A 65-year-old man comes to the physician with complaints of poor balance and near-falls over the last 6 months. He recently began using a cane for ambulation. He also reports memory loss during this period and has difficulty handling finances and keeping appointments. The patient has no headache, trauma, visual difficulty, slurred speech, muscle weakness, back pain, or incontinence. His past medical history includes chronic lymphocytic leukemia. He takes no medications.
Vital signs are within normal limits. The patient has some postural instability on pull-back testing. Gait is slow with short strides. He turns slowly, with several steps. There is no evidence of tremor or rigidity, although he does have increased tone in the lower extremities with brisk reflexes. He scores 24/30 on the Mini-Mental State Examination. The remainder of the physical examination is within normal limits.
Magnetic resonance imaging of the brain with and without gadolinium shows enlarged ventricles.
Which of the following is the most likely diagnosis?

Question

A 65-year-old man comes to the physician with complaints of poor balance and near-falls over the last 6 months.  He recently began using a cane for ambulation.  He also reports memory loss during this period and has difficulty handling finances and keeping appointments.  The patient has no headache, trauma, visual difficulty, slurred speech, muscle weakness, back pain, or incontinence.  His past medical history includes chronic lymphocytic leukemia.  He takes no medications.
Vital signs are within normal limits.  The patient has some postural instability on pull-back testing.  Gait is slow with short strides.  He turns slowly, with several steps.  There is no evidence of tremor or rigidity, although he does have increased tone in the lower extremities with brisk reflexes.  He scores 24/30 on the Mini-Mental State Examination.  The remainder of the physical examination is within normal limits.
Magnetic resonance imaging of the brain with and without gadolinium shows enlarged ventricles.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_988a_22b9_853d_2379b86db68b_MD0002_00 This patient likely has normal-pressure hydrocephalus (NPH). Idiopathic NPH usually occurs in individuals age >60. Secondary NPH can occur in any age group and is usually due to subarachnoid hemorrhage or meningitis leading to impaired cerebrospinal fluid (CSF) absorption. The classic triad of NPH is gait instability, cognitive dysfunction, and urinary incontinence. Patients usually present with a history of falls and complaints of feet being fixed to the floor. Urinary incontinence is a late feature. Gait appears similar to that of Parkinsonism except that in NPH it is more wide based (versus narrow based in Parkinson disease). Increased tone or brisk reflexes in the lower extremities and depressed affect indicate pressure on the frontal and prefrontal cortex from enlarged ventricles. The pull-back test and Mini-Mental State Examination may be abnormal but are nonspecific. Subcortical and frontal dysfunctions are more prominent without cortical dysfunction (eg, aphasia and apraxia). pull-back test Magnetic resonance is a better imaging technique than computed tomography for evaluation of NPH and shows enlarged ventricles out of proportion to sulcal enlargement. The Miller Fisher test (lumbar tap test) confirms the diagnosis of NPH and also helps select patients for treatment. It involves removing 30-50 mL of cerebrospinal fluid via lumbar tap and observing for symptomatic improvement in gait and cognitive function about an hour after the procedure. NPH treatment involves ventriculoperitoneal shunt placement, with clinical improvement in about 60% of patients. (Choice A) Alzheimer disease presents with a slowly progressive dementia that affects memory out of proportion to other cognitive functioning. Patients also have difficulty with cortical functions (eg, aphasia, apraxia), which is not usually seen in NPH patients. Gait disturbance is usually a late feature. (Choice B) Acute myeloid leukemia, but not chronic lymphocytic leukemia, is a common cause of leptomeningeal carcinomatosis. Carcinomatous meningitis usually presents with both focal (eg, cranial nerve palsies, focal weakness) and global symptoms (eg, headache, nausea, vomiting). Symptoms typically develop acutely, over days to weeks. Examination shows multifocal involvement (eg, diplopia, absent knee reflex). (Choice C) Dementia with Lewy bodies presents with progressive cognitive decline, Parkinsonian features (eg, bradykinesia, cogwheel rigidity), and prominent visual hallucinations. (Choice D) Idiopathic intracranial hypertension usually presents with headaches and papilledema on examination. Lumbar puncture (done after neuroimaging) usually shows high opening pressures (>250 mm H₂O). Neuroimaging does not usually show enlarged ventricles, as seen in this patient. Educational objective: The classic triad of normal-pressure hydrocephalus is cognitive dysfunction, gait difficulty, and urinary incontinence. Diagnosis is usually confirmed by magnetic resonance imaging showing enlarged ventricles and symptomatic improvement after removal of 30-50 mL of cerebrospinal fluid via lumbar puncture. Treatment involves ventriculoperitoneal shunting. __________ References: The differential diagnosis and treatment of normal-pressure hydrocephalus. (http://www.ncbi.nlm.nih.gov/pubmed/22282714) Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus. (http://www.ncbi.nlm.nih.gov/pubmed/22705135)

A 65-Year-Old Man Comes to the Physician with Complaints of Poor