Which of the following is NOT part of the classic triad of normal pressure hydrocephalus?

• A. Gait disturbance.
• B. Urinary incontinence.
• C. Cognitive impairment.
• D. Seizures.

Answer: (D)

Normal pressure hydrocephalus is defined by a triad of symptoms: gait disturbance, urinary incontinence, and cognitive impairment. The gait disturbance is often the earliest sign and presents as a magnetic, shuffling, or broad-based walk due to disruption of frontal-subcortical circuits that coordinate movement. Urinary symptoms arise from impaired inhibitory control of the bladder, leading to urgency and incontinence as the condition progresses. Cognitive impairment in NPH tends to be subcortical in pattern, with slowed processing, slowed mental speed, and executive dysfunction rather than a primary memory deficit alone. Seizures are not part of this classic triad; they are not characteristic of NPH and, if they occur, should prompt consideration of other etiologies or concurrent conditions. Diagnostic imaging typically shows ventriculomegaly with normal CSF opening pressure, and improvement can be seen with CSF drainage, with definitive treatment often involving shunting if there’s clinical benefit.