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Bissacco J, Simonetta C, Mascioli D, Zenuni H, Bovenzi R, Grillo P, Di Giuliano F, Stefani A, Mercuri NB, Schirinzi T. Peripheral immunity changes are associated with neurodegeneration and worse clinical outcome in idiopathic normal pressure hydrocephalus. Eur J Neurol 2024; 31:e16179. [PMID: 38130035 DOI: 10.1111/ene.16179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE Idiopathic normal pressure hydrocephalus (iNPH) pathogenesis is multifactorial. Systemic inflammation might have a role in gathering clinical-pathological trajectories. We aimed to shape the peripheral immune profile of iNPH and establish correlations with cerebrospinal fluid (CSF) markers, ventricular enlargement, and clinical outcomes. METHODS We conducted a single-center retrospective-longitudinal study, including 38 iNPH patients and 38 controls. Baseline iNPH Grading Scale and modified Rankin Scale (mRS) scores were collected with peripheral blood cell count, CSF amyloid-β42 (Aβ42), total tau (t-tau), phosphorylated-181-tau, and Evans index. Depending on 5-year outcome, iNPH patients were grouped into "poor outcome" (PO; mRS ≥ 5) and "favorable outcome" (FO; mRS < 5). Biomarkers were compared and correlated with each other. Receiver operating characteristic analysis was performed. RESULTS iNPH patients compared to controls had higher neutrophil-to-lymphocyte ratio (NLR; 2.43 ± 1.04 vs. 1.61 ± 0.47, p < 0.001), higher neutrophils (4.22 ± 0.86 1000/mL vs. 3.48 ± 1.34, p = 0.033), and lower lymphocytes (1.45 ± 0.55 1000/mL vs. 2.07 ± 0.86, p = 0.038), with the expected CSF biomarkers signature. In the patients' cohort, NLR was associated directly with t-tau and inversely with Aβ42. NLR directly correlated with Evans index. PO patients compared to those with FO had higher NLR (3.25 ± 1.40 vs. 2.01 ± 0.77, p = 0.035) and higher t-tau (274.76 ± 114.39 pg/mL vs. 150.28 ± 72.62, p = 0.017), with an area under the curve of 0.786 and 0.793, respectively. CONCLUSIONS iNPH patients present a proinflammatory state associated with neurodegeneration and predicting poor clinical outcome. Systemic inflammation represents a factor in the clinical-pathological progression of iNPH, and the NLR emerges as a potential prognostic index.
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Affiliation(s)
- Jacopo Bissacco
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Clara Simonetta
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Davide Mascioli
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Henri Zenuni
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Roberta Bovenzi
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Piergiorgio Grillo
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Marlene and Paolo Fresco Institute for Parkinson's Disease and Movement Disorders, New York, New York, USA
| | - Francesca Di Giuliano
- Unit of Neuroradiology, Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Alessandro Stefani
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
- Parkinson Unit, Tor Vergata University Hospital, Rome, Italy
| | - Nicola Biagio Mercuri
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Tommaso Schirinzi
- Unit of Neurology, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
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Petrella G, Ciarlo S, Elia S, Piaz RD, Nucera P, Pompucci A, Palmieri M, Pesce A. Idiopathic Normal Pressure Hydrocephalus: The Real Social and Economic Burden of a Possibly Enormous Underdiagnosis Problem. Tomography 2023; 9:2006-2015. [PMID: 37987343 PMCID: PMC10661316 DOI: 10.3390/tomography9060157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
Normal Pressure Hydrocephalus (iNPH) typically affects the elderly and can cause cognitive decline, resulting in its differential diagnosis with other neurodegenerative conditions. Moreover, it is probably underdiagnosed; such under- and misdiagnosis prevents the patient from receiving the right treatment and significantly affects the quality of life and life expectancy. This investigation is an in-depth analysis of the actual incidence of iNPH in the population of the province served by our hospital (circa 580,000 individuals). The first phase of this study was conducted by visualizing a total of 1232 brain CT scans performed in the Emergency Departments of the four hospitals of our network on patients who were admitted for different complaints yet screened as suspicious for iNPH. Subsequently, corresponding Emergency Department medical records were investigated to understand the medical history of each patient in search of elements attributable to an alteration of CSF dynamics. The cohort of positive CT scans, according to the radiological and clinical inclusion criteria, included 192 patients. Among the reasons to require acute medical care, "Fall" was the most common. The cumulative incidence of CT scans suggestive of iNPH among the patients undergoing CT scans was as high as 15.58%, and the period prevalence calculated for the total amount of patients accessing the Emergency Departments was 1.084%. The real incidence of iNPH in the population may be underestimated, and the social burden linked to the assistance of patients suffering from such untreated conditions could be significantly relieved.
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Affiliation(s)
- Gianpaolo Petrella
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Silvia Ciarlo
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Stefania Elia
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Rita Dal Piaz
- Emergency Department, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy;
| | - Paolo Nucera
- Emergency Department, A.O. “Dono Svizzero” General Hospital, Via Appia Lato Napoli, 04023 Formia, Italy;
| | - Angelo Pompucci
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
| | - Mauro Palmieri
- Department of Human Neurosciences, Neurosurgery Division, Università “La Sapienza” di Roma, Viale del Policlinico 155, 00161 Roma, Italy;
| | - Alessandro Pesce
- Neurosurgery Division, A.O. “Santa Maria Goretti” General Hospital, Via Guido Reni 1, 04100 Latina, Italy; (G.P.); (S.C.); (S.E.); (A.P.)
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Pyrgelis ES, Velonakis G, Papageorgiou SG, Stefanis L, Kapaki E, Constantinides VC. Imaging Markers for Normal Pressure Hydrocephalus: An Overview. Biomedicines 2023; 11:biomedicines11051265. [PMID: 37238936 DOI: 10.3390/biomedicines11051265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Idiopathic bormal pressure hydrocephalus (iNPH) is a neurological syndrome that clinically presents with Hakim's triad, namely cognitive impairment, gait disturbances, and urinary incontinence. The fact that iNPH is potentially reversible makes its accurate and early diagnosis of paramount importance. Its main imaging characteristic is the dilation of the brain's ventricular system and the imaging parameters are also included in its diagnostic criteria along with clinical data. There is a variety of different modalities used and a great number of imaging markers that have been described while assessing iNPH patients. The present literature review attempts to describe the most important of these imaging markers and to shed some light on their role in diagnosis, differential diagnosis, and possibly prognosis of this potentially reversible neurological syndrome.
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Affiliation(s)
- Efstratios-Stylianos Pyrgelis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Georgios Velonakis
- Research Unit of Radiology, 2nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sokratis G Papageorgiou
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Elisabeth Kapaki
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
| | - Vasilios C Constantinides
- 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
- Neurochemistry and Biological Markers Unit, 1st Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Eginition Hospital, Vass. Sophias Ave. 74, 11528 Athens, Greece
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Kazui H, Hashimoto M, Takeda S, Chiba Y, Goto T, Fuchino K. Evaluation of Patients With Cognitive Impairment Due to Suspected Idiopathic Normal-Pressure Hydrocephalus at Medical Centers for Dementia: A Nationwide Hospital-Based Survey in Japan. Front Neurol 2022; 13:810116. [PMID: 35693019 PMCID: PMC9184737 DOI: 10.3389/fneur.2022.810116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 04/11/2022] [Indexed: 11/27/2022] Open
Abstract
Objective Treatment of idiopathic normal-pressure hydrocephalus (iNPH) requires collaboration between dementia specialists and neurosurgeons. The role of dementia specialists is to differentiate patients with iNPH from patients with other dementia diseases and to determine if other dementia diseases are comorbid with iNPH. We conducted a nationwide hospital-based questionnaire survey on iNPH in medical centers for dementia (MCDs). Methods We developed a questionnaire to assess how physicians in MCDs evaluate and treat patients with cognitive impairment due to suspected iNPH and the difficulties these physicians experience in the evaluation and treatment of patients. The questionnaire was sent to all 456 MCDs in Japan. Results Questionnaires from 279 MCDs were returned to us (response rate: 61.2%). Patients underwent cognitive tests, evaluation of the triad symptoms of iNPH, and morphological neuroimaging examinations in 96.8, 77.8, and 98.2% of the MCDs, respectively. Patients with suspected iNPH were referred to other hospitals (e.g., hospitals with neurosurgery departments) from 78.9% of MCDs, and cerebrospinal fluid (CSF) tap test was performed in 44 MCDs (15.8%). iNPH guidelines (iNPHGLs) and disproportionately enlarged subarachnoid space hydrocephalus (DESH), a specific morphological finding, were used and known in 39.4% and 38% of MCDs, respectively. Logistic regression analysis with “Refer the patient to other hospitals (e.g., hospitals with neurosurgery departments) when iNPH is suspected.” as the response variable and (a) using the iNPHGLs, (b) knowledge of DESH, (c) confidence regarding DESH, (d) difficulty with performing brain magnetic resonance imaging, (e) knowledge of the methods of CSF tap test, (f) absence of physician who can perform lumbar puncture, and (g) experience of being told by neurosurgeons that referred patients are not indicated for shunt surgery as explanatory variables revealed that the last two factors were significant predictors of patient referral from MCDs to other hospitals. Conclusion Sufficient differential or comorbid diagnosis using CSF tap test was performed in a few MCDs. Medical care for patients with iNPH in MCDs may be improved by having dementia specialists perform CSF tap tests and share the eligibility criteria for shunt surgery with neurosurgeons.
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Affiliation(s)
- Hiroaki Kazui
- Department of Neuropsychiatry, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Mamoru Hashimoto
- Department of Neuropsychiatry, Faculty of Medicine, Kindai University, Osakasayama, Japan
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Tsai ST, Tseng PH, Wu LK, Wang YC, Ho TJ, Lin SZ. Diagnosis and treatment for normal pressure hydrocephalus: From biomarkers identification to outcome improvement with combination therapy. Tzu Chi Med J 2022; 34:35-43. [PMID: 35233354 PMCID: PMC8830549 DOI: 10.4103/tcmj.tcmj_275_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 11/04/2022] Open
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de Oliveira MF, Sorte AAB, Emerenciano DL, Rotta JM, Mendes GAS, Pinto FCG. Long term follow-up of shunted idiopathic normal pressure hydrocephalus patients: a single center experience. Acta Neurol Belg 2021; 121:1799-1806. [PMID: 33136273 DOI: 10.1007/s13760-020-01538-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a condition characterized by gait disturbance, dementia and/or urinary incontinence and enlarged ventricular system due to disturbance of cerebrospinal fluid (CSF). This study aims to describe the long-term experience with patients with iNPH submitted to ventriculoperitoneal shunt (VPS) with the programmable valve STRATA® (Medtronic). We prospectively selected a cohort of patients with a diagnosis of iNPH from January 2010 to April 2013 in a Brazilian tertiary hospital. All patients underwent clinical evaluation, which consists of the Mini-Mental State Examination and Time Up and Go tests and the application of Japanese Scale for Idiopathic Normal Pressure Hydrocephalus in three stages: prior to the TT, 3 h after the TT and 72 h after the TT. Fifty patients were submitted to VPS and followed. There were 32 men and 18 women. Mean age was 77.1 with standard deviation of 10.9. Follow-up time ranged from 96 to 120 months, with mean of 106 months. After 1 year of follow-up, 42 (83%) patients presented with clinical improvement, decreasing to 62% of patients at mid-term follow-up and 38% of patients at late follow-up. Complications occurred in 18% of subjects, needing reoperation in 16%. Our results show relevant clinical impact of shunting in iNPH patients, decreasing over time. Complications should not be underestimated, reaching up to 18% and demanding reoperation in 16% of cases. Thus, although much has been improved with current shunt technology, it is still important to consider the drawbacks of treatment.
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Tan C, Wang X, Wang Y, Wang C, Tang Z, Zhang Z, Liu J, Xiao G. The Pathogenesis Based on the Glymphatic System, Diagnosis, and Treatment of Idiopathic Normal Pressure Hydrocephalus. Clin Interv Aging 2021; 16:139-153. [PMID: 33488070 PMCID: PMC7815082 DOI: 10.2147/cia.s290709] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 12/16/2022] Open
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a rare neurological disorder with no clear prevalence factors and is a significant danger to the elderly. The intracranial glymphatic system is the internal environment that maintains brain survival and metabolism, and thus fluid exchange changes in the glymphatic system under various pathological conditions can provide important insights into the pathogenesis and differential diagnosis of many neurodegenerative diseases such as iNPH. iNPH can be diagnosed using a combination of clinical symptoms, imaging findings and history, and cerebrospinal fluid biomarkers due to the glymphatic system disorder. However, only few researchers have linked the two. Shunt surgery can improve the glymphatic system disorders in iNPH patients, and the surgical approach is determined using a combination of clinical diagnosis and trials. Therefore, we have composed this review to provide a future opportunity for elucidating the pathogenesis of iNPH based on the glymphatic system, and link the glymphatic system to the diagnosis and treatment of iNPH. The review will provide new insights into the medical research of iNPH.
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Affiliation(s)
- Changwu Tan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Xiaoqiang Wang
- Pediatric Neurological Disease Center, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, People's Republic of China
| | - Yuchang Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Chuansen Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Zhi Tang
- Department of Neurosurgery, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Zhiping Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Jingping Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
| | - Gelei Xiao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, People's Republic of China
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Kho J, Hosack T, Boyd E, Mandal AKJ, Missouris CG. Lost Marbles Cannot Be Found: Delayed Diagnosis of Normal Pressure Hydrocephalus. Am J Med 2021; 134:63-66. [PMID: 32289309 DOI: 10.1016/j.amjmed.2020.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Jason Kho
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK
| | - Tom Hosack
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK
| | - Elena Boyd
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK
| | - Amit K J Mandal
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK
| | - Constantinos G Missouris
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK; University of Cyprus Medical School, Nicosia.
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Idiopathic Chronic Hydrocephalus in Middle-age male with lower urinary tract symptoms, erectile dysfunction, gait disturbance, and papilledema. Urol Case Rep 2020; 33:101411. [PMID: 33102108 PMCID: PMC7574333 DOI: 10.1016/j.eucr.2020.101411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/18/2022] Open
Abstract
This report describes a 44-year-old male with a rare case of idiopathic chronic hydrocephalus who came with complaints of intermittent lower urinary tract symptoms (LUTS), erectile dysfunction, gait disturbance, mental disorder, and papilledema. A detailed assessment of voiding dysfunction in the clinical presentation should be explored to find a surgically correctable cause. Hydrocephalus in middle age male is a rare cause of LUTS. Idiopathic chronic hydrocephalus is a surgically correctable disease. Recognition of LUTS and correct confirmation of LUTS diagnosis etiology are important.
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