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Normal Pressure Hydrocephalus Clinical Presentation

  • Author: Michael J Schneck, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Jul 12, 2016
 

History

Patients present with a gradually progressive disorder. As noted above, the classic triad consists of abnormal gait, urinary incontinence, and dementia. The gait disturbance is typically the earliest feature noted and considered to be the most responsive to treatment. The primary feature is thought to resemble an apraxia of gait. True weakness or ataxia is typically not observed.

The gait of NPH is characterized as bradykinetic, broad based, magnetic, and shuffling. The urinary symptoms of NPH can present as urinary frequency, urgency, or frank incontinence. While incontinence can result from gait disturbance and dementia, in a study by Sakakibara and colleagues, 95% of patients had urodynamic parameters consistent with detrusor overactivity.[7]

The dementia of NPH is characterized by prominent memory loss and bradyphrenia. Frontal and subcortical deficits are particularly pronounced. Such deficits include forgetfulness, decreased attention, inertia, and bradyphrenia. The presence of cortical signs such as aphasia or agnosia should raise suspicion for an alternate pathology such as Alzheimer disease or vascular dementia. However, comorbid pathology is not uncommon with advancing age. In one study, more than 60% of patients with iNPH had cerebrovascular disease.[8] In another similar study, more than 75% had Alzheimer disease pathology at the time of shunt surgery.[9]

Patients commonly present with a gait disorder and dementia. On neurologic examination, pyramidal tract findings may be present in addition to the above findings.

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Causes

Normal pressure hydrocephalus may occur due to a variety of secondary causes but may be idiopathic in approximately 50% of patients. Secondary causes of NPH include head injury, subarachnoid hemorrhage, meningitis, and CNS tumor. Another potential cause could be previously compensated congenital hydrocephalus.[10]

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Contributor Information and Disclosures
Author

Michael J Schneck, MD, MBA Vice Chair and Professor, Departments of Neurology and Neurosurgery, Loyola University, Chicago Stritch School of Medicine; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center

Michael J Schneck, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Stroke Council of the American Heart Association, Neurocritical Care Society

Disclosure: Received honoraria from Boehringer-Ingelheim for speaking and teaching; Received honoraria from Sanofi/BMS for speaking and teaching; Received honoraria from Pfizer for speaking and teaching; Received honoraria from UCB Pharma for speaking and teaching; Received consulting fee from Talecris for other; Received grant/research funds from NMT Medical for independent contractor; Received grant/research funds from NIH for independent contractor; Received grant/research funds from Sanofi for independe.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nestor Galvez-Jimenez, MD, MSc, MHA The Pauline M Braathen Endowed Chair in Neurology, Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Additional Contributors

Arif I Dalvi, MD Director, Movement Disorders Center, NorthShore University Health System; Clinical Associate Professor of Neurology, University of Chicago Pritzker Medical School

Arif I Dalvi, MD is a member of the following medical societies: International Parkinson and Movement Disorder Society, European Neurological Society

Disclosure: Nothing to disclose.

Ashvini P Premkumar, MD Associate Director, Movement Disorders Center, NorthShore University HealthSystem, Clinical Instructor of Neurology, University of Chicago Pritzker Medical School

Ashvini P Premkumar, MD is a member of the following medical societies: American Academy of Neurology, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

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T2-weighted MRI showing dilatation of ventricles out of proportion to sulcal atrophy in a patient with normal pressure hydrocephalus. The arrow points to transependymal flow.
CT head scan of a patient with normal pressure hydrocephalus showing dilated ventricles. The arrow points to a rounded frontal horn.
This image shows ventriculomegaly, which is typical in hydrocephalus ex vacuo.
This image shows cortical atrophy, which is the defining feature of hydrocephalus ex vacuo.
 
 
 
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