Medical Student Elective
Case of the Month
Submitted by: Christopher Richardson, MS4, Stony Brook University School of Medicine
Chief Complaint“My leg gave out.”
HPI65 year-old male brought in by EMS 30 minutes after sudden onset of right leg weakness, causing him to stumble while walking with his sister downtown. He denies actually falling or striking his head or extremities, and was able to sit down in a controlled fashion. His sister notes that he just arrived in NYC from his home in Virginia and thinks the episode was provoked by the bright lights and crowds in Manhattan. She states he has had trouble walking for several years. He was able to stand and bear weight immediately after the incident. An EMT who evaluated the patient on scene notes his initial blood pressure was 240/100 and that he seemed confused when EMS arrived. He denies any pain, headache, weakness, or numbness at this time, and states he feels well, but is worried about why this happened.
PMHGlaucoma. No history of hypertension, CAD, or stroke.Social history: None Relevant.
MedsTimolol ophthalmic solution.
PE (pertinent)Vitals: BP 191/98; HR 112; RR 24; O2 99% on RA.General: Patient laying in bed; hair unkempt; clothing damp and smelling of urine.Head and neck: No abrasions/lacerations/contusions; pupils equal and reactive; mouth and pharynx normal; neck supple.Pulmonary: Lungs clear to auscultation bilaterally with no wheezes or rales.Cardiac: Tachycardic with regular rhythm and no murmurs or gallops; no jugular venous distension or peripheral edema.Abdomen: Normal bowel sounds; belly is soft, non-tender and non-distended.Neuro: Patient is alert and oriented to person, place and time, but is generally slow to answer questions and needs them repeated multiple times. Cranial nerves II-XII are intact. Strength is equal and 5/5 bilaterally in upper and lower extremities. Sensation is grossly intact. Gait was not assessed at this time.
Ddx and WorkupInitially, a broad differential diagnosis was considered, with intracranial hemorrhage, stroke, hypertensive emergency, arterial dissection, myocardial infarction and toxic ingestion primary considerations.
EKGSinus tachycardia with no concerning features.
CT HeadPatient sent for an emergent non-contrast CT of the head.
What is the most likely diagnosis for this patient?
ProgressObviously, the patient has very prominent ventricles as demonstrated by the initial Emergency Department CT scan. The question now becomes, does this represent a pathologic hydrocephalus, and, if so, is it of the communicating or obstructive variety?The CT shows “marked dilation of the ventricular system without corresponding enlargement of the cerebral sulci.” This suggests a true hydrocephalus, as opposed to prominent ventricles in a patient with atrophy of brain parenchyma from chronic dementia or traumatic brain injury.
DispositionNeurosurgery was consulted and the patient admitted to the hospital. A brain MRI was obtained the next day.
The MRI shows “marked enlargement of the ventricles without obstructing mass lesion.”
What is the most likely diagnosis for this patient?Normal Pressure Hydrocephalus
Course and TreatmentEarly in his hospital course, the patient was noted to ambulate with a walker for a maximum distance of 20 feet. His neurologic exam remained unchanged from his presentation in the ED. He was continually noted to have difficulty expressing himself and required extra time to answer questions.The treatment for normal pressure hydrocephalus is a ventricular shunt, which is effective in approximately 60 percent of cases in reversing some of the gait and cognitive effects of the disorder. In order to identify patients most likely to respond to treatment, a trial of CSF drainage is performed, and the patient’s response observed.A lumbar drainage procedure was performed on our patient, whereby a small amount (up to 10cc) of CSF was drained every hour. Over the course of several days, the patient’s mental status improved and he was able to increase his daily ambulation.On the basis of this improvement with lumbar drainage, the patient was recommended for a ventriculoperitoneal shunt, which he received three weeks after first visiting the ED.
CT Scan Post-VP Shunt
Follow-UpThe patient was discharged to inpatient rehab, and one week following the procedure he was noted to be able to walk up to 280 feet using a walker and perform all ADLs unassisted. His sister reports that he responds more clearly to questions and seems more expressive in his language, and that his gait is more fluid than she has seen it in years. The patient plans to return to his home in Virginia. His blood pressures returned to the normal range during his admission without any requirement for medication.
Take Home Messages
Final ThoughtsNormal pressure hydrocephalus is generally considered a chronic condition, and the diagnosis is most often considered in the outpatient setting. However, this case serves as a reminder that the differential diagnosis for any emergent problem should include both acute conditions and exacerbations of chronic diseases. This is especially relevant when considering a patient who is traveling and outside of his familiar environment.
SourcesGraff-Radford, NR. “Normal pressure hydrocephalus.” http://www.uptodate.com. April 10, 2012.Shprecher D, Schwalb J, and Kurlan R. “Normal Pressure Hydrocephalus: Diagnosis and Treatment.” Curr Neurol Neurosci Rep. 2008 September; 8(5): 371-376.
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