title: Phosphorylated tau/amyloid beta 1-42 ratio in ventricular cerebrospinal fluid reflects outcome in idiopathic normal pressure hydrocephalus.
abstract: BACKGROUND
  Idiopathic normal pressure hydrocephalus (iNPH) is a potentially reversible cause of dementia and gait disturbance that is typically treated by operative placement of a ventriculoperitoneal shunt. The outcome from shunting is variable, and some evidence suggests that the presence of comorbid Alzheimer's disease (AD) may impact shunt outcome. Evidence also suggests that AD biomarkers in cerebrospinal fluid (CSF) may predict the presence of AD. The aim of this study was to investigate the relationship between the phosphorylated tau/amyloid beta 1-42 (ptau/Aβ1-42) ratio in ventricular CSF and shunt outcome in patients with iNPH.
  
  
  METHODS
  We conducted a prospective trial with a cohort of 39 patients with suspected iNPH. Patients were clinically and psychometrically assessed prior to and approximately 4 months after ventriculoperitoneal shunting. Lumbar and ventricular CSF obtained intraoperatively, and tissue from intraoperative cortical biopsies were analyzed for AD biomarkers. Outcome measures included performance on clinical symptom scales, supplementary gait measures, and standard psychometric tests. We investigated relationships between the ptau/Aβ1-42 ratio in ventricular CSF and cortical AD pathology, initial clinical features, shunt outcome, and lumbar CSF ptau/Aβ1-42 ratios in the patients in our cohort.
  
  
  RESULTS
  We found that high ptau/Aβ1-42 ratios in ventricular CSF correlated with the presence of cortical AD pathology. At baseline, iNPH patients with ratio values most suggestive of AD presented with better gait performance but poorer cognitive performance. Patients with high ptau/Aβ1-42 ratios also showed a less robust response to shunting on both gait and cognitive measures. Finally, in a subset of 18 patients who also underwent lumbar puncture, ventricular CSF ratios were significantly correlated with lumbar CSF ratios.
  
  
  CONCLUSIONS
  Levels of AD biomarkers in CSF correlate with the presence of cortical AD pathology and predict aspects of clinical presentation in iNPH. Moreover, preliminary evidence suggests that CSF biomarkers of AD may prove useful for stratifying shunt prognosis in patients being evaluated and treated for this condition.
authors.affiliation: Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. Roy.Hamilton@uphs.upenn.edu.
authors.forename: Sunil
authors.initials: S
authors.lastname: Patel
authors.forename: Edward B
authors.initials: EB
authors.lastname: Lee
authors.forename: Sharon X
authors.initials: SX
authors.lastname: Xie
authors.forename: Anica
authors.initials: A
authors.lastname: Law
authors.forename: Eric M
authors.initials: EM
authors.lastname: Jackson
authors.forename: Steven E
authors.initials: SE
authors.lastname: Arnold
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Clark
authors.forename: Leslie M
authors.initials: LM
authors.lastname: Shaw
authors.forename: M Sean
authors.initials: MS
authors.lastname: Grady
authors.forename: John Q
authors.initials: JQ
authors.lastname: Trojanowski
authors.forename: Roy H
authors.initials: RH
authors.lastname: Hamilton