Fig. 1: Showing the disproportionately enlarged ventricles and
Evans index of 0.3 validating the diagnosis of normal pressure
hydrocephalus.
To confirm the diagnosis, therapeutic and diagnostic tests were done,
i.e., a Miller-Fisher test /Tap test in which 30 ml of CSF fluid was
removed and patient gait was assessed, which showed significant
improvement. Based on clinical symptoms, physical examination findings,
imaging results, and improvement of symptoms after the tap test, it was
hence confirmed the diagnosis of Normal Pressure Hydrocephalus (NPH),
for which the patient underwent treatment via the placement of a
programmable ventriculoperitoneal (VP) shunt. Subsequently, he displayed
significant postoperative improvement. However, a year later, the
patient returned with new complaints, including blurred vision,
headaches, impaired balance, and recurrent urinary
incontinence. MRI of the brain demonstrated bilateral chronic
subdural hematoma, as shown in Figure 2.