An Unexpected Journey: Understanding Normal Pressure Hydrocephalus (NPH)
Walks in an elderly gentleman, slightly hunched over, leaning on a walking stick, supported gently by his wife, into my clinic. She looks worried but hopeful as she helps him take a seat, and they both turn to me with a mix of relief and anticipation.
You: “Hello, how can I help you both today?”
Wife: “Doctor, I’m so worried about him. He forgets almost everything that happens nowadays. He’s even on medication for Alzheimer’s, but things don’t seem to be improving.”
You: “I see. Can you tell me a bit more about his memory problems?”
She takes a deep breath, clearly eager to get this all out.
Wife: “He can remember things from his childhood like they happened yesterday, but when it comes to what we talked about even a few days back… nothing. And lately, he has these episodes where he’s unsteady on his feet, like he’s drunk. Sometimes, he even bumps into things.”
You nod, listening carefully.
You: “Does he have any issues with urination?”
Her eyes widen as she realizes she’d overlooked something.
Wife: “Yes! I forgot to mention that. He’s always rushing to the bathroom, can barely make it on time, and… well, at night, he has to wear diapers because he’s having accidents.”
You lean back, piecing the symptoms together in your mind. There’s a classic trio here—memory loss, gait disturbances, and urinary incontinence—that feels familiar.
You: “Thank you for sharing all of this. It sounds like he could have a condition known as Normal Pressure Hydrocephalus, or NPH. It’s different from Alzheimer’s, even though they share some symptoms.”
The wife looks puzzled, so you explain further.
You: “In NPH, excess fluid in the brain builds up slowly, expanding the ventricles—the fluid-filled spaces in the brain. This puts pressure on nearby areas that control memory, balance, and bladder control.”
Wife: “So, that’s why he’s having these problems?”
You: “Yes. In NPH, the temporal lobe, which is linked to memory, is on the sides of these ventricles, while the frontal lobe, which controls bladder function, lies in front. As for the balance issues, the motor areas that control walking are at the top.”
The wife nods thoughtfully.
Wife: “So what do we do next?”
The Diagnostic Journey
You: “The first step will be an MRI to see if there’s visible swelling in the ventricles. After that, if needed, we can perform a lumbar puncture, a procedure where we remove a small amount of cerebrospinal fluid to see if his symptoms improve.”
They both nod in agreement. You arrange the MRI and set a follow-up appointment.
Three Days Later
The couple returns, and you review the MRI results with them.
You: “Interestingly, the MRI appears normal, which sometimes happens in NPH cases. Let’s proceed with the lumbar puncture and see how he responds.”
The procedure goes smoothly, and after two hours, you conduct a few tests, noting a marked improvement in his MMSE (Mini-Mental State Examination) score and a steadier gait.
Wife: smiling “He’s walking better already!”
You: “That’s a great sign. We’ll monitor his progress over the next few days, but if his symptoms return, the next step would be a procedure to manage the fluid long-term.”
The Treatment Discussion
A few days later, they’re back in your office, eager to hear what’s next.
Wife: “So, is he cured?”
You: “For now, he’s improving, but without further intervention, the symptoms are likely to return. The long-term solution is a surgery called a ventriculoperitoneal (VP) shunt. This procedure diverts the excess fluid from his brain to his abdomen, where it can be absorbed.”
Wife: “Are there risks?”
You: “Every surgery has risks. With a VP shunt, possible complications include infection, shunt malfunction, and issues with fluid drainage. But with regular follow-ups, we can address these if they arise.”
The couple considers this, and after a moment, the wife squeezes his hand.
Wife: “Let’s do it.”
The Outcome
Two days later, he undergoes the VP shunt surgery without complications. A week after, the man who’d once struggled with every step returns for his follow-up.
You: “It’s great to see you walking so confidently!”
Patient: smiling “Feels good to be able to walk on my own again.”
His wife beams with relief.
A New Beginning
In the weeks that follow, his symptoms remain at bay, and he returns to his daily activities with newfound independence. His wife, though still vigilant, finally has some peace of mind.
This experience underscores the power of thorough diagnosis and the importance of considering all possibilities, especially when symptoms are complex. For those experiencing memory issues, unsteady gait, or urinary difficulties, it’s a reminder that conditions like NPH are manageable with the right care and treatment.
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