A Case of Idiopathic Normal Pressure Hydrocephalus Presenting as Vascular Parkinsonism
American Journal of Psychiatry and Neuroscience
Volume 8, Issue 1, March 2020, Pages: 1-5
Received: Nov. 24, 2019;
Accepted: Dec. 23, 2019;
Published: Jan. 6, 2020
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Talal Meshal Alumri, Department of Neurology, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
Rawan Zeinelabdein Mahgoub, College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
Alawi Aqel Al-Attas, Department of Neurology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
Idiopathic normal pressure hydrocephalus (iNPH) is the most common form of hydrocephalus in adults. It is characterized by dilated ventricles and the Hakim triad, which consists of gait disturbance, cognitive impairment, and urinary incontinence. The gold standard treatment for iNPH is shunting, but frequent lumbar punctures (LPs) are helpful for diagnosis and predicting shunting outcome and is considered the treatment of choice when shunting is not available. One condition with similar presentation to iNPH is Vascular parkinsonism (VP), which is characterized by an established relationship between cerebrovascular diseases and the clinical symptoms of Parkinson’s disease (PD). VP patients usually present with lower-body parkinsonism, including impaired gait, instability, difficulty with maintaining gait, and frequent episodes of freezing. VP is managed by levodopa followed by transcranial magnetic stimulation then vitamin D. LPs are less effective for VP than iNPH. Our case report shows that iNPH may be misdiagnosed with VP. Here we present a case of a 71-year-old male with a history of previous lacunar strokes who was admitted for possible vascular parkinsonism. Eight months prior to coming to the hospital, he developed gait disturbances; and four months later, he developed urinary symptoms. Upon examination, his gait initiation was hesitant, wide-based, and magnetic with decreased arm swing. The patient scored 20 out of 30 points on the Montreal Cognitive Assessment. The only cranial nerve involvement was a diminished gag reflex. Brain magnetic resonance imaging revealed symmetrically enlarged ventricles with mildly dilated sulci. Routine laboratory testing was normal. Two months of treatment with levodopa did not improve his symptoms but draining 50 mL of cerebrospinal fluid (CSF) has dramatically improved his gait. A final diagnosis of iNPH was therefore made. To conclude, iNPH and VP are two manageable diseases but the differential diagnosis between them is particularly challenging due to similar clinical and neuroradiological features. We suggest further studies to establish supporting guidelines by using neuroradiological or neurophysiological biomarkers which may help physicians in ameliorate diagnostic accuracy between the two entities.
Talal Meshal Alumri,
Rawan Zeinelabdein Mahgoub,
Alawi Aqel Al-Attas,
A Case of Idiopathic Normal Pressure Hydrocephalus Presenting as Vascular Parkinsonism, American Journal of Psychiatry and Neuroscience.
Vol. 8, No. 1,
2020, pp. 1-5.
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