Pregunta 93. Cuál es nueva conducta terapéutica más adecuada?



Your answer Was Incorrect

A 74-year-old woman hasprogressive gait problems for past 1 to 2 years. She reports difficulty initiating steps and turning, even though she has not had previous problems walking. She reports occasional bladder incontinence, although she attributes the problem to slowness related to her gait issues. The patient has no cognitive complaints but scores 22 of 30 on the Mini-Mental State Examination (MMSE), missing points in recall, orientation, and attention. She also seems to perform these tests more slowly than expected. Her MRI of the brain is shown. Results of lumbar puncture reveal normal CSF studies and opening pressure. The patient’s symptoms do not improve following the lumbar puncture, despite removal of 40 mL of CSF. What is the most appropriate next step in management?

A. Repeat a high-volume lumbar puncture, with repeat gait and cognitive assessments after 1 hour.
B. Insert an external lumbar drain, with repeat gait and cognitive assessments after 48 hours.
C. Administer acetazolamide therapy, with repeat gait and cognitive assessments after 1 week.
D. Insert a ventriculoperitoneal shunt for permanent diversion of CSF and re assess after 1 month.
E. Evaluate for other causes of her symptoms, as normal pressure hydrocephalus has been ruled out. **
** = Your answer

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.

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