Abstract
Normal pressure hydrocephalus (NPH) is a rare pathological condition of the brain in which the ventricles are enlarged due to cerebrospinal fluid accumulation and is associated with normal opening pressure on lumbar puncture with a large-volume cerebrospinal fluid (CSF) tap. This results in three classical symptoms: mental impairment, gait disturbance, and urinary or fecal incontinence. We present a case of idiopathic NPH in which a 64-year-old retired man with diabetes was brought to the emergency department after recurrent previous falls. The patient complained of an unsteady gait and presented with the typical triad of NPH which is mental impairment, gait disturbance, and incontinence. The patient was a known diabetic, and his gait was characterized by shuffling, bradykinesia, and mild drifting toward the right side. A head computed tomography scan revealed brain tissue volume loss, with disproportionate dilation of the lateral and third ventricles. A lumbar puncture with a large-volume CSF tapping produced normal opening pressure (18 mmHg); thus, the diagnosis of NPH was made. The patient underwent shunt surgery, and his balance and memory improved significantly after the procedure. Also, no event of fecal incontinence occurred. NPH resembles several neurodegenerative disorders. Due to this, it can be difficult to diagnose. Emergency physicians, as frontline healthcare providers, may encounter such cases.NPH should be considered in patients presenting with an unsteady gait, memory impairment, and urinary or fecal incontinence by taking a detailed history and conducting a physical examination to prevent future complications.
Highlights
Hydrocephalus is a condition characterized by the buildup of excess cerebrospinal fluid (CSF) due to either an obstruction within the CSF flow pathway, excess fluid production, or reabsorption defect in the arachnoid villi, leading to its accumulation in and enlargement of the cerebral ventricles [1]
The following findings make the diagnosis of Idiopathic normal pressure hydrocephalus (iNPH) less likely: Intracranial pressure greater than 25 cmH2O, under the age of 40, signs and symptoms that are asymmetrical or fleeting, cortical deficits such as aphasia, apraxia, or paresis, progressive dementia without gait disturbance, and lack of symptoms development
It is one of the neurological conditions that is challenging for some physicians to accurately diagnose and since clinical and radiological results alone are often insufficient to differentiate iNPH from other causes of subcortical dementia, investigations are often needed
Summary
Hydrocephalus is a condition characterized by the buildup of excess cerebrospinal fluid (CSF) due to either an obstruction within the CSF flow pathway, excess fluid production, or reabsorption defect in the arachnoid villi, leading to its accumulation in and enlargement of the cerebral ventricles [1]. The following findings make the diagnosis of iNPH less likely: Intracranial pressure greater than 25 cmH2O (this rules out iNPH by definition), under the age of 40 (iNPH unlikely), signs and symptoms that are asymmetrical or fleeting, cortical deficits such as aphasia, apraxia, or paresis, progressive dementia without gait disturbance (regardless of ventricles enlargement), and lack of symptoms development (a point of concern, as many authors differ on how long signs should be shown in advance) It is one of the neurological conditions that is challenging for some physicians to accurately diagnose and since clinical and radiological results alone are often insufficient to differentiate iNPH from other causes of subcortical dementia, investigations are often needed.
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