Saturday, September 6, 2008

Normal Pressure Hydrocephalus



This 70 years old gentleman presented with difficulty in walking for the past 3 years and recently has urinary incontinence. He also has poor memory for the past 1 year.

Favourite question in MRCP Part 1 and 2a(normally may show you a CT brain with hydrocephalus)

Clearly the triad of NPH are DIA(dementia, incontinence and ataxia)

The gait shown is an apraxic gait which sometimes mimic a gait in Parkinsonism.

The CT brain shows hydrocephalus and an LP done would normally be on the high normal about 15 to 20 cmH2O. The gait improved after CSF drainage.

Treatment would be by inserting a ventriculoperitoneal shunt (VP shunt)

10 comments:

Harry TEOH said...

thanks for this very informative explanation...

mm..
But, may i ask, if there any differential diagnosis for these incontinence, abnormal gait, memory loss??

can it be dementia too??

If got some other DDX, then how to differentiate it?

is it that it occur because of the shrinkage of the brain tissue resulting in the ventricle enlarge??

is it very common?

not possible for medical student final exam, but is it a life-threatening disease?

any other complications?

will patient presented with other psy symptoms?/

thanks for answering....

sorry for asking so many questions...

Thank you very much

Harry TEOH said...

ya, also want to ask few more questions, is it ok??

since he is having urinary incontinence, do we think of an elderly with dementia or parkinson with at the same time have prostate hypertrophy??

because BPH also common in elderly ah...

Harry TEOH said...

ya, to ask also ah..sorry...LAST QUESTION...

sorry..

as we know, VP shunt is able to drain the fluid continuously, but is it work till the patient regain his normal daily activity?
\

and why have urinary incontinence?

i understand of the forgetfulness and apraxic gait, is it due to the brain cells loss?

if yes, then will it restore the patient pre-morbid normal function?

Wuchereria said...

Wow ! I am glad my topic stimulate you. Yes, you may think of dementia but the key here is the hydrocephalus and the gait which you cannot explain alone with dementia. Hydrocephalus can be differentiated from cerebral atrophy from the CT scan though I agree with you that it is not easy. Looking at the widening of the sulci may be helpful. Medical students normally will come out in theory rather than practical but hey, who knows. Psy symptoms is likely as it may be part of the dementia. BPH is common and can easily be rulled out by doing a PR - they do not have dementia or ataxia. The symptoms will improve after LP but will not totally resolve. Hope I have answered all your questions.

Harry TEOH said...

mm, how about VP shunt?
is it the only definitive treatment?
How many percent of successful rate in reducing the symptoms and at the sametime helping them to regain the memory, normal gait and no urinary incontinence?

and WHY they have urinary incontinence?

merlot said...

wei, i presented him for neuro cme leh!

Wuchereria said...

Hey, Merlot. you presented for cme >?? Can you pass me/email me what you presented.

Giant Eagle said...

The radiologist have their own set of rules when determining whether an elderly patient's CT changes is due to hydrocephalus or just atrophic changes inthe brain. Best to ask them.

Anonymous said...

Hi just curious. Was patient walking to the rhythm of the (? drum beat) background noise? ie Does auditory stimulus affect his gait apraxia?

Anonymous said...

Normal Pressure Hydrocephalus-"Wet,Wobbly,Wacky"