Abstract
Normal Pressure Hydrocephalus is a clinical condition associated with gait ataxia, dementia and urinary incontinence and pathologically enlarged ventricles with normal opening pressures. The presenting complaints are highly variable and the characteristic triad is not universally seen. Atypical presentation with subtle Parkinsonian features, Huntingdon movement abnormalities and cognitive dysfunction can resemble many other conditions in the elderly. Impact of cognitive dysfunction in our population with people more than 60 years old still economically vulnerable is significant. NPH is one of the few treatable causes of dementia and thus the need for early recognition and management. Little attention has been given to this potentially treatable condition of the elderly in India. This case series study on 50 patients admitted in Govt TDMC, Alappuzha, with majority older than 70 years of age and of both gender was carried out to determine the spectrum of clinical presentation in patients presenting with clinical or imaging studies suggestive of normal pressure hydrocephalus. In our study, despite all having CT brain suggestive of NPH, the characteristic triad was not universal and many had no clinically correlated findings. Atypical presentation with extra-pyramidal features were seen in 25% cases with distal resting tremor and impaired distal fine movements being the most common presentation. Gait abnormality was seen in 40%cases and most had cognitive dysfunction. A strong negative correlation between cognitive behaviour inventory score, UPDRS (Parkinsonism score) and ACE (Cognitive examination score) was found. The study concluded that even though all patients had CT Brain suggestive of NPH, the characteristic triad was not seen in many and extra-pyramidal presentation and cognitive dysfunction could also be considered as an important spectrum of clinical features.
References
- Hakim S, Adams RD. The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. Observations on cerebrospinal fluid hydrodynamics. J Neuro Sci 1965; 2 (4): 307-27.
- Hakim S, Venegas JG, Burton D. The physics of the cranial cavity, hydrocephalus and normal pressure hydrocephalus: mechanical interpretation and mathematical model. Surg Neurol 1976; 5 (3): 187-210.
- Adams RD, Fischer CM, Hakim S et al. Symptomatic occult hydrocephalus with normal cerebrospinal fluid pressure. A treatable syndrome. N Engl J Med 1965; 273: 117-26.
- Meier U, Konig A, Miethke C. Predictors of outcome in patients with normal pressure hydrocephalus. Eur Neurol. 2004;51(2): 59-67.
- Relkin N, Marmarou A, Bergsneider M et al. Diagnosing Idiopathic normal pressure hydrocephalus. Neurosurgery 2005 ;57 (3 Supplement):S40-52 [discussion ii-v].
- William MA, Razumovsky AY. Cerebrospinal fluid circulation, cerebral odema and the intracranial pressure. Curr Opin Neurol 1993;6(6): 847-53.
- McGirt M, Woodworth G, Coon AL et al. Diagnosis treatment and analysis of long-term outcomes in idiopathic normal pres-sure hydrocephalus. Neurosurgery 2005; 57 (4): 699-705 [discussion 699-705].
- Kevorkian R. Physiology of incontinence. Clin Geriart Med 2004; 20 (3): 409-25.
- Marmarou A, Bergsneider M, Klinge P et al. The value of supplemental prognostic tests for the pre-operative assessment of idiopathic normal pressure hydrocephalus. Neurosurgery 2005; 57 (3 Suppl): S 17-28 [Discussion ii-v].
- Meier U, Zeilenger FS, Kintzel D. Signs symptoms and course of normal pressure hydrocephalus in comparison with cerebral atrophy. Acta Neurochir (Wein) 1999;141(10):1039-48.
- Black PM, Oemann RG, Tzouras A. CSF shunts for dementia, incontinence and gait disturbances. Clin Neurosurgery 1985; 32:632-51.
- Vanneste A. Diagnosis and management of normal pressure hydrocephalus. J Neurol 2000;247(1): 5-14.
- Sudarsky L, Simon S. Gait disorder in late life hydrocephalus. Arch Neurol 1987; 44(3): 263-7.
- Soelberg Sorenson P, ansen EC, Gerris F. Motor disturbances in normal pressure hydrocephalus-special reference to stance and gait. Arch Neurol 19886;43 (1): 34-8.
- Nowak DA, Topka HR. Broadening a classic clinical triad: the hypokinetic motor disorder of normal pressure hydrocephalus also affects the hand. Exp Neurol 2006; 1988(1): 81-7.
- Thomas G, McGirt MJ, Woodwoth G et al. Baseline neuropsychological profile and cognitive response to cerebrospinal fluid shunting for idiopathic normal pressure hydrocephalus. Demet Geriart Cogn Disord 2005;20(2-3):163-8.
- Van Harten B, Courant MN, Scheltens P et al. Validation of the HIV Dementia scale in an elderly cohort of patients with subcortical cognitive impairment caused by subcortical ischemic vascular disease or a normal pressure hydrocephalus. Dement Geriart Cogn Disord 2004;18 (1): 109-14.
- Vanneste J, Augistiin P, Dirven C et al. Shunting normal pressure hydrocephalus: do the benefits outweigh the risks? A multi-centre study and literature review. Neurology 1992; 42(1): 54-9.
Corresponding Author
Dr Rashmi KP
Assistant Professor of Medicine,
Dept of Medicine, Govt T D Medical College, Alappuzha
DOI: https://dx.doi.org/10.18535/jmscr/v5i10.163
