Normal pressure hydrocephalus: Difference between revisions
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*CSF buildup in the ventricles leading to increased intracranial pressure with edema of the periventricular white matter and corona radiata | *CSF buildup in the ventricles leading to increased intracranial pressure with edema of the periventricular white matter and corona radiata | ||
**Sacral motor nerve fibers that produce gait instability; incontinence ensues when compressed | **Sacral motor nerve fibers that produce gait instability; incontinence ensues when compressed | ||
==Clinical Features== | ==Clinical Features== | ||
| Line 23: | Line 21: | ||
==Evaluation== | ==Evaluation== | ||
*CBC | *Initial ED workup | ||
*Chem 7 | **CBC | ||
*[[LP]] | **Chem 7 | ||
**Symptom improvement supports diagnosis<ref name="medscape">Schneck MJ. Normal pressure hydrocephalus. [http://emedicine.medscape.com/article/1150924-overview Medscape. Retrieved 8/4/2016]</ref> | **[[CT brain]] non-con: Ventriculomegaly without signs of obstruction at the level of the third or fourth ventricles | ||
*Additional workup (in coordination with neurology/neurosurgery), consider: | |||
**MRI (done as part of the general work-up, and should be done before LP) | |||
**[[LP]] (definitive diagnosis), with normal opening pressure and CSF studies | |||
***Symptom improvement supports diagnosis<ref name="medscape">Schneck MJ. Normal pressure hydrocephalus. [http://emedicine.medscape.com/article/1150924-overview Medscape. Retrieved 8/4/2016]</ref> | |||
===Normal pressure hydrocephalus vs brain atrophy<ref> Ishii M, Kawamata T, Akiguchi I, Yagi H, Watanabe Y, Watanabe T, Mashimo H (March 2010). "Parkinsonian Symptomatology May Correlate with CT Findings before and after Shunting in Idiopathic Normal Pressure Hydrocephalus". Parkinson's Disease. 2010: 1–7. doi:10.4061/2010/201089. PMC 2951141. PMID 20948890.</ref>=== | |||
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! Normal pressure hydrocephalus !! Brain atrophy | |||
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|align="center"|[[File:Normal pressure hydrocephalus versus atrophy, NPH.jpg|335px]] | |||
|align="center"|[[File:Normal pressure hydrocephalus versus atrophy, CA.jpg|333px]] | |||
|- | |||
| Preferable projection ||colspan=2| Coronal plane at the level of the posterior commissure of the brain. | |||
|- | |||
| Modality in this example || CT || MRI | |||
|- | |||
| CSF spaces over the convexity near the vertex (red ellipse) || Narrowed convexity ("tight convexity") as well as medial cisterns || Widened vertex (red arrow) and medial cisterns (green arrow) | |||
|- | |||
| Callosal angle (blue V) || Acute angle || Obtuse angle | |||
|- | |||
| Most likely cause of leucoaraiosis (periventricular signal alterations, blue arrows) | |||
| Transependymal [[cerebrospinal fluid]] diapedesis | |||
| Vascular encephalopathy, in this case suggested by unilateral occurrence | |||
|} | |||
[[File:CT of Evan's index.jpg|thumb|Evan's index is the ratio of maximum width of the frontal horns to the maximum width of the inner table of the cranium. An Evan's index more than 0.31 indicates hydrocephalus.<ref>hii M, Kawamata T, Akiguchi I, Yagi H, Watanabe Y, Watanabe T, Mashimo H (March 2010). "Parkinsonian Symptomatology May Correlate with CT Findings before and after Shunting in Idiopathic Normal Pressure Hydrocephalus". Parkinson's Disease. 2010: 1–7. doi:10.4061/2010/201089. PMC 2951141. PMID 20948890.</ref>]] | |||
==Management== | ==Management== | ||
* | *Fall precautions | ||
* | *Consult neurology and/or neurosurgery to decide if patient is candidate for inpatient vs outpatient MRI and LP. | ||
* | *LP is rarely done in the ED as it requires MRI before LP, and workup is typically non-emergent and can often be done as outpatient. | ||
==Disposition== | ==Disposition== | ||
*Workup typically is extensive | *Workup typically is extensive, but can often be done as outpatient, depending on your institution. | ||
* | *Decide plan for workup with neurology and/or neurosurgery | ||
*Consider admission if patient lives alone (fall risk), has no follow-up, or is significantly altered. | |||
==Also See== | ==Also See== | ||
Latest revision as of 20:59, 7 December 2022
Background
- Possible reversible cause of dementia
- CSF buildup in the ventricles leading to increased intracranial pressure with edema of the periventricular white matter and corona radiata
- Sacral motor nerve fibers that produce gait instability; incontinence ensues when compressed
Clinical Features
- Gait disturbance is most common and earliest finding
- "Glue-footed" gait: move slowly, take small steps, often wide base, with difficulty turning
- Memory loss and dementia symptoms may be mild, subtle
- Incontinence is usually later stage, though sensation of urinary urgency is usually present before incontinence
- Usually do not have symptoms of increased intracranial pressure, such as headache, nausea, vomiting, visual loss
Differential Diagnosis
- Alzheimer's
- Stroke
- Parkinson's disease
- Electrolyte abnormality
- Malignancy
- Uremic encephalopathy
- Hydrocephalus ex vacuo (diffuse cerebral atrophy on CT)
Evaluation
- Initial ED workup
- CBC
- Chem 7
- CT brain non-con: Ventriculomegaly without signs of obstruction at the level of the third or fourth ventricles
- Additional workup (in coordination with neurology/neurosurgery), consider:
Normal pressure hydrocephalus vs brain atrophy[2]
| Normal pressure hydrocephalus | Brain atrophy | |
|---|---|---|
|
| |
| Preferable projection | Coronal plane at the level of the posterior commissure of the brain. | |
| Modality in this example | CT | MRI |
| CSF spaces over the convexity near the vertex (red ellipse) | Narrowed convexity ("tight convexity") as well as medial cisterns | Widened vertex (red arrow) and medial cisterns (green arrow) |
| Callosal angle (blue V) | Acute angle | Obtuse angle |
| Most likely cause of leucoaraiosis (periventricular signal alterations, blue arrows) | Transependymal cerebrospinal fluid diapedesis | Vascular encephalopathy, in this case suggested by unilateral occurrence |
Evan's index is the ratio of maximum width of the frontal horns to the maximum width of the inner table of the cranium. An Evan's index more than 0.31 indicates hydrocephalus.[3]
Management
- Fall precautions
- Consult neurology and/or neurosurgery to decide if patient is candidate for inpatient vs outpatient MRI and LP.
- LP is rarely done in the ED as it requires MRI before LP, and workup is typically non-emergent and can often be done as outpatient.
Disposition
- Workup typically is extensive, but can often be done as outpatient, depending on your institution.
- Decide plan for workup with neurology and/or neurosurgery
- Consider admission if patient lives alone (fall risk), has no follow-up, or is significantly altered.
Also See
References
- ↑ Schneck MJ. Normal pressure hydrocephalus. Medscape. Retrieved 8/4/2016
- ↑ Ishii M, Kawamata T, Akiguchi I, Yagi H, Watanabe Y, Watanabe T, Mashimo H (March 2010). "Parkinsonian Symptomatology May Correlate with CT Findings before and after Shunting in Idiopathic Normal Pressure Hydrocephalus". Parkinson's Disease. 2010: 1–7. doi:10.4061/2010/201089. PMC 2951141. PMID 20948890.
- ↑ hii M, Kawamata T, Akiguchi I, Yagi H, Watanabe Y, Watanabe T, Mashimo H (March 2010). "Parkinsonian Symptomatology May Correlate with CT Findings before and after Shunting in Idiopathic Normal Pressure Hydrocephalus". Parkinson's Disease. 2010: 1–7. doi:10.4061/2010/201089. PMC 2951141. PMID 20948890.