Normal pressure hydrocephalus

Background
  • Possible reversible cause of dementia
  • CSF buildup in the ventricles leading to increased intracranial pressure with edema of the periventricular white matter and corona radiata
    • Sacral motor nerve fibers that produce gait instability; incontinence ensues when compressed

Clinical Features
  • Gait disturbance is most common and earliest finding
    • "Glue-footed" gait: move slowly, take small steps, often wide base, with difficulty turning
  • Memory loss and dementia symptoms may be mild, subtle
  • Incontinence is usually later stage, though sensation of urinary urgency is usually present before incontinence
  • Usually do not have symptoms of increased intracranial pressure, such as headache, nausea, vomiting, visual loss

Differential Diagnosis

Evaluation
  • CBC
  • Chem 7
  • LP: normal opening pressure
    • Symptom improvement supports diagnosis[1]
  • CT brain: Ventriculomegaly without signs of obstruction at the level of the third or fourth ventricles

Management
  • Diagnostic and therapeutic large volume CSF removal
    • 30-50 mL of CSF with documentation of patient's gait (speed, stride length, number of steps to turn 180 deg) before and within 30-60 minutes after procedure
  • Additional work up warranted for surgical candidate[1] [2]
  • Assessment for Surgical CSF shunting

Disposition
  • Workup typically is extensive and performed as an outpatient.
  • Refer to neurosurgery

Also See

References
  1. Schneck MJ. Normal pressure hydrocephalus. Medscape. Retrieved 8/4/2016
  2. Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: diagnosis and treatment. Curr Neurol Neurosci Rep. 2008 Sep;8(5):371-6.
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