SELF ASSESSMENT COLOUR

REVIEW OF
CLINICAL MEDICINE

Professor Izham Cheong, FRCP

Dr Tan Hui Jan, MMed, MRCP
Dr Wong Ming, MMed, MRCP
Dr Chang Sau Kong, MRCP
A 60 year old man presents with progressive memory loss of 6
months duration. He had difficulty in walking and had frequent falls
at home.
Q: What is the diagnosis?
A: Normal pressure hydrocephalus
The brain CT showed dilatation of the ventricles which was out of
proportion to the widening of the sulci.

Normal pressure hydrocephalus (NPH) is characterized by the

triad of dementia, ataxia and urinary incontinence.
It accounts for 5% demented pts in the older age group (late
middle aged and elderly). NPH may begin with a transient high-
pressure hydrocephalus with subsequent ventricular enlargement.
With further enlargement of the ventricles, CSF pressure returns
to normal. There is intermittent intracranial hypertension.
Clinical symptoms result
from distortion of the central
portion of the corona radiata
by the distended ventricles.
Involvement of the sacral
motor fibres that innervate
the legs and the bladder
gives rise to the ataxia and
urinary incontinence.
Parkinson’s like features
results from intermittent
high pressure leading to
seepage of CSF destroying
the striatonigral area.
Dementia results from
distortion of the
periventricular limbic
system.
CT scan brain showing dilated
ventricles. The white arrow
points to a rounded frontal
horn
Management of these patients suspected to have NPH include a
baseline neuropsychological evaluation and a timed walking test. Prior
to lumbar puncture, the patient is required to walk a fixed distance
and the duration will be timed. A lumbar puncture is then performed
to remove 30 – 50 cc of CSF. After which, the patient walks the same
distance again while being timed. Improvement in gait may be seen in
the form of reduced time to walk a fixed distance, reduced gait apraxia
or reduced freezing of gait. A clear cut improvement in mental status
and/or gait after the timed walking test predicts a favourable response
to shunt surgery.
Surgical CSF shunting includes ventr