A Grumpy Old Man

An ER visit with a change in personality.
By Marven Ewen, MD
Medical Director
A 72-year-old man was brought to the hospital after a grand mal seizure. Upon arrival at his home, the paramedics found the patient to be in a postictal condition and incontinent.

He gradually regained consciousness in the ER shortly after arrival; however, his confusion wasn’t completely clear. His vital signs were within normal limits.

While I was waiting for him to regain consciousness in the ER, I interviewed his wife. She said he had never had a seizure before, but he had been complaining of headaches over the past couple weeks. He had also become grumpy, irritable, and was getting hard to live with.

He didn’t seem to walk normally anymore (she said he “walked like a cowboy who had spent too much time in the saddle”) and had almost fallen due to balance issues several times.  He’d had episodes of urinary incontinence, which was very unusual. There were no new medications or injuries.

I was starting to have suspicions that this patient might have a rapid onset hydrocephalus. This condition, which can be congenital or acquired, can cause several symptoms. The classic triad of symptoms of hydrocephalus are gait problems (wide and shuffling), dementia, and urinary incontinence.

Symptoms may also include headache, irritability, personality changes, blurred vision, nausea, vomiting, loss of appetite, fatigue, and even seizures. It can occur at any age. It can be caused by traumatic injury to the brain, hemorrhagic strokes, infections such as meningitis, or tumors.

Often, the symptoms come on gradually over months, but they may present with a more acute onset. If hydrocephalus is left untreated, it can eventually lead to permanent brain damage and death. But with timely treatment, symptoms will improve.

His workup in the ER included a  CT scan of his brain, which showed significant dilation of his ventricles, confirming the diagnosis of hydrocephalus. Brain ventricles are a connected system of cavities in the brain that contain cerebrospinal fluid. This fluid is produced by the choroid plexus. After the fluid circulates through the ventricles, it is absorbed by the arachnoid granulations into the cerebral venous circulation.

If there is an obstruction to the flow of CSF through the ventricles, or the arachnoid granules are not able to absorb the fluid, then it builds up, putting pressure on the brain.

A neurosurgeon was consulted, and the patient subsequently underwent a procedure to insert a ventriculoperitoneal shunt (VP shunt). This is a tube that drains cerebrospinal fluid from the brain to the peritoneal cavity and thereby reduces the pressure to normal levels.

If hydrocephalus is left untreated, it can eventually lead to permanent brain damage and death.

Subsequently, I received a grateful note from his wife. He had rapid improvement in his symptoms and got his pleasant disposition back, much to her relief.

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