Resident Report 4/25 – NPH

Teaching Points:

  • Clinical Manifestations of Normal Pressure Hydrocephalus
    • Gait Abnormalities
      • One of the first clinical signs of NPH
      • Occurs early on in the disease
      • Typically have “magnetic gait” in which their feet appeared stuck to the ground
      • Wide based gait with externally rotated feet
      • Most likely to respond to large volume lumbar taps
    • Cognitive impairment
      • Patients clinically appear more apathetic, similar to a depressed patient
    • Urinary incontinence
      • Also can occur early on in the disease progression
  • Diagnosis
    • Clinical Manifestations as listed above
    • Imaging – MRI Findings
      • Presence of ventriculomegaly in the absence of sulcal enlargement.
      • Non-obstructing hydrocephalus
      • Presence of ventriculomegaly and increased sulcal size suggestive of generalized senile atrophy (hydrocephalus ex vacuo)
    • Lumbar Puncture with normal opening pressure
      • Other etiologies ruled out with CSF studies
    • Spinal Tap Test
      • Perform large volume spinal tap (30-50cc CSF drainage)
      • Have patient ambulate a certain distance, then turn around and ambulate back, before and after spinal tap test
      • Measure changes in mobility, steps, and timing of ambulation, along with MOCA/MMSE
      • If lumbar test shows significant improvement, patient is likely to respond to VP shunting.

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