A case of normal pressure hydrocephalus presenting as repeated vertigo, headache and nausea and treated effectively with ventriculoparietal shunt surgery

Abstract

Normal pressure hydrocephalus (NPH) is a condition involving pathologically enlarged ventricular size with normal opening pressures on lumbar puncture. NPH is associated with a classic triad of dementia, gait disturbance, and urinary incontinence. We report on a patient with NPH presenting with repeated vertigo, headache and nausea. A 21-year-old woman complained of rotatory vertigo, pulsatile headache, nausea and tinnitus in both ears. Brain MRI findings confirmed a diagnosis of hydrocephalus. The cerebrospinal fluid opening pressure was within normal limits. Since then, the patient has continued to experience vertigo, headache and nausea several times a week, and these symptoms were resistant to medical treatments. Results of pure tone audiometry, caloric tests, and vestibular-evoked myogenic potentials were normal in both ears. One year later, she developed gait disturbance and showed vertical macro square wave jerks on a gaze-evoked nystagmus test. A lumbar tap test revealed that removal of cerebrospinal fluid temporally improved her symptoms. She underwent ventriculoparietal shunt surgery, after which she has been symptom-free. Normal results on audio-vestibular examinations and the postsurgical improvement suggested that increased pressure upon the periventricular white matter, including the central vestibular tract, might have been the cause of her symptoms.