NPH - Normal Pressure Hydrocephalus: An Exploration

A new patient came in the other day referred by her neurologist. An elderly woman, with her husband, began describing her medical history by recalling several seizure episodes and, more recently, her many falling episodes, most of which sent her straight to the emergency room. Unfortunately, neither she nor her husband could remember all the details pertaining to her accidents, but many of the doctors she had seen in the past had deduced that her seizures and her falls were not connected. We, however, weren't convinced.  Drop seizures, the result of the neurological disruption in the brain causing a seizure spreading throughout the entirety of the brain and therefore making one immobile, could have explained the patient's falls, especially since the patient could not remember most of the circumstances in which she fell. Although she had an EEG done, no decisive conclusions had been done concerning the relationship between her seizing and her falls.

Most recently, she had undergone a spinal tap to try to help her restore her balance and a good flow of CSF. A spinal tap, or lumbar puncture, can serve two purposes: collecting a sample of CSF to test for biochemical or microbiological analysis, or as a therapy to relieve increased intracranial pressure.

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The procedure is done by administering a local anesthetic to the lower back while the patient remains in a fetal position. A needle is inserted past the spinal dura to gain access to the spinal fluid. The patient is then monitored for headaches afterwords.

Our patient reported that although her balance did not improve, she felt more alert and more "like herself" after the lumbar puncture. She was worried that she had developed NPH, Normal Pressure Hydrocephalus, a condition that develops slowly over time and arises mostly in the elderly. With Normal Pressure Hydrocephalus, the drainage of CSF in the brain ventricles is blocked, and the swelling of the ventricles can cause serious brain damage.

The "triad" of symptoms that represent the harboring of NPH are increased dementia (increased mental incapacitation), urinary incontinence, and walking with an abnormally wide gait. Our patient had trouble walking because of her bad knee and arthritis, did not complain of bladder problems, and seemed to be fairly mentally healthy. Since her symptoms her so inconclusive, we urged her to hesitate on asking for surgery and to rethink the diagnosis. The solution for NPH is to insert a shunt to relieve CSF pressure and thereby create the effects of the lumbar spine puncture for an indefinite amount of time. However, the risks associated with shunt insertion, especially in an elderly patient, include subdural hematoma and massive intracranial bleeding. Hopefully her falling issues were not brain-related and simply had to do with the arthritis in her knees.

Inserting a shunt in an adult:

http://hydrocephalus.yolasite.com/hydrocephalus.php