Idiopathic normal pressure hydrocephalus (iNPH) is a condition with dilated cerebral ventricles but intracranial pressure within normal limits. The symptoms of gait impairment, cognitive decline and urinary incontinence develop gradually. Treatment with shunt insertion results in improvement in eight out of ten patients. The cerebrospinal fluid tap test (CSF TT) and preoperative magnetic resonance imaging (MRI) are methods used to select patients who may benefit from shunt surgery, but they are performed and interpreted differently in different centers throughout the world. The aim of this thesis was to evaluate the performance of the CSF TT and the underlying mechanisms of improvement in gait function after CSF removal, and to investigate the prognostic value of preoperative MRI scans. Improvement in gait and changes in cerebral blood flow (CBF) after a CSF TT were investigated in two prospective studies that included 39 and 20 patients, respectively. Gait assessment and perfusion MRI were done before and several times during the first 24 hours after a CSF TT. Perfusion was investigated with pseudo-continuous arterial spin labeling. At the group level, gait function was significantly improved at all investigation times, but only one-third of individual CSF TT responders were improved at all investigation times. In patients with increased CBF in lateral and frontal white matter after the CSF TT, gait function improved more than it did in patients with decreased CBF in these regions. However, in the whole sample, there was no significant increase in CBF after CSF removal. Preoperative MRI scans were retrospectively evaluated in 109 patients with iNPH who had undergone shunt surgery. The callosal angle was smaller in shunt responders compared with non-responders. The following findings showed the highest association with a positive outcome after shunting: a small callosal angle, wide temporal horns, and occurrence of disproportionally enlarged subarachnoid space hydrocephalus. In conclusion, CBF in white matter close to the lateral ventricles may play a role in the reversibility of symptoms after CSF removal in patients with iNPH. The CSF TT should be reevaluated if the patient does not initially improve, and preoperative MRI investigations can add prognostic information regarding the selection of shunt candidates.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22636号 / 医博第4619号 / 新制||医||1044(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 高橋 淳, 教授 古川 壽亮, 教授 村井 俊哉 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background: Normal pressure hydrocephalus (NPH) has been an ongoing and challenging field of research for the past decades because two main issues are still not fully understood: the pathophysiologic mechanisms underlying ventricular enlargement and prediction of outcome after surgery. Purpose: To evaluate changes in diffusion tensor imaging (DTI) derived parameters in patients with suspected normal pressure hydrocephalus before and after withdrawal of cerebrospinal fluid (CSF). Material and Methods: Twenty-four consecutive patients with clinical and radiological suspicion of NPH and 14 agematched control subjects were examined with DTI on a clinical 3T scanner. Patients were examined before and 6–36 h after CSF drainage (interval between scans, 5 days). Fifteen patients were finally included in data analysis. Fractional anisotropy (FA) and mean, parallel, and radial diffusivity (MD, PD, RD) were evaluated using a combination of a ROI-based approach and a whole-brain voxel-by-voxel analysis. Results: Alteration of DTI parameters in patients with suspected NPH is regionally different. Compared to the control group, we found an elevation of FA in the subcortical white matter (SCWM) and corpus callosum, whereas the other diffusion parameters showed an increase throughout the brain in variable extent.We also found a slight normalization of RD in the SCWM in patients after lumbar drainage. Conclusion: Our results show that DWI parameters are regionally dependent and reflect multifactorial (patho-) physiological mechanisms, which need to be interpreted carefully. It seems that improvement of gait is caused by a decrease of interstitial water deposition in the SCWM.

Insulation in rotating machines is a common cause for failure. Therefore, research in the area is large and is important to further increase the knowledge of the phenomena related to insulation degradation. This thesis is a case study on 20 stator bars obtained from a generator that had been showing signs of insulation degradation while in operation. The insulation was investigated using a range of measurements to be able to evaluate the degradation of these bars. The measurements performed were electrical partial discharge measurements, acoustic partial discharge measurements, dielectric response measurements, and breakdown testing. Furthermore, a more scientific approach to the commonly used tap test in the industry was conducted, which has not been done before and the purpose was to validate this commonly used test method. It was concluded that the bars have a significant amount of partial discharges within them, and that the stress grading is likely to be blamed in many of the worst cases. Furthermore, the dielectric response measurements provided good information on the thermal stability of the insulation. The set-up of the tap test did not provide reasonable results, and the method approach as well as the experimental set-up was to blame for this. In future work, investigating this specific area could be beneficial. The electrical partial discharge measurements and the breakdown test provided unexpected results when compared, where the former indicated much degradation while the latter proved that the bars can withstand very high voltage levels. / Isolering i roterande maskiner är en vanlig orsak till fel. Forskningen på området är därför omfattande och viktig för att ytterligare öka kunskapen om fenomen som rör isoleringsnedbrytning. Denna avhandling är en fallstudie på 20 statorstänger som erhållits från en generator som hade visat tecken på isoleringsnedbrytning under drift. Isoleringen undersöktes med hjälp av en rad olika mätningar för att kunna utvärdera nedbrytningen av dessa stänger. De mätningar som utfördes var mätningar av elektriska partiella urladdningar, akustiska partiella urladdningar, mätningar av dielektrisk respons och genombrottstester. Dessutom genomfördes ett mer vetenskapligt tillvägagångssätt för det allmänt använda tapptestet i branschen, vilket inte har gjorts tidigare och syftet var att validera denna allmänt använda testmetod. Slutsatsen blev att stängerna har en betydande mängd partiella urladdningar i sig, och att spänningsgraderingen sannolikt får skulden i många av de värsta fallen. Dessutom gav mätningarna av den dielektriska responsen god information om isoleringens termiska stabilitet. Upplägget för tapptestet gav inte rimliga resultat, och detta berodde både på metodiken och på försöksupplägget. I framtida arbete kan det vara bra att undersöka detta specifika område. Mätningarna av den elektriska partiella urladdningen och genombrottstestet gav oväntade resultat när de jämfördes, där de förstnämnda visade på mycket försämring medan de sistnämnda bevisade att stängerna kan motstå mycket höga spänningsnivåer.