Differentials
Parkinson's disease
SIGNS / SYMPTOMS
Asymmetrical symptoms.
Predominant tremor usually affecting face and arms.
INVESTIGATIONS
Levodopa challenge test: symptoms respond to levodopa therapy.
Parkinson's-plus syndromes
SIGNS / SYMPTOMS
Akinetic, rigid syndromes including multisystem atrophy sleep disorder, progressive supranuclear palsy, and corticobasal degeneration.
Sometimes difficult to distinguish from NPH, as clinical features are variable.
Parkinson's-plus syndromes often affect the top half of the body (including speech and facial expressiveness) more severely.
Multisystem atrophy: postural hypotension and impotence may be early features.
Steele-Richardson-Olszewski syndrome: progressive supranuclear gaze palsy (i.e., difficulty directing gaze with preservation of reflex eye movements) dysphagia and dysarthria.
Corticobasal degeneration: markedly asymmetrical arm involvement.
INVESTIGATIONS
Cerebrospinal fluid (CSF) drainage procedure: unresponsive.
Cerebrovascular parkinsonism
SIGNS / SYMPTOMS
Clinically indistinguishable from NPH.
May represent the end result of untreated NPH when ischaemic damage to the brain is irreversible by CSF shunting.
INVESTIGATIONS
CSF drainage procedure: unresponsive.
Alzheimer's dementia
SIGNS / SYMPTOMS
Cognitive impairment generally precedes gait impairment.
INVESTIGATIONS
CSF drainage procedure: unresponsive.
Other dementias
SIGNS / SYMPTOMS
Cognitive impairment generally precedes gait impairment.
INVESTIGATIONS
CSF drainage procedure: unresponsive.
Urinary outflow obstruction
SIGNS / SYMPTOMS
Enlarged prostate.
Urinary hesitancy.
Poor urinary stream.
INVESTIGATIONS
Urodynamic studies: demonstrate obstruction to urinary outflow.
Cervical myelopathy
SIGNS / SYMPTOMS
Upper motor neuron signs in legs (e.g., brisk deep tendon reflexes and extensor plantar responses).
INVESTIGATIONS
MRI cervical spine: demonstrates cervical myelopathy.
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