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So this is a patient who was sent to me with, um,

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gait disturbances and cognitive issues. And they,

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they told me that they thought it was N P H and I looked at the patient. He,

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he just,

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he did not strike me as being someone of nph H 'cause he was just really,

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really sharp. Um, despite having some minor, you know, issues with,

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um, word finding and, and, and other things. Um, so at, at this point,

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my spider sense was tingling, so I sent him for a C S F flow study.

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So the C S F flow study we do here at U C S D includes a sagittal fiesta

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just to kind of get a lay of the land beforehand.

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And as you can see immediately,

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we can see that he has an aqueduct web and there's dilation of the cerebral

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aqueduct. There's bowing of the callosum,

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there's bowing of the recess of the third ventricle, um, right,

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right behind the optic chiasm. So all these things are suggestive that,

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that he has obstructive hydrocephalus due to an aqueduct web. Um,

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at this point I stopped them from doing our traditional flow study,

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which is an axial flow study through the aqueduct,

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where we measure basically the velocity and the, the, um, the,

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the rate of flow through the aqueduct. Uh, in this case,

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I asked them just to do, um, a, uh, uh, a flow through the, uh,

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through the frame of magnum, the sagittal plane with five, 10, and 15 banks.

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And just to kind of look and see if there's any flow through the aqueduct. Um,

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there's no flow through the aqueduct on this patient. As you can see,

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there's only, um,

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movement of C s F in the pre pontine cistern and maybe through the frame of

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magenta, a little bit out of the fourth ventricle,

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probably due to just to and fro flow from pulsation of the cerebellum most

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likely. Um, but, you know, I,

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I think one of the things you have to keep in mind is you wanna set your s on

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the lower end for something like this,

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because presumably if you have aqueduct stenosis,

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you're gonna have a lower flow rate if it's significant. So you need to,

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you need to bump your banks lower and just make sure, um,

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that it's not more than 10 or 15% above what you think the velocity's gonna be

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through there, which is, it's gonna be pretty slow, presumably if it,

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if there's that bad of aqueduct stenosis. Um,

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so that's what we ended up doing in this case. And,

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and I sent this patient for an E T V and after the E T V all of his symptoms

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resolved and his ventricles returned to normal size and he didn't have any

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issues. But again, don't,

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don't go down the rabbit hole of N P H until you've at least seen a sagittal

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fiesta on these patients.