Normal pressure hydrocephalus

Background

May be idiopathic (mostly the focus here) or secondary (to prior infection, ICH, TBI, or radiation)
Idiopathic is more common in older patients and is somewhat a disease of aging

"Wobbly, wet, and wacky"
Earliest symptoms is gait instability/apraxia ("magnetic gait") progressing over months to years
- May be shuffling, magnetic, or wide-based
- Increased mediolateral variability during quiet standing
- Postural instability worsens with eye closure
Next is dementia
- Cognitive symptoms include psychomotor slowing, forgetfulness, decreased attention/concentration, impaired executive function
- Apathy is a notable feature
Usually last symptom is urinary incontinence, in about 50% of patients at diagnosis
- First as urgency with an inability to reach the bathroom in time, then later progressing to incontinence with apathy
There should be no headaches, nausea/vomiting, visual changes, or papilledema

Should have normal CBC, lytes, creatinine, vit B12, TSH, calcium
CT head showing hydrocephalus
Lumbar puncture confirming normal pressure
- CSF glucose and protein are typically normal

Grade	Gait	Cognition	Urinary Incontinence
0	Normal	Within normal range	Absent
1	Unsteadiness without objective abnormality	No clear dementia, but apathy present	Frequency and/or urgency without incontinence
2	Needs a cane	Needs support in social functioning, but remains independent at home	Occasional episodes at night
3	Needs a walker, or 2 canes	Requires partial assistance at home	Intermittent episodes during the daytime
4	Unable to ambulate	Fully dependent	Frequent urinary incontinence

High-volume lumbar puncture (30 to 50 mL)
- Observe for improvement, particularly in gait
- If there is improvement in symptoms, consider implanting a ventriculoperitoneal shunt