A 63-year-old woman with a history of hypertension presents with worsening memory over the past 5 months. Her husband reports that recently she had forgotten to turn off the oven a few times and has forgotten several appointments, which is unusual for her. The patient also endorses urinary incontinence and “clumsiness.” The patient’s hypertension is well-controlled on hydrochlorothiazide. Physical examination shows that her blood pressure is 128/84 mmHg and her pulse is 76/min. Neurologic examination is within normal limits except for a broad-based gait.
Which of the following is the most likely diagnosis?
A. Pseudotumor cerebriNormal pressure hydrocephalus. The patient in this question is presenting with dementia, urinary incontinence, and gait disturbance. This triad, often remembered by “wet, wacky, wobbly,” is characteristic of normal pressure hydrocephalus (NPH). NPH is diagnosed by MRI, which will show dilated ventricles. As one would expect from the name, the opening pressure measured during lumbar puncture is normal. Treatment generally consists of repeated spinal taps to improve the symptoms (by decreasing the pressure exerted on the adjacent cortical tissue by the enlarged ventricles). (B) Alzheimer disease is not associated with gait problems or urinary incontinence. (A) Pseudotumor cerebri is associated with headaches, not memory impairment or dementia. Furthermore, it is typically seen in young, obese females. (D) Although this patient has a history of hypertension, it is well-controlled and thus her symptoms are unlikely to be a result of multi-infarct dementia. This type of dementia tends to be very abrupt in onset and show multiple areas of increased T2-weighted density on MRI in the periventricular regions.