Misdiagnosed as Alzheimer’s: Dramatic Recovery in Patient with Normal Pressure Hydrocephalus Following Ventriculoperitoneal Shunt Placement
Tanya Xi1, Caroline Boynton2, Vito Errico3
1AriBio Co., Ltd., 2Providence College, 3Diagnostic Imaging of Milford
Objective:
To describe a case of presumed end-stage AD that was ultimately diagnosed as NPH and reversed following ventriculoperitoneal (VP) shunt placement.
Background:
Normal Pressure Hydrocephalus (NPH) is an underrecognized, reversible condition that can mimic Alzheimer’s disease (AD), particularly in elderly patients with cognitive decline, gait disturbance, and urinary incontinence. Misdiagnosis often delays treatment and worsens outcomes.
Design/Methods:
An 81-year-old woman with a remote traumatic head injury and a 2-year history of subtle cognitive and gait decline presented with acute delirium. MRI showed ventriculomegaly out of proportion to cortical atrophy. A VP shunt was placed after multidisciplinary review. Given the acute delirium episode in 2025, despite a CSF profile showing elevated p-Tau/Abeta42 ratio (0.083) and low Abeta42 (294 pg/mL) suggestive of AD pathology, her family advocated for a large-volume lumbar puncture (30 mL). Dramatic but transient improvement in cognition and function followed.
Results:
Post-shunt, the patient experienced sustained recovery in memory, speech, mood, and independence. She resumed daily activities, including gardening, storytelling, and socializing. Neurology and neurosurgery teams noted her outcome exceeded expectations and influenced future evaluation pathways for elderly patients with mixed cognitive presentations.
Conclusions:
This case underscores the importance of considering NPH in the differential diagnosis of dementia, especially when symptoms evolve rapidly or fluctuate. CSF biomarkers may not distinguish NPH from coexisting or mimicking AD pathology. Imaging, including a high field MRI of the brain, can prove very useful in diagnosing NPH, using certain MRI brain criteria. Organic, trust-based collaboration between families and clinical teams can profoundly improve inpatient outcomes. Broader awareness of NPH and responsiveness to caregiver insights may prevent irreversible misdiagnosis and support functional recovery.
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