The Importance of Primary Care Cognitive Evaluation in Detecting an Atypical Presentation of Normal Pressure Hydrocephalus.

Normal pressure hydrocephalus (NPH) is a syndrome that characteristically presents with progressive gait impairment, cognitive deficits, and urinary urgency or incontinence. We present a case of a 54-year-old male with a past medical history of alcohol use and no primary care provider with new-onset auditory hallucinations. The patient was found to have a marked enlargement of the supratentorial and infratentorial ventricles on both computed tomography (CT) and magnetic resonance imaging (MRI) and an opening pressure of 21 on the lumbar puncture, concerning for NPH. Clinically, there were signs of cognitive impairment due to memory and cognitive function loss, but the patient lacked gait disturbances or incontinence. Although not common, NPH may present with auditory hallucinations or delusions, as seen with our patient. In this case report, we emphasize the importance of annual cognitive assessments in order to evaluate atypical psychiatric manifestations of neurological disorders. Because clinical symptoms are more likely to be reversible when recognized early in the clinical course and the progression of these symptoms can be prevented with the placement of a ventriculoperitoneal (VP) shunt, it is of utmost importance to accurately recognize and diagnose NPH as early as possible. We also discuss the less commonly known markers of NPH on MRI.