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The patient most likely has normal pressure hydrocephalus (NPH) based on the clinical presentation and imaging studies. Although symptom improvement following a high-volume lumbar puncture is helpful in confirming the diagnosis, it is a specific but insensitive test; therefore, additional investigation is needed if initial interventions are not helpful. Before proceeding with permanent shunt placement, a trial with a lumbar drain can help ascertain whether a shunt will be helpful. In addition, prolonged CSF drainage provides more time to perform formal gait and cognitive testing. Small trials of acetazolamide have not produced enough evidence to support its use in NPH management.
- Williams MA, Malm J. Diagnosis and treatment of idiopathic normal pressure hydrocephalus. Continuum Lifelong Learning Neurol. 2016;22(2):579-599.