NEJM – Ventriculoperitoneal-Shunt Placement for Normal-Pressure Hydrocephalus (see the video!)

A 70-year-old woman presented to the neurology clinic with a 2-year history of gait disturbance, cognitive impairment, and urinary incontinence. Examination revealed a Mini–Mental State Examination (MMSE) score of 12 (on a scale of 0 to 30, with higher scores representing better performance) and a short-stepped, narrow-based, nonataxic gait. The patient walked 7.6 m in 31 seconds (Video 1). Magnetic resonance imaging revealed ballooning of the ventricles, with an Evan’s ratio (the ratio of the width of the frontal horns of the lateral ventricles [45 mm in this patient] to the internal diameter of the skull [122 mm]) of 0.37 (upper limit of the normal range, 0.31) (Panel A). The callosal angle (Panel B, white arrow) — the angle (outlined in white) between the lateral ventricles measured at the level of the posterior commissure (black arrow) on a coronal plane perpendicular to a line between the anterior and posterior commissures — was less than 90 degrees (reference range, 100 to 120). A lumbar puncture revealed a normal opening pressure, a finding consistent with normal-pressure hydrocephalus. Normal-pressure hydrocephalus classically manifests with urinary incontinence, gait disturbance, and dementia. Surgical shunting of cerebrospinal fluid is the main treatment method. A ventriculoperitoneal shunt was placed, which led to a marked improvement in the patient’s gait (Video 2 at 1 month and Video 3 at 6 months); 6 months after shunt placement, she walked 7.6 m in 6 seconds. The MMSE score increased to 20 points at 1 month, with resolution of urinary incontinence, and increased to 28 points at 6 months.

Full report at


Current Internal Medicine resident at Boston University Medical Center, future Hematology and Oncology fellow at Beth Israel Deaconess Medical Center, Harvard Medical School.

You may also like...

Leave a Reply

%d bloggers like this: