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Background and purpose: Disproportionately enlarged subarachnoid space hydrocephalus (DESH) is a radiological biomarker for idiopathic normal pressure hydrocephalus (iNPH). DESH is a subjective measure, based on visual assessments, which may limit its reliability. The aim of this study was to develop and validate a method for the objective quantification of DESH.

Materials and methods: By using a semiautomatic quantitative method, we calculated quantitative DESH (qDESH), defined as a ratio between CSF volumes at high convexities and Sylvian fissures. The analysis was based on three-dimensional T1-weighted images from 35 subjects with iNPH (mean age 74 yrs; 10 females) and 45 controls (mean age 72 yrs; 13 females). The interrater agreement for qDESH was evaluated by the intraclass correlation coefficient, and qDESH was compared with visual assessments performed by two neuroradiologists.

Results: All subjects with iNPH and 13% of the controls visually scored DESH positive. The median qDESH was 2.48 (5th to 95th percentile 0.88 to 5.42) for iNPH and 0.63 (5th to 95th percentile 0.37 to 1.73) for the controls. The area under the receiver operating characteristic curve for qDESH was 0.95 (95% confidence interval 0.90–1) in separating iNPH patients from controls. The interrater agreement for qDESH was 0.99 (95% CI 0.986–0.994, p < 0.001).

Conclusion: Unlike visual DESH, qDESH generates a continuous variable, enabling reproducible quantification of DESH severity. With this method we can objectively investigate the diagnostic accuracy and prognostic assessment of DESH in iNPH.