NPH

strict warning: Only variables should be passed by reference in /var/www/html/prod-lijed/sites/all/themes/lij/node-visual_stim.tpl.php on line 8.
strict warning: Non-static method view::load() should not be called statically in /var/www/html/prod-lijed/sites/all/modules/views/views.module on line 823.
strict warning: Declaration of views_plugin_display::options_validate() should be compatible with views_plugin::options_validate(&$form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/plugins/views_plugin_display.inc on line 1684.
strict warning: Declaration of views_plugin_display_block::options_submit() should be compatible with views_plugin_display::options_submit(&$form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/plugins/views_plugin_display_block.inc on line 184.
strict warning: Declaration of views_plugin_display_page::options_submit() should be compatible with views_plugin_display::options_submit(&$form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/plugins/views_plugin_display_page.inc on line 457.
strict warning: Declaration of views_handler_field_broken::ui_name() should be compatible with views_handler::ui_name($short = false) in /var/www/html/prod-lijed/sites/all/modules/views/handlers/views_handler_field.inc on line 243.
strict warning: Declaration of content_handler_field::options() should be compatible with views_object::options() in /var/www/html/prod-lijed/sites/all/modules/cck/includes/views/handlers/content_handler_field.inc on line 170.
strict warning: Declaration of views_handler_sort_broken::ui_name() should be compatible with views_handler::ui_name($short = false) in /var/www/html/prod-lijed/sites/all/modules/views/handlers/views_handler_sort.inc on line 82.
strict warning: Declaration of views_handler_filter::options_validate() should be compatible with views_handler::options_validate($form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/handlers/views_handler_filter.inc on line 584.
strict warning: Declaration of views_handler_filter::options_submit() should be compatible with views_handler::options_submit($form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/handlers/views_handler_filter.inc on line 584.
strict warning: Declaration of views_handler_filter_broken::ui_name() should be compatible with views_handler::ui_name($short = false) in /var/www/html/prod-lijed/sites/all/modules/views/handlers/views_handler_filter.inc on line 608.
strict warning: Declaration of views_plugin_style_default::options() should be compatible with views_object::options() in /var/www/html/prod-lijed/sites/all/modules/views/plugins/views_plugin_style_default.inc on line 25.
strict warning: Declaration of views_plugin_row::options_validate() should be compatible with views_plugin::options_validate(&$form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/plugins/views_plugin_row.inc on line 61.
strict warning: Declaration of views_plugin_row::options_submit() should be compatible with views_plugin::options_submit(&$form, &$form_state) in /var/www/html/prod-lijed/sites/all/modules/views/plugins/views_plugin_row.inc on line 61.
strict warning: Non-static method view::load() should not be called statically in /var/www/html/prod-lijed/sites/all/modules/views/views.module on line 823.
strict warning: Non-static method view::load() should not be called statically in /var/www/html/prod-lijed/sites/all/modules/views/views.module on line 823.

Posted on 02/05/2010

69y.o. female with no past medical history, complaining of right sided neck pain for five days. Patient was seen for the same at another hospital three days ago and diagnosed with musculoskeletal pain, and muscle spasm after a negative work up. Patient was sent home with ibuprofen, valium and reglan. She states she has not felt relief with the pain medications. Patient is accompanied by two family members. Upon further questioning, the family states that the patient is very tired and has been sleeping constantly for the past three to four days. She has also had an unsteady gait and fallen several times over the same period of time. Patient denies fever, and was in a normal state of health before the neck pain began. She did hit her face once when she fell two days ago without loss of consciousness. Denies nausea, and vomiting. No focal neurologic complaints. No numbness or weakness in the face or extremities. PE showed normal vitals and normal exam except: CN 2-12 intact, motor 4/5, reflexes normal, unable to evaluate gait or finger to nose, heel to shin, because patient kept falling asleep during exam. A non-contrast Head CT was done. What is your diagnosis?

Case provided by Dr. Williams, EM-4

Answer

The Patient has Normal Pressure Hydrocephalus (NPH).

Upon further questioning, the patient admitted to urinary incontinence over the past three days. Cognitive disturbance, gait difficulty, and urinary incontinence are classic findings of NPH.

The symptoms of NPH result from the malabsorption of cerebrospinal fluid. CSF is produced by choroid plexus and flows from the lateral ventricles to the third and fourth ventricles. CSF is reabsorbed by arachnoid villi in the sagittal sinus. NPH develops when the reabsorption is impaired most commonly by subarachnoid hemorrhage or intraventricular bleed. Also, CSF reabsorption can be blocked by any inflammation in the meninges (usually more chronic). A few case reports have shown correlation between hypertension, peripheral vascular disease, carotid/coronary artery disease and NPH. Another small study showed reflux or incompetence of the internal jugular system as a cause of NPH.

A magnetic gait, and urinary urgency are seen in the earliest stages of the disease. Later patients develop unsteady gaits, and urinary incontinence. Cognitive disturbance is a later finding, and begins as a decreased attention and apathy, which can later progress to aphasia, ataxia and other CVA like symptoms.

Emergency department workup includes basic labs, non-contrast head CT and LP. The patient is admitted for ventriculoperitoneal shunt.

The patients show improvement in all symptoms of NPH with vp shunting. The improvements in most cases are gradual. In most studies, at one year follow up, half of the patients continue to be symptom free. Other studies, showed 60% of the patients continued to improve over six years, although many of these patients had shunt revisions.

There were a few findings in this patient that do not fit the classic picture of NPH. First in most cases of NPH, the opening pressure on LP is usually normal. Our patient had an elevated opening pressure or 28mmHg. Secondly, our patient’s symptoms had progressed rather quickly. NPH usually progresses over a few weeks or months.

This patient showed us that we will not always encounter the textbook definition of a disease entity. Occasionally, we will be challenged with slightly unusual presentations.

View All Visual Stims

Clinical Pearl

Video Lecture

Visual Stim

Navigation

NPH