iatroX Rounds #35
The clues
- 1
A 75-year-old man is brought to the GP by his daughter due to a 6-month history of worsening mobility and forgetfulness.
- 2
He describes his walking as if his feet are stuck to the floor, making it difficult to initiate movement.
- 3
His symptoms have progressed gradually, and he has recently developed an increased frequency and urgency of micturition.
- 4
Neurological examination reveals a broad-based, magnetic gait with short steps, but there is no evidence of a resting tremor or rigidity.
- 5
A CT head scan demonstrates enlargement of the lateral and third ventricles out of proportion to any cortical atrophy.
- 6
Following a large volume lumbar puncture with removal of 40 mL of cerebrospinal fluid, his walking speed and balance show a marked improvement.
Normal pressure hydrocephalus is a form of communicating hydrocephalus classically presenting in older adults with the triad of gait disturbance, cognitive impairment and urinary incontinence. It is caused by impaired cerebrospinal fluid absorption and is characterized by ventriculomegaly with normal intracranial pressure.
- Magnetic or apraxic gait
- Ventriculomegaly with normal opening pressure on lumbar puncture
- Classic clinical triad often remembered as wet, wobbly and wacky
- Evans ratio greater than 0.3 on cross-sectional imaging
for education and entertainment. not medical advice.