Normal Pressure Hydrocephalus Presenting Research Articles

The Importance of Primary Care Cognitive Evaluation in Detecting an Atypical Presentation of Normal Pressure Hydrocephalus

The Importance of Primary Care Cognitive Evaluation in Detecting an Atypical Presentation of Normal Pressure Hydrocephalus

Letter to the Editor Regarding the Article: “Acute Presentation of Normal Pressure Hydrocephalus (NPH) Following Transcatheter Aortic Valve Implantation (TAVI): A Novel Interaction Between the First and Third Circulations?”

Letter to the Editor Regarding the Article: “Acute Presentation of Normal Pressure Hydrocephalus (NPH) Following Transcatheter Aortic Valve Implantation (TAVI): A Novel Interaction Between the First and Third Circulations?”

Idiopathic normal pressure hydrocephalus presenting with paroxysmal paraparesis as a cardinal symptom: A case presentation

Idiopathic normal pressure hydrocephalus (iNPH) is a gradually progressive disease affecting the elderly population. The diagnosis of probable iNPH is based on clinical history, physical findings, brain imaging. INPH involves non-obstructive enlargement of the cerebral ventricles combined with one or more symptoms of cognitive decline, impaired gait and balance, and urinary urgency. Our case describes an unusual coexistence of radiological and clinical iNPH symptoms with paroxysmal paraparesis.

Acute Presentation of Normal Pressure Hydrocephalus After Transcatheter Aortic Valve Implantation: A Novel Interaction Between the First and Third Circulations

Idiopathic normal pressure hydrocephalus (iNPH) negatively affects gait and cognition abilities and urine continence in the elderly. It is associated with systemic hypertension, although the exact pathophysiology is still unknown. A correlation to increased intracranial pulsatility and decreased compliance was suggested. Transcatheter aortic valve implantation (TAVI) is increasingly used in the treatment of severe AS. New-onset systemic hypertension affects some patients after TAVI. To identify any association between aortic valve replacement and the development of NPH. A cohort was created retrospectively of all patients who were evaluated for NPH with cerebrospinal fluid (CSF) tap test at a single institute during 2014-2019. Patients were reviewed for a past medical history of aortic valvular disease or aortic valve replacement. A total of 242 patients underwent evaluations for NPH. Of these patients, 133 were considered to have iNPH. Six patients underwent aortic valve replacement before the initial symptoms of NPH: 1 surgical and 5 TAVI. The time from aortic valve replacement to the initial NPH symptoms was <6 months in 3 patients (as low as 1 month in 2 of them). Two patients had functional improvement after CSF tap test and proceeded to receive a shunt, 4 and 6 months after TAVI, respectively. Two patients developed hypertension after TAVI. Pulse pressure increased by >10 mm Hg in 3 patients after TAVI. This is the first case series of symptomatic NPH after TAVI. In this unique subgroup, NPH symptoms can develop rapidly. Post-TAVI iNPH represents a novel interaction between the blood and CSF circulations.

Normal pressure hydrocephalus presenting as psychotic symptoms: A case report

Normal pressure hydrocephalus presenting as psychotic symptoms: A case report

Idiopathic Normal Pressure Hydrocephalus Presenting with Oculomotor Palsy as a Predominant Symptom: A Case Presentation

Idiopathic normal pressure hydrocephalus is a disorder characterized by gait and balance disturbance, cognitive dysfunction, and urinary symptoms caused by an impaired turnover of the cerebrospinal fluid.

A Case of Idiopathic Normal Pressure Hydrocephalus Presenting as Vascular Parkinsonism

Idiopathic normal pressure hydrocephalus (iNPH) is the most common form of hydrocephalus in adults. It is characterized by dilated ventricles and the Hakim triad, which consists of gait disturbance, cognitive impairment, and urinary incontinence. The gold standard treatment for iNPH is shunting, but frequent lumbar punctures (LPs) are helpful for diagnosis and predicting shunting outcome and is considered the treatment of choice when shunting is not available. One condition with similar presentation to iNPH is Vascular parkinsonism (VP), which is characterized by an established relationship between cerebrovascular diseases and the clinical symptoms of Parkinson’s disease (PD). VP patients usually present with lower-body parkinsonism, including impaired gait, instability, difficulty with maintaining gait, and frequent episodes of freezing. VP is managed by levodopa followed by transcranial magnetic stimulation then vitamin D. LPs are less effective for VP than iNPH. Our case report shows that iNPH may be misdiagnosed with VP. Here we present a case of a 71-year-old male with a history of previous lacunar strokes who was admitted for possible vascular parkinsonism. Eight months prior to coming to the hospital, he developed gait disturbances; and four months later, he developed urinary symptoms. Upon examination, his gait initiation was hesitant, wide-based, and magnetic with decreased arm swing. The patient scored 20 out of 30 points on the Montreal Cognitive Assessment. The only cranial nerve involvement was a diminished gag reflex. Brain magnetic resonance imaging revealed symmetrically enlarged ventricles with mildly dilated sulci. Routine laboratory testing was normal. Two months of treatment with levodopa did not improve his symptoms but draining 50 mL of cerebrospinal fluid (CSF) has dramatically improved his gait. A final diagnosis of iNPH was therefore made. To conclude, iNPH and VP are two manageable diseases but the differential diagnosis between them is particularly challenging due to similar clinical and neuroradiological features. We suggest further studies to establish supporting guidelines by using neuroradiological or neurophysiological biomarkers which may help physicians in ameliorate diagnostic accuracy between the two entities.

Normal pressure hydrocephalus mimicking Alzheimer’s disease: such an infrequent case?

Normal pressure hydrocephalus (NPH) is an age-related condition frequently associated with degenerative and vascular brain pathologies. However, cases of NPH with no concomitant brain pathology have been described with important implications in terms of early detection and treatment. We present a case of NPH that commenced with cognitive deterioration similar to Alzheimer's disease (AD). Motor manifestations (i.e., falls and gait dysfunction) appeared 2.5 years after the initiation of memory problems. Apart from ventricular enlarging, no prominent pathologies were found at brain examination. The prevalence of cases of NPH presenting with memory problems may be underestimated given the traditional view of NPH displaying a clinical triad of gait dysfunction, mental decline of "subcortical" appearance, and incontinence. Careful examination of the structural neuroimaging study in the initial assessment and during follow-up could help in diagnosis. Further research on prevalence and detection of "pure" NPH initially resembling AD is warranted.

回転性めまいと頭痛にて発症し，脳室腹腔シャント術により軽快した正常圧水頭症の１症例

Normal pressure hydrocephalus (NPH) is a condition involving pathologically enlarged ventricular size with normal opening pressures on lumbar puncture. NPH is associated with a classic triad of dementia, gait disturbance, and urinary incontinence. We report on a patient with NPH presenting with repeated vertigo, headache and nausea. A 21-year-old woman complained of rotatory vertigo, pulsatile headache, nausea and tinnitus in both ears. Brain MRI findings confirmed a diagnosis of hydrocephalus. The cerebrospinal fluid opening pressure was within normal limits. Since then, the patient has continued to experience vertigo, headache and nausea several times a week, and these symptoms were resistant to medical treatments. Results of pure tone audiometry, caloric tests, and vestibular-evoked myogenic potentials were normal in both ears. One year later, she developed gait disturbance and showed vertical macro square wave jerks on a gaze-evoked nystagmus test. A lumbar tap test revealed that removal of cerebrospinal fluid temporally improved her symptoms. She underwent ventriculoparietal shunt surgery, after which she has been symptom-free. Normal results on audio-vestibular examinations and the postsurgical improvement suggested that increased pressure upon the periventricular white matter, including the central vestibular tract, might have been the cause of her symptoms.

Normal Pressure Hydrocephalus Presenting as Othello Syndrome: Case Presentation and Review of the Literature

Normal pressure hydrocephalus (NPH), an obstruction in the normal flow of CSF through the subarachnoid space, typically presents with a classic “triad” of cognitive impairment, a gait disturbance, and urinary incontinence (1). The etiology of NPH includes subarachnoid spaceoccupying lesion or hemorrhage, chronic meningoencephalitis, changes following acute bacterial meningitis or spinal anesthesia, and carcinomatosis of the meninges (2). Usually, the underlying cause cannot be identified. Idiopathic NPH is clinically diagnosed in most patients during the sixth or seventh decade of life (3). The cognitive impairment in NPH most often manifests as subcortical dementia, though psychiatric and mood symptoms, most often depression, have been described. Most observations of psychiatric sequelae of NPH have been limited to case reports and have included frontal lobe symptoms such as apathy and akinetic mutism, as well as reports of mania, aggression, mood cycling, and psychosis (4–8). In this article, we report a case of NPH presenting as paranoid psychosis with delusional jealousy, otherwise known as the “Othello syndrome.” Case Presentation

Normal Pressure Hydrocephalus

Normal pressure hydrocephalus (NPH) is a neurological disorder characterized by a triad of symptoms: gait disturbance, dementia, and urinary incontinence. To date, the treatment of choice is cerebrospinal fluid diversion with a shunt. Because the clinical presentation of NPH mimics other neurological disorders, or can be perceived by healthcare providers as a natural aging process, it can be misdiagnosed or go undetected for many years. Patients with NPH suffer from debilitating physiological impairments as well as psychological disturbances. There are many different healthcare concerns in this population, including quality-of-life and safety issues. To achieve a more expedient diagnosis and treatment plan, nurses must be educated about this disorder.

症状が急速に進行した特発性正常圧水頭症の2例

症状が比較的急速に進行した特発性正常圧水頭症の2例を経験したので報告する.症例1は正常圧水頭症の3徴である歩行障害, 精神機能低下, 尿失禁を呈し, 2週間で寝たきりとなって内科へ入院した.発症より約6週後に脳室-腹腔シャントを施行した.CT上脳室は軽度縮小し, 症状は改善された.症例2は腹膜透析中の患者で, 歩行障害と記銘力低下で発症した.1カ月半後に内科へ入院し, 2カ月後には歩行不能となった.発症より4カ月後に脳室-右心房シャントを行った.手術から1カ月で症状は完全に消失し, CT上も脳室の明らかな縮小を認めた.特発性正常圧水頭症では比較的急速に症状が進行する症例があり, 速やかな診断と治療が重要と思われた.

Indications for shunting in patients with idiopathic normal pressure hydrocephalus presenting with dementia and brain atrophy (atypical idiopathic normal pressure hydrocephalus).

The indications for shunt operation in patients with idiopathic normal pressure hydrocephalus accompanied by brain atrophy (atypical idiopathic normal pressure hydrocephalus: AINPH) were investigated in 25 patients who satisfied the diagnostic criteria and underwent ventriculoperitoneal (VP) shunting. All patients had no apparent history of intra- or extracranial disease; dementia and gait disturbance as the main complaints; moderate to severe cerebral atrophy and ventricular dilatation and at least periventricular low density around the anterior horn on computed tomography; normal cerebrospinal fluid (CSF) pressure and filling of ventricles or cortical surface space with contrast medium at 24 hours on cisternography. The 15 male and 10 female patients were aged 47-83 years (mean 60.4 years). VP shunting was effective in 12 improved patients and not effective in 13 unimproved patients according to NPH grading. Pathological pressure wave on epidural pressure monitoring was observed in eight of 12 improved patients, but none of 13 unimproved patients. CSF outflow resistance was 35.33 +/- 11.16 mmHg/ml/min in improved patients and 9.12 +/- 3.51 mmHg/ml/min in unimproved patients. Preoperative serum alpha-1-antichymotrypsin value (alpha-1-ACT) was 42.02 +/- 8.64 mg/dl in improved patients and 61.72 +/- 11.03 mg/dl in unimproved patients. Alpha-1-ACT over 55 mg/dl occurred only in unimproved patients. Cerebral arteriovenous difference of oxygen content value (c-AVDO2) before and after surgery was 6.34 +/- 0.9 ml% and 5.91 +/- 0.78 ml% in improved patients and 4.75 +/- 1.85 ml% and 4.81 +/- 1.73 ml% in unimproved patients, respectively. The two cases with preoperative c-AVDO2 value over 8.5 ml% were both unimproved. Mean cerebral blood flow value before and after surgery was 23.51 +/- 4.20 ml/100 g/min and 45.22 +/- 8.11 ml/100 g/min in improved patients and 21.77 +/- 5.12 ml/100 g/min and 24.82 +/- 4.97 ml/100 g/min in unimproved patients, respectively. Cerebral atrophy in improved patients is caused by a cerebral circulation disturbance defined as a cerebral blood flow of penumbra or more due to cerebral arteriosclerosis, etc. A flow-chart of indications of shunt surgery for AINPH was prepared based on the results of the present study.

Normal pressure hydrocephalus and deep white matter stroke: A case report

The symptoms of urinary incontinence, ataxia, and mental confusion are an integral part of the clinical presentation of normal pressure hydrocephalus (NPH). They are also common presentations in the rehabilitation setting of patients who have had a cerebral vascular accident. The concurrence of these entities challenges the physiatrist to carefully diagnose and properly manage the patient to maximize the rehabilitation outcome. In the older population the clinical picture may be clouded by several overlapping conditions such as dementia, deconditioning, and age-related decline in bladder control. A case is presented in which the diagnosis of NPH was made after the patient showed a lack of progress in ambulation despite dramatic improvement in strength of the lower extremities.