je niets mee kunt?Dan gebruik je het nog niet op de juiste manier, in deze aflevering vertel ik je hoe je dat verandert.Ik laat je zien hoe je ChatGPT kunt 'opvoeden' tot een echte sparringpartner voor je podcast. Geen generieke teksten meer die niet klinken zoals jij praat, maar AI-antwoorden die écht passen bij jouw stijl, jouw doelgroep en jouw content.Je hoort onder andere:Waarom ChatGPT jou vaak automatisch gelijk geeft (en waarom dat niet handig is)Hoe je de instellingen en het geheugen van ChatGPT aanpastWat er bij mij in het geheugen staat (en wat ik bewust weer heb verwijderd)Hoe je AI slim inzet om je podcast te hergebruiken: van titels en shownotes tot blogs en social postsEn welke prompts ik gebruik om snel en effectief te werkenPodcasten en AI zijn wat mij betreft een gouden combinatie, maar dan moet je wel weten hoe je het aanpakt. En dát leer je in deze aflevering.---⭐ Aan de slag met AI om je podcast slimmer in te zetten? ⭐Check dan mijn Podcast Freedom Pack voor de handigste scripts, templates, AI prompts én een content planner!---
Aan de slag!Herken jij jezelf in deze overdenking? Vraag de Heilige Geest of Hij je wil openbaren waarin jij bevrijding nodig hebt. En laat voor je bidden.Wil jij uitstappen om Jezus als Bevrijder te delen in levens van anderen? Bid dat God mensen naar je toebrengt die dit nodig hebben. En stap uit! Je mag dit allebei doen in de wetenschap dat in Jezus' verlossingswerk óók Zijn bevrijding jouw deel is.Deze overdenking is geschreven door schrijfster Mathilda van Triest-Cozijnsen.
Dit weekend UFC 318, Poirier vs Holloway. De afscheidspartij van Dustin Poirier, een legende die met pensioen gaat. Wat was jullie favoriete Poirier fight? Is Holloway beter dan de 2 keren hiervoor en maakt hij kans? Of pakt Dustin eindelijk een titel? Check de preview van UFC 318! Like, subscribe en drop die 5 sterren op Spotify! Aan iedereen die gedoneerd heeft, shout out naar jullie! Mocht je nog willen doneren, link hieronder! https://www.gofundme.com/manage/road-to-abu-dhabi-xek86Follow the socials!YT: https://www.youtube.com/@buitendekooi IG: www.instagram.com/buitendekooi TikTok: https://www.tiktok.com/@UCTLy5wrugZswxF0_AU0o6sQ
Aan de slag!Wat raakt je in de tekst van vandaag?Deze overdenking is geschreven door schrijfster Marianne de Bart-van der Lee.
In deze podcast spreekt Judith Cohen met internist-hematoloog Sonja Zweegman (Amsterdam UMC) over de Cepheus-studie. Aan bod komen onder andere de studieresultaten en de uitdaging die de komst van D-Vrd als extra behandeloptie vormt voor artsen die een behandelkeuze moeten maken bij nog onbehandeld multipel myeloom.
Deze talkshow wordt mede mogelijk gemaakt door MSI. Alle meningen in deze video zijn onze eigen. MSI heeft inhoudelijk geen inspraak op de content en zien de video net als jullie hier voor het eerst op de site.Het weekend komt er aan en daar zeggen we geen nee tegen. En waarom zouden we ook. Twee dagen niet werken en mogelijk lekker van de zon en de vrije tijd genieten, dat wil toch iedereen? We gaan dat weekend zoals altijd inluiden met een nieuwe aflevering van Einde van de Week Live. Om de overgang van werken naar rusten voor jou ietwat soepeler te laten verlopen. Klaar op de stoelzitten Jasper, JJ & Koos. Zij gaan hun licht laten schijnen over onder meer de State of Play over Ghost of Yotei, de hype rond Donkey Kong Bananza, de komst van S.T.A.L.K.E.R. 2: Heart of Chornobyl naar de PS5 en Bethesda dat aan meerdere Fallout-games werkt. Dit alles en veel, veel meer kun je zien en horen in de Einde van de Week Live van vrijdag 11 juli 2025.Brengt Ghost of Yotei meer van hetzelfde of zet Sucker Punch nieuwe stappen?Naast de bovenstaande onderwerpen praten de drie ook over de komst van Tony Hawk Pro Skater 3 + 4, de toekomst van Destiny 2, de Tokyo Game Show en er zijn wat nieuwe inzendingen voor Cool of Serious Uncool.Check de ‘nieuwe' Crosshairs 16 HX AI van MSI met een RTX 5070 aan boordNa al het geweld van de Upgrade Jouw Zomer actie, zet MSI dit keer de ‘nieuwe' Crosshair 16 HX AI laptop in de spotlights. Aan boord bevinden zich een Intel Core Ultra 9 275HX Processor, een RTX 5070, een 1TB SSD, 32GB RAM, een 240HZ QHD panel, Thunderbolt4 en USB aansluitingen plus een RGB toetsenbord. Info over deze laptop kun je hier vinden: https://msi.gm/S5C76688 .Scoor de LG CineBeam Q 4K beamer met een dikke kortingLG heeft een buitenkansje voor mensen die van fijne en handzame gear houden. Met de draagbare CineBeam Q 4K beamer kun je jouw films en series bekijken waar je maar wil. In knisperend strak beeld. De CineBeam Q bevat 8,3 megapixels en tovert een scherm tot 120 inch op je muur of plafond. En ja, je kunt er ook een console op aansluiten. Er geldt nu hier een aanbieding bij LG die je 100 euro korting + een 60 euro voucher voor Pathé geeft bij aanschaf: https://tinyurl.com/3acdee24 .Timestamps:00:00:00 Einde van de Week Live van 11 juli00:01:05 Noodweer in Japan.00:07:39 Huishoudelijke mededeling: MSI00:10:02 State of Play: Ghost of Yotei.00:22:30 S.T.A.L.K.E.R. 2: Heart of Chornobyl komt naar PS5.00:24:28 Tony Hawk Pro Skater 3 + 4 bevat tien tracks uit het origineel. 00:29:00 Bethesda werkt aan meerdere Fallout games.00:32:33 Donkey Kong Bananza was bedoeld voor de eerste Switch.00:38:03 Nintendo zegt vaarwel tegen Nintendo Switch Game Vouchers.00:39:38 Tokyo Game Show.00:42:15 BULLETTÎME: LG CineBeam 00:44:21 Meest populaire game voor rest van 2025 op basis van whislist en aandacht. 00:47:47 Activision trekt Call of Duty WWII vanwege hackers.00:51:49 Japans internet zet wereldrecord.00:55:32 Ook in Japan: Het huren van een oma. 00:57:44 Destiny 2 probeert ommekeer te bewerkstelligen. 00:59:03 Nintendo Switch 2 nietmachine wordt geveild.01:00:10 Hulkenberg eerste podium in zijn carriere.01:01:58 Huisnijverheid, gemaakt door Black Thunder. 01:02:44 ‘Jasper doet Tamriel' pt. 201:12:45 COOL OF SERIOUS UNCOOL?
Vanavond hebben wij twee insprekers m.b.t. de Bachschool. Er is ook een inspraakbijdrage beschikbaar van een bewoner die gisteren had willen inspreken, maar uiteindelijk heeft besloten het schriftelijk af te doen. Deze bijdrage treft u in de bijlage.Aan u als raad wordt gevraagd Publieke Sector Accountants B.V. (PSA) voor de boekjaren 2025-2029 aan te wijzen als accountant van de gemeente Soest, als bedoeld in artikel 213 van de Gemeentewet.De Voorjaarsnota 2025 is op 26 juni 2025 oordeelsvormend besproken in de gemeenteraad.De Kadernota 2026 is op 26 juni 2025 oordeelsvormend besproken in de gemeenteraad.D66 heeft samen met POS en ChristenUnie-SGP artikel 47 vragen gesteld over de Bachschool. Deze artikel 47 vragen staan in de bijlage.Moties vreemd1.Versnelling planvorming en duidelijkheid voor bewoners flats Dalweg e.o. (ingediend door PvdA, Soest2002, GroenLinks, POS, CDA, BBS)2.Kosten vervroegde Tweede Kamerverkiezingen (ingediend door PvdA)
Aan de slag!Bid vandaag voor mensen die God nog niet kennen, dat er openingen mogen zijn waarin je over het Evangelie mag vertellen. Dank God voor het feit dat Hij mensen roept en ook bekwaam maakt om Zijn werk te doen, waar dan ook ter wereld.Deze overdenking is geschreven door schrijfster Marije Dekker-Brandwijk.
Aan de hand van persoonlijke top 5 lijstjes bespreken Tim Koomen, Basje Boer, Erik van ‘t Holt, Hedwig van Driel, Julius Koetsier en Jasper ten Hoor hun favoriete films van de jaren negentig. De volgende aflevering van Julius vs Jasper gaat over twee films van Ari Aster: Hereditary (2018) en Midsommar (2019).
Op vrijdag 13/06/25 vertrokken om en bij de 250 fietsers in Banff Canada voor een fietstocht van 4300 km over de Rocky mountains naar de Mexicaanse grens in Antelope Wells.Aan de start 3 Belgen, Jens van Roost werd 2e, Maarten finishte als 7e en Bobby bereikte als 17e de grens.
Aan de slag! God heeft muziek gemaakt zodat wij het konden ontdekken. Naar welke muziek luister jij graag? Zet het vandaag eens aan en luister met hart en ziel! Deze overdenking is geschreven door oud-schrijfster Matthea van den Berg.
Normal pressure hydrocephalus (NPH) is a clinical syndrome of gait abnormality, cognitive impairment, and urinary incontinence. Evaluation of CSF dynamics, patterns of fludeoxyglucose (FDG) uptake, and patterns of brain stiffness may aid in the evaluation of challenging cases that lack typical clinical and structural radiographic features. In this episode, Katie Grouse, MD, FAAN, speaks with Aaron Switzer, MD, MSc, author of the article “Radiographic Evaluation of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California San Francisco in San Francisco, California. Dr. Switzer is a clinical assistant professor of neurology in the department of clinical neurosciences at the University of Calgary in Calgary, Alberta, Canada. Additional Resources Read the article: Radiographic Evaluation of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Grouse: This is Dr Katie Grouse. Today I'm interviewing Dr Aaron Switzer about his article on radiographic evaluation of normal pressure hydrocephalus, which he wrote with Dr Patrice Cogswell. This article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr. Switzer: Thanks so much for having me, Katie. I'm a neurologist that's working up in Calgary, Alberta, Canada, and I have a special interest in normal pressure hydrocephalus. So, I'm very happy to be here today to talk about the radiographic evaluation of NPH. Dr Grouse: I'm so excited to have you here today. It was really wonderful to read your article. I learned a lot on a topic that is not something that I frequently evaluate in my clinic. So, it's really just a pleasure to have you here to talk about this topic. So, I'd love to start by asking, what is the key message that you hope for neurologists who read your article to take away from it? Dr. Switzer: The diagnosis of NPH can be very difficult, just given the clinical heterogeneity in terms of how people present and what their images look like. And so, I'd like readers to know that detailed review of the patient's imaging can be very helpful to identify those that will clinically improve with shunt surgery. Dr Grouse: There's another really great article in this edition of Continuum that does a really great job delving into the clinical history and exam findings of NPH. So, I don't want to get into that topic necessarily today. However, I'd love to hear how you approach a case of a hypothetical patient, say, where you're suspicious of NPH based on the history and exam. I'd love to talk over how you approach the imaging findings when you obtain an MRI of the brain, as well as any follow-up imaging or testing that you generally recommend. Dr. Switzer: So, I break my approach down into three parts. First, I want to try to identify ventriculomegaly and any signs that would support that, and specifically those that are found in NPH. Secondly, I want to look for any alternative pathology or evidence of alternative pathology to explain the patient's symptoms. And then also evaluate any contraindications for shunt surgery. For the first one, usually I start with measuring Evans index to make sure that it's elevated, but then I want to measure one of the other four measurements that are described in the article, such as posterior colossal angle zed-Evans index---or z-Evans index for the American listeners---to see if there's any other features that can support normal pressure hydrocephalus. It's very important to identify whether there are features of disproportionately enlarged subarachnoid space hydrocephalus, or DESH, which can help identify patients who may respond to shunt surgery. And then if it's really a cloudy clinical picture, it's complicated, it's difficult to know, I would usually go through the full evaluation of the iNPH radscale to calculate a score in order to determine the likelihood that this patient has NPH. So, the second part of my evaluation is to rule out evidence of any alternative pathology to suggest another cause for the patient's symptoms, such as neurodegeneration or cerebrovascular disease. And then the third part of my evaluation is to look for any potential contraindications for shunt surgery, the main one being cerebral microbleed count, as a very high count has been associated with the hemorrhagic complications following shunt surgery. Dr Grouse: You mentioned about your use of the various scales to calculate for NPH, and your article does a great job laying them out and where they can be helpful. Are there any of these scales that can be reasonably relied on to predict the presence of NPH and responsiveness to shunt placement? Dr. Switzer: I think the first thing to acknowledge is that predicting shunt response is still a big problem that is not fully solved in NPH. So, there is not one single imaging feature, or even combination of imaging features, that can reliably predict shunt response. But in my view and in my practice, it's identifying DESH, I think, is really important---so, the disproportionately enlarged subarachnoid space hydrocephalus---as well as measuring the posterior colossal angle. I find those two features to be the most specific. Dr Grouse: Now you mentioned the concept of the NPH subtypes, and while this may be something that many of our listeners are familiar with, I suspect that, like myself when I was reading this article, there are many who maybe have not been keeping up to date on these various subtypes. Could you briefly tell us more about these NPH subtypes? Dr. Switzer: Sure. The Japanese guidelines for NPH have subdivided NPH into three different main categories. So that would be idiopathic, delayed onset congenital, and secondary normal pressure hydrocephalus. And so, I think the first to talk about would be the secondary NPH. We're probably all more familiar with that. That's any sort of pathology that could lead to disruption in CSF dynamics. These are things like, you know, a slow-growing tumor that is obstructing CSF flow or a widespread meningeal process that's reducing absorption of CSF, for instance. So, identifying these can be important because it may offer an alternative treatment for what you're seeing in the patient. The second important one is delayed onset congenital. And when you see an image of one of these subtypes, it's going to be pretty different than the NPH because the ventricles are going to be much larger, the sulcal enfacement is going to be more diffuse. Clinically, you may see that the patients have a higher head circumference. So, the second subtype to know about would be the delayed onset congenital normal pressure hydrocephalus. And when you see an image of one of these subtypes, it's going to be a little different than the imaging of NPH because the ventricles are going to be much larger, the sulcal enfacement is going to be more diffuse. And there are two specific subtypes that I'd like you to know about. The first would be long-standing overt ventriculomegaly of adulthood, or LOVA. And the second would be panventriculomegaly with a wide foramen of magendie and large discernomagna, which is quite a mouthful, so we just call it PAVUM. The importance of identifying these subtypes is that they may be amenable to different types of treatment. For instance, LOVA can be associated with aqueductal stenosis. So, these patients can get better when you treat them with an endoscopic third ventriculostomy, and then you don't need to move ahead with a shunt surgery. And then finally with idiopathic, that's mainly what we're talking about in this article with all of the imaging features. I think the important part about this is that you can have the features of DESH, or you can not have the features of DESH. The way to really define that would be how the patient would respond to a large-volume tap or a lumbar drain in order to define whether they have this idiopathic NPH. Dr Grouse: That's really helpful. And for those of our listeners who are so inclined, there is a wonderful diagram that lays out all these subtypes that you can take a look at. I encourage you to familiarize yourself with these different subtypes. Now it was really interesting to read in your article about some of the older techniques that we used quite some time ago for diagnosing normal pressure hydrocephalus that thankfully we're no longer using, including isotope encephalography and radionuclide cisternography. It certainly made me grateful for how we've come in our diagnostic tools for NPH. What do you think the biggest breakthrough in diagnostic tools that are now clinically available are? Dr. Switzer: You know, definitely the advent of structural imaging was very important for the evaluation of NPH, and specifically the identification of disproportionately enlarged subarachnoid space hydrocephalus, or DESH, in the late nineties has been very helpful for increasing the specificity of diagnosis in NPH. But some of the newer technologies that have become available would be phase-contrast MRI to measure the CSF flow rate through the aqueduct has been very helpful, as well as high spatial resolution T2 imaging to actually image the ventricular system and look for any evidence of expansion of the ventricles or obstruction of CSF flow. Dr Grouse: Regarding the scales that you had referenced earlier, do you think that we can look forward to more of these scales being automatically calculated and reported by various software techniques and radiographic interpretation techniques that are available or going to be available? Dr. Switzer: Definitely yes. And some of these techniques are already in development and used in research settings, and most of them are directed towards automatically detecting the features of DESH. So, that's the high convexity tight sulci, the focally enlarged sulci, and the enlarged Sylvian fissures. And separating the CSF from the brain tissue can help you determine where CSF flow is abnormal throughout the brain and give you a more accurate picture of CSF dynamics. And this, of course, is all automated. So, I do think that's something to keep an eye out for in the future. Dr Grouse: I wanted to ask a little more about the CSF flow dynamics, which I think may be new to a lot of our listeners, or certainly something that we've only more recently become familiar with. Can you tell us more about these advances and how we can apply this information to our evaluations for NPH? Dr. Switzer: So currently, only the two-dimensional phase contrast MRI technique is available on a clinical basis in most centers. This will measure the actual flow rate through the cerebral aqueduct. And so, in NPH, this can be elevated. So that can be a good supporting marker for NPH. In the future, we can look forward to other techniques that will actually look at three-dimensional or volume changes over time and this could give us a more accurate picture of aberrations and CSF dynamics. Dr Grouse: Well, definitely something to look forward to. And on the topic of other sort of more cutting-edge or, I think, less commonly-used technologies, you also mentioned some other imaging modalities, including diffusion imaging, intrathecal gadolinium imaging, nuclear medicine studies, MR elastography, for example. Are any of these modalities particularly promising for NPH evaluations, in your opinion? Do you think any of these will become more popularly used? Dr. Switzer: Yes, I think that diffusion tract imaging and MR elastography are probably the ones to keep your eye out for. They're a little more widely applicable because you just need an MR scanner to acquire the images. It's not invasive like the other techniques mentioned. So, I think it's going to be a lot easier to implement into clinical practice on a wide scale. So, those would be the ones that I would look out for in the future. Dr Grouse: Well, that's really exciting to hear about some of these techniques that are coming that may help us even more with our evaluation. Now on that note, I want to talk a little bit more about how we approach the evaluation and, in your opinion, some of the biggest pitfalls in the evaluation of NPH that you've found in your career. Dr. Switzer: I think there are three of note that I'd like to mention. The first would be overinterpreting the Evans index. So, just because an image shows that there's an elevated Evans index does not necessarily mean that NPH is present. So that's where looking for other corroborating evidence and looking for the clinical features is really important in the evaluation. Second would be misidentifying the focally enlarged sulci as atrophy because when you're looking at a brain with these blebs of CSF space in different parts of the brain, you may want to associate that to neurodegeneration, but that's not necessarily the case. And there are ways to distinguish between the two, and I think that's another common pitfall. And then third would be in regards to the CSF flow rate through the aqueduct. And so, an elevated CSF flow is suggestive of NPH, but the absence of that does not necessarily rule NPH out. So that's another one to be mindful of. Dr Grouse: That's really helpful. And then on the flip side, any tips or tricks or clinical pearls you can share with us that you found to be really helpful for the evaluation of NPH? Dr. Switzer: One thing that I found really helpful is to look for previous imaging, to look if there were features of NPH at that time, and if so, have they evolved over time; because we know that in idiopathic normal pressure hydrocephalus, especially in the dash phenotype, the ventricles can become larger and the effacement of the sulci at the convexity can become more striking over time. And this could be a helpful tool to identify how long that's been there and if it fits with the clinical history. So that's something that I find very helpful. Dr Grouse: Absolutely. When I read that point in your article, I thought that was really helpful and, in fact, I'm guessing something that a lot of us probably aren't doing. And yet many of our patients for one reason or other, probably have had imaging five, ten years prior to their time of evaluation that could be really helpful to look back at to see that evolution. Dr. Switzer: Yes, absolutely. Dr Grouse: It's been such a pleasure to read your article and talk with you about this today. Certainly a very important and helpful topic for, I'm sure, many of our listeners. Dr. Switzer: Thank you so much for having me. Dr Grouse: Again, today I've been interviewing Dr Aaron Switzer about his article on radiographic evaluation of normal pressure hydrocephalus, which he wrote with Dr Patrice Cogswell. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.
Misschien vraag jij je ook wel eens af: Hoe weet ik of God tot mij spreekt? Is het Zijn stem, of gewoon mijn eigen gedachte? En... wat als ik niks hoor? In deze aflevering duiken we in het thema: De stem van de herder herkennen. We praten erover met Richard Groenenboom, auteur van het boek Diepgeworteld. Aan de hand van verhalen van vervolgde christenen gaan we op zoek naar hoe God vandaag nog spreekt – via de Bijbel, maar soms ook op verrassende andere manieren."
Tien jaar geleden stierf de markante dichter en schrijver Rogi Wieg. Hij was één van de eerste bekende personen in Nederland die euthanasie kreeg wegens ondragelijk psychisch lijden. De euthanasie van Wieg zorgde voor een tweedeling in zijn nabije omgeving en eindigde in chaos voor de deur van de stervende dichter. Hoe om te gaan met een vriend of geliefde die niet langer verder wil leven? Aan de hand van interviews schetst Frank Kromer een beeld van een groep intimi die radicaal tegenover elkaar komt te staan. De laatste keuze van Rogi Wieg is een documentaire van Frank Kromer. Redactie Koen Schouwenburg, eindmix Gijs Friessen. Eindredactie Jeroen Stout. DOCS is de documentaire podcast van de publieke omroep onder eindredactie van NTR en VPRO. Presentatie: Mina Etemad. Meer informatie: 2doc.nl/docs en docs@ntr.nl
In the July episode of the President's Spotlight, Dr. Jason Crowell and Dr. Natalia Rost discuss the role science plays in what the AAN does. Show reference: https://www.aan.com/about-the-aan/presidents-spotlight
LES 188De vrede van God straalt nu in mij.Waarom wachten op de Hemel? Zij die het licht zoeken bedekken slechts hun ogen. Het licht is nú in hen. Verlichting is slechts een herkenning, en allerminst een verandering. Het licht is niet van deze wereld, maar ook jij die het licht in je draagt bent hier een vreemde. Het licht kwam met jou mee vanuit je geboortehuis en is bij je gebleven, omdat het jou eigen is. Het is het enige wat jij met je meebrengt van Hem die jouw Oorsprong is. Het straalt in jou, omdat het je huis verlicht, en leidt je terug naar waar het vandaan gekomen is en waar jij thuis bent.Dit licht kan niet verloren gaan. Waarom wachten om het in de toekomst te vinden, of geloven dat het al verloren is, of er nooit is geweest? Het kan zo gemakkelijk worden gezien, dat argumenten die bewijzen dat het er niet is lachwekkend worden. Wie kan de aanwezigheid ontkennen van wat hij in zichzelf aanschouwt? Het is niet moeilijk om naar binnen te kijken, want daar begint alle visie. Er is geen waarneming, zij het van dromen of van een waarachtiger Bron, die niet slechts de schaduw is van wat door innerlijke visie wordt gezien. Daar begint waarneming en daar eindigt ze. Dit is haar enige bron.De vrede van God straalt nu in jou, en breidt zich vanuit jouw hart over heel de wereld uit. Ze houdt stil om al wat leeft te liefkozen en laat er een zegen achter die voor eeuwig en altijd blijft. Wat zij geeft moet eeuwig zijn. Ze neemt alle gedachten weg aan wat kortstondig en nietswaardig is. Ze schenkt vernieuwing aan alle vermoeide harten en verlicht alle visie waar ze langsgaat. Al haar geschenken worden aan iedereen gegeven en iedereen is eensgezind in zijn dank aan jou, jij die geeft en die ontvangen hebt.Deze stralende gloed in je denkgeest herinnert de wereld aan wat ze vergeten is, en de wereld schenkt aan jou evenzeer de herinnering terug. Van jou straalt verlossing uit met onmetelijke giften, gegeven en teruggegeven. Aan jou, de gever van het geschenk, zegt God Zelf dank. En door Zijn zegen schijnt het licht in jou helderder, en vermeerdert zo de geschenken die jij de wereld te bieden hebt.De vrede van God kan nooit worden ingedamd. Wie haar in zichzelf herkent, moet haar wel geven. En het middel om haar te geven ligt in zijn inzicht. Hij vergeeft omdat hij de waarheid in zichzelf heeft herkend. De vrede van God straalt nu in jou, en in al wat leeft. In stilte wordt ze universeel erkend. Want wat jouw innerlijke visie beziet is jouw waarneming van het universum.Zit rustig en sluit je ogen. Het licht binnenin jou is toereikend. Dit alleen heeft het vermogen jou de gave van het zicht te schenken. Sluit de buitenwereld buiten en laat je gedachten zich naar de vrede vanbinnen spoeden. Ze kennen de weg. Want oprechte gedachten, onbezoedeld door de droom van wereldse dingen buiten jou, worden de heilige boodschappers van God Zelf.Deze gedachten denk je met Hem. Ze herkennen hun thuis. En ze wijzen met zekerheid naar hun Bron, waar God de Vader en de Zoon één zijn. Gods vrede straalt ze toe, maar ze blijven ook noodzakelijkerwijs bij jou, want ze werden in jouw denkgeest geboren, zoals de jouwe in die van God geboren werd. Ze leiden jou terug naar de vrede, vanwaar zij gekomen zijn, alleen om jou eraan te herinneren hoe jij terug moet keren.Ze slaan acht op de Stem van je Vader, wanneer jij weigert te luisteren. En ze moedigen jou zachtmoedig aan Zijn Woord over wat jij bent te aanvaarden, in plaats van schaduwen en fantasieën. Ze herinneren je eraan dat jij de medeschepper bent van al wat leeft. Want zoals de vrede van God in jou straalt, zo moet ze ook daarop haar stralen werpen.We oefenen vandaag om tot het licht in ons te naderen. We nemen onze dwalende gedachten en brengen ze met zachtheid terug naar waar ze gaan overeenstemmen met alle gedachten die we delen met God. We zullen ze niet laten afdwalen. We laten ze door het licht in onze denkgeest naar huis toe leiden. We hebben ze verraden door ze te gebieden van ons weg te gaan. Maar nu roepen we ze terug en wassen ze schoon van vreemde verlangens en warrige wensen. We geven ze de heiligheid van hun erfgoed terug.Zo wordt onze denkgeest tegelijk met ze hersteld, en we erkennen dat de vrede van God nog altijd in ons straalt en van ons uitstraalt naar al wat leeft en ons leven deelt. We zullen alles en iedereen vergeven en heel de wereld vrijspreken van wat we dachten dat ze ons had aangedaan. Want wij zijn het die de wereld maken zoals we die willen hebben. Nu kiezen we ervoor dat ze onschuldig is, vrij van zonde en open voor verlossing. En we leggen er onze verlossende zegen op, terwijl we zeggen:De vrede van God straalt nu in mij.Laat in die vrede al wat leeft zijn stralen op mij werpen, en laat mij alles zegenen met het licht in mij.
Deze talkshow wordt mede mogelijk gemaakt door LG UltraGear. Alle meningen in deze video zijn onze eigen. LG UltraGear heeft inhoudelijk geen inspraak op de content en zien de video net als jullie hier voor het eerst op de site.Welkom bij Gamekings Daily, de dagelijkse podcast over het laatste nieuwe vanuit de videogames wereld. Elke doordeweeks dag zetten we een verse editie voor je klaar. In 20 minuten bespreken twee hosts van Gamekings het laatste en meest relevante nieuws. Vandaag zit Huey bij JJ aan de witte desk. Met een goed en slecht nieuws. Zo weten we nu al bijna zeker dat Donkey Kong Bananza een hoog cijfer gaat halen in de media, misschien wel een 9.7. Waarop we dat oordeel baseren, dat vertellen de twee je in deze video. Aan de andere kant vlogen er helaas veel mensen uit bij Xbox en loopt de ontwikkeling van Battlefield 6 allerminst soepel. Deze topics en meer zie en hoor je in de GK Daily van donderdag 3 juli 2025.Battlefield 6 moet 100 miljoen spelers gaan halenGK Daily verschijnt op elke doordeweekse dag op je beeldscherm, op de vrijdag na. Dan presenteren we zoals altijd EvdWL, de uitgebreide vodcast over al het game gerelateerde nieuws van de week. In deze GK Daily praten we je ook bij over de nieuwste stunt die Kojima denkt te gaan uithalen bij het maken van zijn nieuwe spel.Krijg 120 euro exclusieve korting op de 27 inch UHD 4K monitor van LG UltraGearLG UltraGear heeft een toffe actie exclusief voor de Gamekings community opgezet. De 27-inch UHD 4K (3840×2160) Nano IPS Black display is namelijk met een korting van 120 euro verkrijgbaar voor onze community. Dit model is de eerste 27-inch gamingmonitor ter wereld met 4K-resolutie en 240Hz refreshrate en biedt daarmee in onze ogen een erg wrede en soepele spelervaring voor gamers, vooral voor liefhebbers van FPS-titels. Interesse, vul hier bij aankoop de code ‘gamekings' in het vakje bij vouchers: https://www.lg.com/nl/monitoren/ultragear-gaming-monitoren/27g850a-b/ .Timestamps:00:00:00 Gamekings Daily van donderdag 3 juli00:00:29 Introductie00:13:41 Xbox ontslaat opnieuw veel mensen00:29:30 BULLETTIME00:32:04 Ontwikkeling Battlefield loopt alles behalve soepel
Normal pressure hydrocephalus (NPH) is a clinical syndrome characterized by the triad of gait apraxia, cognitive impairment, and bladder dysfunction in the radiographic context of ventriculomegaly and normal intracranial pressure. Accurate diagnosis requires consideration of clinical and imaging signs, complemented by tests to exclude common mimics. In this episode, Lyell Jones, MD, FAAN speaks with Abhay R. Moghekar, MBBS, author of the article “Clinical Features and Diagnosis of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Moghekar is an associate professor of neurology at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Clinical Features and Diagnosis of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today I'm interviewing Dr Abhay Moghekar, who recently authored an article on the clinical features and diagnosis of normal pressure hydrocephalus for our first-ever issue of Continuum dedicated to disorders of CSF dynamics. Dr Moghekar is an associate professor of neurology and the research director of the Cerebrospinal Fluid Center at Johns Hopkins University in Baltimore, Maryland. Dr Moghekar, welcome, and thank you for joining us today. Why don't you introduce yourself to our listeners? Dr Moghekar: Thank you, Dr Jones. I'm Abhay Moghekar. I'm a neurologist at Hopkins, and I specialize in seeing patients with CSF disorders, of which normal pressure hydrocephalus happens to be the most common. Dr Jones: And let's get right to it. I think most of our listeners who are neurologists in practice have encountered normal pressure hydrocephalus, or NPH; and it's a challenging disorder for all the reasons that you outline in your really outstanding article. If you were going to think of one single most important message to our listeners about recognizing patients with NPH, what would that be? Dr Moghekar: I think I would say there are two important messages. One is that the triad is not sufficient to make the diagnosis, and the triad is not necessary to make the diagnosis. You know these three elements of the triad: cognitive problems, gait problems, bladder control problems are so common in the elderly that if you pick 10 people out in the community that have this triad, it's unlikely that even one of them has true NPH. On the other hand, you don't need all three elements of the triad to make the diagnosis because the order of symptoms matters. Often patients develop gait dysfunction first, then cognitive dysfunction, and then urinary incontinence. If you wait for all three elements of the triad to be present, it may be too late to offer them any clear benefit. And hence, you know, it's neither sufficient nor necessary to make the diagnosis. Dr Jones: That's a really great point. I think most of our listeners are familiar with the fact that, you know, we're taught these classic triads or pentads or whatever, and they're rarely all present. In a way, it's maybe a useful prompt, but it could be distracting or misleading, even in a way, in terms of recognizing the patient. So what clues do you use, Dr Moghekar, to really think that a patient may have NPH? Dr Moghekar: So, there are two important aspects about gait dysfunction. Say somebody comes in with all three elements of the triad. You want to know two things. Which came first? If gate impairment precedes cognitive impairment, it's still very likely that NPH is in the differential. And of the two, which are more- relatively more affected? So, if somebody has very severe dementia and they have a little bit of gait problems, NPH is not as likely. So, is gait affected earlier than cognitive dysfunction, and is it affected to a more severe degree than cognitive dysfunction? And those two things clue me in to the possibility of NPH. You still obviously need to get imaging to make sure that they have large ventricles. One of the problems with imaging is large ventricles are present in so many different patients. Normal aging causes large ventricles. Obviously, many neurodegenerative disorders because of cerebral atrophy will cause large ventricles. And there's an often-used metric called as the events index, which is the ratio of the bitemporal horns- of the frontal horns of the lateral ventricles compared to the maximum diameter of the skull at that level. And if that ratio is more than 0.3, it's often used as a de facto measure of ventriculomegaly. What we've increasingly realized is that this ratio changes with age. And there's an excellent study that used the ADNI database that looked at how this ratio changes by age and sex. So, in fact, we now know that an 85-year-old woman who has an events index of 0.37 which would be considered ventriculomegaly is actually normal for age and sex. So, we need to start adopting these more modern age- and sex-appropriate age cutoffs of ventriculomegaly so as not to overcall everybody with big ventricles as having possible NPH. Dr Jones: That's very helpful. And I do want to come back to this challenge that we've seen in our field of overdiagnosis and underdiagnosis. But I think most of us are familiar with the concept of how hydrocephalus could cause neurologic deficits. But what's the latest on the mechanism of NPH? Why do some patients get this and others don't? Dr Moghekar: Very good question. I don't think we know for sure. And it for a long time we thought it was a plumbing issue. Right? And that's why shunts work. People thought it was impaired CSF absorption, but multiple studies have shown that not to be true. It's likely a combination of impaired cerebral blood flow, biomechanical factors like compliance, and even congenital factors that play a role in the pathogenesis of NPH. And yes, while putting in shunts likely drains CSF, putting in a shunt also definitely changes the compliance of the brain and affects blood flow to the subcortical regions of the brain. So, there are likely multiple mechanisms by which shunts benefit, and hence it's very likely that there's no single explanation for the pathogenesis of NPH. Dr Jones: We explored this in a recent Continuum issue on dementia. Many patients who have cognitive impairment have co-pathologies, multiple different causes. I was interested to read in your article about the genetic risk profile for NPH. It's not something I'd ever really considered in a disorder that is predominantly seen in older patients. Tell us a little more about those genetic risks. Dr Moghekar: Yeah, everyone is aware of the role genetics plays in congenital hydrocephalus, but until recently we were not aware that certain genetic factors may also be relevant to adult-onset normal pressure hydrocephalus. We've suspected this for a long time because nearly half of our patients who come to us to see us in clinic with NPH have head circumferences that are more than 90th percentile for height. And you know, that clearly indicates that this started shortly at the time after birth or soon afterwards. So, we've suspected for a long time that genetic factors play a role, but for a long time there were not enough large studies or well-conducted studies. But recently studies out of Japan and the US have shown mutations in genes like CF43 and CWH43 are disproportionately increased in patients with NPH. So, we are discovering increasingly that there are genetic factors that underlie even adult onset in patients. There are many more waiting to be discovered. Dr Jones: Really fascinating. And obviously getting more insight into the risk and mechanisms would be helpful in identifying these patients potentially earlier. And another thing that I learned in your article that I thought was really interesting, and maybe you can tell us more about it, is the association between normal pressure hydrocephalus and the observation of cervical spinal stenosis, many of whom require decompression. What's behind that association, do you think? Dr Moghekar: That's a very interesting study that was actually done at your institution, at Mayo Clinic, that showed this association. You know, as we all get older, you know, the incidence of cervical stenosis due to osteoarthritis goes up, but the incidence of significant, clinically significant cervical stenosis in the NPH population was much higher than what we would have expected. Whether this is merely an association in a vulnerable population or is it actually causal is not known and will need further study. Dr Jones: It's interesting to speculate, does that stenosis affect the flow of CSF and somehow predispose to a- again, maybe a partial degree for some patients? Dr Moghekar: Yeah, which goes back to the possible hydrodynamic theory of normal pressure hydrocephalus; you know, if it's obstructing normal CSF flow, you know, are the hydrodynamics affected in the brain that in turn could lead to the development of hydrocephalus. Dr Jones: One of the things I really enjoyed about your article, Abhay, was the very strong clinical focus, right? We can't just take an isolated biomarker or radiographic feature and rely on that, right? We really do need to have clinical suspicion, clinical judgment. And I think most of our listeners who've been in practice are familiar with the use and the importance of the large-volume lumbar puncture to determine who may have, and by exclusion not have, NPH, and then who might respond to CSF diversion. And I think those of us who have been in this situation are also familiar with the scenario where you think someone may have NPH and you do a large-volume lumbar puncture and they feel better, but you can't objectively see a difference. How do you make that test useful and objective in your practice? What do you do? Dr Moghekar: Yeah, it's a huge challenge in getting this objective assessment done carefully because you have to remember, you know, subconsciously you're telling the patients, I think you have NPH. I'm going to do this spinal tap, and if you walk better afterwards, you're going to get a shunt and you're going to be cured. And you can imagine the huge placebo response that can elicit in our subjects. So, we always like to see, definitely, did the patient subjectively feel better? Because yes, that's an important metric to consider because we want them to feel better. But we also wanted to be grounded in objective truths. And for that, we need to do different tests of speed, balance and endurance. Not everyone has the resources to do this, but I think it's important to test different domains. Just like for cognition, you know, we just don't test memory, right? We test executive function, language, visuospatial function. Similarly, walking is not just walking, right? It's gait speed, it's balance, and it's endurance. So, you need to ideally test at least most of these different domains for gait and you need to have some kind of clear criteria as to how are you going to define improvement. You know, is a 5% improvement, is a 10% improvement in gait, enough? Is 20%? Where is that cutoff? And as a field, we've not done a great job of coming up with standardized criteria for this. And it varies currently, the practice varies quite significantly from center to center at the current time. Dr Jones: So, one of the nice things you had in your article was helpful tips to be objective if you're in a lower-resource setting. For you, this isn't a common scenario that someone encounters in their practice as opposed to a center that maybe does a large volume of these. What are some relatively straightforward objective measures that a neurologist or someone else might use to determine if someone is improving after a large-volume LP? Dr Moghekar: Yeah, excellent question, Dr Jones, and very practically relevant too. So, you need to at least assess two of the domains that are most affected. One is speed and one is balance. You know, these patients fall ultimately, right, if you don't treat them correctly. In terms of speed, there are two very simple tests that anybody can do within a couple of minutes. One is the timed “up-and-go” test. It's a test that's even recommended by the CDC. It correlates very well with faults and disability and it can be done in any clinic. You just need about ten feet of space and a chair and a stopwatch, and it takes about a minute or slightly more to do that test. And there are objective age-associated norms for the timed up-and-go test, so it's easy to know if your patient is normal or not. The same thing goes for the 10-meter walk test. You do need a slightly longer walkway, but it's a fairly easy and well-standardized test. So, you can do one of those two; you don't need to do both of them. And for balance, you can do the 30-second “sit-to-stand”; and it's literally, again, 30 seconds. You need a chair, and you need somebody to watch the patient and see how many times they can sit up and stand up from a seated position. Then again, good normative data for that. If you want to be a little more sophisticated, you can do the 4-stage balance test. So, I think these are tests that don't add too much time to your daily assessment and can be done with even trained medical assistants in any clinic. And you don't need a trained physical therapist to do these assessments. Dr Jones: Very practical. And again, something that is pretty easily deployed, something we do before and then after the LP. I did see you mentioned in your article the dual timed up-and-go test where it's a simultaneous gait and executive function test. And I've got to be honest with you, Dr Moghekar, I was a little worried if I would pass that test, but that may be beyond the scope of our time today. Actually, how do you do that? How do you do the simultaneous cognitive assessment? Dr Moghekar: So, we asked them to count back from 100, subtracting 3. And we do it particularly in patients who are mildly impaired right? So, if they're already walking really good, but then you give them a cognitive stressor, you know, that will slow them down. So, we reserve it for patients who are high-performing. Dr Jones: That's fantastic. I'm probably aging myself a little here. I have noticed in my career, a little bit of a pendulum swing in terms of the recognition or acceptance of the prevalence of normal pressure hydrocephalus. I recall when I was a resident, many, many people that we saw in clinic had normal pressure hydrocephalus. Then it seemed for a while that it really faded into the background and was much less discussed and much less recognized and diagnosed, and less treated. And now that pendulum seems to have swung back the other way. What's behind that from your perspective? Dr Moghekar: It's an interesting backstory to all of this. When the first article about NPH was published in the Newman Journal of Medicine, it was actually a combined article with both neurologists and neurosurgeons on it. They did describe it as a treatable dementia. And what that did is it opened up the floodgates so that everybody with any kind of dementia started getting shunts left, right, and center. And back then, shunts were not programmable. There were no antibiotic impregnated catheters. So, the incidence of subdural hematomas and shunt-related infections was very high. In fact, one of our esteemed neurologists back then, Houston Merritt, wrote a scathing editorial that Victor and Adam should lose their professorships for writing such an article because the outcomes of these patients were so bad. So, for a very long period of time, neurologists stopped seeing these patients and stopped believing in NPH as a separate entity. And it became the domain of neurosurgeons for over two or three decades, until more recently when randomized trials started being done early on out of Europe. And now there's a big NIH study going on in the US, and these studies showed, in fact, that NPH exists as a true, distinct entity. And finally, neurologists have started getting more interested in the science and understanding the pathophysiology and taking care of these patients compared to the past. Dr Jones: That's really helpful context. And I guess that maybe isn't rare when you have a disorder that doesn't have a simple, straightforward biomarker and is complex in terms of the tests you need to do to support the diagnosis, and the treatment itself is somewhat invasive. So, when you talk to your patients, Dr Moghekar, and you've established the diagnosis and have recommended them for CSF diversion, what do you tell them? And the reason I ask is that you mentioned before we started recording, you had a patient who had a shunt placed and responded well, but continued to respond over time. Tell us a little bit more about what our patients can expect if they do have CSF diversion? Dr Moghekar: When we do the spinal tap and they meet our criteria for improvement and they go on to have a shunt, we tell them that we expect gait improvement definitely, but cognitive improvement may not happen in everyone depending on what time, you know, they showed up for their assessment and intervention. But we definitely expect gait improvement. And we tell them that the minimum gait improvement we can expect is the same degree of improvement they had after their large-volume lumbar puncture, but it can be even more. And as the brain remodels, as the hydrodynamics adapt to these shunts… so, we have patients who continue to improve one year, two years, and even three years into the course of the intervention. So, we're, you know, hopeful. At the same time, we want to be realistic. This is the same population that's at risk for developing neurodegenerative disorders related to aging. So not a small fraction of our patients will also have Alzheimer's disease, for example, or go on to develop Lewy body dementia. And it's the role of the neurologist to pick up on these comorbid conditions. And that's why it's important for us to keep following these patients and not leave them just to the neurosurgeon to follow up. Dr Jones: And what a great note to end on, Dr Moghekar. And again, I want to thank you for joining us, and thank you for such a wonderful discussion and such a fantastic article on the clinical diagnosis of normal pressure hydrocephalus. I learned a lot reading the article, and I learned a lot more today just in the conversation with you. So, thank you for being with us. Dr Moghekar: Happy to do that, Dr Jones. It was a pleasure. Dr Jones: Again, we've been speaking with Dr Abhay Moghekar, author of a wonderful article on the clinical features and diagnosis of NPH in Continuum's first-ever issue dedicated to disorders of CSF dynamics. Please check it out. And thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.
Aan alle klassenouders die de laatste weken extra creatief uit de hoek komen met cadeau's voor meesters en juffen... stop... echt... te warm... te moe... WIJN IS OOK GOED! Nu we dat direct uit de weg hebben geruimd is het tijd voor Meneer Zwaartekracht. Die komt inmiddels vaker langs bij Alex dan de glazenwasser. Nynke heeft haar telenovela-leven hervat, Hanneke had geluk met een teken van boven van kosmo-Pechtold en Anne haalde vlaai voor Dylan Haegens. In Deurne. Brabant. VLAAI UIT BRABANT. Hanneke, Limburger en vlaaifanaat, kan het nog steeds niet bevatten. En we hebben een tip voor Klaas Dijkhoff, bungalows willen we! Eventueel op elkaar gestapeld. Kijk maar ff wat je doet. Groeten! Anne, Nynke, Alex en Bakkerij Verdeuzeldonk Sponsor: Kobo Plus via Bol Ook eindeloos doorlezen deze zomer? Probeer Kobo Plus nu 30 dagen gratis via bol! Klik op deze link. See omnystudio.com/listener for privacy information.
Vandaag een aflevering in de serie "In Stukken". Het Dumky Trio van Antonín Dvorák wordt in stukken geknipt. Aan de hand van de fragmenten in de mooiste opnames wordt het stuk onder de loep genomen. Panelleden: violist Peter Brunt en pianist Camiel Boomsma.
Herhaling VInleidingWe doen nu opnieuw een herhaling. Deze keer zijn we bereid om meer moeite en meer tijd te besteden aan wat we ondernemen. We beseffen dat we ons aan het voorbereiden zijn op een nieuwe fase in ons begrip. We willen deze stap volledig zetten, opdat we met meer zekerheid, oprechter en met een steviger onderbouwd vertrouwen weer verder kunnen gaan. Onze schreden zijn niet altijd even vast geweest, en twijfels hebben ervoor gezorgd dat we onzeker en langzaam de weg gingen die deze cursus uiteenzet. Maar nu spoeden we ons voort, want we naderen een grotere zekerheid, een bestendiger doel en een zekerder bestemming.Sterk onze voeten, Vader. Laat onze twijfels bedaren en onze heilige denkgeest stil zijn, en spreek tot ons. We hebben geen woorden om aan U te geven. We willen slechts naar Uw Woord luisteren en het ons eigen maken. Leid onze oefening, zoals een vader een klein kind langs een weg leidt die het niet begrijpt. Toch volgt het, zeker dat het veilig is, omdat zijn vader het de weg wijst.Zo brengen we onze oefening bij U. En als we struikelen, helpt U ons overeind. Als we de weg vergeten, rekenen we op Uw onfeilbare herinnering. We dwalen af, maar U zult niet vergeten ons terug te roepen. Versnel onze voetstap nu, opdat we zekerder en sneller tot U kunnen gaan. En we aanvaarden het Woord dat U ons biedt om ons oefenen tot één geheel te maken, wanneer we de gedachten herhalen die U ons gegeven hebt.Hieronder volgt de gedachte die aan de gedachten die we herhalen vooraf moet gaan. Elk daarvan verduidelijkt slechts een aspect van deze gedachte, of helpt die meer betekenis te geven, meer persoonlijk en waar te laten zijn, en meer het heilige Zelf te beschrijven dat we delen met elkaar en waarvoor we ons nu klaarmaken om het opnieuw te kennen:God is louter Liefde, en dus ben ik dat ook.Alleen dit Zelf kent Liefde. Alleen dit Zelf is volmaakt consistent in Zijn Gedachten, kent Zijn Schepper, begrijpt Zichzelf, is volmaakt in Zijn kennis en in Zijn Liefde, en wijkt nooit af van Zijn onveranderlijke staat van eenheid met Zijn Vader en Zichzelf.En dit is het wat ons opwacht aan het einde van de reis. Elke stap die we zetten brengt ons een beetje dichterbij. Deze herhaling zal de tijd onmetelijk bekorten, als we in gedachten houden dat dit ons doel blijft; en dit is het waarop we, al oefenend, afgaan. Laten we ons hart verheffen van de stof naar het leven, terwijl we ons herinneren dat dit ons is beloofd, en dat deze cursus gezonden werd om het pad van licht voor ons te ontsluiten, en ons stap voor stap te leren hoe we terug kunnen keren naar het eeuwige Zelf dat we dachten te hebben verloren.Ik maak de reis met jou. Want ik deel een korte poos je twijfels en je angsten, opdat je tot mij komen kunt die de weg kent waarlangs alle angst en twijfel overwonnen wordt. We gaan samen. Ik moet onzekerheid en pijn wel begrijpen, hoewel ik weet dat ze geen betekenis hebben. Maar een verlosser moet blijven bij hen die hij onderwijst, zien wat zij zien, maar nog steeds in zijn gedachten de weg vasthouden die hem eruit heeft geleid en nu jou eruit zal leiden samen met hem. Gods Zoon wordt gekruisigd tot jij deze weg met mij gaat.Mijn opstanding gebeurt telkens weer wanneer ik een broeder veilig leid naar de plaats waar de reis eindigt en vergeten wordt. Ik word hernieuwd telkens wanneer een broeder leert dat er een uitweg is uit ellende en pijn. Ik word herboren telkens wanneer de denkgeest van een broeder zich tot het licht in hem wendt en naar mij zoekt. Ik ben niemand vergeten. Help mij nu jou terug te leiden naar waar de reis begonnen werd, om met mij een andere keuze te maken.Bevrijd me terwijl je nogmaals de gedachten oefent die ik jou heb gebracht van Hem die jouw bittere nood ziet en het antwoord kent dat God Hem gegeven heeft. Samen herhalen we deze gedachten. Samen wijden we er onze tijd en moeite aan. En samen zullen wij ze onze broeders onderwijzen. God wil niet dat de Hemel incompleet is. De Hemel wacht op jou, net als ik. Ik ben incompleet zonder jouw deel in mij. En wanneer ik heel ben gemaakt, gaan we samen naar ons aloude thuis, voor ons bereid voor tijd bestond en onveranderd door de tijd bewaard gebleven, ongerept en veilig, zoals het ten leste zijn zal wanneer er geen tijd meer is.Laat deze herhaling dan jouw geschenk zijn aan mij. Want dit alleen heb ik nodig: dat jij de woorden zult horen die ik spreek en ze aan de wereld geeft. Jij bent mijn stem, mijn ogen, mijn voeten, mijn handen, waarmee ik de wereld verlos. Het Zelf vanwaaruit ik tot je roep, is niets anders dan het jouwe. Naar Hem zijn wij samen op weg. Neem je broeders hand, want dit is geen weg die we alleen gaan. In hem ga ik met jou, en jij met mij. Onze Vader wil dat Zijn Zoon één is met Hem. Wat kan er leven dat niet één is met jou?Laat deze herhaling een periode worden waarin we een voor jou nieuwe ervaring delen, zij het een zo oud als de tijd, en ouder nog. Geheiligd jouw Naam. Jouw heerlijkheid voor eeuwig onbezoedeld. En jouw heelheid nu compleet, zoals God die gegrondvest heeft. Jij bent Zijn Zoon die Zijn uitbreiding compleet maakt in de jouwe. We oefenen slechts een aloude waarheid die we kenden voordat illusie de wereld scheen op te eisen. En we herinneren de wereld eraan dat zij vrij is van alle illusies, telkens wanneer we zeggen:God is louter Liefde, en dus ben ik dat ook.Hiermee beginnen we elke dag van onze herhaling. Hiermee beginnen en eindigen we elke oefenperiode. En met deze gedachte slapen we in, om opnieuw te ontwaken met deze zelfde woorden op onze lippen, waarmee we een nieuwe dag begroeten. Iedere gedachte die we herhalen omlijsten we ermee, en we benutten de gedachten om dit in onze denkgeest hoog te houden en heel de dag door helder in onze herinnering te bewaren. En zo zullen we inzien, wanneer we deze herhaling hebben beëindigd, dat de woorden die we spreken waar zijn.Toch zijn de woorden maar hulpmiddelen en hoeven ze, behalve aan het begin en aan het eind van de oefenperioden, alleen gebruikt te worden om de denkgeest, zo nodig, aan zijn doel te herinneren. We stellen vertrouwen in de ervaring die uit oefening voortkomt, niet in de middelen die we hanteren. We wachten op de ervaring en beseffen dat alleen hierin overtuigingskracht ligt. We bedienen ons van woorden en proberen telkens en telkens weer daaraan voorbij te gaan naar hun betekenis, die ver voorbij hun klank gelegen is. De klank wordt zwakker en verdwijnt naarmate we de Bron van de betekenis naderen. Het is Hier dat we rust vinden.LES 178Herhaling van de lessen 165-166God is louter Liefde, en dus ben ik dat ook.(165) Laat mijn denkgeest de Gedachte van God niet afwijzen.God is louter Liefde, en dus ben ik dat ook.(166) Aan mij zijn de gaven van God toevertrouwd.God is louter Liefde, en dus ben ik dat ook.
► Probeer Moneybird 120 dagen gratis via: https://www.moneybird.nl/jongbeleggen Zelf geboren in een arm gezin in Surrey, Engeland, is hij uitgegroeid een van de beste Europese beleggers. En we zullen open kaart spelen: wij zijn fan! Maak kennis met Chris Hohn. Filantroop, klimaatactivist en supersuccesvol hedgefundmanager en een CAGR van 18 procent (!) in de afgelopen 21 jaar. Aan de hand van zijn eigen stemgeluid lopen bespreken we barriers to entry, convictie en intuïtie. Daarnaast heeft Pim een nieuw aandeel in mijn portefeuille, de Zweedse serial acquirer Röko! ► Uitgebreide show notes en achtergrondinformatie: https://jongbeleggendepodcast.nl/196-grote-beleggers-chris-hohn ► Word Vriend: https://portfoliodividendtracker.com ► Updates via Instagram: https://www.instagram.com/jongbeleggen ► Mijn volledige portfolio: https://app.portfoliodividendtracker.com/p/jongbeleggen 1) We maken gebruik van programmatic advertising, wat inhoudt dat we geen invloed hebben op de spots die in de podcast worden afgespeeld. Dit is vergelijkbaar met tv, YouTube, radio en de krant, uiteraard met uitzondering van de advertenties die we zelf hebben ingesproken. 2) Deze podcast is 100% expertise-vrij en alleen geschikt voor amusementsdoeleinden. De inhoud mag niet worden beschouwd als financieel advies.See omnystudio.com/listener for privacy information.
Idiopathic intracranial hypertension (IIH), a condition of increased intracranial pressure (ICP), causes debilitating headaches and, in some, visual loss. The visual defects are often in the periphery and not appreciated by the patient until advanced; therefore, monitoring visual function with serial examinations and visual fields is essential. In this episode, Kait Nevel, MD speaks with John J. Chen, MD, PhD, and Susan P. Mollan, MBChB, PhD, FRCOphth, authors of the article “Treatment and Monitoring of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Chen is a professor of ophthalmology and neurology at the Mayo Clinic in Rochester, Minnesota. Dr. Mollan is an honorary professor of metabolism and systems science in the department of neuro-ophthalmology at University Hospitals Birmingham in Birmingham, United Kingdom. Additional Resources Read the article: Treatment and Monitoring of Idiopathic Intracranial Hypertension Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guests: @chenmayo, @DrMollan Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Nevel: Hello, this is Dr Kate Nevel. Today, I'm interviewing Drs John Chen and Susan Mollan about their article on treatment and monitoring of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics. Drs Chen and Mollan, welcome to the podcast. And please, could you introduce yourselves to the audience? Dr Chen: Hello, everyone. I'm John Chen, one of the neuro-ophthalmologists at the Mayo Clinic. Thanks for having us here. Dr Mollan: Yeah, it's great to be with you here. I'm Susan Mollan. I'm a consultant neuro-ophthalmologist in Birmingham, England. Dr Nevel: Wonderful. So great to have you both here today, and our listeners. To start us off, talking about your article, can you share with us what you think is the most important takeaway from your article for the practicing neurologist out there? Dr Chen: Yeah, so our article talked about the treatment and monitoring of IIH. And I think one takeaway point is, IIH is becoming much more prevalent now that there's this worldwide obesity epidemic with obesity having- essentially being the largest risk factor for IIH other than female. It's really important to monitor vision because vision loss is often peripheral vision loss at first, which the patient may be completely unaware of. And so, it's important to pair up with an ophthalmologist so you can monitor the papilledema of the visual fields and make sure they don't get permanent vision loss. And in the article, we also talk about- there's been changes in the treatment of severe IIH, where traditionally, we used VP shunts; but there's been a trend toward using more venous sinus stenting in addition to the traditional surgeries. Dr Nevel: Great, thank you. I think probably most of our listeners or a lot of neurologists out there have a pretty good understanding of kind of the basics of the IIH. But can you kind of just go over a few key characteristics of IIH, and maybe some things that are less commonly known or things that are maybe just been kind of better understood over the past decade, perhaps? Dr Mollan: Yes, certainly. I think, as Dr Chen said, it's because this condition is becoming more prevalent, people recognize it. I think it's- we like to go back to the diagnostic criteria so that we're making a very accurate diagnosis. So, the patients may come in to the emergency room with, say, papilledema that's been identified elsewhere or crashing headaches. And it's important to go through that sort of diagnostic pathway, taking a blood pressure, taking a full blood count to make sure the patient is anemic, and then moving forward with that confirmation of papilledema into urgent neuroimaging, whether it's CT or MRI, but including venography to exclude a venous sinus thrombosis. And then if you have no structural lesion that's causing the raised ICP, it's moving forward with your lumbar puncture and carefully checking those pressures. But the patients may not only have crashing headache, they often have pulsatile tinnitus and neck pain. I think some of the features that we're now recognizing is the systemic metabolic effects that are unique to IIH. And so, there's an increased risk of cardiometabolic disease that's over and above what is conferred by obesity. Also, our patients have a sort of maternal health burden where they get impaired fertility, gestational diabetes and preeclampsia. And there's also an associated mental health burden, amongst other things. So we're really starting to understand the spectrum of the disease a bit more. Dr Nevel: Yeah, thank you for that. And that really struck me in your article, how important it is to be aware of those things so that we're making sure that we're managing our whole patient and connecting them with the appropriate providers for some of those other issues that may be associated. For the practicing neurologist out there without all the neuro-ophthalmology equipment, if you will, what should our bedside exam focus on to help us get maybe an early but accurate picture of the patient's visual function when we suspect IIH to be at play, perhaps before they can get in with the neuro-ophthalmologist? Dr Chen: Yeah, I think at the bedside you can still check visual acuity and confrontational visual fields, you know, with finger counting. Of course, you have to know that those are, kind of, crude kind of ways of screening. With papilledema, oftentimes the visual acuity is intact. And the confrontational visual fields aren't as sensitive as automated perimetry. Another important thing will be to do your direct ophthalmoscope and look at the amount of papilledema. If it's grade one or two papilledema on the more mild side, it's actually not vision threatening. It's the higher degrees of papilledema that can cause rapid vision loss. And so, if you look in and you see grade one papilledema, obviously you need to do the full workup, the MRI, MRV, lumbar puncture. But in terms of rapidly getting to an ophthalmologist to screen for vision loss, it's not going to be as important because you're not going to have vision loss at that low grade. If you look in and you see this rip-roaring papilledema, grade five papilledema, that patient is going to be at very severe risk of vision loss. So, I think that exam, looking at the optic nerve can be very helpful. And of course, talking to the patient about symptoms; is there decreased vision Is there double vision from a sixth nerve palsy? Are there transient visual obscurations which would indicate at least a higher degree of papilledema? That'd be helpful as well. Dr Nevel: Great, thank you. And when the patient does get in with a neuro-ophthalmologist, you talk in your article and, of course, in clinical practice, how OCT testing is important to monitor in this condition. Can you provide for the listeners the definition of OCT and how it plays a role in monitoring patients with IIH? Dr Mollan: Sure. So, OCT is short for optical coherence tomography imaging, and really the eye has been at the forefront of OCT alone. Our sort of cardiology colleagues are catching up on the imaging of blood vessels. But what it allows us to do is give us really good cross-sectional, anatomical-level changes that we can see both in the retina and also at the optic nerve head. And it gives us some really good measurements. It's not so good at sort of saying, is this definitely papilledema or not? That sort of lower end of disc elevation. But it is very good at ruling out what we call the pseudopapilledema. So, things like drusens or these other little masses we find underneath the optic nerve head. But in terms of monitoring, because we can longitudinally take these images and the reproducibility is pretty good at the optic nerve head, it allows us to see whether there's direct changes: either the papilledema getting worse or the papilledema getting better at the optic nerve head. It also gives us some indication of what's going on in the ganglion cell layer complex. And that can be helpful when we're thinking about sort of looking at structure versus function. So, ophthalmologists in general, we love OCT; and we spend much more time nowadays looking at the OCT than we really do the back of the eye. And it's just become critical for patients with papilledema to be able to be very accurate from visit to visit to see what's changing. Dr Nevel: How do you determine how frequently somebody needs to see the neuro-ophthalmologist with IIH and how often they need that OCT evaluation? Dr Chen: Once the diagnosis of IIH is made, how often they need to be seen and how frequent they need to be seen depends on the degree of papilledema. And again, OCT is really nice. You can quantify it and then different providers can actually use the same OCT numbers, which is super helpful. But again, if it's grade three papilledema or higher, or article thickness of 200 or higher, I tend to follow them a little bit more closely, trying to treat them more aggressively. Try to get the papilledema down into a safer zone. If it's grade one or two papilledema, we see them less frequently. So, my first visit might be three months out. They come with grade five papilledema, I'm seeing them within a few days to make sure that's papilledema's come down quickly because we're trying to decide, are they going to need surgery or not? Dr Nevel: Yeah, great. And that's a nice segue into talking a little bit about how we treat patients with IIH after the diagnosis is confirmed. And I'd like to just point out you have a very lovely figure in your article---Figure 5-6,---that I'd like to direct our listeners to read your article and check out that figure, which is kind of an algorithm on how we think about the various treatment options for patients who have IIH, which seems to rely a lot on the degree of presence of papilledema and the presence of vision disturbance. Could you maybe walk us through a little bit about how you think about the different treatment options for patients with IIH and when more urgent surgical intervention might be indicated? Dr Mollan: Yeah, sure. We always find it quite hard in any medical specialty to write these kind of flow diagrams because it's really an individual we're looking at. But these are kind of what we'd say is “broad brushstrokes” into those patients that we worry about, sort of, red disease in those patients, more amber disease. Now obviously, even those patients that may not have severe papilledema, they may have crashing headaches. So, they may be an urgent referral themselves because of that. And so, it's nice to try and work out which end of the spectrum you're working with. If we think of the papilledema, Dr Chen's already laid out the sort of lower end of the prison's scale---our grades one, our grades two---that we're less anxious about. And those patients, we would definitely be having discussions about medical management, which includes acetazolamide therapy; but also thinking about weight management. And it may well be that we talk a little bit further about weight management, but I think it's helpful to sort of coach those conversations after you've made a definite diagnosis. And then laying out the risk that's caused, potentially, the IIH in an individual. And then having a sort of open conversation with them about what changes they can have in their lifestyle alongside thinking about medical therapy. There's some patients with very low levels of papilledema that we decide not to put on medicines initially. As patients progress up that papilledema grade, we're definitely thinking about medical therapy. And our first line from the IIH treatment trial would be using acetazolamide, but we need to be thinking about using appropriate dosing. So, a lot of the patients that I see can be sent to me with very low doses that may be inappropriate for that person. In the IIHTT they used up to four grams daily in a divided dose. And you do need to counsel your patients when you're putting them on acetazolamide because of the side effects. You've got quite a nice table in this article about the side effects. I think if you get the patient on board, that they understand that they will experience side effects, that is helpful because they will expect it, and then possibly tolerate it a bit better. Moving through to that area where we're more anxious, that visual-threatening papilledema. As Dr Chen said, it's sort of like you look in and it's sort of “blood and thunder” in there. And you need to be getting on and encouraging the ophthalmologist to get a formal assessment of the visual field. It's very difficult to determine exactly the level at which- and we talk about the mean deviation in a lot of our research studies. But in general, it's a combination of things: the patient's journey to get to you, their symptoms, what's going on with the visual field, but what's also happening at the OCT. So, we look in and we see that fluid is seeping towards the fovea. We get very anxious, and those patients may not even have enough time for a rapid escalation of acetazolamide. It may well be at the first presentation, which we would term, like, fulminant; that we'd be thinking about surgical intervention. And I think before I stop, the other thing to say is, the surgical landscape is really changing. So, we're having some good studies coming out in terms of stenting. And so, there is a sort of bracket where it may well be that we are thinking about neuroradiological intervention in an earlier case. They may not quite be at that visual-threatening stage, but they may be resistant to medical treatments. Dr Nevel: Thank you for that. What do you think is a potential pitfall or a mistake to avoid, if you will, in the management of patients with IIH? Dr Chen: I think it's- in terms of pitfalls, I think the potential pitfalls I've seen are essentially patients where we don't necessarily create a good patient physician relationship. Where they don't have buy-ins on the treatment, they don't have buy-ins to come back, and they're lost to follow-up. And these patients can be dangerous, because they could have vision threatening papilledema and if not getting the appropriate treatment---and if they're not monitoring the vision---this can lead to poor outcomes. So, I've definitely seen that happen. As Dr Mollan said, you really have to tell them about the side effects from the medications. If you just take acetazolamide, letting them know the paresthesias and the changes in taste and some of these other side effects, they're going to immediately stop the medication. Again, and these medications do work, proven in the IIH treatment trial. So again, I think that patient-physician relationship is very important to make sure they have appropriate follow up. Dr Nevel: The topic of weight loss in this patient population can be tricky, and I know I talked with Susie in a prior interview about how to approach this topic with our patients in a sensitive and compassionate manner. Once this topic is broached, I find many patients are looking for advice on strategies for weight loss, or potentially medications or other interventions. How do you prioritize or think about the different weight loss strategies or treatments with your patients, and how do you think about the way that you recommend these different treatments or not? Dr Mollan: Yeah. I think that's a really great question because we sort of stray here into a specialty that we have not been trained in. One thing I definitely ask my patients: if they've been on a weight loss journey before, and what's worked for them and what's not worked for them. And within our different healthcare systems, we have access to different tiers of weight management approaches. But for the person sitting in front of me, that possibly there may be a long journey to access more professional care, it's about understanding. iIs there things that are free, such as, we have some apps in the National Health Service which are weight management applications where they can actually just start putting in their calories, their daily calorie intake. And those apps can be quite helpful and guiding in terms of targeting areas, but also informing the patient of what types of foods to avoid in their diet and what types of foods to include in their diet. And with some of the programs that are completely complementary, they also sometimes add on things about exercise. But I think it is a really difficult thing to manage as, say, an ophthalmologist or a neurologist, mainly because it's not our area of expertise. And I think we've all got to find, in our local hospitals and healthcare systems, those pathways where the patients may be able to access nutritional support, and sort of behavioral lifestyle therapy support, all the way through to the new medications for weight loss; and also for some people, bariatric surgery pathways. It's a tricky topic. Dr Nevel: So how should we counsel our patients about what to expect in the future in terms of visual outcomes? Dr Chen: I think a lot of that depends on the degree of papilledema when they present. If a patient comes in with grade five papilledema, that fulminant IIH that Dr Mollan had mentioned, these patients can have very severe vision loss. And even if we treat them very aggressively with high-dose medications and urgent surgical interventions, sometimes they can have permanent vision loss. And so, we counsel them that, you know, there's a strong chance that they're going to have a good amount of vision loss. But some patients, we're very surprised and we get a lot of vision back. So, we kind of set expectations, but we're cautiously optimistic that we can get vision back. If a patient presents with more mild papilledema like grade one or two papilledema, they're most likely not going to have any permanent vision loss as long as we're treating them, we're monitoring their vision, they're coming to their follow-ups. They tend to do very well from a vision perspective. Dr Nevel: That's great, thank you. And you know, ties into what you said earlier about really making sure that, you know, we create good- as with any patient, but good physician-patient relationships so that they, you know, trust us and they come to follow up so we can really monitor their vision appropriately. What do you think is going on in research in this area that's exciting? What do you think one of the next breakthroughs or thing that we need to understand the most about treatment and monitoring of IIH? Dr Chen: I think surgically, venous sinus stenting is going to probably take over the bulk of surgeries. We still need that randomized clinical trial, but we have some amazing outcomes with venous sinus stenting. And there's many efforts on randomized clinical trials for venous sinus stenting. So we'll have those results soon. From a medical standpoint, Dr Mollan can actually say, actually, more about this. Dr Mollan: I completely agree. The GLP-1 receptor agonists, the twofold prong approach: one is the weight loss where these patients, you know, have significant weight loss to put their disease into remission; and the other side of it is whether certain GLP-1s have the ability to reduce intracranial pressure. So, a phase 2 study that we undertook here in Birmingham did show that we were able to reduce intracranial pressure, but we don't think it's a class effect. So, I think the sort of big breakthrough will be looking at novel therapies like xenotide and other drugs that, say, work on the proximal kidney tubule. Are they able to reduce intracranial pressure directly? And I think we are on the cusp of a real breakthrough for this disease. Dr Nevel: Great. Thank you so much for chatting with me today. And I really learned a lot, appreciated the opportunity. I hope our listeners learned something today, too. So again, today I've been interviewing Drs John Chen and Susan Mollan about their article on treatment and monitoring of idiopathic intracranial hypertension, which appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.
In this episode, editor-in-chief Joseph E. Safdieh, MD, FAAN, highlights articles studies showing persistent fatigue after TIA, the neurologic complications of measles, and the impact of the dismantling of a CDC surveillance program of epilepsy.
In the first episode of this new series, Dr. Andy Southerland discusses the June updates from the AAN's Capitol Hill Report (CHR). This month's CHR update includes a member story from Dr. José Posas. Stay updated with what's happening on the hill by visiting aan.com/chr. Learn how you can get involved with AAN advocacy.
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Idiopathic intracranial hypertension (IIH) is characterized by symptoms and signs of unexplained elevated intracranial pressure (ICP) in an alert and awake patient. The condition has potentially devastating effects on vision, headache burden, increased cardiovascular disease risk, sleep disturbance, and depression. In this episode, Teshamae Monteith, MD, FAAN speaks with Aileen A. Antonio, MD, FAAN, author of the article “Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Monteith is the associate editor of Continuum® Audio and an associate professor of clinical neurology at the University of Miami Miller School of Medicine in Miami, Florida. Dr. Antonio is an associate program director of the Hauenstein Neurosciences Residency Program at Trinity Health Grand Rapids and an assistant clinical professor at the Michigan State University College of Osteopathic Medicine in Lansang, Michigan. Additional Resources Read the article: Clinical Features and Diagnosis of Idiopathic Intracranial Hypertension Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @headacheMD Guest: @aiee_antonio Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Monteith: Hi, this is Dr Teshamae Monteith. Today I'm interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the June 2025 Continuum issue on disorders of CSF dynamics. Hi, how are you? Dr Antonio: Hi, good afternoon. Dr Monteith: Thank you for being on the podcast. Dr Antonio: Thank you for inviting me, and it's such an honor to write for the Continuum. Dr Monteith: So why don't you start off with introducing yourself? Dr Antonio: So as mentioned, I'm Aileen Antonio. I am a neuro-ophthalmologist, dually trained in both ophthalmology and neurology. I'm practicing in Grand Rapids, Michigan Trinity Health, and I'm also the associate program director for our neurology residency program. Dr Monteith: So, it sounds like the residents get a lot of neuro-ophthalmology by chance in your curriculum. Dr Antonio: For sure. They do get fed that a lot. Dr Monteith: So why don't you tell me what the objective of your article was? Dr Antonio: Yes. So idiopathic intracranial hypertension, or IIH, is a condition where there's increased intracranial pressure, but without an obvious cause. And with this article, we want our readers---and our listeners right now---to recognize that the typical symptoms and learning about the IIH diagnostic criteria are key to avoiding errors, overdiagnosis, or sometimes even misdiagnosis or underdiagnosis. Thus, we help make the most of our healthcare resources. Early diagnosis and management are crucial to prevent disability from intractable headaches or even vision loss, and it's also important to know when to refer the patients to the appropriate specialists early on. Dr Monteith: So, it sounds like your central points are really getting that diagnosis early and managing the patients and knowing how to triage patients to reduce morbidity and complications. Is that correct? Dr Antonio: That is correct and very succinct, yes. Dr Monteith: And so, are there any more recent advances in the diagnosis of IIH? Dr Antonio: Yes. And one of the tools that we've been using is what we call the optical coherence tomography. A lot of people, neurologists, physicians, PCP, ER doctors; how many among those physicians are well-versed in doing an eye exam, looking at the optic disc? And this is a great tool because it is noninvasive, it is high resolution imaging technique that allows us to look at the optic nerve without even dilating the eye. And we can measure that retinal nerve fiber layer, or RNFL; and that helps us quantify the swelling that is visible or inherent in that optic nerve. And we can even follow that and monitor that over time. So, this gives us another way of looking at their vision and getting that insight as to how healthy is their vision still, along with the other formal visual tests that we do, including perimetry or visual field testing. And then all of these help in catching potentially early changes, early worsening, that may happen; and then we can intervene more easily. Dr Monteith: Great. So, it sounds like there's a lot of benefits to this newer technology for our patients. Dr Antonio: That is correct. Dr Monteith: So, I read in the article about the increased incidence of IIH, and I have to say that I completely agree with you because I'm seeing so much of it in my clinic, even as a headache specialist. And I had a talk with a colleague who said that the incidence of SIH and IIH are similar. And I was like, there's no way. Because I see, I can see several people with IIH just in one day. That's not uncommon. So, tell me what your thoughts are on the incidence, the rising incidence of IIH; and we understand that it's the condition associated with obesity, but it sounds like you have some other underlying drivers of this problem. Dr Antonio: Yes, that is correct. So, as you mentioned, IIH tends to affect women of childbearing age with obesity. And it's interesting because as you've seen that trend, we see more of these IIH cases recently, which seem to correlate with that rising rate of obesity. And the other thing, too, is that this trend can readily add to the burden of managing IIH, because not only are we dealing with the headaches or the potential loss of vision, but also it adds to the burden of healthcare costs because of the other potential comorbidities that may come with it, like cardiovascular risk factors, PCOS, and sleep apnea. Dr Monteith: So why don't we just talk about the diagnosis of IIH? Dr Antonio: IIH, idiopathic intracranial hypertension, is also called pseudotumor cerebri. It's essentially a condition where a person experiences increased intracranial pressure, but without any obvious cause. And the tricky part is that the patients, they're usually fully awake and alert. So, there's no obvious tumor, brain tumor or injury that causes the increased ICP. It's really, really important to rule out other conditions that might cause these similar symptoms; again, like brain tumors or even the cerebral venous sinus thrombosis. Many patients will have headaches or visual disturbances like transient visual obscurations---we call them TVOs---or double vision or diplopia. The diplopia is usually related to a sixth nerve palsy or an abducens palsy. Some may also experience some back pain or what we call pulsatile tinnitus, which is that pulse synchronous ringing in their ears. The biggest sign that we see in the clinic would be that papilledema; and papilledema is a term that we only use, specifically use, for those optic nerve edema changes that is only associated with increased intracranial pressure. So, performing of endoscopy and good eye exam is crucial in these patients. We usually use the modified Dandy criteria to diagnose IIH. And again, I cannot emphasize too much that it's really important to rule out other secondary causes to that increased intracranial pressure. So, after that thorough neurologic and eye evaluation with neuroimaging, we do a lumbar puncture to measure the opening pressure and to analyze the cerebrospinal fluid. Dr Monteith: One thing I learned from your article, really just kind of seeing all of the symptoms that you mentioned, the radicular pain, but also- and I think I've seen some papers on this, the cognitive dysfunction associated with IIH. So, it's a broader symptom complex I think than people realize. Dr Antonio: That is correct. Dr Monteith: So, you mentioned TVOs. Tell me, you know, if I was a patient, how would you try and elicit that from me? Dr Antonio: So, I would usually just ask the patient, while you're sitting down just watching TV---some of my patients are even driving as this happens---they would suddenly have these episodes of blacking out of vision, graying out of vision, vision loss, or blurred vision that would just happen, from seconds to less than a minute, usually. And they can happen in one eye or the other eye or both eyes, and even multiple times a day. I had a patient, it was happening 50 times a day for her. It's important to note that there is no pain associated with it most of the time. The other thing too is that it's different from the aura that patients with migraines would have, because those auras are usually scintillating and would have what we call the positive phenomena: the flashing lights, the iridescence, and even the fortification that they see in their vision. So definitely TVOs are not the migraine auras. Sometimes the TVOs can also be triggered by sudden changes in head positions or even a change in posture, like standing up quickly. The difference, though, between that and, like, the graying out of vision or the tunneling vision associated with orthostatic hypotension, is that the orthostatic hypotension would also have that feeling of lightheadedness and dizziness that would come with it. Dr Monteith: Great. So, if someone feels lightheaded, less likely to be a TVO if they're bending down and they have that grain of vision. Dr Antonio: That is correct. Dr Monteith: Definitely see patients like that in clinic. And if they have fluoride IIH, I'm like, I'll call it a TVO; if they don't, I'm like, it's probably more likely to be dizziness-related. And then we also have patient migraines that have blurriness that's nonspecific, not necessarily associated with aura. But I think in those patients, it's usually not seconds long, it's usually probably longer episodes of blurriness. Would you agree there, or…? Dr Antonio: I would agree there, and usually the visual aura would precede the headache that is very characteristic of their migraine, very stereotypical for their migraines. And then it would dissipate slowly over time as well. With TVOs, they're brisk and would not last, usually, more than a minute. Dr Monteith: So, why don't we talk about routine imaging? Obviously, ordering an MRI, and I read also getting an MRV is important. Dr Antonio: It is very important because, one: I would say IIH is also a diagnosis of exclusion. We need to make sure that the increased ICP is not because of a brain tumor or not because of cerebral venous sinus thrombosis. So, it's important to get the MRI of the brain as well as the MRV of the head. Dr Monteith: Do you do that for all patients' MRV, and how often do you add on an orbital study? Dr Antonio: I usually do not add on an orbital study because it's not really going to change my management at that point. I really get that MRI of the brain. Now the MRV, for most of my patients, I would order it already just because the population that I see, I don't want to lose them. And sometimes it's that follow-up, and that is the difficult part; and it's an easy add on to the study that I'm going to order. Again, it depends with the patient population that you have as well, and of course the other symptoms that may come with it. Dr Monteith: So, why don't we talk a little bit about CSF reading and how these set values, because we get people that have readings of 250 millimeters of water quite frequently and very nonspecific, questionable IIH. And so, talk to me about the set value. Dr Antonio: Right. So, the modified Dandy criteria has shown that, again, we consider intracranial pressure to be elevated for adults if it's above 250 millimeters water; and then for kids if it's above 280 millimeters of water. Knowing that these are taken in the left lateral decubitus position, and assuming also that the patients were awake and not sedated during the measurement of the CSF pressure. The important thing to know about that is, sometimes when we get LPs under fluoroscopy or under sedation, then these can cause false elevation because of the hypercapnia that elevated carbon dioxide, and then the hypoventilation that happens when a patient is under sedation. Dr Monteith: You know, sometimes you see people with opening pressures a little bit higher than 25 and they're asymptomatic. Well, the problem with these opening pressure values is that they can vary somewhat even across the day. People around 25, you can be normal, have no symptoms, and have opening pressure around 25- or 250; and so, I'm just asking about your approach to the CSF values. Dr Antonio: So again, at the end of the day, what's important is putting everything together. It's the gestalt of how we look at the patient. I actually had an attending tell me that there is no patient that read the medical textbook. So, the, the important thing, again, is putting everything together. And what I've also seen is that some patients would tell me, oh, I had an opening pressure of 50. Does that mean I'm in a dire situation? And they're so worried and they just attach to numbers. And for me, what's important would be, what are your symptoms? Is your headache, right, really bad, intractable? Number two: are you losing vision, or are you at that cusp where your optic nerve swelling or papilledema is so severe that it may soon lead to vision loss? So, putting all of these together and then getting the neuroimaging, getting the LP. I tell my residents it's like icing on the cake. We know already what we're dealing with, but then when we get that confirmation of that number… and sometimes it's borderline, but this is the art of neurology. This is the art of medicine and putting everything together and making sure that we care and manage it accordingly. Dr Monteith: Let's talk a little bit about IIH without papilledema. Dr Antonio: So, let's backtrack. So, when a patient will fit most of the modified Dandy criteria for IIH, but they don't have the papilledema or they don't have abducens palsy, the diagnosis then becomes tricky. And in these kinds of cases, Dr Friedman and her colleagues, when they did research on this, suggested that we might consider the diagnosis of IIH. And she calls this idiopathic intracranial hypertension without papilledema, IIHWOP. They say that if they meet the other criteria for modified Dandy but show at least three typical findings on MRI---so that flattening of the posterior globe, the tortuosity of the optic nerves, the empty sella or the partially empty sella, and even the narrowing of the transverse venous sinuses---so if you have three of these, then potentially you can call these cases as idiopathic intracranial hypertension without papilledema. Dr Monteith: Plus, the opening pressure elevation. I think that's key, right? Getting that as well. Dr Antonio: Yes. Sometimes IIHWOP may still be a gray area. It's a debate even among neuro-ophthalmologists, and I bet even among the headache specialists. Dr Monteith: Well, I know that I've had some of these conversations, and it's clear that people think this is very much overdiagnosed. So, that's why I wanted to plug in the LP with that as well. Dr Antonio: Right. And again, we have not seen yet whether is, this a spectrum, right? Of that same disease just manifesting differently, or are they just sharing a same pathway and then diverging? But what I want to emphasize also is that the treatment trials that we've had for IIH do not include IIHWOP patients. Dr Monteith: That is an important one. So why don't you wrap this up and tell our listeners what you want them to know? Now's the time. Dr Antonio: So, the- again, with IIH, with idiopathic intracranial hypertension, what is important is that we diagnose these patients early. And I think that some of the issues that come into play in dealing with these patients with IIH is that, one: we may have anchoring bias. Just because we see a female with obesity, of reproductive age, with intractable headaches, it does not always mean that what we're dealing with is IIH. The other thing, too, is that your tools are already available to you in your clinic in diagnosing IIH, short of the opening pressure when you get the lumbar puncture. And I need to emphasize the importance of doing your own fundoscopy and looking for that papilledema in these patients who present to you with intractable headaches or abducens palsy. What I want people to remember is that idiopathic intracranial hypertension is not optic nerve sheath distension. So, these are the stuff that you see on neuroimaging incidentally, not because you sent them, because they have papilledema, or because they have new headaches and other symptoms like that. And the important thing is doing your exam and looking at your patients. Dr Monteith: Today, I've been interviewing Dr Aileen Antonio about her article on clinical features and diagnosis of idiopathic intracranial hypertension, which appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Thank you again. Dr Antonio: Thank you. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.
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