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.