Iola Crawford’s struggles with walking and gait seemed like Parkinson’s disease.

Her problems with forgetfulness and confusion seemed like dementia.

In reality, she had neither condition.

Instead, Crawford was experiencing normal pressure hydrocephalus (NPH), an illness that often resembles Alzheimer’s or Parkinson’s but isn’t. Deema Fattal, M.D., a neurologist and director of the Balance Disorders Clinic at University of Iowa Hospitals and Clinics, says it can be difficult to distinguish the symptoms of NPH and those of Parkinson’s or dementia, leading to occasional misdiagnosis.

“In NPH, difficulty walking is usually the first symptom to appear and memory deficits appear later,” she explains. “This differs from Parkinson’s patients who early on have tremors and not many gait or memory issues, and from Alzheimer’s patients who have memory loss but no major walking problems early on.”

Accurate diagnosis requires an expert physical examination, sophisticated brain imaging by MRI or CT, a spinal tap, and neuropsychological testing. According to Fattal, “Patients often come through various doors before getting an accurate diagnosis. They might come through the memory clinic, or the balance disorders clinic, or the urology clinic since many NPH patients have problems with incontinence.”

The good news is that once NPH is confirmed, it may be treatable.

“A few patients actually improve on their own, without treatment, while about half will worsen and half will stay the same,” Fattal says. “With treatment, there is up to a 60 to 70 percent chance for improvement in walking. However, if memory loss has been going on for more than a couple of years, it probably won’t improve as much with treatment, but the treatment might prevent it from worsening.”

Patrick Hitchon, M.D., a neurosurgeon at UI Hospitals and Clinics, says the treatment of choice for NPH patients is the placement of a cerebrospinal fluid shunt. “An implanted shunt drains cerebrospinal fluid away from the brain, thereby allowing the enlarged ventricles to return to a normal state,” he says.

The procedure itself is relatively simple and has been available for decades to treat increased pressure in the head from a variety of causes.

“The key to a successful outcome is accurate diagnosis, which is why patients should undergo multidisciplinary evaluation by neurology, neurosurgery, and neuropsychology,” Hitchon says. “The work-up of patients who may have NPH often entails a lumbar puncture or other methods of measuring the pressure within the head.”

Once the results suggest the diagnosis of NPH and the patient and family wish to proceed with surgery, the shunt is implanted. The shunting procedure, like all operations, carries some risk. However, in well selected patients, the outcome is gratifying.

Crawford, 70, of Burlington, Iowa, has no regrets after undergoing the procedure in August 2004. She was referred to the Neurosurgery Clinic by Nidal Alkurdy, M.D., a Burlington neurologist. “I could tell a difference within 72 hours,” she says. “I could almost run when before I could hardly walk. It was just amazing!”

Crawford’s husband, Donald, has seen noticeable improvement in his wife’s gait and some improvement in memory and understanding.

For more information, patients and families may call the Neurology Clinic at 319-356- 2572 or call UI Health Access toll-free and ask for Neurology. Patients and families may call the Neurosurgery Clinic at 319-356- 2237 or 319-356-2238.

Physicians wishing patient consultation or referral may call UI Consult and ask for an evaluation at one or both of the above clinics.

ABOUT NPH
Cerebrospinal fl uid (CSF) cushions delicate brain and spinal cord tissue from injuries and maintains a proper balance of nutrients around the central nervous system. Normally, we manufacture a pint of CSF per day, which circulates around the brain and spinal cord and is eventually absorbed into the bloodstream. When an imbalance between release and absorption occurs, an excess of CSF causes the fl uid spaces or ventricles in the brain to enlarge. This, in turn, stretches nerve tissue in the brain, causing malfunction, resulting in the symptoms of normal pressure hydrocephalus. Untreated, NPH creates increased pressure in the head and may cause diffi culty with walking, memory defi cits, and urinary incontinence.

BRAIN PROFILES
CT images compare the brains of a healthy person (left), a patient with Alzheimer’s disease (center) and a patient with NPH (right). Note how the Alzheimer’s brain indicates greater atrophy (shrinkage) and relatively smaller ventricles (see arrows) than that of a patient with NPH.

250,000 Americans with some of the same symptoms as dementia, Alzheimer’s, or Parkinson’s may actually have NPH.