Parkinsonian Patient with Comorbid Normal Pressure Hydrocephalus : Clinical Usefulness of Diagnosis Supported by Neurological Findings

Progressive supranuclear palsy with marked ventricular dilatation mimicking normal pressure hydrocephalus

BACKGROUND

Progressive supranuclear palsy (PSP) patients can show ventricular enlargement mimicking normal pressure hydrocephalus (NPH). The aim of this study was to distinguish PSP patients with marked ventricular dilatation (PSP-vd) from those with normal ventricular system and to evaluate the coexistence of NPH in PSP-vd patients.

METHODS

One hundred three probable PSP patients, 18 definite NPH patients, and 41 control subjects were enrolled in the study. Evans index (EI) > 0.32 associated with callosal angle (CA) < 100° was used to identify PSP-vd patients. Automated ventricular volumetry (AVV) and Magnetic Resonance Hydrocephalic Index (MRHI) were performed on T1-weighted MR images to evaluate the presence of NPH in PSP-vd patients.

RESULTS

Twelve (11.6%) out of 103 PSP patients had both abnormal EI and CA values (PSP-vd). In two of these 12 patients, AVV and MRHI values suggested PSP + NPH. In the remaining 10 PSP-vd patients, AVV and MRHI values were higher than PSP patients with normal ventricular system and controls, but lower than PSP + NPH and NPH patients, suggesting a non-hydrocephalic ventricular enlargement.

DISCUSSION

Our study provides evidence that the combination of EI and CA biomarkers allowed to identify PSP patients with marked ventricular dilatation mimicking NPH. Only a few of these patients had PSP + NPH. Recognition of these PSP patients with enlarged ventricles can positively impact the care of this disease, helping clinicians to identify patients with PSP + NPH who could benefit from shunt procedure and avoid surgery in those with enlarged ventricles without NPH.

A Distinct Scenario of a Patient with Parkinson’s Disease and Comorbid Normal Pressure Hydrocephalus

In literature, patients with coexistence of normal pressure hydrocephalus (NPH) and Parkinsons’s disease (PD) have been rarely reported. Herein, I illustrate the evaluation processes of a remarkable patient with PD and comorbid NPH from my experience, which I think may provide crucial perspectives regarding the management problems of these patients. Besides, the patient had also developed bipolar disorder in the follow-up course and extrapyramidal side effects related to antipsychotic medications, which further complicated the treatment process. I think that results of future reports of larger case series including the long-term follow-up of this group of patients with coexisting NPH and PD would provide substantial perspectives regarding the contributory effects of these two pathophysiologies, as well as management, of NPH in these specific patients with neurodegenerative pathology.