Volume 8, Issue 1, March 2020, Page: 1-5
A Case of Idiopathic Normal Pressure Hydrocephalus Presenting as Vascular Parkinsonism
Talal Meshal Alumri, Department of Neurology, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
Rawan Zeinelabdein Mahgoub, College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
Alawi Aqel Al-Attas, Department of Neurology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
Received: Nov. 24, 2019;       Accepted: Dec. 23, 2019;       Published: Jan. 6, 2020
DOI: 10.11648/j.ajpn.20200801.11      View  379      Downloads  168
Idiopathic normal pressure hydrocephalus (iNPH) is the most common form of hydrocephalus in adults. It is characterized by dilated ventricles and the Hakim triad, which consists of gait disturbance, cognitive impairment, and urinary incontinence. The gold standard treatment for iNPH is shunting, but frequent lumbar punctures (LPs) are helpful for diagnosis and predicting shunting outcome and is considered the treatment of choice when shunting is not available. One condition with similar presentation to iNPH is Vascular parkinsonism (VP), which is characterized by an established relationship between cerebrovascular diseases and the clinical symptoms of Parkinson’s disease (PD). VP patients usually present with lower-body parkinsonism, including impaired gait, instability, difficulty with maintaining gait, and frequent episodes of freezing. VP is managed by levodopa followed by transcranial magnetic stimulation then vitamin D. LPs are less effective for VP than iNPH. Our case report shows that iNPH may be misdiagnosed with VP. Here we present a case of a 71-year-old male with a history of previous lacunar strokes who was admitted for possible vascular parkinsonism. Eight months prior to coming to the hospital, he developed gait disturbances; and four months later, he developed urinary symptoms. Upon examination, his gait initiation was hesitant, wide-based, and magnetic with decreased arm swing. The patient scored 20 out of 30 points on the Montreal Cognitive Assessment. The only cranial nerve involvement was a diminished gag reflex. Brain magnetic resonance imaging revealed symmetrically enlarged ventricles with mildly dilated sulci. Routine laboratory testing was normal. Two months of treatment with levodopa did not improve his symptoms but draining 50 mL of cerebrospinal fluid (CSF) has dramatically improved his gait. A final diagnosis of iNPH was therefore made. To conclude, iNPH and VP are two manageable diseases but the differential diagnosis between them is particularly challenging due to similar clinical and neuroradiological features. We suggest further studies to establish supporting guidelines by using neuroradiological or neurophysiological biomarkers which may help physicians in ameliorate diagnostic accuracy between the two entities.
Idiopathic Normal Pressure Hydrocephalus, Vascular Parkinsonism, Lumbar Puncture
To cite this article
Talal Meshal Alumri, Rawan Zeinelabdein Mahgoub, Alawi Aqel Al-Attas, A Case of Idiopathic Normal Pressure Hydrocephalus Presenting as Vascular Parkinsonism, American Journal of Psychiatry and Neuroscience. Vol. 8, No. 1, 2020, pp. 1-5. doi: 10.11648/j.ajpn.20200801.11
Copyright © 2020 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Williams MA, Malm J. Diagnosis and Treatment of Idiopathic Normal Pressure Hydrocephalus. Continuum (Minneap Minn) 2016; 22: 579-99.
Virhammar J, Laurell K, Cesarini KG, et al. The callosal angle measured on MRI as a predictor of outcomes in idiopathic normal-pressure hydrocephalus. J Neurosurg 2014; 120: 178-184.
Korczyn AD. Vascular parkinsonism – characteristics, pathogenesis and treatment. Nat Rev Neurol 2015; 11: 319-26.
Bovonsunthonchai S, Witthiwej T, Ngamsombat C, et al. Effect of spinal tap test on the performance of sit-to-stand, walking, and turning in patients with idiopathic normal pressure hydrocephalus. Nagoya J Med Sci 2018; 80: 53-60.
Chen Y-C, Chiang S-W, Chi C-H, et al. Early Idiopathic Normal Pressure Hydrocephalus Patients with Neuropsychological Impairment Are Associated With Increased Fractional Anisotropy in the Anterior Thalamic Nucleus. Medicine 2016; 95: e3636.
Ghosh S, Lippa C. Diagnosis and Prognosis in Idiopathic Normal Pressure Hydrocephalus. Am J Alzheimers Dis Other Demen 2014; 29: 583-9.
Blomsterwall E, Svantesson U, Carlsson U, et al. Postural Disturbance in Patients with Normal Pressure Hydrocephalus. Acta Neurol Scand 2000; 102: 284-291.
Maalouf M, Ringman J, Shi J. An Update on the Diagnosis and Management of Dementing Conditions. Rev Neurol Dis 2011; 8: e68-e87.
Shprecher D, Schwalb J, Kurlan R. Normal Pressure Hydrocephalus: Diagnosis and Treatment. Curr Neurol Neurosci Rep 2008; 8: 371-376.
Abdool K, Seegobin K, Ramcharan K, et al. Neurosyphilis With Normal Pressure Hydrocephalus and Dementia Paralytica: Serial Clinical, Laboratory and Radiological Correlations in the 21st Century. Neurol Int 2016; 8: 6812.
Halperin JJ, Kurlan R, Schwalb JM, Cusimano MD, Gronseth G, Gloss D. Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016; 86 (23): 793.
Hailong F, Guangfu H, Haibin T, et al. Endoscopic third ventriculostomy in the management of communicating hydrocephalus: a preliminary study. J Neurosurg 2008; 109: 923-30.
Halperin JJ, Kurlan R, Schwalb JM, et al. Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2015; 85: 2063-2071.
Ishikawa M, Hashimoto M, Mori E, Kuwana N, Kazui H. The Value of the Cerebrospinal Fluid Tap Test for Predicting Shunt Effectiveness in Idiopathic Normal Pressure Hydrocephalus. Fluids Barriers CNS 2012; 9 (1): 1.
Lim TS, Yong SW, Moon SY. Repetitive Lumbar Punctures as Treatment for Normal Pressure Hydrocephalus. Eur Neurol 2009; 62: 293-297.
Critchley M. Arteriosclerotic parkinsonism. Brain 1929; 52: 23-83.
Eadie MJ, Sutherland JM. Arteriosclerosis in Parkinsonism. J Neurol Neurosurg Psychiatry 1964; 27: 237-240.
Parkes JD, Marsden CD, Rees JE, et al. Parkinson’s disease, Cerebral Arteriosclerosis, and Senile Dementia. Clinical Features and Response to Levodopa. Q J Med 1974; 43: 49-61.
Zijlmans JC, Daniel SE, Hughes AJ, et al. Clinicopathological Investigation of Vascular Parkinsonism, Including Clinical Criteria for Diagnosis. Mov Disord 2004; 19: 630-40.
Benamer HT, Grosset DG. Vascular Parkinsonism: A Clinical Review. Eur Neurol 2009; 61: 11-5.
Thanvi B, Lo N, Robinson T. Vascular Parkinsonism – an Important Cause of Parkinsonism in Older People. Age Ageing 2005; 34: 114-119.
van Swieten JC, van den Hout JH, van Ketel BA, et al. Periventricular Lesions in the White Matter on Magnetic Resonance Imaging in the Elderly. A Morphometric Correlation with Arteriolosclerosis and Dilated Perivascular Spaces. Brain 1991; 114: 761-774.
Miguel-Puga A, Villafuerte G, Salas-Pacheco J, et al. Therapeutic Interventions for Vascular Parkinsonism: A Systematic Review and Meta-analysis. Front Neurol 2017; 8: 481.
Yip CW, Cheong PW, Green A, et al. A Prospective Pilot Study of Repetitive Transcranial Magnetic Stimulation for Gait Dysfunction in Vascular Parkinsonism. Clin Neurol Neurosurg 2013; 115: 887-91.
Sato Y, Iwamoto J, Honda Y, et al. Vitamin D Reduces Falls and Hip Fractures in Vascular Parkinsonism but not in Parkinson’s Disease. Ther Clin Risk Manag 2013; 9: 171-176.
Ondo WG, Chan LL, Levy JK. Vascular Parkinsonism: Clinical Correlates Predicting Motor Improvement After Lumbar Puncture. Mov Disord 2001; 17: 91-7.
Schniepp R, Trabold R, Romagna A, et al. Walking Assessment after Lumbar Puncture in Normal-Pressure Hydrocephalus: A Delayed Improvement over 3 Days. J Neurosurg 2017; 126: 148-157.
Wikkelsø C, Andersson H, Blomstrand C, et al. The Clinical Effect of Lumbar Puncture in Normal Pressure Hydrocephalus. J Neurol Neurosurg Psychiatry 1982; 45: 64-69.
Stolze H, Kuhtz-Buschbeck JP, Drücke H, et al. Gait Analysis in Idiopathic Normal Pressure Hydrocephalus – Which Parameters Respond to the CSF Tap Test? Clin Neurophysiol 2000; 111: 1678-1686.
Cucca A, Biagioni MC, Sharma K, et al. Comorbid Normal Pressure Hydrocephalus with Parkinsonism: A Clinical Challenge and Call for Awareness. Case Rep Neurol Med 2018; 2018: 1-8.
Lee H-W, Kang K, Choi D. Unusual Idiopathic Normal Pressure Hydrocephalus Patient with Marked Asymmetric Upper Body Parkinsonism. Ann Indian Acad Neurol 2016; 19: 245.
Kitagaki H, Mori E, Ishii K, et al. CSF Spaces in Idiopathic Normal Pressure Hydrocephalus: Morphology and Volumetry. AJNR Am J Neuroradiol 1998; 19: 1277-84.
Damasceno BP. Neuroimaging in Normal Pressure Hydrocephalus. Dement Neuropsychol 2015; 9: 350-355.
Browse journals by subject