A 77-year-old woman presented to the emergency room after sustaining a fall. She had experienced urinary incontinence for 8 months, confusion, forgetfulness, gait disturbances and frequent falls for 6 months, which were more pronounced for the last 2 weeks. She denied any history of headache, loss of consciousness, visual disturbances or seizure-like activity.

The patient was E4M6V4 with no focal neurological deficits. Her neck was supple with no signs of meningeal irritation. Fundus examination was unremarkable.

Chest radiograph revealed fracture of the seventh, eighth and ninth left ribs. Figure 1 shows a computed tomography (CT) scan of the head showing dilatation of the lateral ventricles that is out of proportion to the patient’s age along with cerebral atrophy (fig 1A,B). Magnetic resonance imaging (MRI), axial section (fig 1C), corroborated the CT findings and showed diffuse dilatation of the ventricular cavities. Indium-111 and diethylene triamine penta-acetic acid (DTPA) cisternography revealed normal ascent of tracer in basal cistern and persistent retention in the lateral ventricles.

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Figure 1 Computed tomography (CT) scan of head showing dilatation of lateral ventricles, out of proportion to age along with cerebral atrophy (A, B).

Magnetic resonance image, axial section (C), showing diffuse dilatation of brain ventricles and cisterns.

A diagnosis of normal pressure hydrocephalus (NPH) was made based upon the diffuse dilatation of all the ventricular cavities, clinical features and no evidence of obstruction on CT, MRI and cisternography. Following discussion of a management plan, the patient and her family decided for ventriculo-peritoneal shunt (fig 2) without a tap test, given the high false negative test rate and low predictive accuracy of a negative test.1

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Figure 2 CT scan of head showing the presence of ventriculoperitoneal shunt in the posterior horn of lateral ventricle.

The patient showed symptomatic improvement during follow-up with continued rehabilitation. Rib fractures were managed conservatively with meticulous analgesia. NPH is a clinical syndrome characterised by a triad of gait disturbance, memory loss and urinary incontinence.2