Clinical Neurology and Neurosurgery 158 (2017) 27–32

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Clinical Neurology and Neurosurgery

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Full Length Article

A new quantitative method to assess disproportionately enlarged MARK

subarachnoid space (DESH) in patients with possible idiopathic normal
pressure hydrocephalus: The SILVER index
⁎
Nicola Benedettoa, , Carlo Gambacciania, Filippo Aquilaa, Davide Tiziano Di Carloa,
Riccardo Morgantib, Paolo Perrinia
a
Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
b
Department of Clinical and Experimental Medicine, Section of Statistics, University of Pisa, Pisa, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: Preoperative diagnosis of idiopathic normal-pressure hydrocephalus (iNPH) remains challenging.
Normal pressure hydrocephalus Recently, the presence of disproportionally enlarged subarachnoid spaces and hydrocephalus (DESH) on
DESH diagnostic images has been linked to clinical improvement after ventriculoperitoneal (VP) shunt placement.
Ventriculoperitoneal shunt In this study we describe a new quantitative method to assess DESH on CT scans and to evaluate its prognostic
Tap test
value.
Patients and methods: A multiplanar reconstruction software was used to retrospectively evaluate prospectively
collected radiological data (CT scans) of 26 controls and 29 consecutive patients that underwent VP shunt
placement for possible iNPH. The ratio between the areas of the sylvian fissure and the subarachnoid space at the
vertex was calculated (SILVER index). The diagnostic accuracy of the SILVER index and the estimate of the best
cut-point were assessed using ROC analysis.
Results: The mean value of the SILVER index was 11.52 ± 14.27 in the study group and 1.68 ± 0.98 in the
control group (p-value < 0.0001). The area under the ROC curve for the SILVER index was 0.903 (95% CI
0.813–0.994). A cut-off value for the SILVER index of 3.75 was extrapolated with a sensitivity and specificity of
0.828 and 0.962 respectively.
Conclusions: The SILVER index is a reliable tool to easily quantify DESH on CT scans of patients with suspected
iNPH. Its high sensitivity and specificity should encourage further investigations in order to confirm its clinical
utility.

1. Introduction response to shunt placement [6].

Idiopathic normal-pressure hydrocephalus (iNPH) is a surgically
treatable form of dementia clinically associated with gait disturbance
and urinary incontinence, as initially described by Hakim and Adams
[1].
Usually affecting elderly people [2], this clinical triad of symptoms
was defined as iNPH after the observation of ventriculomegaly asso-
ciated with normal cerebrospinal fluid (CSF) pressure values [3].
The treatment consists in placing a VP shunt to divert CSF from the
ventricles to the peritoneal cavity [4]. Nowadays, although there is a
great effort to develop a valid diagnostic tool and treat only shunt-
responder patients [5], there are still diagnostic difficulties if we
consider that Japanese guidelines for management of iNPH suggest
that a definite diagnosis can only be made on the basis of a patient’s
In the last few years, several reports have been published regarding
the peculiar brain atrophy pattern affecting patients with iNPH [7–9].
This feature, linked with a positive response to the VP shunt, has been
described as “disproportionately enlarged subarachnoid-space hydro-
cephalus”(DESH) and consists in an enlargement of the sylvian fissures
with normal or narrow sulci at the vertex [8–11].
The presence of DESH on patients’ computer tomography (CT) or
magnetic resonance (MR) imaging scans, is usually evaluated by
complex software analysis [8,12]. This has likely hindered the diffusion
of this parameter in clinical use.
In this paper, we present a simple way to evaluate the presence of
DESH on CT scans through the assessment of an index consisting of a
ratio between the subarachnoid spaces of the Silvian fissure and the
vertex sulci (SILVER). This index could assist physicians in evaluating

⁎
Corresponding author at: Neurosurgical Department, Azienda Ospedialiera Universitaria Pisana (AOUP), Via Paradisa 2, 56127, Pisa, Italy.
E-mail address: n.benedetto@ao-pisa.toscana.it (N. Benedetto).

http://dx.doi.org/10.1016/j.clineuro.2017.04.015
Received 28 January 2017; Received in revised form 10 April 2017; Accepted 16 April 2017
Available online 19 April 2017
0303-8467/ © 2017 Elsevier B.V. All rights reserved.
N. Benedetto et al.
patients with possible iNPH.
2. Material and methods
2.1. Population
We retrospectively reviewed the prospectively collected clinical and
radiological data of 29 patients (study group) with possible iNPH
admitted to our Department between March 2013 and September 2014.
Patients were defined as possible iNPH when they met all the criteria of
the Clinical Guidelines for iNPH of the Japan Neurosurgical Society [6]:
age over 60, presence of at least two symptoms of Hakim’s triad (gait
disturbance, urinary incontinence and cognitive impairment), Evan’s
index > 0.3, and no presence of congenital hydrocephalus or aqueduc-
tal stenosis.
All patients underwent preoperative CSF withdrawal via tap test and
were classified as probable iNPH, according to the same guidelines [6],
on the basis of their clinical response to CSF withdrawal and\or the
presence of DESH on neuroimages.
Every patient eventually defined as probable INPH underwent
placement of a VP shunt with programmable valve (Codman Medos).
Clinical improvement was assessed by comparing the preoperative
and postoperative score of the mini-mental state examination test
(MMSE), the 3 m timed up and go test (TUG), and an Incontinence
Questionnaire-Short Form (ICIQ-SF). Patients were considered clini-
cally improved if at least one of these three scores ameliorated after
surgery. More specifically, a patient was considered improved if one of
these conditions were met: post-op MMSE score moved to an upper
segment (intervals were 0–9, 10–18, 19–23, 24–30), TUG reduced
compared to pre-op, ICIQ-SF score reduced.
We created a control group by selecting 26 CT scans of people from
the same age interval who had accessed our hospital for minor head
trauma and who did not have a medical history of iNPH-related
symptoms.
2.2. Image analysis
The images of each patient were analysed using Synedra personal
view (version 15.0.0.3, downloadable at http://www.synedra.com/en/
downloads/download-purchase-viewer). We used sets of DICOM
images containing at least 64 slices. Each exam was analysed by a
neurosurgeon as follows:
• Using the Multi-Planar reconstruction (MPR) button, we created
sagittal and coronal reconstructions from axial images (Fig. 1). The
axial orientation line was adjusted, on the sagittal view, to results
parallel to the frontal fossa (Fig. 1B). This new axial orientation was
then used to find the two foramens of Monro and then the coronal
orientation line was placed at that level (Fig. 1C). The resulting
coronal slice was used for measurements (Fig. 1A)
• Using the measurement tool we hand-drew the boundaries of the
subarachnoid space between the most cranial point of the superior
frontal gyrus, the falx cerebri and the gyrus cinguli or the most
cranial point where the brain cortex adheres to the falx. (Fig. 2A and
B). Additionally, we calculated the Sylvian fissure to be the area
between the most lateral points of the inferior frontal gyrus, the
superior temporal gyrus and the insular cortex (Fig. 2C). The ratio
between the area of the Sylvian fissure and the area at the vertex
was defined as the SILVER index. When no subarachnoid space was
visible between the superior frontal gyrus and the falx, an arbitrary
value of 10 mm2 was given. As a rule, the right side was used in all
cases.
2.3. Statistical analysis
Categorical data was described by frequency and percentage,
28
Clinical Neurology and Neurosurgery 158 (2017) 27–32
whereas continuous data was described by mean, median and range.
The Kolmogorov-Smirnov test was applied in order to assess the
normality of the distributions of the continuous variables: age and
gender were analysed by the Student t-test (two-tailed) and the Fisher
exact test respectively, while the SILVER index was analysed by the
Mann-Whitney test (two-tailed). Furthermore, to evaluate the symptom
improvement we used the Wilcoxon test (two-tailed). Finally, the
diagnostic accuracy of the SILVER index test and the estimate of the
best cut-point were assessed using the ROC analysis and the area under
curve (AUC) was analysed with a non-parametric test.
Differences were considered significant at P < 0.05.
All statistical analyses were performed using SPSS 21.0 (SPSS Inc,
Chicago, IL, USA).
3. Results
Twenty-two out of 29 patients improved after the tap test (probable
iNPH). Twenty-nine patients with a mean age of 76.9 years (range,
65–88 years) underwent VP shunt placement. The mean follow up was
15.5 months (range 4–29). The control group was composed of 26
patients with a mean age of 76 years (range, 64–86 years) with Evan’s
index < 0.3. The two groups were similar regarding age and sex
distribution (p-value 0.298 and 0.106, respectively). Twenty-five out
of 29 patients of the study group experienced clinical improvement
after placement of the VP shunt.The mean value of the SILVER index
was 11.52 ± 14.27 (range, 0.6–75.45) in the study group and
1.68 ± 0.98 (range 0.58–3.75) in the control group. Patients in the
study group had a higher value of SILVER index (p-value < 0.0001)
compared to the control group (Fig. 3). There weren’t any differences
between patients who had improved and those who had not improved
after surgery in terms of SILVER index score (p = 0.850) or Evan’s
index (p = 0.103).
Demographic and radiological data is summarized in Table 1.
The area under the ROC curve for the SILVER index was 0.903 (95%
CI: 0.813–0.994) (Fig. 4). A cut-off value for the SILVER index of 3.75
was extrapolated with a sensitivity and specificity of 0.828 and 0.962
respectively.
The SILVER index value was compared between patients presenting
all three symptoms and those with only two symptoms of Hakim's triad.
The mean value of the SILVER index was 9.92 and 8.27 in patients with
three and two symptoms, respectively (p = 0.727).
The sensitivity of the tap test in this series was 0.786. The SILVER
index mean value was 12.57 and 10.98 respectively in both improved
and unimproved patients following the tap test (p = 0.899) (Fig. 5).
4. Discussion
The diagnosis of iNPH is still a major issue due to the absence of a
reliable diagnostic tool. A definite diagnosis can only be made after
shunt surgery, by observing a patient’s positive response to the VP
shunt [13]. The lumbar CSF tap test is widely used to select patients
suitable for shunt placement because of its good sensitivity [14,15], but
it cannot be used to exclude them from surgery due to its low specificity
[16]. Placing an external CSF lumbar drainage has been proven to have
a higher sensitivity compared to the tap test [17], however the rate of
complications is also higher and a longer period of hospitalization is
required.
Over the last decades, in parallel with advances in diagnostic
imaging, many efforts have been made to identify characteristic
features of iNPH on diagnostic images. The first attempt to measure
the ventricular system was made by Evans WA in 1942 on patients’
pneumoencephalographies [18]. The ratio in his name can be calcu-
lated as follows: The maximum frontal horn width divided by the
maximum inner diameter of the skull and a value greater than 0.30
means ventriculomegaly. Nevertheless the Evans index, still widely
calculated on CT and MRI scans of patients with suspected iNPH [19],
N. Benedetto et al. Clinical Neurology and Neurosurgery 158 (2017) 27–32

Fig. 1. Screenshot of a CT scan MPR created with the MPR button (red arrow). B Sagittal viewport. The axial orientation line (blue) is rotated to be parallel to the frontal fossa. C Axial
viewport. On this view the coronal orientation Line (red) is placed at the level of the foramens of Monro. A Coronal viewport. The coronal plane obtained through the previous adjustment
is used to calculate the SILVER index. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).

Fig. 2. A After deactivating the orientation lines from the viewport via the specific button (red arrow), the subarachnoid area at the vertex and the Sylvian fissure are calculated with the
free-hand measurement tool. Areas are showed in squared millimeters (red boxes). B Close-up of the area at the vertex. Measurement starts from the most cranial point of the superior
frontal gyrus medial part (arrow), follows the medial surface of the brain until no space between the brain and the falx is recognizable or (as in this case) until the gyrus cinguli
(arrowhead). The measurement is completed following the falx to the inner skull point immediately overhead the starting point (asterisk). C Close-up of the Sylvian fissure. Measurement
starts from the most lateral aspect of the inferior frontal gyrus (arrow), contours the Sylvian fissure and the insular cortex (asterisks) to the most lateral aspect of the superior temporal
gyrus (arrowhead). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

29
N. Benedetto et al. Clinical Neurology and Neurosurgery 158 (2017) 27–32

Fig. 3. Box plot showing comparison of SILVER index values between study group and control group.

Table 1 correlates only with frontal ventricle enlargement and not with
Demographic and radiological data. dilatation of the whole ventricular system [12].
Kitagaki et al. stated that all CSF compartments are involved in the
Study group Control group p-value
pathogenesis of iNPH, hence a dilatation of cerebral sulci, sylvian
Demographic data fissure, and basal cisterns should be interpreted as additional signs of
No of patients 29 26 iNPH in addition to ventricular dilatation [8]. This hypothesis is
mean age (years) [range] 76.9 [65–88] 76.0 [64–86] 0,298 supported by a recent report from Iseki et al. [9] describing an
M:F 19:10 11:15 0,106
asymptomatic patient with an MRI showing Sylvian fissures dilatation
Radiologic data associated with tight subarachnoid spaces at the vertex and normal-
Evans ratio 0,36 [0,31–0,43] 0,26 [0,15–0,29]
sized ventricles. This pattern anticipated the ventricular dilatation and
mean [range]
SILVER INDEX mean 11,52 [0,60–75,45] 1,68 [0,58–75] < 0,0001 the appearance of iNPH symptoms by 8 years.
[range] In 2010, a Japanese prospective multicentric study [11] described

Fig. 4. ROC curve analysis for SILVER index, AUC 0.903 (95% CI: 0.813-0.994).

30
N. Benedetto et al.
Fig. 5. Box plot showing comparison of SILVER index values in patients with and without clinical improvement after tap test. No statistical significance has been found meaning that
SILVER index and tap test can predict the outcome of surgery independently.
on MRI images the relationship existing among ventricles enlargement,
Sylvian fissure enlargement, and tight high-convexity subarachnoid
spaces. The authors called this association ‘disproportionately enlarged
subarachnoid-space hydrocephalus’ (DESH). These MRI features have
been recognized as a useful diagnostic tool for iNPH, and its presence
correlates with a better outcome after VP shunt placement [20].
Nevertheless, assessing the presence of DESH on MRI images can be
tricky for non–experienced physicians, while the proposed qualitative
grading score for the Sylvian fissure (from narrow to highly enlarged)
[11] is susceptible to different interpretations due to its non-quantita-
tive nature. Ishikawa et al. reported a retrospective analysis of 83
patients with iNPH that underwent VP shunt placement [20]. Patients
were classified as DESH, incomplete DESH (divided into 3 further
subgroups), and Non-DESH on the basis of their MRI images. The
classification of MRI findings into these groups is the result of a
Japanese consensus DESH committee. The rates of improvement for
each group after surgery were 73.5% for the DESH group, 87.5% for the
incomplete DESH with enlarged Sylvian fissure subgroup (incomplete-
DESH-s), and 63.6% for the Non-DESH group. Although the DESH and
incomplete-DESH-s had a greater improvement compared to the Non-
DESH, in our opinion the qualitative nature of this classification is the
major drawback to its clinical use.
Yamashita et al. [21] reported that an automatic segmentation and
analysis of the subarachnoid spaces and the ventricular system is
feasible and provides a good sensitivity and specificity in diagnosing
iNPH. Although promising, this technique appears to be confined—at
least for the time being—to those centers with the high–end technology
required.
Inspired by the original work of Dr. Evans [18], we decided to
develop an easy-to-asses index that could help physicians make a
quantitative analysis of the DESH on images of patients presenting
with symptoms possibly related to iNPH.
In our study, CT scan was preferred over MRI because most of the
patients with cognitive impairment and\or gait disorder undergo a CT
scan during the early stages of their diagnostic path, making this exam
widely available in this population. We used the non-commercial
version of Synedra View software but any DICOM software could be
used if the following 3 requirements are met: the possibility to
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Clinical Neurology and Neurosurgery 158 (2017) 27–32
reconstruct the images on different planes; the axial plane can be re-
oriented to run parallel to the frontal fossa, and the area of the region of
interest is shown in squared millimeters.
According to our preliminary results, quantification of the SILVER
index doesn’t require a major expertise in assessing possible iNPH on
patients’ images, but rather the knowledge of few anatomical land-
marks. In addition, the ROC curve demonstrated that the SILVER index
has a sensitivity of 82.8%, greater than the sensitivity of tap test in the
same group of patients (78.6%). It is worth noting that similar values of
the Silver index were observed in improved or unimproved patients
after tap test (Fig. 5). This finding suggests that these two tests are not
linked and could independently predict the outcome after surgery. This
data corroborates similar results reported in recent literature [20].
We did not find any statistically significant difference in the SILVER
index values found in groups of shunt-responders and non responders in
this series. The reason of these false positives is probably linked to the
fact that DESH features are morphological brain modifications char-
acteristic of iNPH, but they don’t provide any information on intracra-
nial mechanoelastic properties that eventually impact on CSF and
cerebral blood circulation. This last aspect has indeed been shown to
correlate with the iNPH-related grade of cerebral compromise and
shunt response [22].
In our opinion this simple method could be useful to evaluate and
quantify the presence of DESH on CT scans of patients with possible
iNPH.
The main limitation of this study is its retrospective design. In fact,
although SILVER index was reliably calculated in all cases, its role in
predicting which patients will respond to treatment needs prospective
validation. In addition, the small sample of this study only allows
reduced statistical inference. Finally, SILVER index was not compara-
tively evaluated on MRI images.
5. Conclusions
The SILVER index is a straightforward method to quantify DESH on
CT scans with high sensitivity and specificity. This new index could be a
useful tool to investigate patients with possible iNPH. Prospective
clinical studies are required to elucidate its effective role in the clinical
N. Benedetto et al.
assessment of these patients.
Funding
No funding was received for this research.
Conflict of interest
All authors certify that they have no affiliations with or involvement
in any organisation or entity with any financial interest (such as
honoraria; educational grants; participation in speakers’ bureaus;
membership, employment, consultancies, stock ownership, or other
equity interest; and expert testimony or patent-licensing arrangements),
or non-financial interest (such as personal or professional relationships,
affiliations, knowledge or beliefs) in the subject matter or materials
discussed in this manuscript.
Ethical approval
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional and/
or national research committee and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants
included in the study.
Acknowledgement
We thank Ms Juliet Strachan for English revision.
References
[1] R.D. Adams, C.M. Fisher, S. Hakim, R.G. Ojemann, W.H. Sweet, Symptomatic occult
hydrocephalus with normal cerebrospinal-fluid pressure, N. Engl. J. Med. 273
(1965) 117–126.
[2] A. Marmarou, H.F. Young, G.A. Aygok, Estimated incidence of normal pressure
hydrocephalus and shunt outcome in patients residing in assisted-living and
extended-care facilities, Neurosurg. Focus 22 (2007) E1.
[3] S. Hakim, R.D. Adams, The special clinical problem of symptomatic hydrocephalus
with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid
hydrodynamics, J. Neurol. Sci. 2 (1965) 307–327 (n.d).
[4] A. Marmarou, M. Bergsneider, N. Relkin, P. Klinge, P.M. Black, INPH guidelines,
part I: development of guidelines for idiopathic normal-pressure hydrocephalus:
introduction, Neurosurgery 57 (2005) 2–4.
[5] A. Marmarou, P. Black, M. Bergsneider, P. Klinge, N. Relkin, Guidelines for
32
Clinical Neurology and Neurosurgery 158 (2017) 27–32
management of idiopathic normal pressure hydrocephalus, Acta Neurochir. Suppl.
95 (Suppl) (2005) 237–240.
[6] E. Mori, M. Ishikawa, T. Kato, H. Kazui, H. Miyake, M. Miyajima, M. Nakajima,
M. Hashimoto, N. Kuriyama, T. Tokuda, K. Ishii, M. Kaijima, Y. Hirata, M. Saito,
H. Arai, H. Japanese Society of Normal Pressure, Guidelines for management of
idiopathic normal pressure hydrocephalus: second edition, Neurol. Med. Chir.
(Tokyo) 52 (2012) 775–809.
[7] M. Sasaki, S. Honda, T. Yuasa, A. Iwamura, E. Shibata, H. Ohba, Narrow CSF space
at high convexity and high midline areas in idiopathic normal pressure hydro-
cephalus detected by axial and coronal MRI, Neuroradiology 50 (2008) 117–122.
[8] H. Kitagaki, E. Mori, K. Ishii, S. Yamaji, N. Hirono, T. Imamura, CSF spaces in
idiopathic normal pressure hydrocephalus: morphology and volumetry, Am. J.
Neuroradiol. 19 (1998) 1277–1284.
[9] C. Iseki, Y. Takahashi, M. Wada, S. Arawaka, T. Kawanami, T. Kato, Changes in the
subarachnoid space precede ventriculomegaly in idiopathic normal pressure
hydrocephalus (iNPH), Intern. Med. 51 (2012) 1751–1753.
[10] I. Akiguchi, Y. Shirakashi, H. Budka, Y. Watanabe, T. Watanabe, A. Shiino,
M. Ogita, Y. Kawamoto, S. Jungwirth, W. Krampla, P. Fischer, Disproportionate
subarachnoid space hydrocephalus-outcome and perivascular space, Ann. Clin.
Transl. Neurol. 1 (2014) 562–569.
[11] M. Hashimoto, M. Ishikawa, E. Mori, N. Kuwana, Diagnosis of idiopathic normal
pressure hydrocephalus is supported by MRI-based scheme: a prospective cohort
study, Cerebrospinal Fluid Res. 7 (2010) 18.
[12] K. Ishii, T. Soma, K. Shimada, H. Oda, A. Terashima, R. Kawasaki, Automatic
volumetry of the cerebrospinal fluid space in idiopathic normal pressure hydro-
cephalus, Dement. Geriatr. Cogn. Dis. Extra 3 (2013) 489–496.
[13] M. Ishikawa, M. Hashimoto, N. Kuwana, E. Mori, H. Miyake, A. Wachi, T. Takeuchi,
H. Kazui, H. Koyama, Guidelines for management of idiopathic normal pressure
hydrocephalus, Neurol. Med. Chir. (Tokyo) 48 (Suppl) (2008) S1–S23.
[14] B. Kahlon, G. Sundbärg, S. Rehncrona, Comparison between the lumbar infusion
and CSF tap tests to predict outcome after shunt surgery in suspected normal
pressure hydrocephalus, J. Neurol. Neurosurg. Psychiatry 73 (2002) 721–726.
[15] R. Walchenbach, E. Geiger, R.T.W.M. Thomeer, J.aL. Vanneste, The value of
temporary external lumbar CSF drainage in predicting the outcome of shunting on
normal pressure hydrocephalus, J. Neurol. Neurosurg. Psychiatry 72 (2002)
503–506.
[16] A. Marmarou, M. Bergsneider, P. Klinge, N. Relkin, P.M. Black, The value of
supplemental prognostic tests for the preoperative assessment of idiopathic normal-
pressure hydrocephalus, Neurosurgery 17 (2005) S17–S28. discussion ii–v.
[17] L.S. Governale, N. Fein, J. Logsdon, P.M. Black, Techniques and complications of
external lumbar drainage for normal pressure hydrocephalus, Neurosurgery 63
(2008) 379–384. discussion 384.
[18] Evans, Encephalographic abnormality, Arch. Neurol. Psychiatry 47 (1942)
931–937.
[19] N. Relkin, A. Marmarou, P. Klinge, M. Bergsneider, P.M. Black, Diagnosing
idiopathic normal-pressure hydrocephalus, Neurosurgery 57 (2005) S4–S16. dis-
cussion ii–v.
[20] Masaatsune Ishikawa, Hisayuki Oowaki, Masahiro Takezawa, Tomofumi Takenaka,
Shigeki Yamada, Kazuo Yamamoto, Disproportionately enlarged subarachnoid
space hydrocephalus in idiopathic normal-pressure hydrocephalus and its implica-
tion in pathogenesis, intracranial press. Brain monit. XV, Acta Neurochir. Suppl.
122 (2016) 287–290.
[21] F. Yamashita, M. Sasaki, M. Saito, E. Mori, A. Kawaguchi, K. Kudo, T. Natori,
I. Uwano, K. Ito, K. Saito, Voxel-based morphometry of disproportionate cere-
brospinal fluid space distribution for the differential diagnosis of idiopathic normal
pressure hydrocephalus, J. Neuroimaging 24 (2014) 359–365.
[22] C. Haubrich, M. Czosnyka, R. Diehl, P. Smielewski, Z. Czosnyka, Ventricular volume
load reveals the mechanoelastic impact of communicating hydrocephalus on
dynamic cerebral autoregulation, PLoS One 11 (2016).