57 Y/O presents with Difficulty walking , Decline in thinking , urinary incontinence

Images

Doctor's Information

Name : Morteza
Family : Sanei Taheri
Affiliation :Radiology Department ,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Hadi Zolfeghari

Case Section

Neuroradiology

Patient's Information

Gender : Male
Age : 57

Clinical Summary

57 Y/O presents with Difficulty walking , Decline in thinking , urinary incontinence

Imaging Findings

MRI & CT demonstrated Ventriculomegaly that is out of proportion to cortical atrophy, ( ventriculo sulcal disproportion). ventriculomegaly is prominent in all three horns of the lateral ventricles, third ventricle with relative sparing of the fourth ventricle. Mild Peri ventricular flair & T2 hyper intensity is noted a few high signal plaque in WM is seen.

Differential Diagnosis

• normal ageing brain
• Alzheimer dementia: may show greater dilatation of perihippocampal fissures 2
• obstructive hydrocephalus: due to mass lesion (e.g. pineal region, tectal plate, midbrain)
• Lewy-body dementia: visual hallucinations and delusions are more prominent
• Parkinson disease: unilateral symptoms are important
• AIDS-dementia complex: positive HIV serology

Final Diagnosis

NPH(Normal pressure hydrocephalus )

Discussion (Related Text)

Normal pressure hydrocephalus occurs when excess cerebrospinal fluid accumulates in the brain's ventricles, which are hollow fluid-filled chambers. NPH is called "normal pressure" because despite the excess fluid, cerebrospinal fluid pressure as measured during a spinal tap is often normal. As brain ventricles enlarge with the excess cerebrospinal fluid, they can disrupt and damage nearby brain tissue, causing symptoms of NPH. NPH primarily affects people in their 60s and 70s. Scientists aren't certain how many older adults have this disorder because common symptoms of NPH are also common in other brain disorders. NPH on MRI Ventriculomegaly out of proportion with sulcal atrophy is the hallmark.
As per Jack and coworkers study, the predictive value of 3 MRI findings used with respect to positive response to CSF shunting, these studies included 1) CSF flow void sign, 2) Peri ventricular T2 hyper intensity and 3) Corpus callosal thinning on sagittal sections.
The underlying cause of NPH remains controversial. One theory is that NPH is an obstructive type of communicating hydrocephalus due to reduced of CSF resorption. A second theory suggests that NPH results from weakening of the ventricular wall due to periventricular white matter ischemic damage 3. The periventricular white matter ischemic change has also been hypothesized to slow the flow of CSF through the extracellular spaces, resulting in a "back-pressure" effect, leading to ventricular enlargement.

References

1-Rosenberg GA. Brain edema and disorders of cerebrospinal fluid circulation In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley's Neurology in Clinical Practice. 6th ed. Philadelphia, Pa: Elsevier Saunders; 2012:chap 59.
2-Neuroradiology Unit, S P Institute of Neurosciences,Solapur,Maharashtra, INDIA, Dr Balaji Anvekar’s Neuroradiology Cases
3. Hurley RA, Bradley WG, Latifi HT et-al. Normal pressure hydrocephalus: significance of MRI in a potentially treatable dementia. J Neuropsychiatry Clin Neurosci. 1999;11 (3): 297-300. J Neuropsychiatry Clin Neurosci (full text) - Pubmed citation
4. Bradley WG. Normal pressure hydrocephalus: new concepts on etiology and diagnosis. AJNR Am J Neuroradiol. 2000;21 (9): 1586-90. AJNR Am J Neuroradiol (full text) - Pubmed citation