Normal Pressure Hydrocephalus: Lessons from Three Patients with Distinct Clinical Outcomes

Abstract

Background: Normal pressure hydrocephalus (NPH) is a potentially reversible cause of gait disturbance, cognitive impairment, and urinary dysfunction in older adults. Early recognition and appropriate neurosurgical assessment may improve outcomes in patients who are suitable for intervention. However, clinical presentations may vary, and comorbid neurological and systemic conditions can complicate diagnosis and management. This case series describes three older male patients with clinical and radiological features suggestive of NPH who had distinct clinical trajectories and outcomes. Methods: This is a retrospective descriptive case study of three patients managed through the Neurology Unit of Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria, between July and November 2025. Clinical records were reviewed for presenting features, neurological examination findings, neuroimaging findings, interventions, and documented outcomes. Results: Case 1 was a 64-year-old man who presented with the classical triad of gait disturbance, cognitive impairment, and urinary incontinence. Brain MRI demonstrated ventriculomegaly with an Evans index of 0.41. A therapeutic cerebrospinal fluid (CSF) tap was planned but was not performed because the patient defaulted from follow-up. Case 2 was a 67-year-old man with the classical triad, expressive aphasia, and ventriculomegaly with an Evans index of 0.34. MRI also demonstrated the absence of the substantia nigra “swallow-tail” sign. A limited CSF tap yielded 10 mL of CSF because of the patient's restlessness, followed by ventriculoperitoneal shunt placement. His Glasgow Coma Scale score improved from 12/15 to 14/15 at discharge. Case 3 was a 76-year-old man who presented with an acute confusional state and urinary incontinence. Brain CT demonstrated ventriculomegaly with an Evans index of 0.40 alongside chronic cerebrovascular and small-vessel ischaemic changes. His acute presentation was considered multifactorial, with probable coexisting NPH. He received medical management and was subsequently transferred to another tertiary centre for neurosurgical evaluation. Conclusion: These cases illustrate the heterogeneous clinical presentation of suspected NPH and the diagnostic challenges posed by coexisting neurological and systemic conditions. The cases also highlight the importance of appropriate neuroimaging, clinical assessment, follow-up, and timely neurosurgical evaluation when NPH is suspected. Management should be individualised and undertaken within a multidisciplinary framework.