Description

A 65-year-old woman was referred to our medicine for the older person day hospital with a 2-year history of frequent falls and progressive memory decline. On examination, she was cautious in her gait, slightly leaning to her left side and very unsteady on turning. MRI of her brain revealed prominence of third and lateral ventricles and increased surrounding signal intensity suggestive of normal pressure hydrocephalus (NPH) (figure 1). She consented to a video-recorded cerebrospinal fluid (CSF) tap test (TT) with removal of 50 mL of CSF. Pre and post (2-hour and 2-day) assessments are shown in table 1.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

MRI of the brain showing prominence of ventricles.

Post CSF TT, she had a 33.3% improvement in the Timed Up and Go Test (TUGT), a less likely tendency to fall and a smoother turn (videos 1 and 2). She subsequently underwent a CSF ventriculoperitoneal shunt procedure with remarkable improvement in her mobility.

NPH is a syndrome which consists of a triad of gait disturbance, cognitive dysfunction and urinary symptoms. Owing to its potentially treatable nature, the selection of patients who may benefit from CSF shunt surgery is important.1 The most widely used prognostic test to assess candidacy for shunt placement is the CSF TT.2 This procedure is proven to have a high positive predictive value when correlated with successful shunt surgery.3 The goal of a standard CSF TT should be to detect change in symptoms as efficiently as possible and should be extended for up to 2 days when the suspicion is high.