Hydrocephalus: Teamwork Uncovers and Successfully Treats Complex Condition

When 81-year-old Chicago resident Margaret Ramirez suddenly developed dementia, balance problems and aggression last spring, it took a multidisciplinary effort working together to accurately diagnose, treat and rehabilitate her.

“My personality had changed,” the retired nurse’s aide recalls. “Things made me angry that I normally would ignore. I was forgetful, and having hallucinations and terrible dreams.”

When she inexplicably began falling at home — as many as eight times in one day — Margaret knew it was time to see her doctor, internal medicine specialist Daniel Vandenberg, M.D.

“I’ve known Mrs. Ramirez for five years. She has a complicated medical history, but she’s a very sharp lady,” Dr. Vandenberg said. “These were brand-new symptoms. She had taken a sharp decline; she was confused, and her balance was gone.”

Could her condition be a warning sign of stroke, the beginnings of Alzheimer’s disease — or something completely different?

Determined to get the bottom of it, Dr. Vandenberg consulted with neurologist Engin Yilmaz, M.D., and ordered a battery of diagnostic tests. After the results came in, a very subtle finding on a CT scan of her head pointed to normal pressure hydrocephalus (NPH). Another highly sophisticated test called a cisternogram confirmed their suspicions.

The term “hydrocephalus” is derived from two Greek words: hydro for water and cephale for head. Hydrocephalus refers to an excessive amount of cerebrospinal fluid within the ventricles of the brain. The ventricles enlarge to accommodate the extra fluid and then press on different parts of the brain, causing a number of different symptoms.

NPH is most often seen in adults over 60 years of age. The three classic symptoms are difficulty walking, mild dementia and impaired bladder control.

Margaret was referred to renowned neurosurgeon Martin Luken, M.D., for implantation of a shunt to drain the excess fluid and alleviate her troubling symptoms.

“A shunt is a thin tube that is implanted in the brain by a neurosurgeon,” Dr. Luken explained. “It is inserted into the ventricles to drain excess fluid away from the brain.”

The tube is routed under the skin from the head to another part of the body, usually the lower abdomen or peritoneum. The fluid drains harmlessly and is later absorbed by the bloodstream.

Dr. Luken implanted the shunt in March, and Margaret began rehabilitation to regain her balance.

Dr. Vandenberg didn’t see an early dramatic improvement and discovered that (due to excessive scarring from previous abdominal surgeries), the shunt wasn’t draining properly.

That’s when Margaret’s team of physicians called on general surgeon Gary Peplinski, M.D., who laparoscopically repositioned the abdominal portion of the shunt in a second, separate procedure.

With the shunt working properly, Margaret began intensive inpatient rehabilitation at the Ingalls Center for Rehabilitative Medicine under the close supervision of medical director and board-certified physiatrist Jeanne Wilson, M.D.

Today, Margaret is back to her old self — sharp as a tack and able to move around without falling. “I’m doing great,” she said. “I’m so grateful to all of my doctors at Ingalls.”

“Mrs. Ramirez’s case is an excellent example of medical teamwork and collaboration,” Dr. Vandenberg concluded. “It’s one of those times when the whole system worked together to improve the life of a patient.”

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