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.