Normal Pressure hydrocephalus--Pearls

neurologyminutiae http://www.medscape.com/viewarticle/540190_1
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Comment
The best teaching on NPH comes from Neill Graff-Radford, whom I first encountered in Iowa City in 1988. Although Neill has a "dry" presentation, he is extremely perceptive.  That said, he has not changed his presentation much in 20 + years.

Among patients with NPH, one hopes to get a history of hypertension, and an enlarged head circumference. One looks for reasons NOT to shunt. One casts doubt upon the motives of the public information campaign. Do the Boston Naming Test (score less than 52 is bad). Ask about a history of prior alcohol use, steroid use, or exposure to the HIV virus or MS (or any other reason to suspect brain atrophy rather than hydrocephalus). Do neuropsych testing (dementia= different diagnosis). Look at the scan at the cortical gyri-- are they atrophied? Do a spinal tap-- not only to test response to removal of fluid, but to send off tau and ABeta 42 protein.

Remember, one half of the shunts work, and a third cause more problems than they are worth. The mettle of the good neurologist is to improve those odds for selected patients.