1. Case presentation in normal pressure hydrocephalus 20160501 中國醫藥大學附設醫院神經部 楊玉婉

2. Normal pressure hydrocephalus presenting with dementia, parkinsonism, and urine incontinence

3. History (1) The 72 year old with histories of DM and HTN retired teacher lady was admitted in neurology ward with complaints of difficulty in walking for 1 year, forgetfulness of 6 months duration and urinary urgency of 5 months duration.

4. History (2) Difficulty in walking was in the form of hesitation in initiating steps, slowness in gait and difficulty in turning around the corners of the path when asked to do so immediately. This problem progressed slowly and he started taking support of one stick and use to avoid going long distances and walked more cautiously. She use to freeze at times while walking.

5. History (3) After few months, she developed difficulty in executing daily routine activities, took longer time in doing daily activities and required some assistance. She also had difficulty in word finding and money handling, started forgetting recent events, names of distant relatives but would remember if given some hint.

6. History (4) She lost the promptness in handling daily activities, which he had before. There was no history of visuospatial disorientation, apraxias or agnosias. She also complained of urinary urgency which was more in the night time and hesitancy and occasional incontinence.

7. Past history & Family history There was no history of stroke in the past. Personal and family history was not significant.

8. General physical examination Blood pressure 140/90 mmHg (on antihypertensive drug), pulse: 84/minute.

9. Neurological examination (1) General appearance: hypomimia, flexed posture. Mini Mental State Examination (MMSE) score 16/30 -recall and calculation: impaired -reaction time: longer

10. Neurological examination (2) Muscle power: normal Deep tendon reflex: UE R/L: +/+, LE R/L: +/+ Babinski sign: R/L: flexer planter response/flexer planter response

11. Neurological examination (3) Extrapyramidal system -rigidity R1’L1’, -finger tapping R2’L2’ -postural instability:+ -no obvious hand tremor

12. Neurological examination (4) Gait: Wide based stance, Slow steps, Shuffling gait, Hesitation at the start of steps.

13. Hematological and biochemical parameters: normal, except glucose: 210 mg/dl.

14. Magnetic Resonance Imaging of Brain

15. Diagnosis: Normal pressure hydrocephalus

16. CSF tap test Draining 50 ml of CSF Opening pressure was: 190 cm of water Normal protein and sugar Cells <5,all lymphocytes

17. Pre and post test assessment of gait and cognitive functions Repeat MMSE showed upgrading of initial score, both recall and calculation improved, reaction time decreased Improving gait

18. Result (1) In face of such marked improvement with CSF tap test, patient underwent lumboperitoneal shunt surgery following which there was near complete recovery of both cognitive and gait disturbance.

19. Result (2) Patient was examined four months after shunt surgery, the shunt is functioning well and he is maintaining the improved cognitive and gait status. Patient is still under follow up to look for shunt functions and its related complications.

20. Discussion (1) Normal pressure hydrocephalus (NPH), also termed symptomatic hydrocephalus, occurs when there is an increase in intracranial pressure (ICP) due to an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles of the brain, which can cause ventriculomegaly. intracranial pressurecerebrospinal fluidventriculomegaly

21. Discussion (2) –clinical manifestations The classic symptom triad (gait disturbance, urinary incontinence, and dementia or mental decline) was first described by Hakim and Adams in 1965. dementia Gait disturbance is first to appear and is the most common symptom.

22. Discussion (3) -pathophysiology Although the exact mechanism is unknown, normal-pressure hydrocephalus is thought to be a form of communicating hydrocephalus with impaired CSF reabsorption at the arachnoid granulations.communicating hydrocephalusarachnoid granulations

23. Discussion (4) -etiology There are 2 types of normal pressure hydrocephalus: idiopathic and secondary. The term idiopathic means that it has no known cause. The secondary type of NPH can be due to a subarachnoid haemorrhage, head trauma, tumour, CNS infection, or a complication of cranial surgery.subarachnoid haemorrhageCNS infection

24. Discussion (5) -treatment Surgery

25. Thank you for your attention!!