(Kiosk 3) The Patient Who Couldn’t Stand up for Himself: A Unique Presentation of Post-traumatic Hydrocephalus

Case Diagnosis: This case is a unique presentation of delayed post-traumatic hydrocephalus.

Case Description: Patient was admitted to a traumatic brain injury (TBI) acute rehabilitation unit after a motor-vehicle crash resulting in severe TBI. During the inpatient rehab course, the patient began having intermittent “sitting attacks” in which he would intentionally and forcefully sit down whenever he entered the restroom. Medical work-up including labs, urine studies, medication review, orthostatic vitals, and electrocardiogram were all unremarkable. In the absence of overt gait dysfunction, these “sitting attacks” were suspected secondary to agitation given his Rancho Los Amigos level IV cognition (confused, agitated). Three days later, the patient presented with new onset urinary incontinence and an increasing frequency of “sitting attacks” now occurring outside the restroom. CT head revealed findings consistent with post-traumatic hydrocephalus (ventriculomegaly with transependymal flow of CSF).

Discussion: To our knowledge, there have been no case studies published regarding this unique presentation of post-traumatic hydrocephalus (PTH). PTH in TBI patients is encountered in around 10-40% of patients with severe head injury. Presentation can vary and may not be initially considered on the differential, especially when masked with common post-TBI complications like agitation. This overlap of presenting symptoms makes early recognition of this syndrome difficult.

Setting: Acute Rehabilitation Unit

Assessment/Results: Patient was transferred to neurosurgical service for ventriculoperitoneal shunt placement. Post-operatively, the patient’s cognition improved significantly (on O-log, Rancho Los Amigos, and MoCA scales) and “sitting attacks” had resolved. Patient was then safely discharged home with family.

Conclusion: PTH is a treatable complication of TBI that can manifest with various clinical signs and symptoms. Early diagnosis and treatment are crucial to prevent further brain damage and improve outcomes. This case highlights the importance of considering PTH in the differential diagnosis of patients with TBI who present with new or worsening neurological deficits.