Incidental Diagnosis of Normal Pressure Hydrocephalus in Elderly Patients Presenting With Acute Neurological Illnesses: A Report of Two Cases

Normal pressure hydrocephalus (NPH) is a potentially reversible neurological condition in older adults characterized by gait disturbance, cognitive decline, and urinary incontinence, but its diagnosis is frequently delayed or missed, especially when patients present with other acute medical issues. We report two illustrative cases where probable NPH was incidentally detected during hospitalization for unrelated acute presentations. In both instances, brain imaging performed for other diagnostic purposes revealed ventriculomegaly, and subsequent cerebrospinal fluid (CSF) analysis confirmed normal opening pressure and composition. Further history revealed previously unaddressed symptoms consistent with probable NPH. Although surgical intervention was not pursued due to advanced age, comorbidities, and patient or family preferences, the diagnosis allowed for informed decision-making and supportive care planning. These cases highlight how NPH may remain cryptic in elderly patients, especially when acute, self-limiting disorders dominate the clinical picture. They underscore the importance of maintaining a broad differential diagnosis and obtaining neuroimaging when chronic symptoms such as urinary incontinence, gait impairment, or cognitive decline are present, even when overshadowed by other diagnoses. Given that timely shunting can result in marked improvements in mobility, cognition, and bladder control in many patients, early identification is essential. At the same time, management of NPH must be individualized, taking into account patient age, comorbidities, surgical risks, and personal or family preferences. In both cases, while definitive intervention was not pursued, awareness of the diagnosis enabled informed shared decision-making and offered targeted long-term surveillance and supportive care.