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*Only for medical professionals to read and share with clinical practical experience.
With the advent of the aging population, we encounter more and more patients with dementia in the clinic, and the treatment of dementia caused by neurodegenerative diseases is the most difficult.
Of course, there are also dementias caused by some causes, such as Wernicke's encephalopathy and paralytic dementia.
If they can be identified, diagnosed, and treated early, some of them can be reversed.
In the case described today, due to the previous diagnosis of cerebral infarction, the patient developed progressively aggravated cognitive impairment and was once diagnosed as vascular dementia, but the patient's dementia symptoms have been getting worse.
Five years later, through imaging and related auxiliary examinations, it was finally diagnosed as dementia caused by other reasons.
After treatment, the patient's dementia symptoms were significantly improved.
Case▌ Medical history The patient had a history of cerebral infarction in 2015, and left his left limbs weak, but he was able to take care of himself.
After 2016, the patient gradually experienced memory decline, slow response, decreased speech, and occasionally failed to answer questions.
He has been in the outpatient clinic and was diagnosed as "vascular dementia".
He was given treatments such as plaque stabilization, anti-platelet aggregation, and nootropics.
During this time, the patient agreed The barriers to knowledge have been increasing.
In 2018, the patient began to experience unsteady walking and abnormal gait, and his family members discovered that the patient had occasional urinary incontinence.
In December 2020, due to unresponsiveness, gait disorder, and urination disorder, the outpatient visit was further aggravated, and he was admitted to the hospital.
▌ Patients with past history have a history of type 2 diabetes for decades.
At present, 0.
5 tid oral metformin tablets + insulin subcutaneous injection control blood sugar, family members complain that blood sugar can be controlled, fasting 6-7mmol/L, and postprandial blood sugar control is 10-12mmol/L about.
The patient had a history of cerebral infarction in 2015 and left his left limb fatigue.
After long-term oral administration of pravastatin tablets and huperzine A.
Denies the history of hypertension, brain trauma, and denies hereditary diseases.
▌ The physical examination is clear, and the physical examination part is cooperative.
Decrease of memory, time, person, and place are available, computing power is decreased, 100-7=? , Clear speech, no visual field defect, double pupils with equal circle diameter, 0.
25cm in diameter, presence of light reflection, no abnormal eye movement, nystagmus (-), bilateral foreline symmetrical, left nasolabial fold slightly shallow, stretched The tongue is centered, the pharyngeal reflex (++), the left upper limb muscle tone is slightly higher, the remaining limb muscle tone is normal, the left limb muscle strength is 5-level, the right limb muscle strength is level 5, and bilateral pathological signs (-).
Mutual aid inspection: not cooperate.
It is difficult to sign with closed eyes and does not cooperate with walking in a straight line.
Tendon reflexes in limbs (-), symmetrical acupuncture sensation, soft neck, Klinefelter's disease, Brucellosis (-)
The video of the patient’s walking is as follows, see video 1: ▌ The 2015 cranial MRI DWI showed lacunar infarction.
Head CT in December 2020 showed enlarged ventricles.
▌ The clinical manifestations of the diagnosed patient are gait disorder, cognitive disorder and urinary incontinence triad.
The condition shows progressive development to varying degrees.
The head CT examination has enlarged ventricles, which is initially considered as "normal pressure hydrocephalus".
Therefore, we gave the patient a lumbar puncture, and the results confirmed that the intracranial pressure was normal, the cerebrospinal fluid routine and biochemical examinations were normal, and 40ml of cerebrospinal fluid was placed.
The patient's gait disorder was significantly improved.
The video is as follows, see video 2: Normal pressure hydrocephalus (NPH), also known as Reversible dementia: refers to the clinical manifestations of the triad of gait disorder, cognitive impairment and urinary incontinence, with progressive development of varying degrees, imaging examination with enlarged ventricles, and cerebrospinal fluid pressure measured at 70-200 mmH20 Clinical syndrome.
After putting cerebrospinal fluid through lumbar puncture, the patient's gait disorder and cognition improved.
The final diagnosis of this patient was: NPH.
What is NPH? Let's take a look at the relevant knowledge of NPH! Clinical manifestations The typical clinical manifestations of NPH are the triad of gait disorder, cognitive disorder and urinary incontinence.
Among them, gait disorders are the most common.
Cognitive disorders and urinary incontinence also have varying degrees of onset.
About half of patients have triad at the same time. 1.
Gait disorder: (95% occurrence rate) NPH patients have characteristic performances when walking: slow walking, unsteady swaying, small step distance, widening of the distance between the feet, reduced height of the feet, obstacles in starting and turning, but walking When the swing arm functions normally.
The symptoms of gait disturbance in early NPH patients are mild and difficult to detect, and they often complain of "dizziness".
As the disease progresses, the typical gait disorder will gradually manifest.
In the late stage, the patient needs assistance to walk, or even unable to walk at all.
The clinical manifestations of some patients are similar to Parkinson's syndrome.
2 Cognitive impairment: (appearance rate of 82%) This performance is part of neuropsychological damage, involving various aspects of cognition, emotion and emotion, and mental behavior.
Including: psychomotor retardation, apathy, emotional indifference, attention, memory, calculation, visual space function and executive dysfunction, etc.
The above situation may be volatile or aggravate in the short term.
This kind of patient lacks initiative and active communication ability, and has reduced ability of daily living.
It is one of the common clinical types of dementia.
Such patients with cognitive dysfunction may recover, so they are called reversible dementia.
3 Urinary incontinence: (occurrence rate 58.
3%) seen in the vast majority of patients with NPH.
Due to neurogenic bladder dysfunction, accompanied by overactive detrusor function.
Patients may experience frequent urination and urgency in the early stage.
As the disease progresses, complete urinary incontinence or even fecal incontinence may occur, and urinary retention may also occur.
4 Other symptoms NPH patients may also have some non-specific symptoms: headache, dizziness (vertigo), prolonged sleep time, Parkinson-like tremor and sexual dysfunction.
In addition, some patients may have other diseases, such as cerebrovascular disease, diabetes, Parkinson's disease, Alzheimer's disease, etc.
Imaging examination: 1 head CT showed enlarged ventricles, Evan's index> 0.
3, and scoliosis cistern widened.
In some patients, low-density shadows were seen in the periventricular white matter. Evan's index=a/b, which is the ratio of the maximum distance between the anterior horns of the lateral ventricles and the maximum cranial cavity at the same level.
2 Brain MRI showed enlarged ventricles, Evan's index> 0.
3; “DESH” sign was visible.
The coronal position shows the narrowing of the sulci and subarachnoid space above the scoliosis cistern and on both sides of the midline, which are more common in the posterior frontal lobe and parietal lobe, while the scoliosis, the lower part of the convex surface of the brain (below the scoliosis) and the ventral sulcus The brain cistern widens, forming the unique "subarachnoid space disproportionately enlarged hydrocephalus", called "DESH" sign.
Auxiliary diagnostic test 1 Lumbar puncture TAP test Lumbar puncture slowly releases CSF, 1ml/min, 30ml-50ml/30mins/d, and when the release of cerebrospinal fluid is not enough to meet the above standards, the final pressure is 0 as the termination point.
The above relevant clinical evaluations were carried out before and after dispensing.
It is recommended that the assessment should be performed at least once within 8 or 24 hours.
If it is negative, the test should be repeated within 72 hours.
For NPH patients, if the symptoms of hydrocephalus gradually improve within 1 to 2 days, it indicates that shunt surgery may be effective.
The positive rate of the test was 94%, and the sensitivity was 42%.
2 Lumbar drainage test (external lumbar drainage, ELD test) This is another important test to predict the effect of shunt surgery in NPH patients after the lumbar puncture TAP test.
Continuous external drainage of CSF through a lumbar puncture catheter, 50ml/8hr x 72hr, daily evaluation of the patient’s nerve function improvement by a specialized neurologist.
If there is improvement after drainage, shunt surgery can improve symptoms, and the NPH patient may benefit from hydrocephalus surgery.
For patients whose symptoms do not improve after the first drainage test, if their clinical symptoms are progressively worsening, it is necessary to repeat the cerebrospinal fluid drainage test.
The review will be carried out at least 1 week later.
The test has a sensitivity of 50%-100% and a specificity of 60%-100%.
Therapeutic shunt surgery is an effective treatment for NPH.
Once diagnosed as NPH, it can be surgically treated as soon as possible after a full assessment is in line with the clinical diagnosis.
Early surgery can significantly improve the patient's condition and prognosis.
The surgical methods mainly include: ventricular-abdominal shunt, lumbar cisterna-abdominal shunt, ventricular-atrial shunt, etc.
The main surgical procedure is ventricular-abdominal shunt.
Postscript: NPH is a treatable and reversible disease.
Early treatment can restore the patient to a normal life.
This patient has been diagnosed with vascular dementia in the early stage, but the patient has not recurred cerebrovascular events, and the symptoms of dementia have been getting worse, so this diagnosis needs to be suspected.
In the end, the patient underwent ventricular shunt and his condition was significantly relieved.
However, if the patient is not treated in time, the patient's condition will be irreversible.
Therefore, the early recognition, early diagnosis, and early treatment of NPH are of great significance.
Note: part of the picture in this article comes from the Internet, infringement can be deleted!
With the advent of the aging population, we encounter more and more patients with dementia in the clinic, and the treatment of dementia caused by neurodegenerative diseases is the most difficult.
Of course, there are also dementias caused by some causes, such as Wernicke's encephalopathy and paralytic dementia.
If they can be identified, diagnosed, and treated early, some of them can be reversed.
In the case described today, due to the previous diagnosis of cerebral infarction, the patient developed progressively aggravated cognitive impairment and was once diagnosed as vascular dementia, but the patient's dementia symptoms have been getting worse.
Five years later, through imaging and related auxiliary examinations, it was finally diagnosed as dementia caused by other reasons.
After treatment, the patient's dementia symptoms were significantly improved.
Case▌ Medical history The patient had a history of cerebral infarction in 2015, and left his left limbs weak, but he was able to take care of himself.
After 2016, the patient gradually experienced memory decline, slow response, decreased speech, and occasionally failed to answer questions.
He has been in the outpatient clinic and was diagnosed as "vascular dementia".
He was given treatments such as plaque stabilization, anti-platelet aggregation, and nootropics.
During this time, the patient agreed The barriers to knowledge have been increasing.
In 2018, the patient began to experience unsteady walking and abnormal gait, and his family members discovered that the patient had occasional urinary incontinence.
In December 2020, due to unresponsiveness, gait disorder, and urination disorder, the outpatient visit was further aggravated, and he was admitted to the hospital.
▌ Patients with past history have a history of type 2 diabetes for decades.
At present, 0.
5 tid oral metformin tablets + insulin subcutaneous injection control blood sugar, family members complain that blood sugar can be controlled, fasting 6-7mmol/L, and postprandial blood sugar control is 10-12mmol/L about.
The patient had a history of cerebral infarction in 2015 and left his left limb fatigue.
After long-term oral administration of pravastatin tablets and huperzine A.
Denies the history of hypertension, brain trauma, and denies hereditary diseases.
▌ The physical examination is clear, and the physical examination part is cooperative.
Decrease of memory, time, person, and place are available, computing power is decreased, 100-7=? , Clear speech, no visual field defect, double pupils with equal circle diameter, 0.
25cm in diameter, presence of light reflection, no abnormal eye movement, nystagmus (-), bilateral foreline symmetrical, left nasolabial fold slightly shallow, stretched The tongue is centered, the pharyngeal reflex (++), the left upper limb muscle tone is slightly higher, the remaining limb muscle tone is normal, the left limb muscle strength is 5-level, the right limb muscle strength is level 5, and bilateral pathological signs (-).
Mutual aid inspection: not cooperate.
It is difficult to sign with closed eyes and does not cooperate with walking in a straight line.
Tendon reflexes in limbs (-), symmetrical acupuncture sensation, soft neck, Klinefelter's disease, Brucellosis (-)
The video of the patient’s walking is as follows, see video 1: ▌ The 2015 cranial MRI DWI showed lacunar infarction.
Head CT in December 2020 showed enlarged ventricles.
▌ The clinical manifestations of the diagnosed patient are gait disorder, cognitive disorder and urinary incontinence triad.
The condition shows progressive development to varying degrees.
The head CT examination has enlarged ventricles, which is initially considered as "normal pressure hydrocephalus".
Therefore, we gave the patient a lumbar puncture, and the results confirmed that the intracranial pressure was normal, the cerebrospinal fluid routine and biochemical examinations were normal, and 40ml of cerebrospinal fluid was placed.
The patient's gait disorder was significantly improved.
The video is as follows, see video 2: Normal pressure hydrocephalus (NPH), also known as Reversible dementia: refers to the clinical manifestations of the triad of gait disorder, cognitive impairment and urinary incontinence, with progressive development of varying degrees, imaging examination with enlarged ventricles, and cerebrospinal fluid pressure measured at 70-200 mmH20 Clinical syndrome.
After putting cerebrospinal fluid through lumbar puncture, the patient's gait disorder and cognition improved.
The final diagnosis of this patient was: NPH.
What is NPH? Let's take a look at the relevant knowledge of NPH! Clinical manifestations The typical clinical manifestations of NPH are the triad of gait disorder, cognitive disorder and urinary incontinence.
Among them, gait disorders are the most common.
Cognitive disorders and urinary incontinence also have varying degrees of onset.
About half of patients have triad at the same time. 1.
Gait disorder: (95% occurrence rate) NPH patients have characteristic performances when walking: slow walking, unsteady swaying, small step distance, widening of the distance between the feet, reduced height of the feet, obstacles in starting and turning, but walking When the swing arm functions normally.
The symptoms of gait disturbance in early NPH patients are mild and difficult to detect, and they often complain of "dizziness".
As the disease progresses, the typical gait disorder will gradually manifest.
In the late stage, the patient needs assistance to walk, or even unable to walk at all.
The clinical manifestations of some patients are similar to Parkinson's syndrome.
2 Cognitive impairment: (appearance rate of 82%) This performance is part of neuropsychological damage, involving various aspects of cognition, emotion and emotion, and mental behavior.
Including: psychomotor retardation, apathy, emotional indifference, attention, memory, calculation, visual space function and executive dysfunction, etc.
The above situation may be volatile or aggravate in the short term.
This kind of patient lacks initiative and active communication ability, and has reduced ability of daily living.
It is one of the common clinical types of dementia.
Such patients with cognitive dysfunction may recover, so they are called reversible dementia.
3 Urinary incontinence: (occurrence rate 58.
3%) seen in the vast majority of patients with NPH.
Due to neurogenic bladder dysfunction, accompanied by overactive detrusor function.
Patients may experience frequent urination and urgency in the early stage.
As the disease progresses, complete urinary incontinence or even fecal incontinence may occur, and urinary retention may also occur.
4 Other symptoms NPH patients may also have some non-specific symptoms: headache, dizziness (vertigo), prolonged sleep time, Parkinson-like tremor and sexual dysfunction.
In addition, some patients may have other diseases, such as cerebrovascular disease, diabetes, Parkinson's disease, Alzheimer's disease, etc.
Imaging examination: 1 head CT showed enlarged ventricles, Evan's index> 0.
3, and scoliosis cistern widened.
In some patients, low-density shadows were seen in the periventricular white matter. Evan's index=a/b, which is the ratio of the maximum distance between the anterior horns of the lateral ventricles and the maximum cranial cavity at the same level.
2 Brain MRI showed enlarged ventricles, Evan's index> 0.
3; “DESH” sign was visible.
The coronal position shows the narrowing of the sulci and subarachnoid space above the scoliosis cistern and on both sides of the midline, which are more common in the posterior frontal lobe and parietal lobe, while the scoliosis, the lower part of the convex surface of the brain (below the scoliosis) and the ventral sulcus The brain cistern widens, forming the unique "subarachnoid space disproportionately enlarged hydrocephalus", called "DESH" sign.
Auxiliary diagnostic test 1 Lumbar puncture TAP test Lumbar puncture slowly releases CSF, 1ml/min, 30ml-50ml/30mins/d, and when the release of cerebrospinal fluid is not enough to meet the above standards, the final pressure is 0 as the termination point.
The above relevant clinical evaluations were carried out before and after dispensing.
It is recommended that the assessment should be performed at least once within 8 or 24 hours.
If it is negative, the test should be repeated within 72 hours.
For NPH patients, if the symptoms of hydrocephalus gradually improve within 1 to 2 days, it indicates that shunt surgery may be effective.
The positive rate of the test was 94%, and the sensitivity was 42%.
2 Lumbar drainage test (external lumbar drainage, ELD test) This is another important test to predict the effect of shunt surgery in NPH patients after the lumbar puncture TAP test.
Continuous external drainage of CSF through a lumbar puncture catheter, 50ml/8hr x 72hr, daily evaluation of the patient’s nerve function improvement by a specialized neurologist.
If there is improvement after drainage, shunt surgery can improve symptoms, and the NPH patient may benefit from hydrocephalus surgery.
For patients whose symptoms do not improve after the first drainage test, if their clinical symptoms are progressively worsening, it is necessary to repeat the cerebrospinal fluid drainage test.
The review will be carried out at least 1 week later.
The test has a sensitivity of 50%-100% and a specificity of 60%-100%.
Therapeutic shunt surgery is an effective treatment for NPH.
Once diagnosed as NPH, it can be surgically treated as soon as possible after a full assessment is in line with the clinical diagnosis.
Early surgery can significantly improve the patient's condition and prognosis.
The surgical methods mainly include: ventricular-abdominal shunt, lumbar cisterna-abdominal shunt, ventricular-atrial shunt, etc.
The main surgical procedure is ventricular-abdominal shunt.
Postscript: NPH is a treatable and reversible disease.
Early treatment can restore the patient to a normal life.
This patient has been diagnosed with vascular dementia in the early stage, but the patient has not recurred cerebrovascular events, and the symptoms of dementia have been getting worse, so this diagnosis needs to be suspected.
In the end, the patient underwent ventricular shunt and his condition was significantly relieved.
However, if the patient is not treated in time, the patient's condition will be irreversible.
Therefore, the early recognition, early diagnosis, and early treatment of NPH are of great significance.
Note: part of the picture in this article comes from the Internet, infringement can be deleted!
