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A patient's wife brings him in with a 3 month history of progressive problems with attention, mood and memory. On review of systems, she also references that he frequently doesn't get to the bathroom in time, and a progressive inability to hold his urine. What physical exam finding would best support a possible diagnosis of normal pressure hydrocephalus?
A. Disdiadochokinesia
B. Shuffling gait
C. Vertical nystagmus
D. Resting hand tremors
E. Lip fasciculation
Answer: B. Shuffling gait. The classic triad of normal pressure hydrocephalus (NPH) is cognitive impairment / dementia-like symptoms, urinary incontinence, and gait instability (shuffling, freezing, and "feet stuck" on initiating movement). Disdiadochokinesia is an inability to perform rapid alternating movements due to cerebellar lesions. Vertical nystagmus is seen in CNS injuries or lesions of the cerebellum or midbrain. Resting tremors and lip fasciculations can bee seen in Parkinson's disease.
A 90 year old man is brought in having fallen at home and hit his head on the wall on his way down. He had no reported loss of consciousness. In the Emergency Department, a CT of the head was obtained which showed ventriculomegaly out of proportion to sulcal atrophy. The admitting physician is concerned for underlying normal pressure hydrocephalus. What additional neuroimaging findings would most support a diagnosis of NPH?
A. Abnormal CSF flow through the cerebral aqueduct.
B. Disproportionate sulcal atrophy in the frontal lobes compared to other portions of the brain.
C. Periventricular white matter changes.
D. Watershed lacunar infarcts.
Answer: A. Abnormal CSF flow through the cerebral aqueduct. Neuroimaging findings supportive of NPH on either CT or MRI scan include the abnormal CSF flow. Periventricular white matter changes are non-specific findings suggestive of small vessel ischemic disease, although these are seen in 50% of patients with NPH. Watershed lacunar infarcts are more consistent with cerebrovascular disease. Disproportionate atrophy can be seen in areas of injury, stroke, or other pathologies like frontotemporal dementia.
A diagnosis of normal pressure hydrocephalus can be made based solely on MRI or CT neuroimaging results.
A. True
B. False
Answer: B. False. While neuroimaging can suggest NPH, actual diagnosis requires a combination of clinical, imaging, and diagnostic steps. Lumbar puncture is often performed to confirm normal CSF pressure and to establish if the patient's clinical symptoms will improve.