Case #1: From a 2008 CorePsych NPH Post ↑
Case #2: From a Patient in 2013 ↓
The only interesting ideas are heresies.
Susan Sontag 1975
His obvious ADHD symptoms: disorganization, unable to finish tasks, and often ‘lost in daily activities.' History: Concussions, several, from old football injuries can significantly aggravate ADHD symptoms with the associated brain injury.
The Tomographic View: The operational word for this deeper brain study is Tomography. Tomography slices provide an accurate, measurable difference for NPH: Normal Pressure Hydrocephalus – see the Video [showing the typical gait] at the bottom of this page for more information about how this exceedingly treatable condition remains so frequently overlooked.
Yes, The NPH Clinical Triad: 1. Gait Disturbance [Ataxia] with falling, 2. Dementia, 3. Urinary Incontinence. Interestingly these physical symptoms remained diminished, as is often the case, while his clinical complexity found attribution as “mental problems” – needing psychiatric consultation.
Chief Psych Complaint in this 76 yo male: memory deterioration, long-standing ADHD symptoms recently worse, and, yes, some clear metabolic problems.
This patient: evaluated by urologists, neurologists [considering Alzheimer's], psychiatrists, and internal medicine folk presented with 8 different specific drug interactions, from the variety of meds attempting to deal with his array of symptoms. These tomographic views/slices provided at the time from Amen Clinic in Atlanta, successfully reviewed by Dr Amen for a chief complaint of “brain deterioration.”
Interestingly, his surface 3-D renderings, looked actually quite good – but looking at the tomographic slices, the inside of the brain, revealed another story. Take a moment to review those two samples above of his SPECT imaging, and you'll see what immediately came to our attention: Those blue areas in the center simply shouldn't look like this: these pictures are the blue holes of swollen ventricles, on multiple levels, multiple slices. across the brain.
SPECT showed some other typical findings: prefrontal cooling [inadequate blood perfusion] with a long history of ADHD symptoms, temporal lobe cooling with not understanding communications well, and anger “out-of-the-blue.” An important additional note: SPECT findings showed him free of Alzheimer's and no frontal-temporal dementia. NPH can contribute to all of these symptoms with the increase in internal brain pressure.
First review this commentary from the Neurology Channel, then see the video below to further clarify NPH diagnostic details.
The Neurology Channel gives this additional NPH overview:
“Normal pressure hydrocephalus (NPH) is a condition that involves the build-up of fluid in the brain. Normally, a fluid called cerebrospinal fluid (CSF) circulates around the brain and spinal cord. This fluid cushions, cleanses, and brings nutrients to the cells in the brain and spine. CSF is produced in small, hollow spaces within the brain called ventricles. For people in good health, excess CSF normally drains away into the bloodstream as fresh CSF is produced.
When cerebrospinal fluid does not drain properly, the cerebrospinal fluid builds up in the ventricles and NPH can occur. This build up puts pressure on the brain, interfering with healthy brain function. NPH most commonly affects the areas of the brain that control leg movement, bladder function, and cognitive abilities such as problem solving, speaking, and remembering.
‘Hydrocephalus‘ was once called ‘water on the brain,' but we now know that the water is CSF. The term ‘normal pressure' refers to the fact that this type of hydrocephalus, which generally develops slowly, has a lower CSF pressure than other types of hydrocephalus. Normal pressure hydrocephalus occurs mainly in people over the age of 60 and symptoms may be mistaken for other disorders, such as Parkinson's disease, Alzheimer's disease, dementia, or Creutzfeldt-Jakob disease. However, with proper diagnosis and treatment many of the symptoms of NPH can be controlled or greatly reduced. In some cases, a nearly complete recovery is possible.”
Shunt technology, to deliver the CSF back into the blood stream, has improved in recent years, and this condition can likely be significantly corrected. This SPECT case proved the truth of the axiom: we do need to look at the brain to see what's going on, and in this case, inside the brain.
Tomographic Views with SPECT brain imaging provide considerable diagnostic assistance for NPH diagnosis. Without SPECT he would remain almost completely untreatable, and psychiatric meds would fail to render the improvement he sought. His treatment with 40 mg of Prozac, blocking CYP 2D6 and CYP 3A4 often contributes to a dementia-like state, as I've reported elsewhere here at CorePsych and on YouTube.