Ishida Tetsuro, Murayama Tomonori, Kobayashi Seiju
Department of Psychiatry Japan Health Care University Sapporo Japan.
Department of Psychiatry Asahikawa Keisenkai Hospital Asahikawa Japan.
PCN Rep. 2022 Sep 2;1(3):e43. doi: 10.1002/pcn5.43. eCollection 2022 Sep.
Idiopathic normal pressure hydrocephalus (iNPH) is a common form of dementia that causes gait disturbance, cognitive impairment, and urinary incontinence. iNPH is a "treatable dementia" that can be treated with shunt surgery, but this can be ineffective in some cases and can be accompanied by complications. As a result, many patients with iNPH do not undergo surgery. However, there is insufficient evidence on effective treatments other than surgical therapy.
A 75-year-old woman presented to our hospital with a chief complaint of cognitive decline. She showed reduced motivation and inactivity. Brain magnetic resonance imaging showed a high score on the Evans Index (maximum width between bilateral lateral ventricular anterior horns/maximum intracranial cavity in the same slice). The subarachnoid space was enlarged at and below the Sylvian fissure, and narrowed at the higher arcuate region. She was diagnosed with iNPH. However, no shunt surgery was performed; 11 months later, she had a generalized convulsive seizure with loss of consciousness. An electroencephalogram showed generalized epileptic discharges. The possibility of surgery for her iNPH was ruled out. Levetiracetam prevented seizure recurrence and cognitive functions such as spontaneity and motivation were improved.
It is often assumed that surgery is the only effective treatment for patients with iNPH. However, as in the present case, symptomatic epileptic seizures may be a factor in dementia. Even in the absence of surgical treatment, we should examine the cause of dementia in patients with iNPH and consider pharmacological treatment, including antiepileptic drugs.
特发性正常压力脑积水（iNPH）是痴呆的一种常见形式，可导致步态障碍、认知障碍和尿失禁。iNPH是一种“可治疗的痴呆症”，可通过分流手术进行治疗，但在某些情况下可能无效，且可能伴有并发症。因此，许多iNPH患者未接受手术治疗。然而，除手术治疗外，关于有效治疗方法的证据不足。
一名75岁女性因认知能力下降为主诉前来我院就诊。她表现出动力下降和活动减少。脑部磁共振成像显示埃文斯指数（双侧侧脑室前角之间的最大宽度/同一切片中的最大颅内腔）得分较高。蛛网膜下腔在外侧裂及其下方扩大，在较高的弓形区域变窄。她被诊断为iNPH。然而，未进行分流手术；11个月后，她出现了伴有意识丧失的全身性惊厥发作。脑电图显示全身性癫痫放电。她接受iNPH手术的可能性被排除。左乙拉西坦预防了癫痫复发，并且改善了诸如自发性和动力等认知功能。
人们通常认为手术是iNPH患者唯一有效的治疗方法。然而，如本病例所示，症状性癫痫发作可能是痴呆的一个因素。即使在没有手术治疗的情况下，我们也应该检查iNPH患者痴呆的原因，并考虑包括抗癫痫药物在内的药物治疗。
