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NPH Diagnosis — RACP Adult Medicine MCQ

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ModerateGeriatric MedicineNPH DiagnosisRACP Adult Medicine

A 72-year-old man presents with progressive confusion and memory loss over 6 months. He has urinary incontinence and a magnetic gait (feet appear stuck to the floor). CT brain shows ventriculomegaly with no sulcal widening or cortical atrophy. Evans' index is 0.35 (abnormal >0.3). What additional test confirms the diagnosis?

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Correct answer: C — Large-volume lumbar puncture with gait assessment before and after

The Hakim triad (gait disturbance, urinary incontinence, cognitive impairment) with ventriculomegaly disproportionate to sulcal widening and Evans' index >0.3 strongly suggests normal pressure hydrocephalus (NPH). A high-volume LP (removing 30–50 mL CSF) with structured gait assessment before and after (improvement in gait within 1–4 hours supports the diagnosis) is the key diagnostic test. Improvement predicts response to VP shunt placement. Gait is the symptom most likely to improve with shunting; dementia is least likely to improve.

Reference: eTG – 2025 – Neurology; EAN – 2020 – NPH Guidelines