Esther is a 72-year-old woman with a confirmed diagnosis of normal pressure hydrocephalus (NPH) and emerging signs of possible Parkinson's disease. She has experienced significant functional decline since September 2025 and is currently wheelchair-dependent with minimal ambulation.

Her medical journey began with a comprehensive Prenuvo whole-body MRI in January 2024, which first identified ventriculomegaly — dilated ventricles disproportionate to brain atrophy — raising suspicion for NPH. An external lumbar drain (E shunt) was placed as a trial, which produced brief but meaningful improvement lasting approximately one day, confirming that her brain responds to CSF pressure relief. However, she subsequently developed generalized pain and was hospitalized, and has experienced progressive decline since.

As of her most recent appointments (April 30 and May 1, 2026), her neurosurgical and neurology teams are recommending placement of a permanent ventriculoperitoneal (VP) shunt, while continuing to evaluate for co-existing parkinsonian features that may be contributing to her motor symptoms.

Surgical History

Laparoscopic cholecystectomy (May 31, 2022, MidHudson Regional Hospital), hysterectomy, left total knee replacement, E shunt placement for NPH, decompression surgery for prior spinal fluid flow obstruction, and history of right breast lumpectomy.

Medical History

Normal pressure hydrocephalus, diabetes mellitus, hypertension, hyperlipidemia, possible prior stroke, chronic small vessel ischemic disease. Family history notable for father with frequent syncopal episodes and small TIAs.

Current Medications

As of May 1, 2026 (discharge medication reconciliation). No known medication allergies.

Primary Normal Pressure Hydrocephalus (NPH)

Normal pressure hydrocephalus is a condition in which cerebrospinal fluid (CSF) — the clear fluid that cushions the brain — accumulates in the brain's ventricles (internal cavities), causing them to enlarge and press on surrounding brain tissue. Unlike other forms of hydrocephalus, the fluid pressure measurements can appear "normal" on a single reading, which historically made diagnosis challenging. The classic clinical presentation involves a triad of symptoms: gait disturbance (difficulty walking), cognitive decline (dementia), and urinary incontinence.

Esther's case: Her January 2024 Prenuvo MRI first identified ventriculomegaly — ventricles enlarged beyond what would be explained by age-related brain atrophy alone. This was the initial red flag. The diagnosis was subsequently confirmed when an external lumbar drain (E shunt trial) produced immediate, albeit temporary, clinical improvement. This is a well-established diagnostic test: if draining CSF improves symptoms, it confirms the brain is being adversely affected by fluid accumulation and predicts a favorable response to permanent shunting.

Current status: Despite the positive trial response, Esther has experienced significant functional decline since September 2025, progressing to wheelchair dependence. Both her neurosurgeon (Dr. Dalfino) and neurologist (Dr. Tamai) now recommend a permanent ventriculoperitoneal (VP) shunt — a surgically implanted device that continuously drains excess CSF from the brain's ventricles into the abdominal cavity, where it is safely absorbed by the body. The shunt includes a programmable valve that allows physicians to adjust the drainage rate non-invasively after surgery.

Prognosis considerations: The positive E shunt response is an encouraging prognostic indicator. However, the degree of recovery can vary, and outcomes are generally better when shunting is performed earlier in the disease course. The presence of co-existing white matter ischemic changes and possible parkinsonian features may temper the expected improvement from shunting alone.

Evaluating Possible Parkinson's Disease

During the April 30, 2026 neurosurgery visit, Dr. Dalfino observed a parkinsonian appearance and a left upper extremity pill-rolling tremor — a rhythmic, involuntary movement of the thumb and fingers that is one of the hallmark signs of Parkinson's disease. Parkinson's and NPH can present with overlapping symptoms, particularly regarding gait disturbance and motor slowing, which makes distinguishing between the two (or identifying their co-existence) clinically important.

Why this matters: If Parkinson's disease is contributing to Esther's motor decline, a VP shunt alone may not fully address her mobility issues. Conversely, if her symptoms are primarily NPH-driven, shunting could produce more substantial improvement. Dr. Tamai's evaluation was specifically aimed at clarifying this question. Carbidopa-levodopa (Sinemet), the primary medication for Parkinson's, was previously trialed and may be reconsidered.

Notably: Esther's speech remains clear and fluent, and her higher cognitive function is intact — which is a positive sign. Cognitive preservation suggests that brain tissue damage from either condition has not yet become severe.

Monitor Cerebrovascular Health

Both the 2024 Prenuvo MRI and subsequent imaging have demonstrated chronic small vessel ischemic changes (also called white matter hyperintensities or leukoaraiosis) scattered through the brain's deep white matter. These represent areas where tiny blood vessels in the brain have been damaged over time, leading to small regions of tissue injury. This is associated with cardiovascular risk factors including hypertension and diabetes — both of which are in Esther's medical history.

The Prenuvo also noted a small lacunar infarct (a very small stroke in the deep brain tissue), consistent with her past medical history noting a possible prior stroke. These microvascular changes are common in older adults but can contribute to cognitive and motor symptoms, and managing cardiovascular risk factors (blood pressure, blood sugar, cholesterol) is the primary strategy to slow progression.

Surgical Cholecystectomy (2022)

In May 2022, Esther was admitted to MidHudson Regional Hospital with acute cholecystitis — an inflamed gallbladder caused by gallstones. Her white blood cell count was markedly elevated at 21.57 (normal <10), indicating significant infection. She underwent a successful laparoscopic cholecystectomy (minimally invasive gallbladder removal) on May 31, 2022. A post-operative HIDA scan confirmed no bile leak, and she was discharged in good condition on June 1.

Approximately two weeks later (June 13, 2022), she returned to the ED with shortness of breath and persistent cough. A CT angiogram ruled out pulmonary embolism. The workup incidentally discovered a possible 1 cm splenic artery aneurysm, which was flagged for monitoring. This is the surgery that the Prenuvo scan later confirmed (noting the absent gallbladder).

Reassuring Lab Work & Systemic Health (March 2026)

Esther's comprehensive metabolic panel, complete blood count, thyroid function, and inflammatory markers are all within normal limits as of March 2026. This is clinically reassuring as it suggests her major organ systems (kidneys, liver, thyroid) are functioning well and there is no active systemic infection or inflammatory process.

Informational Musculoskeletal & Other Findings

The Prenuvo scan identified several age-appropriate musculoskeletal findings: small bilateral joint effusions in the shoulders and hips, a right knee effusion, and status post left total knee replacement. Two ~2 cm bone lesions in the right tibia and left humerus are most likely benign enchondromas or bone infarcts — plain film X-rays were recommended for confirmation. Sigmoid diverticulosis (small outpouchings in the colon wall) was noted and is benign unless symptomatic. Thickened pericardial fat was noted in association with her weight (207 lbs at 5'7").

Action Items Recommended Next Steps

1. VP Shunt Placement: Schedule permanent ventriculoperitoneal shunt surgery as recommended by both Dr. Dalfino (neurosurgery) and Dr. Tamai (neurology). The positive E shunt trial response supports a favorable prognosis for shunt-responsive NPH.

2. Parkinson's Disease Workup: Await Dr. Tamai's formal assessment regarding parkinsonian features. If confirmed, carbidopa-levodopa therapy may be restarted alongside or independently of shunt planning.

3. Vitamin D Supplementation: Begin or continue Vitamin D3 2,000 IU daily. Particularly important given limited mobility and reduced sun exposure.

4. Nutritional Support: Monitor albumin levels as a marker of nutritional status. The decline from 4.1 to 3.2 g/dL during the September 2025 hospitalization warrants attention to adequate protein and caloric intake.

5. Bone Lesion Follow-up: Obtain plain film X-rays of right tibia and left humerus to confirm benign nature of the lesions identified on Prenuvo (likely enchondromas).

6. Splenic Artery Aneurysm: The possible 1 cm splenic artery aneurysm found incidentally on CT in June 2022 should be monitored. Confirm with Esther's PCP whether follow-up imaging has been completed.